353 - Treatment of High-Grade Spondylolisthesis

Abstract

Management of high-grade spondylolisthesis (HGS) remains one of the most challenging conditions for spine surgeons because of the diverse patient population and the lack of high-quality evidence to guide treatment decisions. The prevalence of HGS is uncertain because of the asymptomatic nature of a large percentage of patients. The pathophysiology and treatment considerations are often unique depending on the age and alignment of the patient. Young patients with isthmic or congenital HGS will more frequently demonstrate progression of their slip, while adults may demonstrate a more rigid deformity. Treatment options include conservative management, decompression, reduction versus in situ fusion, posterolateral fusion with or without anterior fusion, transsacral fixation, and sacral dome osteotomies. Surgical decision making must take into account the patient’s symptoms, flexibility of deformity, comorbidities, lumbosacral and sacropelvic alignment, and the severity of their Spinal Deformity Study Group (SDSG) classification score. Although there have been significant advances in understanding the pathophysiology of HGS and in the development of an improved classification system, management still remains guided mostly by level III evidence, with an absence of large-scale high-quality trials to identify the unique characteristics and applicable surgical technique that will result in improved outcomes on a patient-specific basis. This is not surprising given the rarity of this condition, differences in surgical strategy, and the general lack of consensus among spine surgeons.