Lumbar intervertebral endplate autograft fusion on patients with lumbar spinal instability and lumbar spondylolisthesis

doi:10.21203/rs.3.rs-4924720/v1

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Lumbar intervertebral endplate autograft fusion on patients with lumbar spinal instability and lumbar spondylolisthesis

https://doi.org/10.21203/rs.3.rs-4924720/v1

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Background

Lumbar interbody fusion with standalone local bone grafts sufficed for single-level low-grade spondylolisthesis via the open posterior approach. This study aimed to assess the impact of lumbar intervertebral endplate autograft fusion on middle-aged and elderly adults with lumbar spinal instability and spondylolisthesis.

Methods

32 patients with these conditions were included in the study at a hospital between June 2018 and January 2023, undergoing either lumbar intervertebral endplate autograft fusion or intervertebral graft fusion.

Results

The two groups showed no significant differences in postoperative measures except for the JOA low back pain score and SF-36 score, which were better in the endplate autograft fusion group. The endplate fusion ratio was significantly higher in the autograft fusion group.

Conclusions

Lumbar intervertebral endplate autograft fusion may be a promising approach for patients with lumbar spine instability and low-grade spondylolisthesis, potentially leading to a higher endplate fusion ratio compared to conventional methods.

spinal fusion

autograft

lumbar vertebrae

spondylolisthesis

joint instability

Lumbar pain is a common spinal issue, with a prevalence of about 4.2% in China [1]. Lumbar pain is a leading cause of years lived with a disability, according to the Global Burden of Disease Study [2]. Acute lumbar pain has a high risk of developing into chronic lumbar pain [3]. Lumbar pain is often caused by spondylosis, an umbrella term encompassing the progressive degeneration of the spine and affecting the bones, joints, and discs [4]. Most cases of lumbar pain are mechanical in nature [4]. Lumbar instability due to spinal ligaments is an important cause of lumbar pain [5]. In addition, spondylolisthesis (i.e., the displacement, usually anterior, of a vertebral body relative to the adjacent inferior vertebral body) is another important cause of lumbar pain in adults [6, 7]. Analgesia and anti-inflammatory drugs can be used to manage the pain, but some patients will eventually require surgery [7].

Current surgical approaches include the reduction and internal fixation for lumbar spinal instability or lumbar spondylolisthesis combined with laminectomy, spinal canal decompression, and intervertebral body fusion [7–9], as also supported by the available guidelines [10, 11]. The popular surgical approaches for intervertebral body fusion include intervertebral body columnar bone graft fusion, intervertebral body cage bone graft fusion, and intervertebral body cancellous bone fusion [7, 9]. Irrespective of the technique, surgery aims to improve spinal stability and manage pain [7, 9]. Evidence of the superiority of a given technique over others remains poor [9].

Still, the use of allograft or cadaver bone requires its availability from a bone bank, and the required sterilization steps can damage the bone tissues [12]. There is also a risk of disease transmission, such as hepatitis B or C [13]. Autografts are considered the gold standard for spinal fusion and can be harvested from the iliac crest, proximal tibia, distal femur, fibula, ribs, and distal radius at the time of surgery [14]. There is complete histocompatibility, there are no risks of infection transmission, and they possess osteogenic, osteoinductive, and osteoconductive properties.

A previous study showed that lumbar interbody fusion with standalone local bone grafts was sufficient for single-level low-grade spondylolisthesis treated with interbody fusion through the conventional open posterior approach [15], but their patients were in their 40s, and lumbar instability was not considered. Therefore, this study aimed to explore the impact of lumbar intervertebral endplate autograft fusion on middle-aged and older adult patients with lumbar spinal instability complicated with spondylolisthesis.

Study design and patients

This study included patients who were diagnosed with lumbar spinal instability combined with spondylolisthesis and underwent surgical treatment in the Department of Orthopedics of the First People’s Hospital of Shangqiu Affiliated with Xinxiang Medical College between June 2018 and January 2023. The inclusion criteria were 1) lumbar spinal instability [16, 17], 2) spondylolisthesis Meyerding grading Ⅰ or Ⅱ degrees [18, 19], 3) lumbar spinal instability with right and left anterior oblique position radiographs suggestive of spondylolysis and magnetic resonance imaging (MRI) of the lumbar spine suggestive of lumbar disc herniation (LDH), 4) 40 to 65 years of age, 5) treated with lumbar intervertebral endplate autograft fusion or intervertebral fusion graft fusion, and 6) internal fixations were removed within 2 years after surgery. The exclusion criteria were 1) with more than two lumbar spinal instabilities or spondylolistheses, 2) severely reduced cardiopulmonary, hepatic, or renal function, or 3) incomplete clinical data. The study was approved by the Ethics Committee of the First People’s Hospital of Shangqiu Affiliated with Xinxiang Medical College. All patients provided a signed informed consent form.

Surgery

Depending upon the patient’s and family’s preference, patients underwent either lumbar intervertebral endplate autograft fusion or intervertebral graft fusion. All patients underwent reduction and internal fixation of the lumbar spine, laminectomy, and spinal canal decompression.

For lumbar intervertebral endplate autograft fusion (Fig. 1), after the posterior median incision was made to reveal the vertebral plate, the C-arm X-ray machine was positioned, and then long-arm “U”-shaped screws (Beijing Fuller Technology Development Company) were placed via the pedicle of the vertebral arch. The nail placement range included the instability or spondylolisthesis of the lumbar spine and its upper and lower lumbar spine, and the connecting rod of the internal fixation system (Beijing Fuller Technology Development Company) was pre-bent about 16°-20° and placed in the “U”-the shaped screw. The spinous process and the vertebral plate of the instability or spondylolisthesis of the vertebral body were removed, and the removed bone was prepared for bone grafting. At this time, loosen the screws of the tightened inferior vertebral body screws to open the stiff endplate space between the instability or spondylolisthesis vertebral body and its inferior vertebral body, and then tighten the screws of the inferior vertebral body, and finally slowly tighten the screws of the instability or spondylolisthesis vertebral body screws to reset the vertebral body by using the screw pulling effect. The physiological anterior curvature of the lumbar spine was restored to approximately 16°-20°. The endplate space was restored to the same height or slightly higher than the height of the adjacent endplate space. The nerve root canal of the instability or spondylolisthesis of the lumbar spine was enlarged and decompressed, the nerve roots were separated and retracted, and an incision was made through the posterior longitudinal ligament (the space between the instability or spondylolisthesis and the inferior vertebral body) to remove the herniated nucleus pulposus and clean the soft tissues between the endplates with a scratching device to avoid bony endplate damage. The decompressed spinous process and vertebral plate bone were crushed into soybean-sized particles, which were implanted through the posterior longitudinal ligament incision and percussed and compacted to make a faceted bone mass parallel to the endplate space, allowing the bone mass to expand to the ventral cortical shell margin of the vertebral body. The posterior longitudinal ligament incision was closed with 1–2 stitches as appropriate, the field was flushed, a drainage tube was placed, and the wound was closed.

Generally, the internal fixation was removed 2 years after lumbar intervertebral endplate autograft fusion, and follow-up started about 2 years after the internal fixation was removed, with a follow-up interval of 1 to 1.5 years. The lumbar spine X-ray was performed to assess the endplate fusion. The final follow-up time was January 2023.

Data collection

The demographic and clinical data of the patients were collected, mainly including age, sex, weight, and cardiovascular history. The clinical data included instability with spondylolisthesis vertebral body segments, number of unstable vertebral bodies, the severity of spondylolisthesis vertebral bodies, time from the postoperative return to the ward to discharge, number of cases of internal fixation removal at 2 years postoperatively, time from internal fixation removal to final follow-up, endplate space height, anterior curvature of the lumbar spine, fusion area to endplate area ratio, Japanese Orthopaedic Association (JOA) low back pain score [20], SF-36 score [21], adjacent segment disease, and Oswestry disability index at discharge and final follow-up.

Statistical analysis

Statistical analysis was performed using SPSS 19.0 (IBM Corp., Armonk, NY, USA). The continuous data conforming to the normal distribution were presented as mean ± standard deviation (SD) and analyzed using Student’s t-test. Those with skew distribution were presented as median (range) and analyzed using the Mann-Whitney U-test. Categorical data were presented as n (%) and analyzed using the chi-square test. Two-sided P-values < 0.05 were considered statistically different.

Characteristics of the patients

Forty-four patients were included in this study, and 12 patients were excluded during follow up because of severe cardiopulmonary and renal diseases (n = 5), trauma (n = 3), adjacent vertebral body tumor lesion (n = 1), and loss to follow-up (n = 3). Finally, 16 patients were included in each group. All patients in this group were hospitalized for spinal internal fixation removal 2 years before the study follow-up. There were no significant differences between the two groups (Table 1).

Table 1

Baseline information table of the patients
Clinical information	Lumbar intervertebral endplate autograft fusion (n = 16)	Intervertebral graft fusion (n = 16)	P
Age, years, mean ± SD	52.3 ± 11.2	52.9 ± 3.9	0.273
Sex, n (%)			0.786
Male	9 (56.25%)	10 (62.50%)
Female	7 (43.75%)	6 (37.50)
Past medical history of cardiovascular disease, n (%)	3 (18.75%)	2 (12.50%)	0.811
Vertebral segments of spondylolisthesis, n (%)			0.912
L3	4 (25.00%)	5 (31.25%)
L4	9 (56.25%)	8 (50.00%)
L5	3 (18.75%)	3 (18.75%)
Number of unstable vertebral bodies, n (%)	10 (62.50%)	9 (56.25%)	0.931
Severity of spondylolisthesis			0.926
I degree	4 (25.00%)	5 (31.25%)
II degree	2 (12.50%)	2 (12.50%)
Time from the postoperative return to the ward to discharge (days)	5	4.5	0.913
Number of cases of internal fixation removal at 2 years postoperatively, n (%)	16 (100%)	16 (100%)	0.950
Time from the postoperative period to the last follow-up visit, months, mean ± SD	58.1 ± 1.2	59.1 ± 1.8	0.876

Surgical outcomes

There were no significant differences between the two groups regarding the endplate space, anterior curvature of the lumbar spine, JOA low back pain score, SF-26 score, adjacent segment disease, and Oswestry disability index (all P > 0.05). But the lumbar intervertebral endplate autograft fusion group was more likely to have lower JOA low back pain score than the intervertebral graft fusion group (0.8 ± 0.6 vs. 1.0 ± 1.9), and have higher SF-26 score (65.6 ± 3.6 vs. 61.9 ± 8.2). The endplate fusion ratio was significant higher in the lumbar intervertebral endplate autograft fusion group compared with the intervertebral graft fusion group (78.3 ± 1.9% vs. 40.1 ± 0.9%, P = 0.001) (Table 2).

Table 2

Comparison of parameters of different fusion methods
Clinical information	Lumbar intervertebral endplate autograft fusion (n = 16)	Intervertebral graft fusion (n = 16)	P
Endplate space, mm, mean ± SD			0.596
Preoperative	58.1 ± 1.2	7.2 ± 0.9
Operative period	13.6 ± 0.2	13.9 ± 1.2
Final Follow-up	12.0 ± 1.6	11.9 ± 0.2
Anterior curvature of the lumbar spine, °, mean ± SD			0.862
Preoperative	9.1 ± 0.9	9.2 ± 0.6
Operative period	16.1 ± 1.2	16.9 ± 1.1
Final Follow-up	14.9 ± 1.8	14.2 ± 0.9
Endplate fusion ratio, %, mean ± SD			0.001
Final Follow-up	78.3 ± 1.9	40.1 ± 0.9
JOA low back pain, mean ± SD			0.789
Operative period	2.2 ± 3.6	2.3 ± 3.5
Final Follow-up	0.8 ± 0.6	1.0 ± 1.9
SF-36 score, mean ± SD			0.896
Operative period	36.1 ± 8.3	36.6 ± 8.0
Final Follow-up	65.6 ± 3.6	61.9 ± 8.2
Adjacent segment disease, n (%)			0.906
Operative period	10 (62.50%)	11 (68.75%)
Final Follow-up	5 (31.25%)	4 (25.00%)
Oswestry disability index, mean ± SD			0.718
Operative period	59.1 ± 10.6	58.9 ± 3.6
Final follow-up	13.2 ± 6.1	13.1 ± 7.8

Typical case

A 52-year-old female patient was admitted to the hospital in June 2011 with lumbosacral pain affecting her sitting and walking for over 2 years. On admission, pressure pain was noted on both sides of the spine and spinous processes of the L4-5 vertebral body. The pressure pain could spread to the hip. X-ray showed a first-degree spondylolisthesis of the L4 vertebral body (Fig. 2A-B). The diagnosis was lumbar spinal instability and spondylolisthesis. In October 2011, reduction and internal fixation of the lumbar vertebral body, L4 laminectomy and decompression, and L4-5 lumbar intervertebral endplate autograft fusion were performed. Postoperative frontal and lateral radiographs showed that the bone particles were located between the endplates (Fig. 2C-D). She was discharged 15 days after surgery. Positive and lateral radiographs reviewed in June 2013 showed endplate autograft fusion (Fig. 2E-F). The JOA low back pain score was 0.6, and the SF-36 score was 65. Internal fixation removal was performed, and front and lateral radiographs showed endplate autograft fusion (Fig. 2G-H). In 2015, a follow-up computed tomography (CT) plain scan showed endplate autograft fusion with a fusion area of approximately 80% of the endplate area (Fig. 2I-J). Review radiographs in 2016 showed no further instability or spondylolisthesis of the vertebral body (Fig. 2K-L), with a JOA low back pain score of 0.6 and an SF-36 score of 67.

The results showed the endplate fusion ratio was significant higher in the lumbar intervertebral endplate autograft fusion group compared with the intervertebral graft fusion group, but other parameters were not significant difference. It suggested that lumbar intervertebral endplate space autograft fusion may be a potential method to treat lumbar spine instability and spondylolisthesis.

The patients were followed up for 5–8 years after the removal of their internal fixation and were enrolled 2–3 years after surgery, and the vertebral body and fusion space had fully completed the fusion process when the internal fixation was removed, and no implant failures were observed in the two groups. A previous study reported a fusion rate of 98.3% with a local graft and 96.3% with an iliac graft [22]. Therefore, all patients had internal fixation removal at 2 years after complete fusion. The surgical effect at this stage could better reflect the long-term effect. The intervertebral endplate autograft is a new procedure proposed by the present study. In the procedure proposed here, the bone pieces were worked into soybean-size pieces and were packed in the intervertebral endplate space; no cage was used. The longest follow-up time was 5–8 years, showing appropriate surgical outcomes and a higher ratio of endplate fusion compared with the conventional procedure.

A cage allows for maintaining the intervertebral disc height and adds stability to the anterior column. Two previous studies showed that fusion without a cage or with a cage resulted in similar intervertebral disc height and foraminal height [15, 23]. All patients included in the present study had lumbar instability and spondylolisthesis and failure of conservative treatments. Therefore, the surgical outcomes depend upon decompression and fusion. Increasing the foraminal height is an indirect method to increase the intervertebral disc height [24]. In the present study, both groups showed improvements in the JOA and SF-36 scores, suggesting surgery effectiveness.

This study included both middle-aged and older adult patients. The main difference between the two patient populations is that older adults often develop adjacent intervertebral disorders after lumbar fusion [25]. On the other hand, only performing decompression without fusion has a high rate of exacerbation [26]. Therefore, fusion remains the best strategy. In the present study, there were no significant differences between the two groups in the rate of adjacent intervertebral disorder, suggesting that both methods appear appropriate for older adults.

This study has limitations. Grouping was based on the surgery the patients underwent, possibly leading to bias. The patients were from a single center, leading to a small sample size.

In conclusion, compared with conventional intervertebral body bone graft fusion, lumbar intervertebral endplate space autograft fusionmay be a potential method for patients with lumbar spine instability and single-level first- or second-degree spondylolisthesis by open surgery but achieved a higher-endplate fusion ratio. Further high-grade evidence from prospective, multicenter randomized clinical trials with large sample sizes is needed.

MRI: magnetic resonance imaging

LDH: lumbar disc herniation

SD: standard deviation

Ethics approval and consent to participate

This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This work was approved by the Medical Ethics Committee of Shangqiu First People's Hospital (Yi Lun Shen 2019-16). Informed consent was obtained from all patients.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analysed during this study are included in this published article

Competing interests

The authors declare that they have no competing interests

Funding

This work was supported by the Henan Province Science and Technology Tackling Program Project (112102310685).

Authors' contributions

Shun Zhang carried out the studies, participated in collecting data, and drafted the manuscript. Shun Zhang and Chuanlin Zhang performed the statistical analysis and participated in its design. All authors read and approved the final manuscript.

Acknowledgements

None.

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No competing interests reported.

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Version 1

posted

You are reading this latest preprint version

Lumbar intervertebral endplate autograft fusion on patients with lumbar spinal instability and lumbar spondylolisthesis

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Study design and patients

Surgery

Data collection

Statistical analysis

Results

Characteristics of the patients

Surgical outcomes

Typical case

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1