Tài liệu The results of transforaminal lumbar interbody fusion for isthmic lumbosacral spondylolisthesis.

MINISTRY OF EDUCATION AND MINISTRY OF HEALTH TRAINING HANOI MEDICAL UNIVERSITY VU MINH HAI THE RESULTS OF TRANSFORAMINAL LUMBAR INTERBODY FUSION FOR ISTHMIC LUMBOSACRAL SPONDYLOLISTHESIS MASTER’S THESIS HANOI-2019 MINISTRY OF EDUCATION AND MINISTRY OF HEALTH TRAINING HANOI MEDICAL UNIVERSITY VU MINH HAI THE RESULTS OF TRANSFORAMINAL LUMBAR INTERBODY FUSION FOR ISTHMIC LUMBOSACRAL SPONDYLOLISTHESIS Speciality : Surgery Code : 60720123 MASTER’S THESIS Supervisor: MD. NGUYEN HOANG LONG HANOI- 2019 ACKNOWLWDGEMENTS I would like to express my deep gratitude to the teachers and colleagues working at the Faculties, Departments in Universities and Hospitals,... for their efforts in training and creating the best conditions for me in the process of learning, working as well as completing this thesis: Department of Surgery, Hanoi Medical University Department of Spine Surgery, Viet Duc University Hospital Office of Postgraduate Management, Hanoi Medical University Department of General Planning, Viet Duc University Hospital I would like to sincerely thank MD. Nguyen Hoang Long for directly supervising me throughout the process of completing this thesis. Spiecial thanks to MD. Duong Dai Ha for encouraging and motivating me to continue with this English thesis. Special thanks to teachers in the Council for their valuable suggestions, advice and dedicated help to me in completing this dissertation. Thanks to the staff of the Department of Spine Surgery, Viet Duc University Hosptital for their companion, monitoring, sharing, help to me in the period of studying in the department. Finally, I would like to express my deep gratitude to my parents, uncle and aunt, friends and colleagues for encouraging and supporting me in study, research and life. Hanoi, August 8, 2019 Vu Minh Hai AFFIDAVIT I am Vu Minh Hai, a graduate student at Hanoi Medical University, majoring in Surgery,26th session. 1. This is my own thesis directly under the guidance and supervision of MD. Nguyen Hoang Long. 2. This research does not coincide with any other studies published in Vietnam. 3. The data and information in the research are completely accurate, truthworthy and objective which have been verified and approved by the research institution. I assume overall responsibility with the law for these commitments. Hanoi, September 9, 2019 Vu Minh Hai ABBREVIATIONS MRI : Magnetic resonance imaging CT : Computed tomography TLIF : Transforaminal lumbar interbody fusion PLIF : Posterior lumbar interbody fusion ODI : Oswestry Disability Index TABLE OF CONTENTS INTRODUCTION .......................................................................................... 1 Chapter 1: OVERVIEW ................................................................................ 4 1.1. History ................................................................................................................ 4 1.1.1. Global ........................................................................................... 4 1.1.2. Vietnam ........................................................................................ 5 1.2. Lumbar spine anatomy ..................................................................................... 6 1.2.1. Lumbar Intervertebral Segment ................................................... 7 1.2.2. Connective components of the spine .......................................... 8 1.3. Pathogenesis of lumbar spondylolisthesis ..................................................... 12 1.4. Clinical and paraclinical manifestations. ...................................................... 15 1.4.1. Clinical. ...................................................................................... 15 1.4.2. Paraclinical ................................................................................. 20 1.4.3. Diagnosis .................................................................................... 29 1.5. Treatment ......................................................................................................... 29 1.5.1 Non-Surgical ............................................................................... 29 1.5.2. Surgery ....................................................................................... 30 Chapter 2: SUBJECTS AND RESEARCH METHODS ......................... 41 2.1 Subjects ............................................................................................................. 41 2.1.1. Criteria for patient selection ....................................................... 41 2.1.2. Criteria for patient exclusion ..................................................... 41 2.1.3. Research process ........................................................................ 42 2.2. Research Methods. .......................................................................................... 42 2.2.1. Research design. ........................................................................ 42 2.2.2. Methods to collect research data ................................................ 42 2.2.3. Research information ................................................................. 43 2.2.4. Standards of diagnosis ............................................................... 43 2.2.5. Post-operative assessment and follow-up .................................. 47 2.3. Data analysis .................................................................................................... 50 2.4. Ethics in research............................................................................................. 50 Chapter 3: RESULTS .................................................................................. 51 3.1. General characteristics of the patients ........................................................... 51 3.1.1. Distribution of patients by age ................................................... 51 3.1.2. Gender distribution .................................................................... 52 3.1.3. Distribution by occupation ......................................................... 52 3.1.4. Medical history .......................................................................... 53 3.2. General characteristics of etiopathogenesis .................................................. 53 3.2.1. Onset and pathogenesis .............................................................. 53 3.2.2. Incubation period ....................................................................... 54 3.2.3. Medication treatment before hospital admission ....................... 54 3.2.4. Spondylolisthesis locations ........................................................ 55 3.3. Clinical and paraclinical manifestations ....................................................... 56 3.3.1. Clinical ....................................................................................... 56 3.3.2. Paraclinical ................................................................................. 59 3.4. Postoperative results........................................................................................ 61 3.4.1. Improvement of symptoms ........................................................ 61 3.4.2. Degree of slippage before and after surgery .............................. 61 3.4.3. Re-examination results ............................................................... 62 Chapter 4: DISCUSSION ............................................................................ 63 4.1. General features ............................................................................................... 63 4.1.1. Gender ........................................................................................ 63 4.1.2. Age ............................................................................................. 63 4.1.3. Occupation ................................................................................. 64 4.1.4. Medical history and medication treatment ................................ 64 4.2. Etiopathogenesis.............................................................................................. 65 4.2.1. Onset and development .............................................................. 65 4.2.2. Incubation period ....................................................................... 65 4.2.3 Locations of spondylolisthesis .................................................... 65 4.3. Clincal and radiographic manifestations ....................................................... 66 4.3.1. Clinical symptoms ..................................................................... 66 4.3.2. Radiographs ............................................................................... 71 4.4. Treatment results ............................................................................................. 74 4.4.1. Surgical indications .................................................................... 74 4.4.2. Results immediately after surgery ............................................. 75 4.4.3. Evaluation 6 months post-operatively ....................................... 76 4.5. intra- and post- operative complications ....................................................... 77 4.6. Medical record illustration.............................................................................. 78 CONCLUSION ............................................................................................. 85 REFERENCES MEDICAL RECORD SAMPLE LIST OF TABLES Table 3.1: Distribution by occupation ..................................................... 52 Table 3.2: Distribution by medical history .............................................. 53 Table 3.3: Incubation period .................................................................... 54 Table 3.4: Medication treatment .............................................................. 54 Table 3.5: Locations of spondylolisthesis ................................................ 55 Table 3.6: Onset symptoms ...................................................................... 56 Table 3.7: Functional symptoms .............................................................. 56 Table 3.8: Preoperative physcal symptoms ............................................. 56 Table 3.9: Preoperative sensation disorders ............................................ 57 Table 3.10: Movement disorders according to ASIA ................................ 58 Table 3.11: Spondylolisthesis locations affected clinical symptoms ........ 58 Table 3.12: Spondylolisthesis grades affected clinical symptoms ............ 59 Table 3.13: Sorts of radiography were used .............................................. 59 Table 3.14: MRI images............................................................................. 60 Table 3.15: Pre- and post-operative result comparison ............................. 61 Table 3.16: Pre-and post-oprative grade of spondylolisthesis ................... 61 Table 3.17: Recovery according to ODI .................................................... 62 Table 3.18: Recovery according to VAS ................................................... 62 Table 3.19: Bone fusion after 6 months ..................................................... 62 LIST OF CHARTS Chart 3.1 : Distribution by age ................................................................. 51 Chart 3.2 : Distribution of patients by gender .......................................... 52 Chart 3.3 : Disease onset........................................................................... 53 Chart 3.4: Spondylolisthesis locations ..................................................... 55 Chart 3.5: Conventional X-ray ................................................................ 60 LIST OF FIGURES Figure 1.1: Lumbar vertebrae ...................................................................... 8 Figure 1.2: Connective components of lumbar spine................................ 11 Figure 1.3: Spondylolisthesis Occurence .................................................. 14 Figure 1.4: “Stair step” characteristic ....................................................... 15 Figure 1.5: Lumbar radicular pain............................................................. 17 Figure 1.6: Lasègue‟s Test ........................................................................ 18 Figure 1.7: Lumbar radiculopathy ............................................................. 19 Figure 1.8: Scotty dog sign........................................................................ 21 figure 1.9: Myerding grading classification ............................................. 22 Figure 1.10. Technique of measurement of anterior translation and positive / anterior rotation on lateral flexion view of the lumbar spine. ..... 24 Figure 1.11. Technique of measurement of posterior translation and negative / posterior rotation on lateral extension view of the lumbar spine....................................................................... .....24 Figure 1.12: Saccoradiculography............................................................... 25 Figure 1.13: CT images ............................................................................... 26 Figure 1.14: Magnetic Resonance Imaging................................................. 28 Figure 1.15: Posterolateral fusion ............................................................... 34 Figure 1.16: PLIF technique........................................................................ 36 Figure 1.17: TLIF technique ....................................................................... 37 Figure 1.18: AVS (Adaptive Vertebral Spacer) Cage ................................. 39 Figure 4.1: Conventional X-ray before surgery ........................................ 79 Figure 4.2: Post-operative MRI ................................................................. 80 Figure 4.3: X-ray screened immediately after surgery.............................. 80 Figure 4.4: X-ray taken after 6 months of surgery .................................... 81 Figure 4.5: Postoperative MRI periodically .............................................. 81 Figure 4.6: pre-operative plain x-rays ....................................................... 82 Figure 4.7: Functional pre-operative x-rays .............................................. 83 Figure 4.8: MRI before surgery................................................................. 83 Figure 4.9: X-rays immediately after surgery ........................................... 84 Figure 4.10: X-rays and CT 6 months postoperatively ............................... 84 1 INTRODUCTION The spine condition called isthmic spondylolisthesis or spondylolytic spondylolisthesis occurs when one vertebral body slips forward on the one below it because of a small fracture in a piece of bone that connects the two joints on the back side of the spinal segment [1],[2],[6],[13]. The fracture in this small piece of bone, called the pars interarticularis, is caused by stress to the bone. While the fracture tends to occur most commonly when an individual is young (around 5 to 7 years old), for most people symptoms typically do not develop until adulthood. There is another spike in occurrence of lower back pain from spondylolisthesis in adolescence. It is estimated that 5 to 7% of the population has either a fracture in this small piece of bone (a fracture of the pars interarticularis) or a spondylolisthesis (slipped vertebral body), but in most cases there are no symptoms.1 It has been estimated that 80% of people with a spondylolisthesis will never have symptoms, and if it does become symptomatic, only 15 to 20% will ever need surgical correction [2], [5],[7],. The disease was described by Belgian obstetrician Herbinaux in 1782 when he discovered that the forward sliding of the spine in relation to the sacrum obstructs the vagina in some patients [13]. The term was coined in 1854 with a combination of two Greek words, "spondylos" meaning vertebra and "ilisthos" meaning "a slip". According to previous domestic and foreign studies, this disease is one of the leading causes of low back pain, a major impact on the life and economy of patients, and a burden for society [14]. Spondylolisthesis has a variety of causes, but there are two main causes are congenital isthmic bone hypoplasia or minor and sustained minor injuries (stress fracture) ... Each cause. of the disease causes a specific anatomical 2 alteration, however, the most common feature is to cause characterized by anomalous forward movement of the vertebrae‟s body along with the pedicles, transverse processes and upper facet joints. isthmic spondylolisthesis is of great interest nowadays because the proliferation of many sports requires excessive upper body movement with flexibility, twist that easily lead to pars fracture and eventually spondylolisthesis in teenagers. [24],[29] Because the disease develops silently, so when the patient has a pinched nerve that clearly causes symptoms that they have to visit doctors. Moreover, due to many causes of disease, the clinical condition is often diverse, easily confused with spondylosis. However, with the understanding of anatomy, pathophysiology and especially the development of medical imaging equipment with the introduction of many modern therapeutic aids such as computed tomography, magnetic resonance imaging (MRI) scan, we have made important strides in the diagnosis and treatment of diseases [30], [35], [42], [47]. Indications for internal medicine treatment are used in mild spondylolisthesis, mild nerve compression, surgery is considered when internal medicine treatment fails or in cases of high grade spondylolisthesis, severe nerve compression. There are many surgical techniques that have been applied so far, such as Gill surgery, Gill surgery combined with posterolateral bone grafting over the transverse processes of the vertebrae, pedicular fixation combined with posterolateral bone grafting or interbody fusion, direct pars repair ... or recently, minimally invasive surgery such as percutaneous pedicle screw, axial lumbar interbody fusion [15], [22], [28], ... In Vietnam, spondylolisthesis has just been of interest since the late 20th century. In the past, most of the surgical treatment is pedicular fixation with posterolateral bone grafting but after a while, there are broken screws and 3 spondylolisthesis [1],[2],[6]. Currently, in many specialized medical facilities on neurosurgery and spine surgery, this disease has been operated by transforaminal lumbar interbody fusion. In order to evaluate the effectiveness of the surgical method as well as to assess the advantages and disadvantages of it, we conducted the research titled: "The results of transforaminal lumbar interbody fusion for isthmic lumbosacral spondylolisthesis" with two goals: 1. Description of clinical features, imaging diagnosis of patients with isthmic lumbosacral spondylolisthesis. 2. Evaluation of the results of transforaminal lumbar interbody fusion in treatment. 4 Chapter 1 OVERVIEW 1.1. History 1.1.1. Global For the first time, spondylolisthesis was mentioned by Belgian obstetrician Herbinaux in 1792 on the occasion of a dystocia (L5-S1 spondylolisthesis) [75]. In 1854, Kilian was the first to refer to the term “Spondylolisthesis”, derived from a Greek word with two compound words, “spondyl” means “vertebra body” and “olisthesis” means sliding. The same year, Robert discovered pars defect when performing an autopsy to study spinal anatomy. In 1858, Landl determined the cause of sliding due to the discontinuity of lamina in the area between the two superior and inferior facet joints (Spondylolysis). Later, Naugebauer (1881) figured out persistent pars lesion in spondylolisthesis patients. However, he alleged that this defect might or might not cause spondylolysis, later known as degenerative spondylolisthesis [78] [79]. In 1955, Newman introduced the categorization of Spondylolysis is into five categories: dysplastic, isthmic, degenerative, traumatic and pathological, and in 1976, Wiltse collected and presented a classification of Spondylolisthesis into six different types [71]. In terms of diagnosis, because of many different causes, spondylolisthesis has various clinical manifestations, with no specific symptoms, so it has often been confused with intervertebral disc herniation and spinal stenosis ... Since 1895, Röntgen‟s finding out X-ray has made a breakthrough in spondylolisthesis diagnosis. Following that, Dandy performed saccoradiculography (1919), especially with the advent of 5 computed tomography (Hounsfield-1971) and Magnetic resonance imaging (MRI) scans (Damadian, Hawles - 1978, 1979). making major breakthroughs in accuracy of spondylolisthesis diagnosis. In terms of treatment, Burns [74] first described fixation in 1933. Today a variety of surgical methods are available. In 1955, Gill introduced Nerve root decompression without fusion, called Gill‟s procedure [48]. However, this method causes further spinal instability. In 1969, Harrington and Tullos was pioneers in pedicular fixation and they described spondylolisthesis reduction via pedicular screws [57]. In the second half of the 20th century, many types of spinal fixation instruments were invented with increasingly simple designs, technical safety and stronger in fixation. Bone grafting in spondylolisthesis treatment was also mentioned very early. In 1944, Brigg and Milligan described the technique of interbody fusion by filling the bone chips of lamina into the intervertebral disc space. Bone grafting is one of the most important tasks of spondylolisthesis fixation. There are many bone grafting techniques: bone grafting of the pars defect, posterior bone grafting, posterolateral bone grafting, interbody fusion with local bone graft alone, combination posterolateral bone grafting and interbody fusion. posterolateral bone grafting and interbody are two most commonly applied techniques. There are many materials used for bone grafting, such as bone from the iliac crest, lamina, fibula, or homogenous bone. The most recent is the use of artificial graft (Cage) to assist in interbody bone grafting with local bone. 1.1.2. Vietnam Spinal pathology is considered and mentioned from the 50s of last century. However, it was not until the second half of the 20th century that 6 there were many types of instruments for spinal fixation. Therefore, surgery to treat pathologic and injured spine has been really widely applied. Doan Le Dan (1996-1999) operated for 10 cases of lumbar spine fractures by pedicular screws [8]. Vu Tam Tinh studied the size of Vietnamese pedicles. From the results, he held that the pedicular screw for the Vietnamese should be less than or equal to 5mm in diameter [10]. According to Nguyen Dac Nghia, the diameter of pedicular screws should be 4.5 mm for Vietnamese [6]. In addition, there are some studies evaluating surgical results of the authors: Bui Huy Phung (2000), Nguyen Ngoc Khang (2002), Nguyen Danh Do (2002), Phan Trong Hau (2002) ... 1.2. Lumbar spine anatomy The lumbar spine refers to the lower back, where the spine curves inward toward the abdomen. It starts about five or six inches below the shoulder blades, and connects with the thoracic spine at the top and extends downward to the sacral spine[81]. "Lumbar" is derived from the Latin word "lumbus," meaning lion, and the lumbar spine earns its name. It is built for both power and flexibility - lifting, twisting, and bending. The lumbar spine has several distinguishing characteristics:  The lower the vertebra is in the spinal column, the more weight it must bear. The five vertebrae of the lumbar spine (L1-L5) are the biggest unfused vertebrae in the spinal column, enabling them to support the weight of the entire torso.  The lumbar spine's lowest two spinal segments, L4-L5 and L5-S1, which include the vertebrae and discs, bear the most weight and are therefore the most prone to degradation and injury. 7  The lumbar spine meets the sacrum at the lumbosacral joint (L5-S1). This joint allows for considerable rotation, so that the pelvis and hips may swing when walking and running. The spinal cord travels from the base of the skull through the spinal column and ends at about T12-L1 - where the thoracic spine meets the lumbar spine. At that point numerous nerve roots from the spinal cord continue down and branch out, forming the "cauda equina," named for its resemblance to a horse's tail. These nerves extend to the lower extremities (buttocks, legs and feet). Because the spinal cord does not run through the lumbar spine, it is quite rare that a lower back problem would result in spinal cord damage or paralysis. The lower spine curves slightly inward, toward the abdomen. This inward curve of the spine is called lordosis. 1.2.1. Lumbar Intervertebral Segment Physicians usually explain a patient's pathology by focusing on one intervertebral segment, or spinal segment. The lumbar spine has 5 intervertebral segments, termed lumbar segment 1 through 5 (e.g. L1, L2, L3, L4, and L5). Each lumbar spine segment is comprised of:  Two vertebrae, such as L4-L5, stacked vertically with an intervertebral disc between them. A healthy disc is cushiony, with a lot of water, and has a sponge-like substance. It acts like a shock absorber in the spine, allowing flexibility and providing protection from jarring movements.  The two adjacent vertebrae are connected in the back of the spine by two small joints called facet joints. The facet joints of the lumbar spine allow movement to bend and twist the low back in all directions.  There are nerves that branch off from the spinal column at each level of the spine. They pass through small holes in the back of the lower spine. They 8 then connect together to form the sciatic nerve, which travels into the legs down the back of each thigh and into the calves and feet. Doctors usually talk about a patient's lumbar disc problem, or nerve or other lower back problem, as the level that includes two vertebrae and the disc between them, such as L3-L4 or L4-L5. If the disc at the very bottom of the spine is affected, that segment is called the lumbosacral joint L5-S1 (the S stands for sacral, which are the segments below the lumbar spine). Figure 1.1: Lumbar vertebrae [9] 1.2.2. Connective components of the spine 1.2.2.1. Interbody joint (Intervertebral disc) Discs are actually composed of two parts: a tough outer portion and a soft inner core, and the configuration has been likened to that of a jelly doughnut.