Sacral dome resection and single-stage posterior reduction in the treatment of high-grade spondylolisthesis in a young girl

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Introduction: The treatment of high-grade spondylolisthesis remains controversial in terms of in situ fusion versus reduction. The aim of operation in this patient is to restore the spino-pelvic alignment, sagittal profile of the spine and prevention of progression of slip with a minimal neurological risk.
 Case presentation: 18 years old schooling girl referred with a history of backache and right lower limb numbness over lateral aspect of foot for four years duration. She also had intermittent lower back pain, produced by long distant walking and relived by rest. It was aggravated by standing for long duration. There was no radiation of pain, no red flag sign or no cauda equina symptoms. Apart from her right lower limb neurology which was her power MRC grade IV in L5 and S1 myotome, other examinations were normal. X-Ray revealed grade V spondyloptosis. MRI showed evidence of right exiting L5 nerve root entrapment with grade V spondyloptosis. She underwent single stage posterior instrumentation of L4 - S1vertebrae, sacral dome resection, reduction of L5 over S1, interbody fusion of L5 - S1 and posterolateral intertransverse fusion of L4 to S1 vertebrae. She was ambulated on post-operative day one without brace. There was no worsening of neurology.
 Conclusion: Lumbosacral spondylolisthesis grade V can be treated using posterior approach alone to obtain reduction, decompression, and solid fusion. The sacral dome resection is a shortening osteotomy of the lumbosacral spine which allows a single-stage reduction of L5 without lengthening of lumbosacral region in high-grade spondylolisthesis, which helps to avoid neurological complications.