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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 40-51

Lateral and oblique interbody fusions in degenerative and isthmic spondylolisthesis

Division of Spine Surgery, Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada

Date of Submission11-Aug-2020
Date of Acceptance11-Jan-2021
Date of Web Publication28-Jan-2021

Correspondence Address:
Ganesh Swamy
Division of Spine Surgery, Department of Orthopaedic Surgery, University of Calgary, Rm 0441 Gr Fl McCaig Tower, 3134 Hospital Dr NW, Calgary AB T2N 5A1.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ISJ.ISJ_66_20

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While symptomatic degenerative and isthmic spondylolisthesis cause pain and surgical management improves quality of life, it is less clear which surgical strategies are most helpful. In this review, we seek to outline the accuracy and reliability of classification schemes and suggest how machine-learning tools can potentially help identify optimal surgical strategies for individual patients. In addition, we examine the role of new surgical strategies in degenerative and isthmic spondylolisthesis, namely using lateral and oblique interbody fusions. Herein we discuss lateral and oblique interbody fusions in spondylolisthesis within a framework of accepted surgical goals, sagittal plane balance considerations, and cost-effectiveness.

Keywords: Degenerative spondylolisthesis, lateral interbody fusions, low-grade isthmic spondylolisthesis, oblique interbody fusions

How to cite this article:
Swamy G, Singh V, Evaniew N, Thomas KC. Lateral and oblique interbody fusions in degenerative and isthmic spondylolisthesis. Indian Spine J 2021;4:40-51

How to cite this URL:
Swamy G, Singh V, Evaniew N, Thomas KC. Lateral and oblique interbody fusions in degenerative and isthmic spondylolisthesis. Indian Spine J [serial online] 2021 [cited 2021 Apr 18];4:40-51. Available from: https://www.isjonline.com/text.asp?2021/4/1/40/308206

  Introduction: Surgery Is Helpful in Degenerative Spondylolisthesis Top

As described elsewhere in this Indian Spine Journal Symposium, the classification and management of spondylolisthesis has advanced significantly in the past 25 years. Since the first clear descriptions of the positive effects of surgery,[1] and especially since unequivocal support for surgical management afforded by the SPORT trial,[2] surgical management has become the standard-of-care. The effect size of surgical intervention for spondylolisthesis is large, with a similar magnitude to popular and cost-effective interventions such as total hip and knee arthroplasty,[3],[4] with outcomes close to achieving population norms. These gains are durable even at 8-year follow-up,[5] albeit with a reoperation rate of 22% among SPORT participants with complete follow-up. Spondylolisthesis operations are cost-effective over a 2-year time horizon in a North American cost environment,[6],[7] and therefore likely to be cost-effective in other settings where costs are much lower.

Particularly in the past ten-years, surgical techniques have evolved dramatically. Many surgeons perform decompressions via minimally invasive surgery (MIS) instruments[8] and some with even less-invasive modern endoscopic equipment.[9],[10] Likewise, interbody fusions can be performed via MIS posterior or standard open posterior transforaminal lumbar interbody fusion (TLIF) techniques, but a renaissance of less-invasive anterior options are gaining popularity. These include lateral interbody fusions through direct lateral access[11] or oblique access.[12] Finally, pedicle screw placement has many more options, with advances in intra-operative 3D imaging allowing for optimal fixation in small or rotated pedicles[13] with higher accuracy than other techniques.[14]

In this review, we present recent surgical innovations for the treatment of degenerative and low-grade isthmic spondylolisthesis, and discuss their relative efficacy, safety, durability, and cost-effectiveness.

  Delineation Of Goals Top

In broad categories, the treatment of patients with symptomatic spondylolisthesis demands consideration of neural decompression needs, optimal fusion techniques, and perhaps consideration of sagittal plane balance. Adoption of new techniques can be considered if our goals are accomplished more easily, and thus goal setting must be fully considered.

  Decompression Only Versus Fusion: Predicting Stability Top

The indications for and effectiveness of fusion in addition to decompression for patients with degenerative spondylolisthesis remain major controversies in this field. Some studies report that fusion is associated with small but measurable improvements in health-related quality of life (HRQOL) versus decompression,[15],[16],[17] but others have failed to identify important differences.[18] In a randomized controlled trial of 66 patients, Ghogawala et al.[15] reported a cumulative reoperation rate of 14% among patients who underwent fusion in addition to decompression compared to 34% among those who underwent decompression alone. All revision operations in the decompression alone group were fusions at the affected level, which might reflect incomplete assessments of stability at the spondylolisthesis level.

Simmonds et al.[19] performed a systematic review of predictors of post-decompression stability. While derived from low-level evidence, a qualitative imaging guide was proposed, with facet joint effusions, disc angle on flexion–extension radiographs, “restabilization” signs (including osteophyte formation and peri-discal ossification) and low back pain forming the major criteria. Validation of this scale is taking place in a multi-center study, but as of now this proposed scale (entitled DSIC, or degenerative spondylolisthesis instability classification) remains unvalidated. Several others have proposed imaging criteria that predict instability in small cohorts and remain unvalidated.[20],[21],[22]

Even for very simple measurements in spondylolisthesis management, experienced observers (surgeons and spine fellows) have interobserver reliability of 0.78 for Meyerding grade and 0.89 for slip percentage,[23] but much less for other common measurements. Such variability in measurements likely arises from variability in radiographic technique and difficulty in accurately identifying endplate extents. MR-based classification of intervertebral disc degeneration via Pfirrman grading is well accepted, but also subject to poor interobserver reliability amongst experienced observers, ranging between 0.65 and 0.67.[24] Measurements from human observers may not be sufficiently reproducible to deduce patterns predicting stability in spondylolisthesis.

Further pursuit of imaging biomarkers that predict long-term survival of a decompression-alone continues, with current efforts directed at a large image- and data-sharing efforts to enable artificial intelligence or machine-learning approaches.[25] The use of these high-order patterns, self-teaching pattern recognition algorithms to describe images has the potential to solve one of the biggest challenges in spinal disorders allowing reproducible classification of large imaging datasets.

  Sagittal Balance Considerations in Spondylolisthesis Top

Curiously, while degenerative spondylolisthesis is an acquired sagittal plane deformity, we have not yet arrived at conclusive evidence whether sagittal balance restoration in fusions results in better outcomes. The distinction between degenerative and low-grade isthmic spondylolisthesis is poor in many of the case series addressing this topic, making interpretation difficult.

Barrey et al. found that pelvic incidence (PI) is significantly higher for patients with degenerative spondylolisthesis than control patients (60° ± 10.6° vs 52° ± 10.7°),[26] and it follows that sagittal plane deformities during a degenerative process may result from the higher shear forces in the L4-S1 segment.[27] However, these data are confounded by the sex difference in degenerative spondylolisthesis (86% women vs 52% men in degenerative cohort),[26] as women generally have a higher PI than men.[28] PI is also much higher in isthmic spondylolisthesis than controls (66° ± 15° vs 52°).[29] Intuitively, given the recent emphasis on accurate sagittal plane reconstruction in adult deformity, but also in short lumbar fusions to reduce adjacent segment disease,[30],[31],[32] it follows that restoration of spinopelvic balance would be a goal for spondylolisthesis fusions.

A recent systematic review of the influence of focal lordosis on HRQOL in degenerative spondylolisthesis found no correlation between local alignment and outcomes,[33] but there are several small observational studies outside this review that support the importance of spinopelvic balance in this condition. Kim et al.[34] examined 18 patients undergoing fusions for degenerative spondylolisthesis, and defined groups by improvement in pelvic tilt (PT). They found if PT was reduced [and lumbar lordosis (LL) increased], changes in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were generally higher. Radovanovic et al.,[35] in a study of 84 patients, of whom 45 remained sagitally unbalanced after fusion, found better general health and spine specific HRQOL improvements in degenerative spondylolisthesis patients who were in sagittal balance across all measured outcomes. He et al.[36] reported that in degenerative spondylolisthesis patients with persistent postoperative back pain, PT restoration was significantly less than those with successful outcomes.

The evidence surrounding sagittal plane restoration in low-grade isthmic spondylolisthesis is similarly low-level evidence, consisting of relatively small case series. Bourghli et al.[37] presented 34 patients undergoing fusions and found that the 4 patients with poor outcomes had inadequate sagittal balance restoration. Maciejczak and Jablonska-Sudol[38] found that in 11 of 103 patients with persistent spinopelvic imbalance postoperatively, there was no difference in VAS or ODI as compared to balanced patients.

Despite inconsistent literature, surgeons caring for patients with degenerative or isthmic spondylolisthesis must make reasoned technical decisions about restoring sagittal spinopelvic parameters, balancing potential desirable and undesirable effects. It seems clear that patients with either degenerative or isthmic spondylolisthesis have a higher PI, which in a spinal deformity context would predict the need for a higher lordosis in the construct to balance the spine, particularly in the L4-S1 region.[39] Thus, the consideration of sagittal balance may be entertained in spondylolisthesis patients, and adoption of new surgical techniques should offer ease-of-use to surgeons in restoring sagittal balance while not increasing complications.

  The rationale for Lateral Interbody Fusions in Spondylolisthesis Top

With the advent of lateral interbody fusions,[11] a new technology has arisen that has seen use in degenerative spondylolisthesis fusions. The primary advantages to using lateral interbodies are a less-invasive method for achieving the dual goals of decompression (through indirect means) and fusion, with the added advantage of easy deformity correction.

  Indirect Decompression with Lateral Interbody Cages Top

Adequate intervertebral distraction, tensioning of the ligamentum flavum and restoration of spinal alignment should increase space for neural elements [Table 1]. Formica et al.[40] performed a systematic review on the ability of lateral interbody fusions to indirectly decompress the thecal sac. The level of evidence was low and derived from 42 studies. Foraminal decompressions were reliably measured, with a mean increase of foraminal area of 38%, and central stenosis also reliably improved by 29%. Lateral recess or subarticular stenosis is poorly reported in the literature, likely due to the difficulty in reliably measuring this area. An earlier systematic review carried out by Lang et al.[41] confirmed these findings, with mean foraminal and central area increases of 36% and 25%. Indirect decompressions are likely a lasting intervention, with MR-based measurements showing an increase in areas between 2-weeks and 6-months postoperatively and maintaining these increases until 2-years postoperatively.[42]
Table 1: Outcomes of direct versus indirect decompression in degenerative spondylolisthesis

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Subsidence of interbody cages is likely to result in loss of indirect decompression. Several authors have cautioned against the use of lateral interbody fusions when bone density is low, as cage subsidence is more likely.[43],[44],[45] One can also surmise that those with severe facet joint degeneration may represent a very stiff motion segment which also may not distract; however, this has not been the case when formally examined.[46] Thus, degree of facet joint degeneration is not necessarily a contraindication to indirect decompression.

The severity of stenosis, based on MR grading, may predict failure of indirect decompression. Li et al.[47] suggested that while severe stenosis patients also see increased neural areas, a high proportion (16/18 patients with Schizas D severe stenosis) required an open decompression within 1-week of the lateral fusion. Similarly, Nakashima et al.[48] reported 3 of 158 patients (104 of whom underwent surgery for degenerative spondylolisthesis) had post-fusion neurological deterioration.

  Fusion Rate with Lateral Interbody Cages Top

In a recent systematic review, Formica et al.[49] reviewed fusion rates with different types of interbody cages. The review was again hampered by low levels of evidence, low numbers of patients, variation in radiographic assessment of fusion and graft materials. The overall fusion rate for lateral interbodies was 89% based on 8 studies, while the TLIF and anterior lumbar interbody (ALIF) fusion rates were 94% and 95%, respectively.

However, this aggregate fusion rate includes authors reporting un-instrumented and instrumented lateral lumbar interbody fusion (LLIF), which have a lower fusion rate. Manzur et al.[50] performed a systematic review on fusion rates in LLIF and found an overall fusion rate of 80% in un-instrumented LLIF as compared to 91% in instrumented fusions. In perhaps the largest published series to date, Nourian et al.[51] report a 95% fusion rate in instrumented LLIF with recombinant human bone morphogenetic protein-2 (rhBMP-2) as the graft material, while un-instrumented LLIF had an 83% fusion rate.

The fusion rate in lateral interbody techniques is also influenced by interbody graft choices. While rhBMP-2 is highly likely to result in successful fusion, it is also cost-prohibitive in much of the world. Berjano et al.[52] described differential fusion rates with autograft (from morcelized laminae) achieving fusion less than calcium triphosphate graft (75% vs 89%). Similarly, Parker and Malham[53] reported a higher fusion rate for rhBMP-2 as compared to β-TCP in a mixed instrumented and un-instrumented cohort of LLIF (96% vs 80%).

  Sagittal Balance Correction with Lateral Interbody Cages Top

A purported advantage to LLIF is better segmental lordosis restoration. Uribe et al.[54] performed a review of segmental lordosis changes with lateral interbody fusions and found a mean increase of 3.9° per level. Segmental lordosis with LLIF is significantly influenced by placement (more lordosis when more ventral) and by cage height (more lordosis when taller).[55]

In comparison to TLIFs, LLIFs may, on average, better restore lordosis. Sembrano et al.[56] found that segmental lordosis increases more in LLIF than in TLIFs, but with high variance (3.2° ± 3.6° LLIF vs 1.9° ± 3.9° TLIF). However, just as technical variations can influence lordosis generation with LLIF, the same is true of TLIFs. Anand and Kong[57] describe an MIS-TLIF technique generating 7° of lordosis per level. Jagannathan et al.[58] describe even up to 20.2° ± 4.2° of segmental lordosis restoration with TLIFs. In contrast, Salem et al.[59] found 1.8° ± 6.7° of segmental lordosis with TLIFs, with loss of lordosis after initial on-table correction.

With the relatively high variance in all of these point estimates, it is hard to conclude that LLIFs provide better sagittal balance correction. Better data are required.

  Neurological Complication Rate and the Use of Neurological Monitoring Top

While the range of complications from an injury to retroperitoneal structures is wide, perhaps the most worrisome is that of neurological complications. The LLIF procedure rests on the anatomic relationships between the lumbar plexus components and the psoas muscle, with the ventral half of the psoas in the L1-2 to L4-5 corridor generally devoid of nerves.[60] The rates of permanent motor deficits with LLIF has been estimated at 3%[61] [Table 2].
Table 2: Neurological Complications of TLIF/PLIF versus LLIF/OLIF

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Development of neurological deficits may be technique dependent. Uribe et al.[62] suggested that neurological injury varied with length of time in which a lateral retractor was open, as well as change in triggered EMG thresholds. Pre-psoas approaches (or oblique lateral interbody fusions) have a 1% neurological injury rate, suggesting that staying more ventral in the disc space may be protective. In our experience, docking the retractor in the ventral half of the disc space is preferable, particularly in those patients with large psoas bulk.

Preventing nerve injuries can be achieved via approach modifications or using multi-modal neuromonitoring. While some authors suggest the use of motor-evoked potentials,[63],[64] most authors prefer triggered EMG monitoring through the psoas.[62],[65],[66],[67] However, there is much variability in the proposed use of neurological monitoring. Some propose that via “shallow-docking” and directly visualizing the path through the psoas (with microscope or endoscopic visualization as an aide), direct nerve injury can be avoided and thus neuromonitoring is not essential.[68] In a cautionary note, Cheng et al.[69] found a higher rate of neurological injuries using a shallow-docking technique as opposed to a monitored technique.

In summary, while the neurological injury rate is low in lateral interbody fusions, it is possible that neuromonitoring can render the procedure safer. Of course, neuromonitoring may detect neurological injuries in any lumbar procedure, as some authors would recommend its use in lumbar TLIFs.[70] Surgeons can avoid neurological injury with lower retractor times and relatively ventral position in the disc space.

  LLIF/OLIF in Degenerative Spondylolisthesis Top

While adopted by many surgeons, there is still little evidence that the use of lateral interbody fusions in degenerative spondylolisthesis improves outcomes [Table 3]. In the only randomized study in this field, Sembrano et al.[71] performed a multi-center study of degenerative spondylolisthesis patients with a randomized arm (n = 29) and an observational arm (n = 26), with patients undergoing either lateral interbody fusion or TLIF with supplemental screw fixation. Improvements in HRQOL was similar between groups, as was patient satisfaction. The only significant difference was a significantly less blood loss in the LLIF group, and significantly higher transient hip pain in the LLIF group. Fusion rates were also not significantly different in the two groups (100% LLIF and 96% TLIF).[72]
Table 3: Outcomes of TLIF/PLIF versus LLIF/OLIF in degenerative spondylolisthesis

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In a retrospective, single-institution study, Kono et al.[73] reported on 40 patients operated consecutively, with 20 having TLIF and 20 having LLIF in degenerative spondylolisthesis. Findings were similar to Sembrano et al.,[71] with no difference in the HRQOL, but less bleeding and more transient thigh pain in the LLIF group.

Wu et al.[74] compared stand-alone Oblique Lumbar Interbody Fusion (OLIF; n = 31) to PLIF and pedicle screws (n = 47) in patients with degenerative spondylolisthesis. No difference in ODI or JOA scores were seen at over one-year follow-up, with operative time and blood loss being significantly less in the OLIF group, and transient thigh pain being significantly more common in the OLIF group. Three further case series have similar numbers and similar results.[75],[76],[77]

When examined critically, it is unclear whether LLIF or OLIF techniques improve procedural metrics or patient outcomes in degenerative spondylolisthesis. Small differences in blood loss are unlikely to be significant. Blizzard and Thomas[78] suggest that lateral interbody fusions combined with percutaneous screw insertion in the lateral position can improve operating room efficiency, and had a mean operative time of 88 minutes, as opposed to a mean operative time of 224 minutes for MIS TLIFs.[79] It is unlikely that lateral interbody techniques would significantly improve outcomes in the short term, as suggested by Sembrano et al..[71] The impact of sagittal plane balance on longer-term outcomes remains to be deciphered in degenerative spondylolisthesis and is likely to be better achieved by lateral techniques. Nonetheless, the published case series present consistent evidence that the technique is safe and set the stage for larger investigations to refine technique and discern patient-specific variables (e.g. osteoporosis cutoff, graft choices in smokers, etc.).

  LLIF/Oblique Lumbar Interbody Fusion in Isthmic Spondylolisthesis Top

Low-grade isthmic spondylolisthesis is often grouped with degenerative spondylolisthesis by some authors but should be distinguished. While most degenerative spondylolistheses are at L4-5, then at L3-4, most isthmic spondylolistheses are at L5-S1[80] which is not accessible from a lateral approach.

Silvestre et al.[81] first described an anterior approach to the L5-S1 disc performed from the left side with the patient in lateral decubitus position. Woods et al.[12] further described the technical details and termed the approach as the OLIF51. Although the approach is like a classic retroperitoneal anterior lumbar approach,[82] the authors suggest it is less invasive, as lateral positioning allows for gravity-related movement of the peritoneal contents away from the operative field. As the iliac bifurcation moves to the right, the left common iliac vein is the structure which requires the most attention, as it drifts into the left side of the L5-S1 intervertebral disc. Woods et al.[12] described the use of an access surgeon for these cases, with a 10% vascular injury rate in their small series.

Anterior fusions for spondylolisthesis were first described over 80 years ago,[83] and thus are far from new concepts. Kim et al.[84] described a series of 40 patients undergoing ALIF or posterolateral fixation and found no difference at one year in outcomes or fusion rate. Jacobs et al.[85] performed a systematic review of the spondylolisthesis literature of that era and found them to be generally favoring posterior approaches. Viglione et al.[86] performed a systematic review on stand-alone ALIF for isthmic spondylolisthesis and found there to be limited evidence and insufficient quality of studies from which to draw conclusions. Alhammoud et al.[87] performed a systematic review of combined anterior-posterior cases versus posterior fusions in isthmic spondylolisthesis and found no difference in clinical outcomes or radiographic outcomes, but again citing poor evidence quality. In sum, to date, there is no known advantage of ALIFs in isthmic spondylolisthesis.

The ease of the intervention and improved instrumentation will likely lead to more descriptions of the OLIF51 technique in isthmic spondylolisthesis in the coming years, with comparative effectiveness research inevitably to follow.

  Authors’ Experience Top

In our experience, OLIF or LLIF for degenerative spondylolisthesis, when combined with percutaneous posterior instrumentation, is highly effective [Figure 1]. The primary rationale for the use of these techniques in our experience is the ease of use. A secondary rationale is the ease of sagittal balance restoration.
Figure 1: A 71-year-old woman with known morbid obesity and insulin-dependent diabetes, with previous history of TIA requiring stenting and COPD. She presented with intractable back pain and 100-m walking tolerance due to neurogenic claudication primarily, but also limited by shortness of breath due to COPD. The diagnosis was degenerative spondylolisthesis with central and lateral recess stenosis. The surgical procedure consisted of a single-sitting but two-stage operation. The first stage was in the lateral position with the left side up, and an OLIF performed at L4-5 with rhBMP-2 as the graft material. The second stage was performed prone with fluoroscopy for percutaneous screw insertion. OR time was 4 hours (inclusive of the flip) and blood loss <100mL. Postoperatively, she had marked relief of low back pain and could walk up to 1 kilometer

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In degenerative spondylolisthesis, the surgery can be performed first prone then lateral, or vice versa. Lateral interbody fusion in degenerative spondylolisthesis mandates an approach to the anterior one-third of the lower vertebra to avoid an overly posterior approach to the disc space in question. Rod placement through the percutaneous screw extenders reduces the slip. We routinely use 4 mg of rhBMP-2 as the graft material in a single-level fusion.

The choice of OLIF versus LLIF in our institution is dependent on local anatomical factors and surgeon preference. We feel that there is little outcome difference between the two techniques, both resulting reliably in the technical outcomes discussed here. In some cases when approaching L4-5, particularly with a “deep-seated” L4-5 interspace, LLIF is not feasible and mandates an OLIF approach. The placement of the interbody cage should be in the coronal plane to allow for optimal lordosis generation; an OLIF approach need not result in an oblique cage, as the implant can be tapped into the coronal plane. We expect that next-generation implants will be steerable for this indication.

The workflow is similar in low-grade isthmic spondylolisthesis, although a thorough open L5 root decompression is necessary to avoid traction-related nerve root injuries. The OLIF51 often mandates a resection of the inferior aspect of L5 to access the disc space. Higher lordosis cages (18° or 21°) with narrower posterior heights often are easier to place given the often-collapsed disc spaces. A thorough left-to-right release of the annulus fibrosus is required to allow distraction. The reduction is much easier in our experience than a traditional posterior approach, as rod placement through the pedicle screw extenders reduces the olisthesis without difficulty [Figure 2] and [Figure 3].
Figure 2: A 46-year-old woman with primary complaint of low back pain, walking tolerance of 30–45min and bilateral painful dysesthetic pain in the L5 root distribution. Walking tolerance was 100 m. She was diagnosed with painful Gr II isthmic spondylolisthesis at L5-S1, with the primary goals of operation being stable fusion and decompression. We performed screw insertion through paramedian incisions, both >5 cm from midline, at L5 and S1 with navigation. This was followed by formal decompression of the L5 roots bilaterally through a midline incision. The OLIF L5-S1 was performed through a left-sided OLIF approach, and an osteotome was used to resect the inferior-most aspect of the L5 vertebral body. A 15° interbody cage with 4 mg of rhBMP-2 was placed with an interference screw. The rods were dropped through the screw extenders and the screws were compressed. OR time was approximately 7h, and estimated blood loss was 1100mL. She was discharged 4 days later. At the follow-up, she has very little back pain nor leg pain, and is able to walk 4.5 km

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Figure 3: 30-year-old with index surgery carried out at an outside institution two-years ago. Her back pain and right leg pain were much worse than before, with persistent perineal numbness. Severely disabled in activity tolerance. We first ensured she stopped smoking and cessed narcotic use over a 6-month period. She was diagnosed with a pseudarthrosis of the L4-S1 construct. The surgery consisted of three stages in a single-sitting. A midline posterior approach was performed to remove the previous screws, and new screws placed with navigation. A difficult revision decompression was performed of the thecal sac and L5 nerve roots. An L5-S1 OLIF (with resection of the caudal aspect of the L5 vertebral body) with plate fixation, and an L4-5 LLIF were performed in the lateral decubitus position. Finally, rods were placed from a formal prone posterior approach. OR time was 14h and blood loss of 700mL incurred. No complications were seen postop and discharge occurred on day 7 postop

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  Is It Worth It? Cost-analysis of New Techniques Top

The SPORT study provided a robust dataset on which we could establish baseline cost-effectiveness estimates. Decompressions for stenosis are cost-effective, at $77600 USD per quality-adjusted life year (QALY) gained.[6] In contrast, most surgeries for degenerative spondylolisthesis in the SPORT study were fusions with instrumentation, and costs tripled from $7159 to $21489, and a resultant cost-effectiveness estimate of $115600 USD/QALY for degenerative spondylolisthesis. Jones and Polly[88] reviewed all cost-effectiveness studies in degenerative spondylolisthesis and found fusions to be cost-effective in degenerative spondylolisthesis as compared to decompression alone. They noted that a longer follow-up period is required for fusions to achieve cost-effectiveness thresholds and dilute up-front costs, provided that the fusions are durable and do not require revision surgeries.

There are no published cost-effectiveness analyses of lateral interbody fusions in the degenerative or low-grade isthmic spondylolisthesis literature. Less-invasive options can be cost-effective, as reduced blood loss, decreased hospital stay and accelerated rehabilitation can save costs.[89] It is possible that a higher up-front cost be preferable, even in low-cost environments.

While the cost-effectiveness of surgical interventions allows formal and rigorous evaluation of new techniques in high-income countries, the WHO recommends a different approach in middle- and low-income countries. Interventions costing less than the per capita GDP are deemed “very cost-effective” and those less than 3X GDP are deemed “cost-effective.”[90],[91] Costs vary widely between different jurisdictions, and thus such analyses are difficult to implement without concerted efforts by local surgeons. To the best our knowledge, there are no published cost-effectiveness analyses in middle- and low-income countries of this very common surgical procedure, presenting a compelling opportunity.

  Conclusions Top

Surgeons must treat degenerative and isthmic spondylolisthesis by using highly effective surgical approaches with resultant low immediate-term complication rate, and high durability (i.e. low revision surgery rate). To date, there is no compelling evidence supporting the use of lateral and oblique interbody fusions in degenerative and low-grade isthmic spondylolisthesis, with only a small case series. These techniques have the potential to be less invasive with fewer resultant complications, and demand cost-effectiveness investigations.[101]

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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