Background context:

Degenerative lumbar spondylolisthesis (DLS) is a debilitating condition associated with poor preoperative functional status. Surgical intervention has been shown to improve functional outcomes in this population though the optimal surgical procedure remains controversial. The importance of maintaining and/or improving sagittal and pelvic spinal balance parameters has received increasing interest in the recent DLS literature. However, little is known about the radiographic parameters most associated with improved functional outcomes among patients undergoing surgery for DLS.

Purpose:

To identify the effect of preoperative sagittal spinal alignment on functional outcome after DLS surgery.

Study design:

Retrospective cohort study.

Patient sample:

Two-hundred forty-three patients in the Canadian Spine Outcomes and Research Network (CSORN) prospective DLS study database.

Outcome measures:

Baseline and one-year postoperative leg and back pain on the ten-point Numeric Rating Scale and baseline and one-year postoperative disability on the Oswestry Disability Index (ODI).

Methods:

All enrolled study patients had a DLS diagnosis and underwent decompression in isolation or with posterolateral or interbody fusion. Global and regional radiographic alignment parameters were measured at baseline and one-year postoperatively including sagittal vertical axis (SVA), pelvic incidence (PI) and lumbar lordosis (LL). Both univariate and multiple linear regression was utilized to assess for the association between radiographic parameters and patient-reported functional outcomes with adjustment for possible confounding baseline patient factors.

Results:

Two-hundred forty-three patients were available for analysis. Among participants, the mean age was 66 with 63% (153/243) female with the primary surgical indication of neurogenic claudication in 197/243 (81%) of patients. Worse PI-LL mismatch was correlated with more severe disability [ODI, 0.134, p<0.05), worse leg pain (0.143, p<0.05) and worse back pain (0.189, p<0.001) one-year postoperatively. These associations were maintained after adjusting for age, BMI, gender and preoperative presence of depression (ODI, R² 0.179, β, 0.25, 95% CI 0.08, 0.42, p=0.004; back pain R² 0.152 (β, 0.05, 95% CI 0.022, 0.07, p <0.001; leg pain score R² 0.059, β, 0.04, 95% CI 0.008, 0.07, p=0.014). Likewise, reduction of LL was associated with worse disability (ODI, R² 0.168, β, 0.04, 95% CI -0.39, -0.02, p=0.027) and worse back pain (R² 0.135, β, -0.04, 95% CI -0.06, -0.01, p=0.007). Worsened SVA correlated with worse patient reported functional outcomes (ODI, R² 0.236, β, 0.12, 95% CI 0.05, 0.20, p=0.001). Similarly, an increase (worsening) in SVA resulted in a worse NRS back pain (R² 0.136, β, 0.01, 95% CI .001, 0.02, p=0.029) and worse NRS leg pain (R² 0.065, β, 0.02, 95% CI 0.002, 0.02, p=0.018) scores regardless of surgery type.

Conclusions:

Preoperative emphasis on regional and global spinal alignment parameters should be considered in order to optimize functional outcome in lumbar degenerative spondylolisthesis treatment.