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

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>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 &lt; 0.01) and slip angle improved from an average of 18° to 8° (n = 16; p &lt; 0.01). No patient experienced L-5 or other motor deficit postoperatively.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>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.</jats:p></jats:sec>

“Reverse Bohlman” technique for the treatment of high grade spondylolisthesis in an adult population

“…The degree of reduction obtained is consistent with previous series with all posterior techniques, where slip reduction was not attempted with specific maneuvers as described by Hart 30 and Bartolozzi 19 who performed reduction only in patients with more than 70% slip. The significant improvement of the spondylolisthesis kyphotic angle and moderate recovery of slip grade are commonly related to positioning over the operating table and any mild instability coupled with viscoelastic properties of the intervertebral disk.…”

“…Hart reported 2 nonunions in a series of 16 patients treated with an all posterior modified Bohlman technique using a transsacral titanium cage. 30 Bartolozzi reported no pseudoarthrosis in a series of 15 patients treated with partial reduction, posterior decompression, screw fixation and interbody fusion with a posteriorly inserted transsacral titanium cage. 19 Karampalis had 1 pseudoarthrosis in a series of 7 patients treated with circumferential fusion after reduction with Margerl's external fixation.…”

“…The pseudoarthrosis rate after fusion in the literature varies from 0% to 39% with the majority being under 15%. 19,30,34 High pseudoarthrosis and complication rates have been associated with higher-grade spondylolisthesis and fusion in situ. Hart reported 2 nonunions in a series of 16 patients treated with an all posterior modified Bohlman technique using a transsacral titanium cage.…”

Treatment of High Grade Isthmic Spondylolisthesis by Anterior Lumbar Interbody Fusion with Structural Fibular Allograft

“…The technique has been utilized with modifications as the standard treatment of high grade, high slip angle spondylolisthesis [15,16] . Hart et al [19] performed a retrospective review of 16 patients with high grade spondylolisthesis treated with augmented Bohlman using either fibular graft or titanium mesh cage for oblique posterior interbody fusion. Average slip percent improved from 62% to 37%, with slip angle improving from 18 to 8 degrees.…”

“…However, circumferential approaches have been shown to increase fusion rates due to a more favorable fusion environment [17,18] . Since Bohlman first described this technique in 1982, other surgeons have modified the original approach to include different steps [19,20] , or to be performed from an anterior approach with posterior instrumentation, also known as a reverse Bohlman [21,22] . However, each of these described cases was performed via an open posterior incision.…”