Treatment of single-level lumbar spondylolisthesis by percutaneous endoscopic decompression and fusion (PE-PLIF)

doi:10.21203/rs.3.rs-1860579/v1

Purpose: To investigate the effect of percutaneous endoscopic lumbar decompression and fusion (PE-PLIF) for L4/5 lumbar spondylolisthesis. Methods: From September 2019 to June 2020, six patients (two men, four women) with l4/5 lumbar spondylolisthesis from the Department of Orthopedics, Bethune Hospital of Shanxi Province were treated with PE-PLIF. Their ages ranged from 43 to 77 years, with an average of (59.66±17.33) years. The duration of operation, blood loss, blood transfusion, and complications were recorded. Results were evaluated by visual analogue scale (VAS) and Oswestry Disability Index (ODI). Student's t- test was used to compare the parameters before and after operation. Results: Six patients were followed up for an average of 13 months (6~20 months), and their symptoms were significantly improved. VAS scores of low back pain and leg pain at three days (2.19±0.49, 1.47±0.63, respectively) and 24 months (0.41±0.54, 0.24±0.27, respectively) were significantly improved compared with preoperative scores (7.83 ±1.17, 6.50±0.80, respectively). The differences were statistically significant ( t =18.717, 6.771, 17.511, 8.021, all P < 0.001). The ODI score at the last follow-up was also significantly lower than that before surgery (53% ±9% vs 17%±7%, P < 0.001). During the follow-up period, screw extraction occurred in only one patient, and no obvious complications occurred in the other five patients. No complications occurred. Conclusion: PE-PLIF can achieve satisfactory short-term efficacy in the treatment of single-level lumbar spondylolisthesis with a low complication rate and quick postoperative recovery. It is a safe and effective way to treat single-level lumbar spondylolisthesis.

Full-endoscopic

lumbar spondylolisthesis

surgical treatment

fusion

Lumbar spondylolisthesis is one of the most common diseases which require spinal surgery, with the highest incidence being 5.9%~11.5% for L4-5 and L5-S1 [1, 2]. Lumbar spondylolisthesis is also the most common cause of lumbar canal stenosis, often causing symptoms such as lumbago or radicular pain, and in serious cases intermittent claudication, causing sensory-motor dysfunction of the lower limbs [3, 4]. Surgical treatment is often needed if conservative treatment fails.

Open posterior lumbar interbody fusion (PLIF) is a classic surgical method for the treatment of lumbar spondylolisthesis, but it also has the disadvantages of a large incision, high blood loss and high requirements for the general physical condition of patients. With the innovation and progress of minimally invasive surgery, technology and special instruments, minimally invasive surgical treatment of lumbar spondylolisthesis (mild, moderate or less than grade II spondylolisthesis) has gradually become the mainstream. However, the effectiveness of various surgical procedures and the resulting complications are controversial. This study retrospectively analyzed patients with single-level mild and moderate (grade I and II) lumbar spondylolisthesis who underwent percutaneous endoscopic joint protrusion lumbar decompression and fusion surgery (PE-PLIF) in our hospital from September 2019 to June 2020, and reported the surgical method and short-term efficacy of PE-PLIF.

I. General information and inclusion and exclusion criteria

From September 2019 to June 2020, six patients (two men, four women) with L4/5 single-level lumbar spondylolisthesis were treated by PE-PLIF in the Department of Orthopedics, Bethune Hospital, Shanxi Province. The age ranged from 43 to 77 years, with an average of (59.66 ± 17.33) years. This study has been approved by the ethics committee of [BLINDED FOR REVIEW], approval no.: ([BLINDED FOR REVIEW], Nov 4, 2020). Informed consent was obtained from all individual participants included in the study.

Inclusion criteria: ① patients were diagnosed with lumbar spondylolisthesis, Meyerding grade II or below, with single segmental lesions (L4-5), who required surgical intervention after six months of regular conservative treatment was ineffective; ② PE-PLIF surgery was performed; ③ imaging examination was consistent with the patient's clinical manifestations and symptoms; ④ the main outcome measures were pain relief, lumbar function assessment and sagittal imaging parameters; ⑤ Retrospective case-control analysis was performed. Exclusion criteria: ① previous lumbar surgery or trauma history; ② patients with congenital spinal malformation or severe developmental spinal stenosis; ③ patients with severe osteoporosis who needed bone cement reinforcement; ④ patients with ankylosing spondylitis, other immune diseases or metabolic bone diseases; ⑤ patients with mental disorders or inability to cooperate with follow-up and evaluation.

II. Surgical method

Preoperative routine examination and preparation for spinal surgery were performed, and endotracheal intubation was performed under general anesthesia.

Preoperative preparation and positioning: The patient was placed in prone position on a routine operating room table, adjusted into a 'lumbar bridge' position of hip flexion and lumbar kyphosis with knees bent, so the L4-5 disc space was perpendicular to the ground and the L4-5 pedicle was marked (Fig. 1).
Positioning and facet shaping: on the left side of the L4-5 spinous process gap, 1.5cm was opened to locate the insertion point, and a puncture needle was placed through the insertion point so the needle end of the G-arm was positioned at the connection between the upper edge of L5 lamina and the superior articular process. The guide needle was inserted through the puncture needle (Fig. 1), and about 1.5cm of skin, subcutaneous tissue and deep fascia were cut at the insertion point. Under G-arm guidance, a soft tissue expander was inserted into the L4-5 left articular process through the incision along the guide wire, and the working sleeve was inserted (Fig. 2). Entry observation was conducted under continuous saline irrigation.
Endoscopic spinal decompression: endoscopic laminectomy and an endoscopic bone knife were used alternately to remove the left lower articular process of L4 and the left upper articular process of L5. The left ligamentum flavum of L4-5 were removed, followed by endoscopic radiofrequency ablation for hemostasis (Fig. 3). A radiofrequency probe was used to fully separate and release the L5 nerve root, and different nucleus pulposus forceps were used to alternately clamp the protruding disc tissue and intervertebral disc tissue, followed by radiofrequency ablation for hemostasis. Sufficient decompression of walking roots, outlet roots, and dura was performed (Fig. 4).
Intervertebral disc management: the nerve root was protected with a working sleeve, and the L4-5 disc and endplate were treated with a reamer with an anteroposterior-lateral perspective. The intervertebral disc tissue and cartilage endplate were treated with nucleus pulposus forceps and endplate curettes (Fig. 4). The nerve root and upper and lower cartilage endplates were examined again under endoscopy.
Intervertebral disc space opening: the disc space was opened step by step, accompanied by removal of the disc.
Intervertebral bone graft and fusion device placement: an intervertebral funnel bone graft device was used to fill the upper and lower facet bone forceps into the intervertebral disc space. The bone was filled into the special intervertebral fusion device and placed in the intervertebral disc space. Antero-posterior and lateral fluoroscopy confirmed that the position of the fusion device was more than 3/4 of the anterior or contralateral vertebrae, and the height of the fusion device was subsequently adjusted from 8mm to 12mm. Fluoroscopy observed the recovery of the height of the intervertebral space and confirmed that the fusion device was in good position (Fig. 5).
Pedicle screw fixation: the L4-5 bilateral pedicle edge was cut for 1-2 cm of layered skin, subcutaneous tissue and deep fascia, and the G-arm and percutaneous puncture needle guided the pedicle screw needle. The G-arm was used to determine the location, followed by the guide pin screw and the percutaneous pedicle screws. A prebent fixed rod was installed and screws tightened under pressure (Fig. 6).

For grade I spondylolisthesis, a fusion device was placed first after decompression, followed by decompression and reaming, and then pedicle screw placement and connecting rod fixation. For patients with grade II spondylolisthesis, a fusion device was placed first after decompression, and then the fusion device was placed and vertebrae separated. When the spondylolisthesis was reduced, a pedicle screw could be placed and a connecting rod added for fixation. For patients with obvious hyperplasia and cohesion of bilateral facet joints shown by preoperative CT, bilateral decompression was performed first. After decompression, the fusion device was placed but not opened. Pedicle screw fixation was performed on the opposite side of the inserted fusion device, and connecting rods were placed for extension before the fusion device was adjusted and opened. When fluoroscopy showed the fusion device was in position, a screw was placed by the fusion device to fix the connecting rod (Fig. 7). This position was confirmed again by fluoroscopy. The drainage tube was indwelled and sutured.

III. Operative indicators and postoperative management

The duration of surgery, amount of blood loss, blood transfusion, and related complications were recorded. The visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to assess pain and function. After the operation, patients were given anti-infection and nutritional symptomatic support therapy. This consisted of routine application of antibiotics within 24 hours and later functional exercises for strengthening of the upper and lower limbs. Anteroposterior and lateral lumbar radiographs were taken three to seven days after the operation, and then with a support belt was worn to facilitate sitting and movement. Excessive bending and weight-bearing activities were prohibited for three months, after which the waist support was removed.

IV. Statistical methods

SPSS 22.0 was used for statistical analysis. All measurement data were expressed as frequency or percentage. χ̅ ± s t-test was used to compare the measurement data of each observation index before and after surgery, and P < 0.05 was considered statistically significant.

I. Operation situation

All six cases were at L4/5 with single segmental lesions, and the operative time was 180–280 min, with an average of 207 min. Intraoperative blood loss was 70 ~ 120ml, with an average of 88ml. No patient received blood transfusion. The active time in the operating theater was 20-48h, with an average of 27h (Table 1). Preoperative low back pain VAS score (7.83 ± 1.17), leg pain VAS score (6.50 ± 0.80), and ODI score (53% ±9%) were collected (Tables 1 and 2; Figs. 7 and 8).

Table 1

General data and efficacy related evaluation parameters of six patients
Serial number	Sex	Age	Operation time (min)	Blood loss (ml)	Operation time (h)	Intervertebral fusion time (min)	Low back pain VAS score				Leg pain VAS score			ODI Score (%)
							The last time before and after surgery			The last time before and after surgery				At the end of preoperative time
1	female	77	240	120	48	6	21	9	3		0	7	2	0	60	10
2	male	43	220	70	24	6	17	8	2		1	5	1	0	38	10
3	female	57	210	70	24	6	17	7	2		0	9	2	0	38	8
4	female	48	180	100	20	3	14	7	4		1	7	1	0	62	8
5	female	68	190	90	24	6	9	9	3		1	5	1	0	62	18
6	male	60	200	80	24	6	6	7	2		0	6	1	1	58	26

Table 2

Preoperative and postoperative VAS and ODI scores of six patients
Time	VAS (points)		ODI Score (%)
Time	Low back pain	Leg pain	ODI Score (%)
preoperative	7.83 ± 1.17	6.50 ± 0.80	53% ± 9%
Postoperative: 3 days	2.19 ± 0.49	1.47 ± 0.63	-
Final follow-up (24 months)	0.41 ± 0.54	0.24 ± 0.27	17% ± 7%
T value	17.491	8.017	12.512
P values	0.000	0.000	0.000

II. Follow-up

All six patients were followed up for 6–20 months (mean: 13 months). The symptoms of lumbago and leg pain were significantly relieved after surgery compared with that before surgery, and the VAS scores of lumbago and leg pain were significantly decreased three days after surgery and at the last follow-up compared with that before surgery (P < 0.001). The ODI score at the last follow-up was also significantly lower than that before surgery (P < 0.001). X-ray, CT and MRI examinations were performed at 3 days and 1, 3, 6, 12, 18 and 24 months after the operation. The results indicated that adequate decompression, load reduction, fusion device and pedicle screw position were obtained in the responsible segment (L4-5). At the six month follow-up, radiographs showed bony fusion in the intervertebral space. Only one case had partial screw removal during load reduction due to osteoporosis, and the patient had no improvement in symptoms at the later follow-up, which may be due to osteoporosis and obvious hypertrophy of facet joints on the non-decompression side.

Degenerative lumbar spondylolisthesis is a disease characterized by degenerative changes of the spine. Lumbar spondylolisthesis and instability often cause obvious symptoms of lumbar and leg pain [5]. With the increasing capability of minimally invasive surgery and technology, applied anatomy, spine-pelvis parameters, and imaging evaluation for lower lumbar spondylolisthesis, and the progress of specially designed surgical instruments, minimally invasive surgery has become prevalent in the treatment of degenerative lumbar spondylolisthesis. Currently, minimally invasive fusion has been gradually tried in degenerative lumbar spondylolisthesis, mainly including the following fusion methods specified according to the surgical approach: Minimally invasive surgery transforminal lumbar interbody fusion (MIS-TLIF), minimally invasive oblique anterior lumbar interbody fusion (OLIF), extreme lateral lumbar interbody fusion (XLIF), direct lateral approach interbody fusion (DLIF), minimally invasive surgery anterior lumbar interbody fusion (MIS-ALIF), and axial lumbar interbody fusion (AxiaLIF) via the anterior sacral approach.

Traditional open PLIF surgery is considered to have achieved good efficacy in the treatment of degenerative lumbar spondylolisthesis, but it also has some disadvantages, including: extensive paraspinal muscle dissection and excision of supraspinal and interspinous ligaments during PLIF surgery, which may affect the stability of the posterior column of the spine; excessive intraoperative traction of paravertebral muscles which can lead to postoperative ischemic necrosis, fibrosis, and muscle weakness; and bone including the spinous process and vertebral body should be removed which may increase intraoperative bleeding, resulting in postoperative low back pain symptoms [6]. However, PE-PLIF surgery does not require extensive dissection of paraspinal muscles and soft tissues. Through accurate intraoperative fluoroscopy, only part of the upper and lower articular processes and lamina are removed, which greatly retains the posterior structure of the spine, minimizes the impact on the stability of the posterior column of the spine, and improves the postoperative stability of the spine (Fig. 9).

MIS-TLIF has been widely recognized in the treatment of mild and moderate lumbar spondylolisthesis. Price et al. [7] compared 452 MIS-TLIF and traditional TLIF cases in a single center, and found that although MIS-TLIF and Traditional TLIF have similar clinical and imaging effects, MIS-TLIF has the advantages of less intraoperative bleeding, shorter operation times, shorter hospital stays and fewer deep infections at the surgical site. However, MIS-TLIF surgery also has some disadvantages. MIS-TLIF surgery completely destroys the facet joint on one side and affects the bone-muscle-ligament complex in the posterior column of the spine. Moreover, it is relatively difficult to symmetrically place an interbody fusion device in the intervertebral space during MIS-TLIF surgery, and the stability of the postoperative spine is more dependent on the fixation of pedicle screws [8]. Chen et al. [9] found that after MIS-TLIF, serum creatine kinase increased significantly. Serum creatine kinase is considered to be an indicator of muscle injury during lumbar surgery [10, 11]. This may be caused by electrocauterization of the muscle during MIS-TLIF, narrow channel space, and incorrect use of anatomical marks. Since MIS-TLIF is a sub-channel procedure, a narrow channel space and inadequate continuous irrigation in an aqueous environment may result in substantial re-absorption of creatine kinase.

Some authors also reported that MIS-TLIF did not significantly reduce the incidence of surgical complications [12, 13]. As a minimally invasive operation, MIS-TLIF surgery has certain technical difficulties, including narrow channel operation space, long intraoperative fluoroscopy time, incomplete exposure of anatomical marks, high operation difficulty and a steep learning curve [14].

Oblique anterior lumbar interbody fusion (OLIF) is a lumbar interbody fusion between anterior and lateral approaches with the advantage of avoiding most important nerves and blood vessels. In the treatment of degenerative lumbar spondylolisthesis, indirect decompression can effectively relieve clinical symptoms and correct vertebral spondylolisthesis. Sato et al. [15] examined 20 cases of minimally invasive OLIF treatment and the assessment of curative effect and imaging results showed postoperative spinal canal diameter, vertebral canal sagittal diameter, spinal canal, intervertebral disc height and intervertebral foramen area were significantly increased, the upper vertebral body sliding significantly reduced, and compared with preoperative measurements, waist pain, leg pain and numbness symptoms was significantly reduced. However, OLIF also may result in intervertebral collapse after fusion failure, lumbar plexus nerve injury, transient motor weakness, and limb numbness [16]. Dural and ureteral injuries have also been reported in recent years.

By learning various minimally invasive fusion surgeries and mastering the anatomy of the bone-muscle-ligament complex of the posterior column of the spine, our team designed the PE-PLIF minimally invasive endoscopic fusion technique and successfully applied it in clinical practice. The core concepts of this technique are as follows: 1. Improved safety under the surveillance of percutaneous early endoscopic technology, specifically the partial resection of the upper and lower articular processes and laminectomy under endoscopic surveillance; 2. The protection of nerve roots though protection sleeve rotation and decompression and fusion device placement under endoscopic supervision [17, 18]; 3. The transfacet joint approach does not destroy the bone-muscle-ligament complex structure of the posterior column of the spine, and thus reduces the influence on the postoperative stability of the spine as much as possible; 4. A certain amount of autologous bone can be obtained during the operation, which can be used for intervertebral bone graft fusion and can realize the ideal preparation of the bone graft bed; 5. The height adjustable interbody fusion device can restore the normal height of the interbody space, avoid the displacement of the interbody fusion device, and achieve the purpose of indirect decompression; 6. The minimally invasive surgery increases postoperative recovery; 7. The anatomy is consistent with the open surgical approach, easy to master, and the learning curve is short and slow.

The results of this study showed that for single-level mild to moderate (grades I and II) L4-5 lumbar spondylolisthesis treated with percutaneous endoscopic joint thrust decompression and fusion (PE-PLIF), postoperative symptoms such as low back pain and leg pain were significantly relieved, and only one asymptomatic screw prolapse was observed after follow-up. No serious postoperative complications occurred. This operation is clinically useful and may be worth popularizing for further study.

Acknowledgements

The author of this article would like to thank the following experts and personnel for their assistance: Professor Feng Haoyu, for the design and implementation of this study and for providing valuable advice; Dr. He Liming, for assistance in article writing and language; Professors Wang Rui and Chang Qiang, for assisting in the surgery; attending physician Xi Lei Ming, for assisting in preoperative imaging following data collection and for assistance in article writing; Dr. Ma Yongzhuang and Dr. Wang Yue, for assisting in the follow-up data collection.

Compliance with Ethical Standards

Conflicts of Interest

There were no conflicts of interest to declare.

Funding

None.

Ethical Approval

This study has been approved by the ethics committee of Shanxi Bethune hospital, approval no. :(yxll-2020-073, Nov 4, 2020).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Consent to Publish

The participant has consented to the submission of the case report to the journal.

Data availability

The data used to support the findings of this study are included within the article.

Author contributions

Conceptualization: Haoyu Feng, Methodology: Liming He, Formal analysis and investigation: Zhenwu Gao, Writing - original draft preparation: Lieming Xi; Writing - review and editing: Yongzhuang Ma, Funding acquisition: Qiang Chang, Resources: Rui Wang, Supervision: Yue Wang

Sakai T, Sairyo K, Takao S, Nishitani H, Yasui N (2009) Incidence of lumbar spondylolysis in the general population in Japan based on multidetector computed tomography scans from two thousand subjects. Spine 34:2346–2350. https://doi.org/10.1097/BRS.0b013e3181b4abbe
Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ (2009) Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine 34:199–205. https://doi.org/10.1097/BRS.0b013e31818edcfd
Lurie J, Tomkins - Lane C (2016) Management of lumbar spinal stenosis [J]. BMJ 352:h6234. DOI: 10.1136/bmj.h6234
Wu A-M, Zou F, Cao Y, Xia D-D, He W, Zhu B, Chen D, Ni W-F, Wang X-Y, Kwan K (2017) Lumbar spinal stenosis: an update on the epidemiology, diagnosis and treatment. AME Med J 2:63. https://doi.org/10.21037/amj.2017.04.13
Jacobsen S, Sonne-Holm S, Rovsing H, Monrad H, Gebuhr P (2007) Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study. Spine 32:120–125. https://doi.org/10.1097/01.brs.0000250979.12398.96
Fan SW, Hu ZJ, Fang XQ, Zhao FD, Huang Y, Yu HJ (2010) Comparison of paraspinal muscle injury in one-level lumbar posterior inter-body fusion: modified minimally invasive and traditional open approaches. Orthop Surg 2:194–200. https://doi.org/10.1111/j.1757-7861.2010.00086.x
Price JP, Dawson JM, Schwender JD, Schellhas KP (2018) Clinical and Radiologic Comparison of Minimally Invasive Surgery With Traditional Open Transforaminal Lumbar Interbody Fusion: A Review of 452 Patients From a Single Center. Clin Spine Surg 31:E121–E126. https://doi.org/10.1097/bsd.0000000000000581
Potter BK, Freedman BA, Verwiebe EG, Hall JM, Polly DW Jr, Kuklo TR (2005) Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients. J Spinal Disord Tech 18:337–346. https://doi.org/10.1097/01.bsd.0000166642.69189.45
Chen B, Han Z, Chien-Heng L, Zhang Y (2019) Short- and medium-term follow-up of minimally invasive transforaminal lumbar interbody fusion for lumbar spondylolisthesis. J Spine Surg 5:297–302
Arts M, Brand R, Van Der Kallen B, Lycklama À, Nijeholt G, Peul W (2011) Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial. Eur Spine J 20:51–57. https://doi.org/10.1007/s00586-010-1482-y
Tang Y, Zhang M (2017) Minimally invasive transforaminal interbody fusion for the treatment of degenerative spondylolisthesis [J]. J Cerv Lumbar Pain 38:234–238
Tang X (2017) Clinical analysis of PLIF and MIS-TLIF for treatment of lumbar degenerative disease in elderly patients. Dissertation, Jilin University
Zhou X (2018) A comparative study of mis-TLIF and PLIF in the treatment of lumbar spondylolisthesis. Dissertation, Shanxi Medical University
Lee KH, Yeo W, Soeharno H, Yue WM (2014) Learning curve of a complex surgical technique: minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). J Spinal Disord Tech 27:E234–E240. https://doi.org/10.1097/bsd.0000000000000089
Sato J, Ohtori S, Orita S, Yamauchi K, Eguchi Y, Ochiai N, Kuniyoshi K, Aoki Y, Nakamura J, Miyagi M, Suzuki M, Kubota G, Inage K, Sainoh T, Fujimoto K, Shiga Y, Abe K, Kanamoto H, Inoue G, Takahashi K (2017) Radiographic evaluation of indirect decompression of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lateral interbody fusion for degenerated lumbar spondylolisthesis. Eur Spine J 26:671–678. https://doi.org/10.1007/s00586-015-4170-0
Kim J-S, Choi WS, Sung JH (2016) Minimally Invasive Oblique Lateral Interbody Fusion for L4-5: Clinical Outcomes and Perioperative Complications. Neurosurgery 63:190–191. https://doi.org/10.1227/01.neu.0000489803.65103.84
Kubota G, Orita S, Umimura T, Takahashi K, Ohtori S (2017) Insidious intraoperative ureteral injury as a complication in oblique lumbar interbody fusion surgery: a case report. BMC Res Notes 10:193. https://doi.org/10.1186/s13104-017-2509-9
Chang J, Kim JS, Jo H (2017) Ventral Dural Injury After Oblique Lumbar Interbody Fusion. World Neurosurg 98:881e.
1-881.e4
.. https://doi.org/10.1016/j.wneu.2016.11.028

Treatment of single-level lumbar spondylolisthesis by percutaneous endoscopic decompression and fusion (PE-PLIF)

Status:

Version 1

Abstract

Figures

Introduction

methods

Results

Discussion

Declarations

References

Status:

Version 1