Oral Presentation 50th International Society for the Study of the Lumbar Spine Annual Meeting 2024

The Role of Paraspinal Muscles in Degenerative Spondylolisthesis L4/L5: A Cross-Sectional Study in 138 Patients Undergoing Surgery (#MP-14a)

Paul C Köhli 1 2 3 , Lukas Schönnagel 1 2 , Jan Michael Hambrecht 1 , Jiaqi Zhu 4 , Erika Chiapparelli 1 , Ali Guven 1 , Gisberto Evangelisti 1 , Krizia Amoroso 1 , Roland Duculan 1 , Jennifer Shue 1 , Koki Tsuchiya 1 , Marco D Burkhard 1 , Carol Mancuso 5 6 , Andrew A Sama 1 , Frederico P Girardi 1 , Frank P Camissa 1 , Alexander P Hughes 1
  1. Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, United States
  2. Center for Muskulokeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
  3. BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
  4. Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, United States
  5. Weill Cornell Medical College, New York, NY, United States
  6. Hospital for Special Surgery, New York, NY, United States

Introduction: Degenerative lumbar spondylolisthesis (DLS) is a common spinal condition that can lead to severe disability from back pain and/ or neural compression with radicular pain or neurogenic claudication. Despite decades of research, the exact etiology of DLS is unclear. A multifactorial etiology is proposed based on degeneration of disc and facet joints along with biologic, biomechanical and behavioral factors (1). Recent studies highlight possible involvement of paraspinal musculature degeneration in patients with spinal stenosis or asymptomatic patients with DLS based on CT measurements (2,3).  We hypothesize that there is progressive muscle degeneration occurring in the segmental stabilizer multifidus (MF) and the multi-segmental erector spinae (ES). Therefore, this study aims to evaluate the association between paraspinal muscle degeneration and degree of vertebral slippage in patients undergoing surgery for DLS.

Methods: In this retrospective, cross-sectional study, we analyzed L4/5 degenerative spondylolisthesis patients treated with decompression or fusion surgery from 2016-2018, excluding multilevel or non-degenerative cases. On preoperative imaging, we assessed relative vertebral slippage using standing X-rays and analyzed the Pfirrmann grading of the disc on sagittal MRI, and facet degeneration paraspinal muscle parameters such as cross-sectional area (CSA), functional CSA (fCSA, mm2), muscle height index (HI, cm2/m2) and fatty infiltration (FI) using axial MRI at the L4/5 level. Patient demographics, surgery details, and two-year follow-up data were also extracted. We employed descriptive statistics, unpaired t-tests, Mann-Whitney U tests, and Fisher's exact test for comparative analyses. Linear regression models were used to examine the relationship between each muscle parameter and the degree of L4/L5 slippage, adjusting for the covariates sex, age, BMI, disc and facet joint degeneration, and back pain severity. A p-value < 0.05 was considered significant.

Results:  138 patients (56 % female) were included for analysis. Patients with Meyerding 2 (M2) (N = 25) vs Meyerding 1 (M1) DLS (n = 113), were predominantly female (76 % in M2, 51 % in M1) and had a lower BMI (p = 0.01). In the Meyerding 2 group, there was a significantly higher Pfirrmann score, lower fCSAMF and lower BMI, but higher FIMF and FIES. Age, facet degeneration, fCSAPsoas and HIPsoas did not differ between groups. The multivariable linear regression models indicated that higher values of FIES (Estimate = 0.14, 95% CI [Confidence Interval] = 0.01–0.27, p = 0.03), FIMF (Estimate = 0.15, 95% CI = 0.05–0.24, p = 0.003), fCSAPsoas (Estimate = 0.0003, 95% CI = 0.0001–0.0006, p = 0.03), and HIPsoas (Estimate = 1.09, 95% CI = 0.44–1.73, p = 0.004) were associated with higher relative vertebral slippage.

Discussion:  Our research revealed a significant correlation between the deterioration of the segmental stabilizer MF and the multi-segmental ES muscles and the extent of vertebral slippage. Additionally, a larger psoas fCSA, when adjusted for other variables, was indicative of more severe slippage. This suggests the involvement of a progressive muscular asymmetry in the pathomechanism of vertebral slippage. However, further longitudinal studies are necessary to validate this assumption conclusively.

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