Search

Study Design Case series with surgical technical note. Objectives This article reports experiences and results of muscle-preserving temporary C0-C2 fixation for the treatment of atlanto-occipital dislocation (AOD). Methods AOD is a rare injury caused by high-energy trauma, occurring in less than 1% of pediatric trauma patients. Recommended treatment is C0-C2 fusion which, however, will result in significant loss of mobility in the craniocervical junction (CCJ), especially C1-C2 rotation. An alternative approach, with the ability of preserving mobility in the C1-C2 segment, is a temporary fixation that allows the ligaments to heal, after which the implants can be removed to regain function in the CCJ joints. By using a muscle-preserving approach and navigation for the C2 screws, a relatively atraumatic fixation of the CCJ can be achieved with motion recovery after implant removal. Results We present two cases of AOD treated with temporary fixation. A 12-year-old boy involved in a frontal car collision, as a strapped back seat passenger, was treated with temporary C0-C2 fixation for 10 months. Follow-up at 11 months after implant removal included clinical evaluation, computed tomography, magnetic resonance imaging (MRI), and flexion-extension X-rays. He was free of symptoms at follow-up. The CCJ was radiographically stable and he had 45 degrees of C1-C2 rotation.A 7-year-old girl was hit by a car as she got off a bus. She was treated with temporary fixation for 4 months after which the implant was removed. Follow-up at 8 years included clinical evaluation and MRI in rotation. She was free of symptoms. The ligaments of the CCJ appeared normal and her C1-C2 rotation was 30 degrees. Conclusion C0-C2 fixation without fusion allows the CCJ ligaments to heal in pediatric AOD. By removing the implants after ligament healing, rotation in the C1-C2 segment can be regained without subsequent instability. Both our patients tolerated the treatment well and were free of symptoms at follow-up.By using minimally invasive muscle-preserving technique and navigation, temporary fixation of the CCJ can be achieved with minimal damage to the soft tissues allowing recovery of almost normal function after implant removal.

Aims Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse. Methods We retrieved data from the Swedish spine register about 3,291 patients who underwent primary surgery for a lumbar disc prolapse between January 2007 and December 2008. These patients were followed until December 2020 to record all additional lumbar spine operations and the reason for them. Results In total, 681 of the 3,291 patients (21%) needed one or more additional operations. More than three additional operations was uncommon (2%; 15/906). Overall, 906 additional operations were identified during the time period, with a mean time to the first of these of 3.7 years (SD 3.6). The most common reason for an additional operation was recurrent disc prolapse (47%; 426/906), followed by spinal stenosis or degenerative spondylolisthesis (19%; 176/906), and segmental pain (16%; 145/906). The most common surgical procedures were revision discectomy (43%; 385/906) and instrumented fusion (22%; 200/906). Degenerative spinal conditions other than disc prolapse became a more common reason for additional surgery with increasing length of follow-up. Most patients achieved the minimally important change (MIC) for the patient-reported outcomes after the index surgery. After the third additional spinal operation, only 20% (5/25) achieved the MIC in terms of leg pain, and 29% (7/24) in terms of the EuroQol five-dimension index questionnaire visual analogue scale. Conclusion More than one in five patients operated on for a lumbar disc prolapse underwent further surgery during the 13-year follow-up period. Recurrent disc prolapse was the most common reason for additional surgery, followed by spinal stenosis and segmental pain. This study shows that additional operations after primary disc surgery are needed more frequently than previously reported, and that the outcome profoundly deteriorates after the second additional operation. The findings from this study can be used in the shared decision-making process. Cite this article: Bone Joint J 2022;104-B(5):627–632.

ObjectivesTo identify rates of additional operation after the index operation for degenerative lumbar spine diseases.DesignRetrospective register study.SettingNational outcome data from Swespine, the National Swedish spine register.ParticipantsA total of 4705 patients who underwent one-level surgery for degenerative disk disease (DDD) or lumbar spinal stenosis (LSS) with or without degenerative spondylolisthesis (DS) between 1 January 2007 and 31 December 2010 were followed from 1 January 2007 to 31 December 2020 to record all cases of additional lumbar spine operations.InterventionsOne-level spinal decompression and/or posterolateral fusion for degenerative spine diseases.Primary outcome measuresNumber of additional operations.ResultsAdditional operations were more common at adjacent levels for patients with LSS with DS treated with decompression and fusion whereas additional operations were more evenly distributed between the index level and the adjacent levels for DDD treated with fusion and LSS with and without DS treated with decompression only. For patients younger than 60 years, treated with decompression and fusion for LSS with DS, the additional operations were evenly distributed between the index level and the adjacent levels.ConclusionsThere are different patterns of additional operations following the index procedure after surgery for degenerative spine diseases. Rigidity across previously mobile segments is not the only important factor in the development of adjacent segment disease (ASD) after spinal fusion, also the underlying disease and age may play parts in ASD development. The findings of this study can be used in the shared decision-making process when surgery is a treatment option for patients with degenerative lumbar spine diseases as the first operation may be the start of a series of additional spinal operations for other degenerative spinal conditions, either at the index level or at other spinal levels.

Purpose Most patients with lumbar disc herniations requiring surgery have concomitant back pain. The purpose of the current study was to evaluate the outcome of surgery for lumbar disc herniations in patients with no preoperative back pain (NBP) compared to those reporting low back pain (LBP). Methods 15,418 patients surgically treated due to LDH with primary discectomy from 1998 until 2020 were included in the study. Self-reported low back pain assessed with a numerical rating scale (NRS) was used to dichotomize the patients in two groups, patients without preoperative back pain (NBP, NRS = 0, n = 1333, 9%) and patients with preoperative low back pain (LBP, NRS > 0, n = 14,085, 91%). Patient reported outcome measures (PROMs) collected preoperatively and one-year postoperatively were used to evaluate differences in outcomes between the groups. Results At the one-year follow-up, 89% of the patients in the NBP group were completely pain free or much better compared with 76% in the LBP group. Significant improvement regarding leg pain was seen in all measured PROMs in both groups oneyear after surgery. In the NBP group, 13% reported clinically significant back pain (NRS difference greater than Minimally Clinical Important Difference (MICD)) at the one-year follow-up. Conclusions Patients without preoperative back pain are good candidates for LDH surgery. 13% of patients without preoperative back pain develop clinically significant back pain one-year after surgery.

Background and purpose — There are several national value sets for SF-6D. For studies conducted in countries without a country-specific value set the authors may use a value set from a neighboring or culturally similar county. We evaluated the consequences of using different national value sets in SF-6D index-based outcome analyses. Patients and methods — Patients surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017 were recruited from the national Swedish spine register. 16,398 procedures were eligible for analysis. The SF-6D health states were coded to SF-6D preference indices using value sets for 9 countries. The SF-6D index distributions were then estimated with kernel density estimation. The change in SF-6D index before and after treatment was evaluated with the standardized response mean (SRM). Results — There was a marked variability in mean and shape for the resulting SF-6D index distributions. There were considerable differences in SF-6D index distribution shape before and after treatment using the same value set. The effect sizes of 2-year change (SRM) were in most cases similar when the 9 value sets were applied on pre- and post-treatment data. Interpretation — We found a marked variability in SF-6D index distributions when a single large data set was applied to 9 national SF-6D value sets. Consequently, we recommend that SF-6D index data from studies conducted in countries without country-specific SF-6D value sets is interpreted with caution.

Background and purpose — There are different opinions on how to surgically address lumbar spinal stenosis with concomitant degenerative spondylolisthesis (DS). We investigated reoperation rates at the index and adjacent levels after L4–5 fusion surgery in a large cohort of unselected patients registered in Swespine, the national Swedish spine register. Patients and methods — 6,532 patients, who underwent surgery for L4–5 spinal stenosis with or without DS between 2007 and 2012, were followed up to 2017 to identify reoperations at the index and adjacent levels. The reoperation rates for decompression and fusion were compared with the reoperation rates for decompression only and for patients with or without DS. Patient-reported outcome data were collected preoperatively, and at 1 and 2 years after surgery and used to evaluate differences in outcome between index operations and reoperations. Results — For spinal stenosis with DS, the reoperation rate at the index level was 3.0% for decompression and fusion and 6.0% for decompression only. At the adjacent level, the corresponding numbers were 9.7% and 4.2% respectively. For spinal stenosis without DS, the reoperation rate at the index level was 3.7% for decompression and fusion and 6.2% after decompression only. At the adjacent level, the corresponding numbers were 8.1% and 3.8% respectively. For the reoperations at the adjacent level, there was no difference in patient-reported outcome between extended fusion or decompression only. Interpretation — Single-level lumbar fusion surgery is associated with an increased rate of reoperations at the adjacent level compared with decompression only. When reoperations at the index level are included there is no difference in reoperation rates between fusion and decompression only.

The purpose of the current study was to apply a single large longitudinal EQ-5D-3L data set to several national EQ-5D-3L value sets and explore differences in EQ-5D-3L index density functions and effect sizes before and after treatment. Patients, surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017, were recruited from the national Swedish spine register. A total of 27,328 procedures were eligible for analysis. The EQ-5D health states were coded to EQ-5D-3L summary indices using value sets for 9 countries: Argentina, Australia, Canada, China, Germany, Italy, Sweden, the UK, and the US. The EQ-5D-3L summary index distributions were then estimated with kernel density estimation. The change in EQ-5D-3L index before and after treatment was evaluated with the standardized response mean (SRM). There was a high variability in the resulting EQ-5D-3L index density functions. There were also considerable differences in EQ-5D-3L index density functions before and after treatment using the same value set. Effect sizes of 2-year change (SRM), however, were similar when the 9 value sets were applied on pre- and post-treatment data. We found a marked variability in EQ-5D-3L index density functions when a single large data set was applied to 9 national EQ-5D-3L value sets. Consequently, studies that aggregate international data, e.g. meta-analyses, may produce misleading results if the underlying differences in EQ-5D-3L index density functions are inadequately handled. On the basis of the results of our study, we recommend against pooling of different national EQ-5D-3L index data.

Purpose The EQ VAS is an integral part of EQ-5D, a commonly used instrument for health-related quality of life assessment. This study aimed to calculate the minimal important change (MIC) thresholds for the EQ VAS for improvement and deterioration after surgery for disk herniation or spinal stenosis. Methods Patients, who were surgically treated for disk herniation or spinal stenosis between 2007 and 2016, were recruited from the Swedish spine register. Preoperative and 1-year postoperative data for a total of 25772 procedures were available for analysis. We used two anchor-based methods to estimate MIC for EQ VAS: (1) a predictive model based on logistic regression and (2) receiver operating characteristics (ROC) curves. The SF-36 health transition item was used as anchor. Results The EQ VAS MIC threshold for improvement after disk herniation surgery ranged from 8.25 to 11.8 while the corresponding value for deterioration ranged from − 6.17 to 0.5. For spinal stenosis surgery the corresponding MIC values ranged from 10.5 to 14.5 and − 7.16 to − 6.5 respectively. There were moderate negative correlations (disk herniation − 0.47, spinal stenosis − 0.46) between the 1 year change in the EQ VAS and the SF-36 health transition item (MIC anchor). Conclusions For EQ VAS, we recommend a MIC threshold of 12 points for improvement after surgery for disk herniation or spinal stenosis, whereas the corresponding threshold for deterioration is − 7 points. There are marked differences between the EQ VAS MIC for improvement and deterioration after surgery for disk herniation or spinal stenosis. The MIC value varied depending on the method used for MIC estimation.

Purpose The Oswestry Disability Index (ODI) and the Neck Disability Index (NDI) scoring algorithms used by the Swedish spine register (Swespine) until April 2022 handled missing items somewhat differently than the original algorithms. The purpose of the current study was to evaluate possible differences in the ODI and NDI scores between the Swespine and the original scoring algorithms. Methods Patients surgically treated for degenerative conditions of the lumbar or cervical spine between 2003–2019 (lumbar) and 2006–2019 (cervical) were identified in Swespine. Preoperative and 1-year postoperative ODI/NDI data were used to evaluate differences between the Swespine and the original ODI/NDI algorithms with adjustment for at most 1 or 2 missing items using mean imputation. Results The preoperative as well as the 1-year postoperative ODI/NDI were approximately 1 unit out of 100 smaller for the Swespine algorithm, irrespective of adjustment model. The differences between preoperative and postoperative ODI/NDI scores were similar between the Swespine and the original scoring algorithms. There were occasional statistically significant differences between the preoperative–postoperative differences due to large sample sizes. Conclusions The Swespine algorithms, used until April 2022, underestimated the ODI and NDI by approximately 1 out of 100 units compared with the original algorithms. In addition, there were no statistically significant differences between the original algorithms when adjusting for at most 1 or 2 missing items. The algorithm has now been changed, also for historical data.

Observational study. To evaluate adjacent segment disk degeneration (ASD) after fusion without attempted reduction at a young age for high-grade isthmic spondylolisthesis. The clinical relevance of ASD remains unclear. Previous studies have shown that spinal fusion is associated with increased ASD but without influence on clinical outcome. Since high-grade spondylolisthesis is a severe kyphotic deformity, one could hypothesize that fusion without attempted reduction in young patients leads to accelerated adjacent segment disk degeneration in adult life. Anterior and posterior disk heights were evaluated on supine radiographs of the spine 8 years and 29 years after fusion without attempted reduction for high-grade spondylolisthesis and also on standing radiographs 8 years and 33 years after surgery. Pelvic parameters were evaluated on standing radiographs obtained 33 years after surgery. Health-related quality of life was evaluated with the Scoliosis Research Society (SRS)-22r questionnaire. One segment above fusion the anterior disk height significantly decreased on standing radiographs. Two segments above the fusion, the anterior disk height significantly decreased on supine as well as on standing radiographs. The largest reduction was found two segments above the fusion where the disk height was reduced from 33 to 28% of anterior vertebral height between the measurements at mean 8 years and mean 33 years after surgery. There were no statistically significant decreases in posterior disk heights in any measurement. The disk height showed a moderate negative correlation to PT. There was no correlation between disk height reduction and SRS-22r outcome. In our long-term follow-up of fusion without attempted reduction for high-grade spondylolisthesis in young patients, we found only a minor but statistically significant reduction in adjacent segment disk height which had no apparent impact on clinical outcome. Level IV.

In spine surgery single item patient-reported outcome assessment has been used for many years. Items 1 and 2 of SF-36 are used for assessment of general health. We used these items to explore single item, self-rated, general health assessment after spine surgery. Patients operated for lumbar disc herniation or lumbar spinal stenosis between 2007 and 2017, were recruited from the national Swedish spine register. A total of 16,910 procedures were eligible for analysis. The responsiveness of the SF-36 general health assessment items to surgical treatment was evaluated with the standardized response mean (SRM). Improvement in self-rated general health was used to dichotomize SF-36 profiles and EQ VAS distributions. For disc herniation, 5852 (83%) patients reported improvement in general health 1 year after surgery. For spinal stenosis, the corresponding numbers were 6,482 (66%). The additional improvement after year 1 was small. The responsiveness of the SF-36 item 2 (the health transition item) to surgical treatment of disc herniation or spinal stenosis was substantial. There was a clear association between improvement in SF-36 item 2 and improvements in all domains of SF-36. Surgery for disc herniation or spinal stenosis improve patients’ perception of general health 1 year after surgery. The improvement in general health after year 1 is limited. The SF-36 item 2 is a responsive measure of self-rated general health that may be used for dichotomization of SF-36 and EQ VAS data when evaluating surgical outcome in spine surgery.

Observational study.To evaluate self-image after in situ fusion for high-grade isthmic spondylolisthesis.Certain clinical findings such as short trunk or waistline skin folds are often seen in high-grade spondylolisthesis. Since treatment with spinal fusion in situ does not address appearance, self-image and also health-related quality of life might be negatively affected in the short-term as well as the long-term perspective. This observational study evaluated health-related quality of life outcome including self-image three decades after in situ fusion for high-grade isthmic spondylolisthesis in relation to healthy controls.Thirty-eight of 39 consecutive patients, fused in situ for high-grade isthmic spondylolisthesis at a young age, completed the Scoliosis Research Society (SRS)-22r questionnaire 28-41 years after surgery. The results were compared with the results of an age- and gender-matched control group.We found that the SRS-22r self-image domain scores were statistically significantly lower in patients than in controls whereas the pain and mental health scores were similar in patients and controls. Also, the SRS-22r function domain scores were statistically significantly lower in patients but the difference in means was small. We found no correlation between severity of slip and SRS-22r outcome.In situ fusion for high-grade isthmic spondylolisthesis is a safe treatment option in the long term from a function and pain perspective, but the results of our study suggest that self-image is negatively affected long into adult life.Level IV.

The study evaluated perceptions of general health (GH) after surgical treatment of spinal stenosis and disk herniation. We used a large longitudinally collected data set to explore differences in responsiveness between the SF-36 GH domain, EQ VAS, EQ-5D index, and SF-6D index. Patients, surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017, were recruited from the national Swedish spine register. A total of 14,883 procedures were eligible for analysis. The responsiveness of the SF-36 GH domain to surgical treatment was evaluated with the standardized response mean (SRM) and effect size (ES). The internal consistency of the GH domain was evaluated, ceiling and floor effects were assessed, and the correlation between GH domain and EQ VAS was analyzed. The SF-36 GH domain did not respond to surgical treatment of spinal stenosis and disk herniation. In contrast, EQ VAS, EQ-5D index, and SF-6D showed moderate to large responsiveness. There were pronounced ceiling effects in items 11a–c of the SF-36 GH domain. There was a negative effect size of change for item 11c. The internal consistency of the GH domain was satisfactory. There were marked differences in the correlations between EQ VAS and the GH domain preoperatively and postoperatively. The SF-36 GH domain should be used with caution when evaluating effects on GH perceptions after spine surgery procedures. The lack of responsiveness is most probably explained by ceiling effects for items 11a–c and a negative effect size of change for item 11c.

Study design Register study with prospectively collected data. Objective The aim was to investigate reoperation rates at the index level and the adjacent levels after surgery for lumbar L3-4 spinal stenosis with concomitant degenerative spondylolisthesis (DS). Summary of background data There are different opinions on how to surgically address lumbar spinal stenosis with DS. The potential benefit of fusion surgery should be weighed against the risks of future reoperations because of adjacent segment degeneration. Data on the reoperation rate at adjacent segments after single level L3-4 fusion surgery are limited. Materials and methods A total of 372 patients, who underwent surgery for lumbar L3-4 spinal stenosis with DS (slip >3 mm) between 2007 and 2012, were followed between 2007 and 2017 to identify reoperations at the index level and adjacent levels. The reoperation rate for decompression and fusion was compared with the reoperation rate for decompression only. Patient-reported outcome measures before and 1 year after surgery were evaluated. Results The reoperation rate at the index level (L3-4) was 3.5% for decompression and fusion and 5.6% for decompression only. At the cranial adjacent level (L2-3), the corresponding numbers were 6.6% and 4.2%, respectively, and the caudal adjacent level (L4-5), the corresponding numbers were 3.1% and 4.9%, respectively. The effect sizes of change were larger for decompression and fusion compared with decompression only. The effect sizes of change were similar for leg pain and back pain. Conclusions We could not identify any differences in reoperation rates at the cranial or caudal adjacent segment after decompression and fusion compared with decompression only for L3-4 spinal stenosis with DS. The improvement in back pain is similar to the improvement in leg pain after surgery for L3-4 spinal stenosis with DS.

The current literature on clinical appearance after surgery for high-grade spondylolisthesis is inconclusive. The few long-term comparative studies on surgical reduction versus in situ fusion report contradictory findings concerning appearance-related issues. The purpose of the current study was to evaluate and quantify clinical appearance three decades after in situ fusion for high-grade isthmic spondylolisthesis. The Scoliosis Research Society (SRS)-22r questionnaire, digital photographs and standing lateral radiographs were used to evaluate clinical appearance for 22 patients three decades after in situ fusion for high-grade spondylolisthesis. The appearance was assessed by two spine surgeons, by the patient themselves, and by quantification of cosmesis relevant radiographic variables including pelvic parameters and sagittal balance. The surgeon inter- and intraobserver reliability of the photographic evaluation of the trunk deformity was at most moderate (Cohen’s kappa 0.5). Correlation analysis revealed at most medium correlation between radiographic outcome and self-rated (SRS-22r) self-image (Spearman’s rank correlation coefficient 0.3). The agreement between patient and surgeon-rated trunk appearance was poor (Cohen’s kappa 0.2). Photographic evaluation of the trunk deformity in high-grade spondylolisthesis is unreliable. There were only weak correlations between patient self-assessed trunk appearance and radiographic parameters. The results reflect the pronounced subjectivity of cosmesis, and that the trunk deformity in high-grade spondylolisthesis is not easily observed. IV.

Brugada Syndrome (BrS) is a genetic condition associated with ventricular fibrillation and sudden cardiac death. In BrS, several pharmacological agents may increase the risk for arrhythmia and total intravenous anesthesia with propofol (TIVA) may be contraindicated due to the increased risk of perioperative cardiac arrest. Anesthesia with halogenated volatile agents has to be used instead, making monitoring of sensory and motor evoked potentials in spine surgery problematic. Furthermore, hyperthermia may induce ventricular arrhythmia in BrS, thus making temperature control of paramount importance. The purpose of this paper is to describe the particular challenges of anesthesia and intraoperative neuromonitoring associated with corrective spinal surgery in an adolescent girl with BrS. We present an analysis of a multidisciplinary approach to performing corrective spine surgery in an otherwise healthy 14-year-old girl with scoliosis. Before surgery, multidisciplinary meetings were conducted, including anesthesia and intensive care, pediatric cardiology as well as the spine team. The surgery was performed with inhalation anesthesia using sevoflurane and cardiac monitoring. Continuous somatosensory potentials were monitored as well as motor evoked potentials. The patient underwent corrective surgery from Th3 to L2. With a multidisciplinary team approach involving anesthesia and cardiology outlining the appropriate precautions, scoliosis correction with intraoperative neuromonitoring, can be safely performed in patients with BrS using inhalation anesthesia.

Background This case series of consecutive patients evaluated sagittal balance and health-related quality of life (HRQoL) 3 decades after in situ arthrodesis for high-grade isthmic spondylolisthesis. Methods Global sagittal balance, pelvic parameters, and compensatory mechanisms were evaluated on standing lateral radiographs of the spine and pelvis for 28 of 39 consecutive patients, 28 to 41 years after in situ arthrodesis for high-grade L5 to S1 spondylolisthesis. The mean age at surgery was 14 years (range, 9 to 24 years), and the mean age at the time of follow-up was 48 years (range, 39 to 59 years). A subset of the radiographic parameters was compared with the corresponding data from an 8-year follow-up examination of the same patients. HRQoL was evaluated with the Scoliosis Research Society (SRS)-22r questionnaire. Results We found that 3 of the 28 patients had a global sagittal imbalance (T1 spinopelvic inclination of >0°). Signs of compensatory mechanisms, such as reduced thoracic kyphosis and pelvic retroversion, were frequent. There was a significant decrease in sacral slope compared with 8-year follow-up data (p = 0.01). The median SRS-22r subscore was on the same level as Swedish normative data. We found no association between radiographic parameters and SRS-22r outcome. Conclusions Three decades after in situ arthrodesis for high-grade spondylolisthesis, radiographic signs of noncompensated sagittal imbalance were observed in only a few individuals. The patients had normal SRS-22r scores. There was no association between any radiographic parameter and SRS-22r outcome. The findings are relevant in the controversial discussion on whether to perform a reduction procedure to treat high-grade spondylolisthesis. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this mixed prospective and retrospective case series was to evaluate the long-term health-related quality of life and physical disability after in situ arthrodesis for high-grade isthmic spondylolisthesis.Thirty-five of forty consecutive patients who had in situ spinal arthrodesis for high-grade isthmic spondylolisthesis at a mean age of fifteen years (range, nine to twenty-five years) completed validated questionnaires (Short Form-36 [SF-36], EuroQol-5 Dimensions [EQ-5D], Zung depression scale, Oswestry disability index [ODI], Million score, and back and leg pain visual analog scale [VAS]) and underwent physical examination twenty-nine years (range, twenty-three to thirty-five years) after surgery. The mean age at the time of follow-up was forty-three years (range, thirty-seven to fifty-one years). In the absence of a formal control group, the scores on the SF-36 and EQ-5D were compared with Swedish normative data. The proportion of patients at work was compared with an age-matched control group derived from official statistics of Sweden. The Million score at the long-term follow-up was compared with the corresponding results at the mid-term follow-up of the same patients at a mean age of twenty-two years.The scores on the SF-36 and EQ-5D were similar to the scores of the general Swedish population. The mean Zung depression scale score was 30 (range, 20 to 52), the mean ODI score was 10 (range, 0 to 34), the mean back pain VAS score was 13 (range, 0 to 72), and the mean leg pain VAS score was 9 (range, 0 to 60). The Million score averaged 28 (range, 0 to 109) and was slightly worsened compared with the score of 19 (range, 0 to 94) at the mid-term follow-up (p = 0.034). The proportion of patients at work was the same as that for the age-matched general Swedish population.Our study shows good outcomes in health-related quality of life, disability, pain, and ability to work at up to twenty-nine years after in situ lumbar spine arthrodesis for high-grade isthmic spondylolisthesis.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.