Surgical Management Of High-grade Spondylolisthesis Research Articles

Philosophies and Surgical Techniques for High-Grade Spondylolisthesis Treatment with Literature Review.

High-grade spondylolisthesis is defined as cases with more than 50% displacement and spondylolisthesis with Meyerding grade III and higher. The surgical management of high-grade spondylolisthesis is highly controversial. Many surgical methods have been reported such as posterior in situ fusion, instrumented posterior fusion with or without reduction, combined anterior and posterior procedures, spondylectomy with reduction of L4 to the sacrum (for spondyloptosis), and posterior interbody fusion with trans-sacral fixation. The literature has recently mentioned minimally invasive transforaminal lumbar interbody fusion for high-grade spondylolisthesis. This study aimed to review the recent literature that describes the surgical outcomes associated with various surgical techniques used for high-grade spondylolisthesis. Recent articles were searched on search engines such as PubMed and Google Scholar using keywords such as "high-grade spondylolisthesis," "surgical techniques," and "complications." The surgical management of high-grade spondylolisthesis is an area of significant controversy. The literature is replete with regards to the need for reduction, decompression, levels of fusion, the nature of instrumentation, surgical approaches including open, minimally invasive, and "mini-open" procedures, and various techniques for reducing the slip and fusion strategy. The three basic options of high-grade spondylolisthesis include in-situ fusion, partial reduction and fusion, and complete reduction. Various techniques have been described for high-grade spondylolisthesis. Spine deformity study group classification gives guidelines about balanced and unbalanced pelvis and advises reduction and fusion in case of unbalanced pelvis for correction of biomechanical and global sagittal alignment. Each of the surgical techniques has its advantages and disadvantages. However, individual authors' experience, skill levels, and anatomic reduction with fusion techniques have yielded encouraging results.

Utility of intraoperative neurophysiological monitoring in detecting motor and sensory nerve injuries in pediatric high-grade spondylolisthesis

BACKGROUND CONTEXTIntraoperative neuromonitoring (IONM) during surgical correction of spinal deformity has been shown to reduce iatrogenic injury in pediatric and adult populations. Although motor-evoked potentials (MEP), somatosensory-evoked potentials (SSEP), and electromyography (EMG) have been shown to be highly sensitive and specific in detecting spinal cord and nerve root injuries, their utility in detecting motor and sensory nerve root injury in pediatric high-grade spondylolisthesis (HGS) remains unknown. PURPOSEWe aim to assess the diagnostic accuracy and therapeutic impact of unimodal and multimodal IONM in the surgical management of HGS. STUDY DESIGN/SETTINGRetrospective cohort study. PATIENT SAMPLEPediatric patients undergoing posterior spinal fusion (PSF) for treatment of HGS. Outcome MeasuresData on patient demographics, spinopelvic and spondylolisthesis parameters, and the presence of pre-and postoperative neurological deficits were collected. METHODSIntraoperative MEP, SSEP, and EMG alerts were recorded. Alert criteria were defined as a change in amplitude of more than 50% for MEP and/or SSEP, with or without change in latency, and more than 10 seconds of sustained EMG activity. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each modality and the combination of MEP and SSEP. The 95% confidence intervals (CIs) were calculated using the exact (Clopper-Pearson) method. RESULTSFifty-four pediatric patients with HGS undergoing PSF between 2003 and 2021 in a single tertiary center were included. Seventy-two percent (39/54) of patients were female; the average age of patients was 13.7±2.3 years. The sensitivity of MEP in detecting new postoperative neurologic deficit was 92.3% (95% CI [64.0–99.8]), SSEP 77.8% (95% CI [40.0–97.2]), EMG 69.2% (95% CI [38.6–90.9]), and combination MEP and SSEP 100% (95% CI [73.5–100]). The specificity of MEP was 80.0% (95% CI [64.4–91.0]), SSEP 95.1% (95% CI [83.5–99.4]), EMG 65.9% (95% CI [49.4–79.9]), and combination MEP and SSEP 82.9% (95% CI [67.9–92.9]). The accuracy of SSEP was 92.0% (95% CI [80.8%–97.8%]), and the combination of MEP and SSEP was 86.8% (95% CI [74.7%–94.5%]). Twelve (22.2%) patients had a new motor or sensory deficit diagnosed immediately postoperatively. Nine patients made a full recovery, and 3 had some neurologic deficit on final follow-up. CONCLUSIONUnimodal IONM using SSEP and MEP alone were accurate in diagnosing sensory and motor nerve root injuries, respectively. The diagnostic accuracy in predicting motor and sensory nerve injuries in pediatric HGS improved further with the use of multimodal IONM (combining MEP and SEP). We recommend the utilization of multimodal IONM in all HGS PSF surgeries.

Review Article On Recent Trends in Surgical Techniques for High-grade Spondylolisthesis

Introduction: High-grade spondylolisthesis is defined as cases with more than 50% displacement and spondylolisthesis with Meyerding grade III and higher. The surgical management of high-grade spondylolisthesis is highly controversial. Many surgical methods have been reported like posterior in situ fusion, instrumented posterior fusion with or without reduction, combined anterior and posterior procedures, spondylectomy with reduction of L4 to the sacrum (for spondyloptosis), posterior interbody fusion with trans-sacral fixation. Minimally invasive transforaminal lumbar interbody fusion for high-grade spondylolisthesis has also been recently mentioned in literature. This study aimed to review the recent literature which has described the surgical outcomes associated with various surgical techniques used for high-grade spondylolisthesis Materials and Methods: Recent articles were searched on search engines such as PubMed, Google Scholar with the use of Keywords like ‘High-grade Spondylolisthesis’, ‘Surgical Techniques’ ‘complications’. Discussion: The surgical management of high-grade spondylolisthesis is an area of significant controversies. The literature is replete with regards to need for reduction, need for decompression, levels of fusion, the nature of instrumentation, surgical approaches including open, minimally invasive, and “mini-open” procedures, as well as various techniques for reduction of the slip and fusion strategy. The three basic options of high-grade spondylolisthesis include in-situ fusion, partial reduction and fusion, and complete reduction. Conclusion: Various techniques have been described for high-grade spondylolisthesis. Spine Deformity Study Group (SDSG) classification gives guidelines about balanced and unbalanced pelvis and advising reduction and fusion in case of unbalanced pelvis for correction of biomechanical and global sagittal alignment. Each of the surgical techniques has their own advantages and disadvantages. Although individual a

Review Article On Recent Trends in Surgical Techniques for High-grade Spondylolisthesis

Introduction: High-grade spondylolisthesis is defined as cases with more than 50% displacement and spondylolisthesis with Meyerding grade III and higher. The surgical management of high-grade spondylolisthesis is highly controversial. Many surgical methods have been reported like posterior in situ fusion, instrumented posterior fusion with or without reduction, combined anterior and posterior procedures, spondylectomy with reduction of L4 to the sacrum (for spondyloptosis), posterior interbody fusion with trans-sacral fixation. Minimally invasive transforaminal lumbar interbody fusion for high-grade spondylolisthesis has also been recently mentioned in literature. This study aimed to review the recent literature which has described the surgical outcomes associated with various surgical techniques used for high-grade spondylolisthesis Materials and Methods: Recent articles were searched on search engines such as PubMed, Google Scholar with the use of Keywords like ‘High-grade Spondylolisthesis’, ‘Surgical Techniques’ ‘complications’. Discussion: The surgical management of high-grade spondylolisthesis is an area of significant controversies. The literature is replete with regards to need for reduction, need for decompression, levels of fusion, the nature of instrumentation, surgical approaches including open, minimally invasive, and “mini-open” procedures, as well as various techniques for reduction of the slip and fusion strategy. The three basic options of high-grade spondylolisthesis include in-situ fusion, partial reduction and fusion, and complete reduction. Conclusion: Various techniques have been described for high-grade spondylolisthesis. Spine Deformity Study Group (SDSG) classification gives guidelines about balanced and unbalanced pelvis and advising reduction and fusion in case of unbalanced pelvis for correction of biomechanical and global sagittal alignment. Each of the surgical techniques has their own advantages and disadvantages. Although individual authors’ experience, skill levels, anatomic reduction with fusion techniques has yielded highly encouraging results. Keywords: High-grade spondylolisthesis, Surgical techniques, In situ fusion, Reduction and fusion, Complications

Erratum: Surgical management of high-grade spondylolisthesis: Current recommendations

Erratum: Surgical management of high-grade spondylolisthesis: Current recommendations

Surgical management of high-grade spondylolisthesis: Current recommendations

Spondylolisthesis is the slippage of one vertebra over the adjacent vertebrae and a usual cause of low back pain and spinal imbalance. High-grade spondylolisthesis (HGS) is defined as Meyerding grades III, IV, and V or greater than 50% anterior translation of vertebrae resulting in spinal canal stenosis and neural compression. Management of HGS has been varied and fraught with opinions and its spectrum of management consists of in situ fusion, fusion and reduction combination techniques and vertebrectomy. Literature review was done on the various modalities of treatment and studies showed good clinical outcomes with the procedures. This review highlights the biomechanics of HGS and spondyloptosis, description of techniques of in situ fusion, reduction and fusion and, thereby, evaluate and give current recommendations in the surgical management of HGS. A systematic search of PubMed, Cochrane, and Google Scholar for papers relevant to HGS was performed. Twenty-one articles were included after title, abstract, and full-text review and grouped to analyze the effect of surgical approach, instrumentation, reduction, and decompression on patient radiographic and clinical outcomes. The level of evidence was low in ascertaining the superiority of one technique over the other. HGS is a complex disorder that can be addressed with varying procedures for it. No single technique has been proven to be better than the other. Each of the procedures described earlier has their own advantages and disadvantages, and these have to be weighed with the clinical scenario and the individual skill level of the treating surgeon before deciding on the appropriate procedure. The ideal recommendations for doing the above procedures were enumerated. However, no single procedure can be taken as the best fit for the given condition as the literature does not show one to be better than the other.

High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management.

Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS. Literature review. HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others. HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

Surgical management of high-grade spondylolisthesis

High-grade spondylolisthesis, defined as Meyerding grades III, IV, and V or greater than 50% anterior translation, represent a unique spinal pathology. Most commonly isthmic in etiology and predominantly affecting adolescent patients, these slips are associated with unique management considerations and surgical challenges for treatment. Reduction and decompression are controversial management strategies, whereas fusion has long been the definitive surgical modality to prevent slip progression and neurologic deterioration. Fusion methods including posterior in situ, posterior instrumented, anterior, and circumferential have been reported with varying successes. We examine the evolution of our evaluation and surgical management of these challenging clinical scenarios.

Long-Term Experience With Reduction Technique in High-Grade Spondylolisthesis in the Young.

Surgical management of high-grade spondylolisthesis in the young is not only challenging but also controversial, from in-situ fusion to complete reduction. It is fraught with dangers such as neurological injury, pseudoarthrosis, and progressive deformity with subsequent global sagittal imbalance. We describe our experience of progressive reduction technique and restoration of lumbosacral alignment. This study is a retrospective review of patients who underwent surgery between 1998 and 2012. The surgical technique involved positioning the hips in extension with traction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction maneuver, wide decompression, and gradual reduction of the deformity and maintenance of reduction with interbody fusion. All patients were serially assessed at 1, 3, and 6 months and yearly thereafter with clinical, radiological, and Oswestry Disability Index and Visual Analogue Scale outcome measures. Twenty-seven patients with high-grade spondylolisthesis at L5-S1 (3 cases grade 3, 7 grade 4, 17 grade 5) with an average age of 13.9 years were reviewed. Mean follow-up was 120 months (range 24-192). All patients presented a solid fusion at the 6-month visit; mean slip percentage was reduced from 89% to 23%, with all cases reduced to grade 2 or less. The slip angle improved from 45° to 3° postoperatively, with improvement in sacral slope from 13° to 35°. Four spondyloptosis patients had concomitant scoliosis which corrected spontaneously after the surgery and did not need further intervention. All but one patient (96.2%) had good functional outcomes and returned to their full normal activities. One patient developed a deep infection necessitating implant removal, with eventual deformity progression leading to a poor outcome. Three patients (11.1%) suffered partial drop foot that resolved in full by 12 weeks. Our technique demonstrated a significant reduction of high grade spondylolisthesis, with restoration of global sagittal balance via correction of the lumbosacral kyphosis. Though surgically demanding, it is safe and reproducible. IV.

Surgical Management of High-Grade Spondylolisthesis

Surgical Management of High-Grade Spondylolisthesis

Surgical Management of High-Grade Spondylolisthesis

Puvanesarajah, Varun MD; Mayo, Benjamin C. BA; Massel, Dustin H. BS; Hassanzadeh, Hamid MD Author Information

High-grade spondylolisthesis treated using a modified Bohlman technique: results among multiple surgeons

The ideal surgical management of high-grade spondylolisthesis remains unclear. Concerns regarding the original Bohlman transsacral interbody fusion technique with stand-alone autologous fibular strut include late graft fracture and incomplete reduction of lumbosacral kyphosis. The authors' goal was to evaluate the radiographic and surgical outcomes of patients treated for high-grade spondylolisthesis with either transsacral S-1 screws or standard pedicle screw fixation augmenting the Bohlman posterior transsacral interbody fusion technique. A retrospective review of patients who underwent fusion for high-grade spondylolisthesis in which a Bohlman oblique posterior interbody fusion augmented with either transsacral or standard pedicle screw fixation was performed by 4 spine surgeons was completed. Estimated blood loss, operating time, perioperative complications, and need for revision surgery were evaluated. Upright pre- and postsurgical lumbar spine radiographs were compared for slip percent and slip angle. Sixteen patients (12 female and 4 male) with an average age of 29 years (range 9-66 years) were evaluated. The average clinical follow-up was 78 months (range 5-137 months) and the average radiographic follow-up was 48 months (range 5-108 months). Ten L4-S1 and 6 L5-S1 fusions were performed. Five fibular struts and 11 titanium mesh cages were used for interbody fusion. Six patients had isolated transsacral screws placed, with 2 (33%) of the 6 requiring revision surgery for nonunion. No nonunions were observed in patients undergoing spanning pedicle screw fixation augmenting the interbody graft. Six patients experienced perioperative complications including 3 iliac crest site infections, 1 L-5 radiculopathy without motor involvement, 1 deep vein thrombosis, and 1 epidural hematoma requiring irrigation and debridement. The average estimated blood loss and operating times were 763 ml and 360 minutes, respectively. Slip percent improved from an average of 62% to 37% (n = 16; p < 0.01) and slip angle improved from an average of 18° to 8° (n = 16; p < 0.01). No patient experienced L-5 or other motor deficit postoperatively. The modified Bohlman technique for treatment of high-grade spondylolisthesis has reproducible outcomes among multiple surgeons and results in significant improvements in slip percent and slip angle. Fusion rates were high (14 of 16; 88%), especially with spanning instrumentation augmenting the oblique interbody fusion. Rates of L-5 motor deficit were low in comparison with techniques involving reduction of the anterolisthesis.

Evidence-Based Medicine Analysis of Isthmic Spondylolisthesis Treatment Including Reduction Versus Fusion In Situ for High-Grade Slips

: Literature review. : The purpose of this article is to review the available literature and to attempt to formulate evidence-based recommendations for the surgical treatment of high-grade spondylolisthesis in the pediatric population. : The surgical management of high-grade spondylolisthesis remains controversial due to the lack of high level evidence. Prospective randomized studies have not been completed. : Through an electronic database search and published literature cross-reference, appropriate studies were identified and assigned the appropriate level of evidence. : There were no Level I or II evidence on this topic with our search. The best level of evidence that we have on this topic is retrospective comparative studies. We found 5 such articles which compared fusion in situ to reduction and fusion for high-grade spondylolisthesis. Pseudarthrosis rates are decreased by performing an instrumented reduction with a fusion. However, there is no significant difference in a clinical outcome of patients treated in situ versus reduction. : Because of the paucity of high levels of evidence, we are not able to formulate clear guidelines for treatment of high-grade spondylolisthesis based on the best evidence available in the published literature.

Spondylolysis and Spondylolisthesis in Children and Adolescents: II. Surgical Management

Surgical management is indicated for children and adolescents with spondylolysis and low-grade spondylolisthesis (< or =50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low-grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw-laminar hook fixation are surgical options. The ideal surgical management of high-grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high-grade spondylolisthesis.

Anterior transvertebral interbody cage with posterior transdiscal pedicle screw instrumentation for high-grade spondylolisthesis

Adult high-grade degenerative spondylolisthesis represents the extreme end of the spectrum for spondylolisthesis and is consequently rarely encountered. Surgical management of high-grade spondylolisthesis requires constructs capable of resisting the shear forces at the slipped L5-S1 interspace. The severity of the slip, sacral inclination, and slip angle may make conventional approaches to 360 degrees fusion difficult or hazardous. Transdiscal pedicle screw fixation, transvertebral fibular graft fusion, and transvertebral cage fixation are techniques that have been developed to establish anterior column load sharing and to resist shear forces at the L5-S1 interspace, given the anatomical constraints accompanying high-grade spondylolisthesis. In this technical note the authors describe the procedure for implanting an in situ anterior L5-S1 transvertebral cage and performing L4-5 anterior lumbar interbody fusion, followed by placement of posterior S1-L5 vertebral body transdiscal pedicle screws for management of high-grade spondylolisthesis.

Correction of lumbosacral kyphosis in high grade spondylolisthesis and spondyloptosis

Spondyloptoses, but also high-grade spondylolistheses, usually only develop at the lumbosacral junction and are nearly always classed among dysplastic spondylolistheses. Kyphosis of the lumbosacral junction leads to compensation mechanisms with increased lumbar lordosis and straightening of the pelvic tilt with involvement of the hip and knee joints. Reconstructing a physiological sagittal profile by more or less complete repositioning with permanent fusion of only the lumbosacral motion segment is thus of primary importance in the surgical management of high-grade spondylolisthesis and spondyloptosis. This aim led to the following treatment modality: Dorsal repositioning following sacral dome resection with subsequent intersomatic fusion with the posterior lumbar interbody fusion (PLIF) technique. This procedure was performed in 11 patients between January 1995 and January 1998 for six grade IV spondylolistheses and five spondyloptoses. Four patients had undergone previous surgery. Measurements of the slip angle (Boxall), sagittal translation (Taillard), sacral inclination (Boxall), and sagittal rotation (Wiltse and Winter) were done in the follow-up and to check the postoperative results. Denis' pain scale was used to classify pre- and postoperative complaints as well as those of the last examination. Only one inadequate repositioning occurred in a previously operated patient who required instrumentation from L4 to S1 after a pedicle screw had been torn out at L5. In another previously operated patient, the dura was damaged intraoperatively and managed accordingly. Postoperatively, this patient developed a unilateral nerve root syndrome, which did not improve in the further course. Another patient developed decompensation of the adjacent cranial motion segment in the follow-up period. In ten cases complete or nearly complete reposition was achieved. Firm bone consolidation was seen in all patients. Complaints were markedly reduced in all patients compared to the preoperative status.