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

Abstract

Background: 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. Methods: Literature review. Results: 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. Conclusions: 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 spinopelvic 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.

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“…Spondylolisthesis is further classified by into Grades IV-V based on the percent of anterior translation [2]. High grade spondylolisthesis (Grades VI-V), greater than 50% anterior translation, accounts for 11.3% of cases in the adult population [3]. Most cases in adults regardless of grade are asymptomatic or report vague lower back pain [1,3].…”

“…High grade spondylolisthesis (Grades VI-V), greater than 50% anterior translation, accounts for 11.3% of cases in the adult population [3]. Most cases in adults regardless of grade are asymptomatic or report vague lower back pain [1,3]. However, if the slip progresses and spino-pelvic balance is altered patients can experience severe pain, significant deformity, and difficulty ambulating [4].…”

“…However, if the slip progresses and spino-pelvic balance is altered patients can experience severe pain, significant deformity, and difficulty ambulating [4]. Surgical intervention is necessary when slip progression is imminent or severe neurologic symptoms develop [3]. Surgical treatment in these cases is challenging and requires substantial preoperative planning due to complexity of deformity and loading forces on the lumbar spine.…”

“…Surgical treatment in these cases is challenging and requires substantial preoperative planning due to complexity of deformity and loading forces on the lumbar spine. In recent review of the current literature Kunze, et al found in situ fusion provides adequate fixation with lower incidence of neurologic complications [3]. However, this approach does not correct abnormal sagittal spino-pelvic balance seen in high grade spondylolisthesis.…”

“…Robotic assisted spinal surgery offers significant promise in complex cases with improved surgical planning capabilities and operative precision. • 360° fusion with fibular strut in-situ fusion and Gill laminectomy • 360° with L5 corpectomy and PIF with Gill laminectomy [3,5,7] Due complexity and heterogeneity seen in these deformities no single technique has been proven consistently superior. Panel of 4 spine surgeons reviewed the imaging and collectively decided to precede with anterior lumbar interbody fusion (ALIF) and PIF with Gill laminectomy and sacral dome osteotomy.…”