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Is There Additional Value to Flexion-Extension Radiographs for Degenerative Spondylolisthesis?

Spine 2020 November 11
STUDY DESIGN: Multi-Center Retrospective Study.

OBJECTIVE: Flexion-Extension radiographs are frequently used to assess motion in patients with degenerative spondylolisthesis. However, they expose patients to additional radiation and increase cost. The aim of this study is to determine if flexion-extension radiographs provide additional information not seen on upright neutral radiographs and supine MRI that may guide surgical decision-making.

SUMMARY OF BACKGROUND DATA: Supine MRI and upright neutral radiographs are routinely performed in patients with for degenerative spondylolisthesis. It is unclear if additional flexion-extension views play a significant role in surgical planning for this patient population.

METHODS: From the Quality Outcomes Database, patients who had surgery for grade 1 degenerative spondylolisthesis were identified. Magnitude of slip on pre-op supine MRI, upright neutral, flexion and extension radiographs were measured. Additional motion was defined as ≥3 mm slip difference between radiographs. For the purpose of this analysis, patients with a slip ≥7 mm on upright neutral radiographs were assumed to require a fusion.

RESULTS: 191 patients were identified. Mean age was 61.6 years (114 females, 60%). Only 31 patients (16%) had additional motion on flexion-extension views not seen on upright neutral x-rays versus supine MRI. Of these 31 patients, 19 had slips <7 mm on upright x-ray, generating equipoise for fusion.

CONCLUSIONS: Flexion-extension radiographs may play a limited role in management of degenerative spondylolisthesis. The subset of patients for which flexion-extension views were most likely to provide value were patients with smaller slips (<7 mm) with no evidence of motion on standing radiographs versus MRI. In 90% of spondylolisthesis cases, information utilized for surgical planning may be ascertained by comparing motion between supine MRI and upright lateral radiographs.

LEVEL OF EVIDENCE: 3.

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