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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 91-96

Grade III Spondylolisthesis L5-S1 Treated by Minimally Invasive Spine Transforaminal Lumbar Interbody Fusion (MIS-TLIF) in a Patient of Rheumatoid Arthritis

Department of Spine Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India

Date of Submission27-Apr-2019
Date of Decision13-Aug-2019
Date of Acceptance12-Jan-2020
Date of Web Publication05-Feb-2020

Correspondence Address:
Dr. Vinay H Patel
Dr. Vinay H. Patel, Department of Spine Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Four Bungalows, Andheri West, Mumbai, Maharashtra.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/isj.isj_28_19

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We present a case of a 76-year-old woman on treatment for rheumatoid arthritis, who was bedridden for the past 3 months due to severe neurological claudication. The patient’s radiologic evaluation showed Grade III spondylolisthesis. Spondylolisthesis was treated with minimally invasive transforaminal lumbar interbody fusion (TLIF) in which the reduction was achieved with distraction and restoring height at the disc space. She had no claudication on day 0 postoperative, and she was able to walk for 10min and climb a floor of stairs at discharge. At 6 weeks, she was able to carry out her activities of daily living independently. Computed tomography scan carried out at 1-year follow-up showed bony union at L5-S1 interspace. Thus, minimally invasive TLIF carried out for Grade III spondylolisthesis achieved good reduction with the described technique and had excellent functional results at 2-year follow-up.

Keywords: Excellent functional outcome, high-grade spondylolisthesis, minimally invasive spine surgery, oswestry disability index score, rheumatoid arthritis, Transforaminal lumbar interbody fusion

How to cite this article:
Patel VH, Peshwattiwar VB. Grade III Spondylolisthesis L5-S1 Treated by Minimally Invasive Spine Transforaminal Lumbar Interbody Fusion (MIS-TLIF) in a Patient of Rheumatoid Arthritis. Indian Spine J 2020;3:91-6

How to cite this URL:
Patel VH, Peshwattiwar VB. Grade III Spondylolisthesis L5-S1 Treated by Minimally Invasive Spine Transforaminal Lumbar Interbody Fusion (MIS-TLIF) in a Patient of Rheumatoid Arthritis. Indian Spine J [serial online] 2020 [cited 2022 Dec 4];3:91-6. Available from: https://www.isjonline.com/text.asp?2020/3/1/91/277804

  Introduction Top

Rheumatoid arthritis (RA) involves cervical spine more adversely.[1],[2] In a recent study, the involvement of the lumbar spine in RA has accounted for 46.4% of patients with L5-S1 spondylolisthesis, the risk of which increases with age and body mass index (BMI).[3] Surgical management with reduction of spondylolisthesis and fusion is becoming the method of choice for high-grade spondylolisthesis.[4],[5],[6] While open surgeries are routinely performed for fusion with or without spondylolisthesis, minimally invasive (MI) procedures are advantageous as they maintain the bony and soft tissue architecture.[7],[8] We discuss a MI technique of achieving reduction by restoring the disc height, not depending on the pedicle screws to maneuver for reduction.

In this report, we present a case of high-grade lumbosacral spondylolisthesis in a woman with RA managed by MI transforaminal lumbar interbody fusion (TLIF), which achieved complete fusion with the technique discussed.

  Case Report Top

A 76-year-old woman, known case of RA with BMI of 27.7, under antimetabolite treatment with methotrexate, presented to the outpatient department having been bedridden more than 3 months because of debilitating right lower limb neurological deficit. She had lower back pain and right lower limb claudication, which progressively worsened over 20 years. On examination, she had extensor hallucis longus weakness on the right side and had urinary incontinence. She had a palpable step at the lumbosacral junction. Radiographs showed Grade III spondylolisthesis of L5 over S1 [Figure 1] and [Figure 2]. Subsequent magnetic resonance imaging (MRI) showed severe stenosis at the canal and foramina at L5-S1 level [Figure 3].
Figure 1: X-ray Lumbo-Sacral spine lateral—extension

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Figure 2: X-ray Lumbo-Sacral spine lateral—flexion

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Figure 3: Axial view of magnetic resonance imaging at L5-S1 level

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Her RA was under control for the past two years on methotrexate. Her C-reactive protein levels were 0.52. She was American Society of Anesthesiologists (ASA) III and underwent MI decompression and interbody fusion with help of tubular retractor, stabilized with percutaneous pedicle screws and rods under general anaesthesia [Figure 4].
Figure 4: X-ray Lumbo-Sacral spine—postoperative. Fixation showing reduction of spondylolisthesis with cage

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The patient had immediate improvement in her claudication, and she walked on the day of surgery under physiotherapist’s guidance. Her walking distance progressively improved in the next 2 days, and she started staircase climbing on day 2 of surgery. Her standing time improved to 15min. Her visual analog scale (VAS) score at discharge was 1/10 and ODI score was 28, which improved from a preoperative VAS of 9/10 and ODI score of 71. At 30 days postop she could sit cross-legged, squat and resumed her activities of daily living which she performs till present [Figure 5] and [Figure 6]. The patient recovered from urinary incontinence at 1 week post surgery.
Figure 5: Postoperative 1 month, the patient was able to perform squatting

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Figure 6: Patient able to sit cross-legged at 1-month postoperative

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She was regularly followed up at 1, 3, and 6 months with pain and mobility improving progressively. Computed tomography scan carried out at 1-year post surgery showed bridging bony bars between L5-S1 disc spaces, suggestive of bony fusion [Figure 7] and [Figure 8].
Figure 7: Computed tomography scan showing fusion

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Figure 8: Computed tomography coronal view showing fusion

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  Surgical Technique Top

The patient was positioned prone on parallel jelly bolsters, the table was given a head high position till the C-arm image of the L5-S1 disc space showed end plates parallel. This allows for a more vertical orientation of the L5-S1 disc, which is otherwise at an angle to the perpendicular from the floor of operation theatre. This orientation makes it easy to handle instruments intraoperatively. After standard sterile skin preparation and draping, approximately 2.5cm incision was made 2cm to the right of the midline for a paramedian approach to L5-S1 disc, and a tubular retractor of size 5 (Minimally invasive spine [MIS] Posterior Lumbar Access [PLA] System, Thompson Surgical Instruments, Traverse City, Michigan, USA) was deployed after serial dilatation of the muscles with dilators. Position was checked on C-arm. L5-S1 facetectomy was carried out using a chisel; the bone harvested was cut to small chips for use as bone graft later. The level was decompressed under microscopic magnification. Traversing S1 root was retracted medially with a nerve root retractor, and the epidural veins were coagulated with bipolar cautery in the foraminal region. The disc space in high-grade spondylolisthesis was not wide enough for easy preparation. It was accessed by using a Penfield retractor first to confirm the space and was checked on C-arm. Approximately 10 × 4mm piece of the posterior part of the sacral body was nibbled out using Kerrison punches to get access to the L5-S1 disc space. Serial blunt pucca chisels were then used to jack up the disc space. Pucca chisel was pushed in as parallel to end plate and once in, it was gently turned vertical to distract the disc space; after each size upgrade, the chisel was left in for approximately 2minutes to hold the distraction and stretch the soft tissue. Any forceful distraction was avoided to prevent end plate damage, as the patient was osteoporotic. The end plates were distracted to 13mm. End plate was scrapped with a ring curette to remove the cartilaginous end plates. Grade III spondylolisthesis was reduced to Grade I just with the distraction of the end plates and restoration of the disc height [Figure 4]. A trial of size 13 × 22mm was a snug fit and a cage of 13-mm height (bullet cage; Spineway, Ecully, France) was implanted with bone graft. Percutaneous screws (Solera Medtronic, 6.5mm, Minneapolis, Minnesota USA) were passed under C-arm guidance. A No. 11 French 15-cm J needle was used to gain access to the pedicle at three o’clock position at the right side and nine o’clock at the left side. These were advanced into the pedicle slanted medially for approximately 2cm. A check C-arm shot was taken to confirm that the medial border of the pedicle was not crossed before the J needles entered the vertebral body ensuring an intrapedicular passage. Guide wires were inserted and tapped over 6.5-mm pedicle screws (Solera Medtronic), which were then inserted over guide wires in L5 and S1 pedicles bilaterally. Rods of measured size were then inserted using the ‘Sextant’ device and fastened to the screws under compression. The final position was checked under C-arm, and the wound was closed in layers.

  Discussion Top

Women with RA have a higher risk of instability of the cervical spine, though in a recent study, involvement of the lumbar spine has accounted for 46.4% of patients with L5-S1 instability, the risk of which increases with age and BMI.[3]

MI technique has advantages of maintaining the bony architecture, minimal tissue dissection, lesser blood loss, better postoperative pain scores, and faster recovery period.[8] In this surgery, total blood loss was 100mL, postoperative VAS on discharge was 1/10, and ODI score was 28. The patient started ambulation on the day of surgery; climbed stairs on day 2 after operation, and could squat and sit cross-legged within 30 days of surgery. Isaacs et al.[9] compared open posterior lumbar interbody fusion and MI-TLIF and found that the length of stay was significantly shorter in the MIS group with 3.4 days compared to 5.1 days (P < 0.02) in open surgery. Intravenous medications were stopped on day 2 and she was discharged on day 7. Stay was prolonged for rehabilitation, as the patient was bedridden for more than a month with urinary incontinence.

MI-TLIF has been used to treat low-grade spondylolisthesis with good clinical results;[10],[11],[12] however for high-grade spondylolisthesis, open procedure was preferred.[13],[14] Rajkumar et al.,[15] in their study of 36 patients with Grade II and III spondylolisthesis, have been successful in achieving almost complete reduction by MI technique with the help of rocking screw technique, which depends majorly on the screw purchase to maneuver for reduction. Another reported case of reducing high-grade spondylolisthesis by Changa et al.,[16] treated with MI-TLIF, used disc distraction and screw reduction to achieve complete reduction. In both the studies, the patients had excellent functional results at 2-year follow-up. However, in cases with osteoporosis, screw pullouts are a possibility if used to perform any reduction maneuver. Restoration of disc height is a safer way to reduce the spondylolisthesis with lesser stress on screws as they do not participate in obtaining the reduction.[17]

In our case, we carried out reduction of high-grade spondylolisthesis through a MI procedure, which relied on mainly restoring the disc height with the help of unilateral facetectomy, adequate disc space preparation by a thorough discectomy, and gradual distraction using blunt pucca chisels to distract and restore disc height. This distraction is sufficient to reduce the spondylolisthesis in most cases. We were able to restore it to 13mm in our case. However, in cases where there is severe facetal arthropathy bilaterally, it is mandatory to perform either an over-the-top decompression with opposite side medial facet removal or a bilateral facet excision by docking the tube on opposite side. This ensures that the exiting nerve root does not get trapped in the hypertrophied facet while distracting the disc space.

Once the disc space was restored, the pedicle screws were inserted in situ under compression. We used Solera screw (Medtronic) that has a dual thread pattern (OSTEOGRIP), which gives enhanced fixation at the bone implant interface adding to the stability of construct in patients with osteoporosis.

Postoperatively, all our patients are mobilized on the day of surgery under guidance, and at discharge, they are taught to climb a floor of stairs and walk for more than 500 meters. All our patients with stable fixation are made to sit cross-legged and to squat at one month after surgery as the stresses at the level are not different from the ones when patient ambulates or during activities of daily living and are unlikely to have any bearing for screw pullout.

  Conclusion Top

Unilateral facet excision, a meticulous disc space preparation transforaminally, gradual disc height restoration, maintaining it with interbody cage and in situ pedicle screws achieved acceptable reduction. The patient had good postoperative pain relief and recovery from neurological deficit. Bony fusion was observed at one year. Further follow-up of this case is required to document any long-term complications. Also more studies in the younger age-group also should be taken into account, considering heavy mechanical demands of the active individuals.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Conlon PW, Isdale IC, Rose BS. Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 1966;25:120-6.  Back to cited text no. 1
Ranawat CS, O’Leary P, Pellicci P, Tsairis P, Marchisello P, Dorr L. Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am 1979;61:1003-10.  Back to cited text no. 2
Lawrence JS, Sharp J, Ball J, Bier F. Rheumatoid arthritis of the lumbar spine. Ann Rheum Dis 1964;23:205-17.  Back to cited text no. 3
Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356: 2257-70.  Back to cited text no. 4
Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, et al. The maine lumbar spine study, part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 1996;21:1787-94; discussion 1794-5.  Back to cited text no. 5
Malmivaara A, Slätis P, Heliövaara M, Sainio P, Kinnunen H, Kankare J, et al; Finnish Lumbar Spinal Research Group. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976) 2007;32:1-8.  Back to cited text no. 6
Wu JC, Mummaneni PV. Using lumbar interspinous anchor with transforaminal lumbar interbody fixation. World Neurosurg 2010;73:471-2.  Back to cited text no. 7
Mummaneni PV. Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. Neurosurgery 2008;62:E1384.  Back to cited text no. 8
Isaacs RE, Podichetty VK, Santiago P, Sandhu FA, Spears J, Kelly K, et al. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation. J Neurosurg Spine 2005;3:98-105.  Back to cited text no. 9
Kim JS, Jung B, Lee SH. Instrumented minimally invasive spinal-transforaminal lumbar interbody fusion (MIS-TLIF): Minimum 5-year follow-up with clinical and radiologic outcomes. Clinical Spine Surgery2018;31:E302-E309.  Back to cited text no. 10
Rouben D, Casnellie M, Ferguson M. Long-term durability of minimal invasive posterior transforaminal lumbar interbody fusion: A clinical and radiographic follow-up. J Spinal Disord Tech 2011;24:288-96.  Back to cited text no. 11
Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. Neurosurgery 2007;60:203-12; discussion 212-3.  Back to cited text no. 12
Harrington PR, Tullos HS. Spondylolisthesis in children. Observations and surgical treatment. Clin Orthop Relat Res 1971;79:75-84.  Back to cited text no. 13
Karampalis C, Grevitt M, Shafafy M, Webb J. High-grade spondylolisthesis: Gradual reduction using magerl’s external fixator followed by circumferential fusion technique and long-term results. Eur Spine J 2012;21:S200-6.  Back to cited text no. 14
Rajkumar DV, Hari A, Krishna M, Sharma A, Reddy M. Complete anatomic reduction and monosegmental fusion for lumbar spondylolisthesis of Grade II and higher: Use of the minimally invasive “rocking” technique. Neurosurg Focus 2017;43:E12.  Back to cited text no. 15
Changa PY, Liao CH, Wu JC, Tu TH, Faya LY, Huang WC, et al. Reduction of high-grade lumbosacral spondylolisthesis by minimally invasive transforaminal lumbar interbody fusion: A technical note. Int Neuro 2015;2:79-82.  Back to cited text no. 16
Rosenberg WS, Mummaneni PV. Transforaminal lumbar interbody fusion: Technique, complications, and early results neurosurgery. Neurosurgery 2001;48:569-74; discussion 574-5.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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