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CASE REPORT
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 274-278  

Conservative treatment of degenerative spondylolisthesis using a rigid brace: A case study


Traumatology and Orthopaedics Department, Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic People's Republic of Korea

Date of Submission25-Apr-2019
Date of Decision27-Nov-2019
Date of Acceptance06-Jan-2020
Date of Web Publication3-Jun-2020

Correspondence Address:
Dong-Won Mun
Pyongyang Medical College, Kim II Sung University, Ryonhwa-Dong, Teasong District, Pyongyang
Democratic People's Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_104_19

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  Abstract 


Surgery is not always required in patients with spondylolisthesis. Meanwhile, surgical adverse events contribute significantly to postoperative morbidity. Restriction of the patient's activities, muscle rehabilitation, and other nonoperative measures, including the intermittent use of a rigid back brace, often are sufficient if the symptoms are minimal, and the slippage is mild. The study aimed to figure out the efficacy of conservative treatment using rigid brace in patients with degenerative spondylolisthesis. A total of patients (12 men and 18 women) who were hospitalized as a degenerative spondylolisthesis without neurological deficit at L4–L5 or L5–S1 from June 2015 to April 2017 underwent the rigid bracing. This study investigated pain, satisfaction, rate of reduction obtained according to the initial slip degrees, and degree of slip after the removal of immobilization at follow-up with radiographs of the patients with L4–L5 or L5–S1 spondylolisthesis. Twenty-eight patients (93.3%) complained no back pain and were satisfied with the rigid bracing. The complete reduction rate after reduction maneuver was 76.7% and after removal of the brace, in 15 patients, the slip disappeared at follow-up. Degenerative lumbar spondylolisthesis without neurological deficit can be treated successfully with rigid bracing with good outcomes.

Keywords: Conservative treatment, degenerative spondylolisthesis, rigid brace


How to cite this article:
Mun DW, Yu HC, Ko MS, Pak HH. Conservative treatment of degenerative spondylolisthesis using a rigid brace: A case study. Med J DY Patil Vidyapeeth 2020;13:274-8

How to cite this URL:
Mun DW, Yu HC, Ko MS, Pak HH. Conservative treatment of degenerative spondylolisthesis using a rigid brace: A case study. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 25];13:274-8. Available from: https://www.mjdrdypv.org/text.asp?2020/13/3/274/285750



Level of evidence: Level IV, case series, treatment study


  Introduction Top


Degenerative spondylolisthesis is a common pathologic condition that can lead to significant clinical symptoms.[1] Surgery is not always necessary for spondylolisthesis.[2] In addition, surgical adverse events contribute significantly to postoperative morbidity.[3] Some patients require reoperation because of complications, such as persistent pain, and infection, or because of progressive degenerative changes, such as adjacent segment disease. Previous studies have reported an approximately 10%–38% rate of reoperation in the surgical treatment of degenerative lumbar spondylolisthesis.[4],[5],[6],[7]

Restriction of the patient's activities, muscle rehabilitation, and other nonoperative measures, including the intermittent use of a rigid back brace, often are sufficient if the symptoms are minimal and the slippage is mild.[2] Several authors found that a wide range (10%–38%) of the reoperation rate for the surgical treatment of degenerative lumbar spondylolisthesis has been reported in the previous publications.[4],[5],[6],[7]

In literature, conservative measures are usually effective because fewer than 10% of symptomatic patients eventually require operative treatment.[8] Children and adolescents in whom the spondylolysis is of long duration are treated routine nonoperative measures, including a brief period of bed rest or brace immobilization.[2]

Objective

The objective of this study is to figure out the efficacy of the conservative treatment using rigid brace in patients with degenerative spondylolisthesis at L4–L5 or L5–S1.


  Materials and Methods Top


This study included thirty patients (18 men and 12 women) with a diagnosis of various grade and single-level lumbar degenerative spondylolisthesis, who underwent brace immobilization. The patients were referred for lumbar magnetic resonance imaging from January 2013 to June 2015 for symptomatic back pain. All patients were evaluated with referral by an experienced orthopedic surgeon. Patients with a history of spine surgery, infection, trauma, or tumor were excluded from this study.

The follow-up was performed for 1 year and evaluated the reduction of the spine during 12 months. The radiographs showed that the deformity at L4-5 (17 patients) was higher than sacrolized L5 (13 patients).

Rigid brace (Taedonggang, Pyongyang, DPR of Korea) that can be controllable was designed and applied for the degenerative spondylolisthesis.

The rationale of the orthosis is three points of immobilization, including the sternum, symphysis pubis, and degenerated vertebra [Figure 1].
Figure 1: Three points for the brace immobilization of degenerative spondylolisthesis

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According to the position and degree of spondylolisthesis, reduction varied using the reduction table. The degree of lysis varies from person to person, and the lysis direction is unequal. Before using the rigid brace, the patients were reduced and confirmed with radiographs.

General structure of the rigid brace

Main skeleton

This is the main part of the rigid brace made from stainless steel, providing the efficient elasticity and strength.

The iron pads are fixed with screws to change the length and width of the brace [Figure 2].
Figure 2: The rigid brace for degenerative spondylolisthesis

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Sternum fixation pad

The sternum fixation pad is designed to attach to a sternum and is coated with the pressed sponge to decrease the soft-tissue damage.

It can be controlled with the screws in the middle [Figure 2].

Back pad

The back pad is connected to the main structure with the string.

Moreover, the position of the pad can be varied to increase the fixation strength; it can maintain rigid stability [Figure 2].


  Method Top


Reduction

The reduction of the spondylolisthesis can be achieved on the reduction table according to the degree and direction of the spondylolisthesis. In patients with 0–5° of slip angle, we placed them prone with the knees extended and hips flexed on the reduction table for about 30–60 min [Figure 3]. In contrast, for those with 5–10° of slip angle, we allowed them to be prone with knees flexed and hips hyperextended on the reduction table for about 30–60 min [Figure 4].
Figure 3: Reduction maneuver in cases with 0°–5° of slip angle

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Figure 4: Reduction maneuver in cases with 5°–10° of slip angle

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Immobilization

After reduction of the spondylolisthesis, attach the main structure to the thorax, and tighten the string firmly on the region.

Duration of immobilization

According to the degree and position of the spondylolisthesis, we divided the patients into two groups.

The first group with L4-5 was placed with the rigid brace for 45 days after reduction, and the second group with sacralized L5 was immobilized for 60 days.

Slip degree after reduction maneuver and after removing the brace, estimate the radiographs.

Result analysis

Improvement of back pain

The main index in the observation of the clinical symptom is the local pain and the status of the spine in the lateral radiographic view.

Radiographic assessment

With the position of anteflexion and retroflexion, confirm the status of the spine under the lateral radiographic view.

Observe the improvements of the slip with the slip degree and average angle of the interarticulation.


  Results Top


At 1-year follow-up, we collected the data related to our patients' back pain through their complaints. We missed none of them to the follow-up. Twenty-eight patients (93.3%) complained no back pain and were satisfied with the rigid bracing.

As shown in [Table 1], the rigid brace immobilization of degenerative spondylolisthesis resulted in the rate of reduction in 83.3% (25 patients). In detail, of nine patients with slip degree <0%, one patient achieved bad reduction, 2 of 11 cases with 10% <slip degree 20%, and 2 in 10 with 20% <slip degree 30% also obtained bad reduction.
Table 1: Reduction state according to the slip degree

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[Table 2] reveals the changes of the slip degree after reduction in patients with degenerative spondylolisthesis. Using the different reduction techniques, there is an improvement in degrees with L4/5, and the reduction rate is over 76.7%.
Table 2: Changes in the slip degree after reduction

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[Table 3] shows the states of the degenerative spondylolisthesis after immobilization. At 1-year follow-up, in 15 patients, the slip disappeared.
Table 3: State of the spondylolisthesis according to fixation period

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  Discussion Top


Lumbar degenerative spondylolisthesis can cause significant pain and symptomatology, usually presenting as neurogenic claudication or radicular symptoms.[9] Most patients who have a greater proportion of back pain than leg pain can be managed nonsurgically.[8]

In our study, we selected thirty patients that had been diagnosed lumbar degenerative spondylolisthesis without a neurological deficit to find out the efficacy of conservative treatment of rigid brace. Of them, 28 cases (93.3%) complained no back pain and were satisfied with the rigid bracing, which demonstrates the brace can contribute to release pain caused by lumbar spondylolisthesis in individuals with mild slip degree and it provides no discomfort to them.

We also observed reduction rate by the rigid bracing according to the initial slippage degree. Generally, radiographs are used to diagnose and characterize lumbar spondylolisthesis.[1] Radiographic measurements showed that 25 patients recovered good alignment and there was no statistically significant difference in reduction rate according to the slippage degree (P > 0.05) [Figure 5] and [Figure 6].
Figure 5: (a-c) Case 1 with 5°–10° of slip angle. Standing lateral a b c radiograph showing L4-5 spondylolisthesis. (a) Radiograph before treatment. (b) Radiograph after reduction. (c) Radiograph at the 7 months follow-up

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Figure 6: (a-c) Case 2 with 0°–5° of slip angle. Standing lateral radiograph showing L4-5 spondylolisthesis. (a) Radiograph before treatment. (b) Radiograph after reduction. (c) Radiograph at the 9 months follow-up

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We applied two reduction maneuvers considering slip angle. Combination of reduction maneuvers and the rigid bracing resulted in complete reduction in 23 cases (76.7%). In this study, 17 patients with 0–5° of slip angle, we placed them prone with the knees extended and hips flexed on the reduction table for about 30–60 min, whereas for those with 5–10 degree of slip angle, we allowed them to be prone with knees flexed and hips hyperextended on the reduction table for about 30–60 min. We believe that these reduction techniques are mandatory before bracing and effective to improve outcomes of the conservative treatment for lumbar degenerative spondylolisthesis.

At 1-year follow-up, we investigated the recurrence of spondylolisthesis after removal of the rigid brace. Of 23 patients recovered normal alignment of the lumbar lordosis, Eight lost reductions, therefore, 15 cases maintained their reduction of the slip. Eight patients in whom the reduction lost had participated in contact sports and vigorous labor activities after removal of the brace. This implies care should be taken after removal of the brace with patients with lumbar spondylolisthesis who are treated with it.

There was no reduction rate in detail in other references; therefore, we cannot compare our results with others published in the literature.

This study has some limitations that the number of patients is significantly small, and the follow-up may not be long enough. We believe additional investigations such as comparison with cast or surgery and recurrence during long-term follow-up could be performed in the future.


  Conclusion Top


The rigid bracing of the spondylolisthesis is very effective in the conservative treatment of the lumbar degenerative spondylolisthesis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Phan KH, Daubs MD, Kupperman AI, Scott TP, Wang JC. Kinematic analysis of diseased and adjacent segments in degenerative lumbar spondylolisthesis. Spine J 2015;15:230-7.  Back to cited text no. 1
    
2.
Canale ST, Beaty J. Scoliosis and kyphosis. In: Canale ST, et al., editors. Campbell's Operative Orthopaedics. 12th ed. Philadelphia: Mosby; 2013. p. 1843, 1846.  Back to cited text no. 2
    
3.
Kelly AM, Batke JN, Dea N, Hartig DP, Fisher CG, Street JT, et al. Prospective analysis of adverse events in surgical treatment of degenerative spondylolisthesis. Spine J 2014;14:2905-10.  Back to cited text no. 3
    
4.
Blumenthal C, Curran J, Benzel EC, Potter R, Magge SN, Harrington JF Jr, et al. Radiographic predictors of delayed instability following decompression without fusion for degenerative grade I lumbar spondylolisthesis. J Neurosurg Spine 2013;18:340-6.  Back to cited text no. 4
    
5.
Deyo RA, Martin BI, Kreuter W, Jarvik JG, Angier H, Mirza SK, et al. Revision surgery following operations for lumbar stenosis. J Bone Joint Surg Am 2011;93:1979-86.  Back to cited text no. 5
    
6.
Ghogawala Z, Benzel EC, Amin-Hanjani S, Barker FG 2nd, Harrington JF, Magge SN, et al. Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative grade I spondylolisthesis. J Neurosurg Spine 2004;1:267-72.  Back to cited text no. 6
    
7.
Kim CH, Chung CK, Park CS, Choi B, Hahn S, Kim MJ, et al. Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: A nationwide cohort study. Spine J 2013;13:1230-7.  Back to cited text no. 7
    
8.
Matthews LS. Spondylolisthesis. In: Chapman MW, editor. Chapman's Orthopaedic Surgery. 3rd ed. 20 Pickering St. Needham, MA 02492, US.: Lippincott Williams & Wilkins; 2001. p. 4153.  Back to cited text no. 8
    
9.
Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. AQ8: Please provide publisher location. Clin Orthop Relat Res 1982;(165):110-23.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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