Reduction of degenerative anterolisthesis using an expandable interbody device
Samuel Bartrom1
, Micah Smith2
Contributions: (I) Conception and design: M Smith; (II) Administrative support: M Smith; (III) Provision of study materials or patients: M Smith; (IV) Collection and assembly of data: M Smith; (V) Data analysis and interpretation: S Bartrom; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors.
Background: Degenerative spondylolisthesis is a condition characterized by back pain and radiculopathy due to nerve root impingement caused by misalignment of adjacent vertebral bodies. Surgical intervention with interbody fusions has been shown to have better outcomes than non-surgical approaches. Traditionally, static implants have been used to aid in arthrodesis of the unstable joint. A recent development in interbody fusion procedures is the use of expandable interbody devices which can expand bidirectionally to conform to endplate irregularities. This allows the spine to decompress naturally to fit each patient’s unique anatomy, restoring spinal alignment and reducing spondylolisthesis in an individualized manner. Previous expandable interbody devices were regarded as inferior to their static counterparts due to high rates of non-union. The emergence of newer expandable implants that use a polyester mesh composed of polyethylene terephthalate thread has provided similar rates of fusion among both types of implants. The primary objective of this study was to illustrate the reduction of grade I/II degenerative anterolisthesis through a percutaneous trans-Kambin triangle far lateral approach using a single implant composed of a polyethylene terephthalate thread.
Methods: A retrospective chart review was performed on patients who received an oblique far lateral trans-Kambin triangle percutaneous approach with placement of the studied implant to correct a grade I or II spondylolisthesis from 2/9/2018 to 5/26/2021. Demographic information was recorded from the electronic medical record system. Spondylolisthesis slip distance, foraminal height, anterior disc height, and posterior disc height were documented for both the pre-operative and post-operative radiographs.
Results: For the 20 patients included in the study, the mean pre-operative spondylolisthesis was 5.2 mm, and the mean post-operative spondylolisthesis was 1.1 mm. The average change in spondylolisthesis was 4.1 mm, an 85.4% reduction. Sixty-five percent of the patients had complete reduction of spondylolisthesis with a post-operative measurement of 0 mm. Significant improvements were also observed in foraminal height as well as anterior and posterior disc height.
Conclusions: The use of the expandable interbody device using a far lateral trans-Kambin approach displayed exceptional ability to reduce grade I/II degenerative spondylolisthesis. Radiographically, this surgical combination provided excellent, long-term decompressive abilities regarding foraminal height, disc height, and spondylolisthesis reduction.
Keywords: Expandable interbody device; spondylolisthesis; interbody fusion
Submitted Dec 31, 2024. Accepted for publication Mar 24, 2025. Published online Jul 28, 2025.
doi: 10.21037/jss-24-175
Highlight box
Key findings
• The expandable interbody device studied was effective at reducing low-grade spondylolisthesis.
• The expandable device demonstrated excellent decompressive abilities with significant post-procedural improvement in foraminal and disc height.
• Minimally invasive approaches can be as effective at reducing spondylolisthesis compared to open surgical techniques.
What is known and what is new?
• In the past, expandable interbody devices were deemed inferior to fixed devices due to high rates of non-union.
• Newer bi-directionally expandable interbody devices made of polyester mesh with polyethylene terephthalate thread self-contour to each individual’s endplates exhibited near complete reduction of the anterolisthesis using ligamentotaxis with similar rates of fusion when compared to non-expanding interbody devices.
What is the implication, and what should change now?
• The use of expandable interbody devices as a fixed device alternative is in the treatment of grade I/II spondylolisthesis is supported based on the findings in this study.
Introduction
Background
Degenerative spondylolisthesis commonly presents with back pain and radiculopathy due to misalignment of adjacent vertebral bodies that causes nerve root impingement (1). Surgical decompression through interbody fusion is a proven method for treatment, offering greater improvement in long-term pain relief and function than those treated non-operatively (2,3). Numerous surgical techniques have been developed with minimally invasive approaches rising in popularity over their open counterparts due to shortened recovery times, less intraoperative blood loss, reduced postoperative pain, and preservation of paraspinal muscles and soft tissue structures (4-7). Previous studies have found that percutaneous interbody fusion approaches successfully reduce grade I and II spondylolisthesis by an average of 27.7% to 61.8% (8-11).
Rationale and knowledge gap
A recent development in interbody fusion procedures is the use of expandable interbody devices as opposed to previous static implants. These conformable devices offer significantly more surface area contact with adjacent vertebrae resulting in superior disc space distraction and graft stability. Additionally, the ability of the implant to expand bidirectionally and conform to endplate irregularities causes the spine to decompress naturally to fit each patient’s unique anatomy, restoring spinal alignment and reducing spondylolisthesis in an individualized manner (12-14). Historically, expandable interbody devices were regarded as inferior due to their high rates of ineffective arthrodesis (15). With the emergence of newer implants that use a proprietary polyester mesh pouch made of polyethylene terephthalate thread, sufficient arthrodesis has been achieved in 98% of patients, exhibiting that expandable interbody technology can be reliable (13,16).
Objective
The primary objective of this study was to illustrate the reduction of grade I/II degenerative anterolisthesis through a percutaneous trans-Kambin triangle far lateral approach using a single implant composed of a polyethylene terephthalate thread. Demonstrating an increase in disc space and foraminal height post-operatively as well as long-term maintenance of the radiographic findings were secondary outcomes investigated. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-175/rc).
Methods
Study design
An Institutional Review Board-approved retrospective chart review on patients who received an oblique far lateral trans-Kambin triangle percutaneous approach for placement of the implant to correct a grade I or II spondylolisthesis from 2/9/2018 to 5/26/2021. The procedures were carried out by the same fellowship-trained board-certified orthopedic spine surgeon at Orthopaedics Northeast. Inclusion criteria were age greater than 18 years old, the procedure only involving a single level between L1 and S1 with primary diagnosis of degenerative anterolisthesis with correlating symptoms. Exclusion criteria included patients with active malignancy, patients with primary diagnoses of retrolisthesis, lytic spondylolisthesis, degenerative scoliosis, stenosis/claudication, or discitis, and patients with multilevel fusions or multi-level anterolistheses (Table 1). During the period indicated, 153 patients underwent the studied procedure with only 20 meeting the inclusion/exclusion criteria. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Parkview Health (No. SERF-ONE19-1219 ALIF) and individual consent for this retrospective analysis was waived. Orthopaedics Northeast works closely with Parkview Health, which is a hospital and obtains ethics approval for research studies through Parkview.
Table 1
| Inclusion criteria |
| • Patients are at least 18 years of age at the time of the procedure |
| • Patients that underwent a single level procedure with the studied polyester implant between L1 and S1 |
| • Primary diagnosis of degenerative grade I/II spondylolisthesis with correlating symptoms |
| Exclusion criteria |
| • Patients with active malignancy |
| • Patients with multilevel fusions |
| • Patients with primary diagnosis of lytic spondylolisthesis |
| • Patients with retrolisthesis |
| • Patients with degenerative scoliosis |
| • Patients with of stenosis/claudication |
| • Patients with discitis/osteomyelitis |
| • Adjacent segment disease |
Surgical technique
Pedicle screws were first placed in standard fashion using biplanar fluoroscopy. For cage placement, an incision was made from a standardized technique based on preoperative imaging (axial magnetic resonance imaging or computed tomography myelogram). Access to Kambin’s triangle was achieved as a cannulated neuromonitoring probe was advanced under biplanar fluoroscopy. Guide pin was then placed into the disc space. Sequential dilation inside the disc was then accomplished and working cannula and baseplate were placed. The discectomy was completed by using expanding shaver blade, articulating curettes, brushes, and pituitaries. Once the endplates were appropriately prepared, iliac crest autograft was placed into the anterior aspect of the disc space. The cage was deployed and then expanded by post-packing the proprietary allograft mixture under fluoroscopy to the appropriate specifications. Rods were then placed subfascial and fastened according to manufacturing specifications with set screws.
Data collection
Demographic information was recorded from the electronic medical record system which included age, sex, body mass index (BMI), and the comorbidity of diabetes. Additional data were extracted from the surgical operative notes such as surgical level, estimated blood loss, operating room time, closing time, and length of stay.
Pre-operative, 2-week post-operative, and long-term post-operative plain radiographs were obtained from the Picture Archive and Communicating System (PACS). Using the measuring tool incorporated in the PACS, spondylolisthesis slip distance, foraminal height, anterior disc height, and posterior disc height were documented for both the pre-operative and post-operative radiographs. Pre-operative to post-operative change and percent change were calculated for each radiographic parameter. Neutral standing plain radiographs were used to obtain all measurements. The measurements were taken by a board-certified orthopedic spine surgeon.
Statistical analysis
IBM SPSS Statistics (version 29.0.1.0) was used to carry out all statistical analysis. Paired-samples t-test was used to compare pre-operative and post-operative radiograph parameters.
Bias
Bias was reduced by having the same board-certified orthopedic surgeon take all radiographic measurements. Additionally, strict inclusion and exclusion criteria were set to minimize potential confounders.
Results
Demographic data
The cohort of 20 patients that underwent the procedure and met all inclusion and exclusion criteria was 60% female and exhibited a mean age of 63.2 years and a mean BMI of 32.6 kg/m2. The most common fusion level was L4–L5 (75.0%). Average blood loss was 70.0 mL, and the average operative time and closing times were 68.8 and 21.4 min, respectively. No intra-operative complications were recorded. Mean length of hospital stay was 1.1 days with 75.0% of patients being discharged on post-operative day 1 or earlier. Thirty-five percent of the cohort had a pre-operative diagnosis of diabetes mellitus. Other baseline demographic and surgical details are displayed in Table 2.
Table 2
| Cohort characteristics | Number of patients | Mean ± SD or % |
|---|---|---|
| Demographics | ||
| Age (years) | 20 | 63.2±12.1 |
| Female | 12 | 60.0 |
| BMI (kg/m2) | 17 | 32.6±5.3 |
| Comorbidities | ||
| Diabetes mellitus | 7 | 35.0 |
| Surgery details | ||
| Surgical level | ||
| L2–L3 | 2 | 10.0 |
| L3–L4 | 2 | 10.0 |
| L4–L5 | 15 | 75.0 |
| L5–S1 | 1 | 5.0 |
| Other | ||
| Blood loss (mL) | 20 | 70.0±26.4 |
| OR time (min) | 18 | 68.8±14.5 |
| Closing time (min) | 18 | 21.4±8.4 |
| Length of stay (days) | 20 | 1.1±1.8 |
BMI, body mass index; OR, operating room; SD, standard deviation.
The average long-term follow-up imaging was obtained 493 days post-operatively. The shortest duration follow-up was 69 days, and the longest was 964 days.
Spondylolisthesis
Mean pre-operative spondylolisthesis was 5.2 mm with the maximum being 13 mm (Figure 1, Table 3). Two weeks after surgical intervention, the average spondylolisthesis was 1.1 mm with the maximum being 4 mm. The average change in spondylolisthesis was 4.1 mm, an 85.4% reduction. Sixty-five percent of the patients had complete reduction of spondylolisthesis with a post-operative measurement of 0 mm. The average spondylolisthesis among the long-term follow up studies was 1.3 mm (Table 4). A patient with excellent correction of spondylolisthesis is shown in Figure 2.
Table 3
| Measurement | Pre-op distance (mm) | 2-week post-op distance (mm) | P value (a vs. b) | Change (mm) | Percent change (%) |
|---|---|---|---|---|---|
| Spondylolisthesis | 5.2 | 1.1 | <0.001 | 4.1 | 85.4 |
| Foraminal height | 16.5 | 22.4 | <0.001 | 5.9 | 35.8 |
| Anterior disc height | 8.3 | 12.2 | <0.001 | 3.9 | 47.0 |
| Posterior disc height | 3.8 | 8.8 | <0.001 | 5.0 | 131.6 |
| Global disc height | 10.2 | 16.6 | <0.001 | 6.4 | 62.7 |
a: pre-op distance (mm); b: 2-week post-op distance (mm). Post-op, post-operative; pre-op, pre-operative.
Table 4
| Measurement | Pre-op distance (mm) | 2-week post-op distance (mm) | Long-term follow-up distance (mm) | P value | |
|---|---|---|---|---|---|
| a vs. c | b vs. c | ||||
| Spondylolisthesis | 5.2 | 1.1 | 1.4 | <0.001 | 0.14 |
| Foraminal height | 16.5 | 22.4 | 21.4 | <0.001 | 0.06 |
| Anterior disc height | 8.3 | 12.2 | 11.2 | <0.001 | 0.002 |
| Posterior disc height | 3.8 | 8.8 | 6.9 | <0.001 | 0.18 |
| Global disc height | 10.2 | 16.6 | 14.6 | <0.001 | 0.006 |
a: pre-op distance (mm); b: 2-week post-op distance (mm); c: long-term follow-up distance (mm). Post-op, post-operative; pre-op, pre-operative.
Decompressive parameters
Foraminal height increased from 16.5 to 22.4 mm at 2-week post-operatively, resulting in a 35.8% increase (Figure 3). Pre-operative anterior disc height and posterior disc height were 8.3 and 3.8 mm (Figure 3, Table 3). Two-week post-operatively, they increased to 12.2 and 8.8 mm, respectively, displaying a 62.7% increase in global disc height (anterior + posterior/2). Long-term follow-up imaging exhibited an average foraminal height of 21.4 mm, an anterior disc height of 11.2 mm, a posterior disc height of 6.9 mm, and a global disc height of 14.6 mm (Table 4).
Discussion
Key findings
The radiologic and clinical outcomes of this study demonstrate the application of a biplanar expandable interbody device in a far lateral trans-Kambin approach to treat mild-moderate degenerative spondylolisthesis. To the best of the author’s knowledge, there has not been research demonstrating the efficacy of percutaneous cage placement for the reduction of anterolisthesis. The primary objective of this study was to demonstrate the reduction of spondylolisthesis using the procedural methods outlined. The average reduction in spondylolisthesis was 85.4%.
Comparison with similar research
The reduction in spondylolisthesis observed in this study is greater than what previous literature has reported when using percutaneous approaches. Sembrano et al. (9) evaluated the improvements in grade I and II degenerative spondylolisthesis when employing minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) (26 patients) and extreme lateral interbody fusion (XLIF) (29 patients) with a fixed interbody device. They observed slip distance to decrease from 3.8 and 3.4 mm pre-operatively to 1.6 and 1.3 mm 2-week post-operatively (P<0.05). This equates to a reduction of 57.9% using a MIS-TLIF approach and 61.8% utilizing the XLIF approach. A 2012 study by Rodgers et al. (17) displayed a 73% slip reduction at 2-week post-operatively when using the XLIF technique with a fixed interbody device to treat grade II spondylolisthesis. Higher grades of spondylolisthesis have greater capacity to be reduced, which likely contributed to the greater reduction in this study. These two studies exhibit excellent reduction, which corroborates the 85.4% reduction in this study. Other studies, all using fixed interbody devices and minimally invasive approaches, have shown improvement to a lesser degree (8,11,18,19).
Previously, open approaches provided greater reduction capabilities over minimally invasive techniques. Su et al. (20), illustrated significantly improved decreases in reduction of low-grade degenerative spondylolisthesis using open techniques as compared to MIS-TLIF (67%±34% vs. 37%±51%, P=0.018). Another study by Tsutsumimoto et al. (10) supports these results as they found an 81.4% reduction in the open group vs. a 53.3% reduction in the minimally invasive group (P=0.010). The results of an 85.4% reduction in this paper using a totally percutaneous trans-Kambin triangle technique suggest that minimally invasive techniques can be as effective as open techniques in slip reduction.
Implications and actions needed
This paper exhibits the power in deploying an interbody device and relying on ligamentotaxis can lead to adequate reduction of an anterolisthesis when compared to static devices. It supports the use of expandable interbody devices as an alternative to fixed devices which have been traditionally used.
Secondary objective
The first secondary objective of the study was to prove increases in foraminal height, anterior disc height, and posterior disc height after surgical correction. The expandable interbody device coupled with the trans-Kambin approach in this study yielded a 35.8% increase in foraminal height, 47.0% increase in anterior disc height, and a 131.6% increase in posterior disc height, resulting in a 62.7% increase in global disc height. A 2022 systematic review by Nikaido and Konno (21) evaluated 412 publications to analyze the radiologic and clinical outcomes of lateral lumbar interbody fusions in the decompression of grade I and grade II degenerative spondylolisthesis. With all studies utilizing a fixed interbody device, the mean global disc height increase was 55%, and the average foraminal height increase was 21.2%. The results of the present study surpass the averages reported in the systematic review and endorse the efficacy of the far lateral approach at increasing foraminal height, anterior disc height, and posterior disc height. Optimization of these radiologic parameters help to contribute to greater neural decompression, which is the primary clinical goal of spinal surgery.
Another secondary objective was to investigate the maintenance of the radiographic findings of the study. Spondylolisthesis, anterior disc height, posterior disc height, and global disc height were all significantly improved compared to the pre-operative measurements. No significant difference was observed between the 2-week and long-term follow-up measurements besides posterior disc height and global disc height which decreased slightly. Though the posterior and global disc heights were decreased when the long-term radiographic measurements were compared to the 2-week post-operative findings, they were 81.6% and 59.2% greater than their pre-operative measurements, respectively. This suggests that the procedure provided effective long-term decompression in all parameters that were followed.
Limitations of the study
The constraints of this study are that it was a single-arm trial and its small sample size which hinder its generalization to the general population. Furthermore, indistinct electronic medical record notes made evaluation of Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) data inaccurate and therefore unethical to use and report for publication. Although follow-up was sufficient, it was not clear if VAS entries were for back or lower extremity pain. Other long-term studies observing the clinical outcomes of similar polyester mesh implants in lumbar interbody fusions have shown significance in improving VAS and ODI scores (13,16). Similarly, this study did not observe fusion rates in these cases. Future evaluation of fusion rates between expandable interbody devices and non-expandable ones is needed to assess the efficacy of the expandable device.
A second limitation of the study was that radiographic interpretation was completed by an orthopedic spine surgeon. Spine surgeons have sufficient experience to interpret imaging in this manner; however, the data would have been best extracted by an independent radiologist to remove any bias.
Conclusions
The use of the expandable interbody device using a far lateral trans-Kambin approach displayed significant ability to reduce grade I/II degenerative spondylolisthesis. Radiographically, this surgical combination provided effective long-term decompression in regard to foraminal height, disc height, and spondylolisthesis reduction. This supports the use of expandable interbody devices in the treatment of low-grade spondylolisthesis as an alternative to fixed interbody devices. These results are the first to demonstrate the power of solely placing a biplanar expandable device and relying on ligamentotaxis to reduce an anterolisthesis percutaneously. Assessment of clinical outcomes using this procedure should be studied in the future to observe if the increase in decompression provides significant subjective improvements.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-175/rc
Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-175/dss
Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-175/prf
Funding: This work was supported by
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-175/coif). M.S. reports relationships with Ventris Medical (consultant) and SurGenTec (consultant, royalties, and stock options). Both authors report that the study was supported in part by Spineology. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Parkview Health (No. SERF-ONE19-1219 ALIF) and individual consent for this retrospective analysis was waived. Orthopaedics Northeast works closely with Parkview Health, which is a hospital and obtains ethics approval for research studies through Parkview.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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