An Innovative Scoring System Combining Clinical and Radiological Factors for Determining Spinal Fusion Necessity in Degenerative Spondylolisthesis is Valid: A Hypothesis


Vol 10 | Issue 1 | January-June 2024 | page: 03-06 | Shashank O. Jajoo, Ashok Kumar Shyam Murari, Siddharth Aiyer, Pramod Bhilare, Shailesh Hadgaonkar, Ajay Kothari, Parag Sancheti

https://doi.org/10.13107/jmt.2024.v10.i01.212


Author: Shashank O. Jajoo [1], Ashok Kumar Shyam Murari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Parag Sancheti [1]

[1] Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.

Address of Correspondence
Dr. Shashank O. Jajoo,
Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: shankrocks139.sj@gmail.com


Abstract

Background: As the global population ages and lifestyles become more sedentary, Degenerative spondylolisthesis has emerged as a major cause of lower back pain and disability. It poses significant challenges for both patients and healthcare professionals. One of the most critical decisions in the treatment is whether to pursue non-operative options like physiotherapy, medication, or lifestyle modifications, or to explore surgical intervention. This decision is often made based on careful evaluation of various clinical, radiological, and patient-specific factors, but a standardized and universally accepted comprehensive scoring system for evaluating these factors is widely absent in current clinical practice. Moreover, there’s an ongoing debate over the appropriate surgical management, with one group supporting stand-alone decompression, whereas other group supporting decompression along with fusion. A new scoring system can provide standardized criteria for surgical management of Degenerative spondylolisthesis. This thesis aims to validate a new scoring system that addresses the limitations of existing tools and embraces a more holistic and patient-specific approach, that can guide healthcare providers and patients in deciding optimal surgical management in cases of Lumbar Degenerative Spondylolisthesis.
Hypothesis: An innovative scoring system combining clinical and radiological factors for determining spinal fusion necessity in degenerative spondylolisthesis is valid.
Clinical Importance: A subgroup of patients with Degenerative Spondylolisthesis can get away with just stand-alone decompression, without the need of fusion which is more morbid surgical intervention. This have benefits of reduced surgical risk, reduced surgical time, shorter recovery time, preservation of motion, lower cost of surgery, etc. This scoring system can help to identify that subgroup of patients.
Future Research: We will also keep a close follow up with patient and check whether they get benefitted by undergoing surgery based on the proposed new scoring system. Future research should focus on validating the system across diverse patient populations and clinical settings through multi-center trails.
Keywords: Degenerative spondylolisthesis, stand-alone decompression, Fusion, scoring system


Background
As the global population ages and lifestyles become more sedentary, Degenerative spondylolisthesis has emerged as a major cause of lower back pain and disability. It poses significant challenges for both patients and healthcare professionals. One of the most critical decisions in the treatment is whether to pursue non-operative options like physiotherapy, medication, or lifestyle modifications, or to explore surgical intervention. This decision is often made based on careful evaluation of various clinical, radiological, and patient-specific factors, but a standardized and comprehensive scoring system for evaluating these factors is widely absent in current clinical practice. Moreover, there’s an ongoing debate over the appropriate surgical management, with one group supporting stand-alone decompression, whereas other group supporting decompression along with fusion.
Over the years, numerous classification systems and guidelines have been developed to assist healthcare professionals in making informed decisions regarding fusion surgery for degenerative lumbar spondylolisthesis. Meyerding classification [1] , Wiltse classification [2], and the Clinical And Radiographic Degenerative Spondylolisthesis Classification (CARDS) [3], have offered valuable insights into the assessment of spinal instability and spondylolisthesis severity. However, despite their utility, these systems often lack the comprehensiveness and precision required to accommodate the evolving understanding of this condition and the nuances of individual patient cases. The main reason behind this debate is that Lumbar Degenerative Spondylolisthesis is assumed to be a homogenous entity and such oversimplification of the disease can lead to undertreatment or overtreatment. The relevance of the popularly followed Meyerding classification is limited because slips associated with Degenerative Spondylolistheisis rarely progress beyond grade I [1] or 30 percent unless there has been surgical interference [2]. Moreover, patients with high grade listhesis might not have much clinical complaints [2]. SPORT (Spine Patient Outcome Research Trial) in 2007 was a multi-centre trial which concluded that patients with degenerative spondylolisthesis treated surgically showed substantially greater improvement in pain than patients treated non-surgically [3, 4]. But there’s no mention about which type surgical management is better. Many other studies have been done in past to compare stand-alone decompression and fusion for Degenerative Spondylolisthesis, but none of them considered any scoring system to make the decision to manage patients [5–8]. A new scoring system can provide standardized criteria for surgical management of Degenerative spondylolisthesis [9]. This thesis aims to validate a new scoring system that addresses the limitations of existing tools and embraces a more holistic and patient-specific approach, that can guide healthcare providers and patients in deciding optimal surgical management in cases of Lumbar Degenerative Spondylolisthesis.

Hypothesis
This newly developed clinic-radiological scoring system will provide a reliable, evidence based method to decide whether fusion is necessary in cases of degenerative spondylolisthesis, leading to improved patient outcome and consistent surgical decision making. It integrates clinical symptoms, physical examination findings and radiological parameters to generate a holistic score.
Components of Scoring System (Total 11 points) are as follows : 1) Mechanical back pain, 2) Age < 70 years, 3) High-demand activity, 4) Segmental kyphosis, 5) Segmental dynamic spondylolisthesis, 6) Disk height, 7) Bilateral facet effusion, 8) Sagittal facets, 9) Technical factor [9].
The idea is to study reliability of the variables used in the new clinic-radiological scoring system, and to compare the inter-observer and intra-observer reliability of the new clinic-radiological scoring system [10].

Positive Evidence
1. Objective Decision-Making: - A scoring system provides the standardized objective parameters, reducing the variability in surgical decision-making among different surgeons.
2. Tailored Treatment: - Patients receive treatment based on a comprehensive individual assessment, potentially leading to better clinical outcomes and patient satisfaction.
3. Preliminary Data:- Preliminary studies and pilot cases have shown that patients selected for standalone decompression based on lower scores had good outcomes (only 7.6 percent patients undergoing standalone decompression underwent a secondary fusion surgery) [9].

Negative Evidence
1. Complexity:- The scoring system may be perceived as complex and time-consuming, potentially leading to resistance in adoption.
2. Subjectivity in Scoring:- Some elements of the score, such as the assessment of high demand activity and technical factor, may still be subjective despite the scoring guidelines.
3. Need for Validation:- The system requires extensive validation through large-scale, multicenter studies to confirm its reliability and effectiveness.

Index Example case
A 75-year-old female presents with chronic low back pain and intermittent radicular symptoms in the right leg. Patient had moderate demand activity. Radiological evaluation shows a Grade I spondylolisthesis at L4-L5, but no dynamic translation or segmental kyphosis on dynamic lateral imaging with significant disc height reduction. MRI showed bilateral facet effusion, but no sagittal orientation of facets. Total score came out to be 3, and based on the scoring system, the patient underwent standalone decompression without fusion. Now the patient is doing well at one year follow up.

Discussion
The creation of a new clinico-radiological scoring system represents a significant step forward in the management of Degenerative Spondylolisthesis. This discussion will explore the potential impacts, benefits, and obstacles associated with this system, based on the hypothesis that it can effectively guide the decision to favor standalone decompression when suitable.
Current literature highlights the variability in surgical decision-making for Degenerative Spondylolisthesis, often based on subjective assessments and surgeon experience [6]. The proposed scoring system introduces a standardized method, reducing this variability. By integrating clinical symptoms, physical examination findings, and radiological parameters into a composite score, it ensures a thorough and consistent evaluation of each patient’s condition.
Literature suggests that standalone decompression can be highly effective for selected patients, offering benefits such as lower surgical risks, faster recovery, and preservation of spinal motion [5]. However, the criteria for selecting these patients are not well-defined. The scoring system could fill this gap, providing clear guidelines to identify candidates for standalone decompression, thus promoting its use when appropriate. By providing an evidence-based method for decision-making, the scoring system may enhance patient outcomes, resulting in better pain relief, functional recovery, and overall satisfaction.
Despite its potential benefits, the complexity of the scoring system may pose a barrier to its adoption. Surgeons need adequate training to use the system effectively, and the additional time required for scoring could be seen as burdensome, particularly in high-volume clinical settings. Streamlining the scoring process and integrating it into routine practice will be crucial for its success. The proposed system requires extensive validation through large-scale, multicenter studies to confirm its reliability and effectiveness. Although preliminary data and pilot cases are promising (only 7.6 percent patients undergoing standalone decompression underwent a secondary fusion surgery), robust evidence is necessary to gain widespread acceptance in the orthopedic community [9]. This will involve rigorous testing across diverse patient populations and clinical settings.

Clinical Importance
The validation of a new clinico-radiological scoring system to determine the need for fusion holds significant clinical importance and have potential of transforming the management of degenerative spondylolisthesis. The scoring system standardizes the decision-making process, reducing the variability that currently exists among surgeons. This standardization ensures that patients receive consistent and appropriate care, regardless of the treating surgeon.
A subgroup of patients with Degenerative Spondylolisthesis can get away with just stand-alone decompression, without the need of fusion which is more morbid surgical intervention. This have benefits of reduced surgical risk, reduced surgical time, shorter recovery time, preservation of motion, lower cost of surgery, etc. By accurately identifying patients who can benefit from decompression alone, the system helps avoid unnecessary fusion surgeries, thereby minimizing the associated morbidity and healthcare expenses.

Future Direction
In this thesis, patients will be given scoring by 2 spine consultants, 4 spine fellows and 2 residents in the department of Orthopaedics. The inter-observer and intra-observer reliability of the proposed scoring system will be done. We will also keep a close follow up with patient and check whether they get benefitted by undergoing surgery based on the proposed new scoring system.
Future research should focus on validating the system across diverse patient populations and clinical settings. Additionally, integration with digital health technologies, such as electronic health records (EHRs) and artificial intelligence (AI), could streamline the scoring process and enhance its accuracy [11]. AI algorithms could assist in analyzing radiological parameters, providing a more objective assessment and reducing the potential for human error.


References

1. Martin FH, Foundation FHMM, Surgeons AC of. Surgery, Gynecology & Obstetrics [Internet]. Franklin H. Martin Memorial Foundation; 1932. 371–377 p. Available from: https://books.google.co.in/books?id=oRInMK5Hq0QC
2. Wiltse LL, Newman PH, Macnab I. Classification of spondylolisis and spondylolisthesis. Clin Orthop. 1976 Jun;(117):23–9.
3. Kepler CK, Hilibrand AS, Sayadipour A, Koerner JD, Rihn JA, Radcliff KE, et al. Clinical and radiographic degenerative spondylolisthesis (CARDS) classification. Spine J. 2015 Aug;15(8):1804–11.
4. Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson ANA, Blood EA, et al. Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. N Engl J Med. 2007 May 31;356(22):2257–70.
5. Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, et al. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med. 2016 Apr 14;374(15):1424–34.
6. Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med. 2016 Apr 14;374(15):1413–23.
7. Austevoll IM, Hermansen E, Fagerland MW, Storheim K, Brox JI, Solberg T, et al. Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis. N Engl J Med. 2021 Aug 5;385(6):526–38.
8. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802–8.
9. Kulkarni AG, Kunder TS, Dutta S. Degenerative Spondylolisthesis: When to Fuse and When Not to? A New Scoring System. Clin Spine Surg Spine Publ. 2020 Oct;33(8):E391–400.
10. McHugh ML. Interrater reliability: the kappa statistic. Biochem Medica. 2012;22(3):276–82.
11. Li Z. Digital Orthopedics: The Future Developments of Orthopedic Surgery. J Pers Med. 2023 Feb 6;13(2):292.


How to Cite this Article: Jajoo SO, Murari AS, Aiyer S, Bhilare P, Hadgaonkar S, Kothari A, Sancheti P. An Innovative Scoring System Combining Clinical and Radiological Factors for Determining Spinal Fusion Necessity in Degenerative Spondylolisthesis is Valid: A Hypothesis. Journal Medical Thesis 2024 January-June ; 10(1):03-06.

 

 


Download Full Text PDFFull Text HTML