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

Abstract

Background: 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.Methods: 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.Results: 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 458 to 38 postoperatively, with improvement in sacral slope from 138 to 358. 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.Conclusion: 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.Level of Evidence: IV

Is Reduction and Fusion Required for High-grade Spondylolisthesis?

“…Moreau et al 36 also found a high neurological complication rate (34%), although all symptoms had improved by 6 months. Similarly, Sudarshan et al 32 saw a neurological complication rate of 11%, and all resolved by 12 weeks postoperatively. Other groups have shown increased rates of new permanent deficits of up to 12%, but there was not a significant difference compared with patients undergoing in situ fusion.…”

“…Others have shown improvement of the listhesis by 37%-66% without significant loss of correction and normalization of lumbar and thoracic curvature, slip percentage, slip angle, lumbosacral angle, and sagittal balance. 28,31,32,35,36 Similarly, meta-analysis demonstrated an improvement in slip angle of 21% with reduction compared with only 3% for the in situ group (P < 0.003). 16 Reduction and circumferential fusion have also been shown to have improved PROs.…”

“…Similarly, patients with a pseudarthrosis had an average increase in slip angle of 12 degrees, while patients undergoing reduction and circumferential fusion had an improvement of 25 degrees 6. Other groups have shown 100% fusion rates and no slip progression on imaging at 6 months postoperatively with reduction and fusion 31,32. Shufflebarger and Geck28 reported a 100% arthrodesis rate at final follow-up of reduction and posterior lumbar interbody fusion, but had 1 patient with 16 degrees of slip progression before fusion and 1 patient whose deformity progressed below the fusion construct at S1–S2.…”

“…6 Other groups have shown 100% fusion rates and no slip progression on imaging at 6 months postoperatively with reduction and fusion. 31,32 Shufflebarger and Geck 28 reported a 100% arthrodesis rate at final follow-up of reduction and posterior lumbar interbody fusion, but had 1 patient with 16 degrees of slip progression before fusion and 1 patient whose deformity progressed below the fusion construct at S1-S2. These cases of deformity progression are likely explained by the authors' decision to only place pedicle screws at L5-S1, rather than extending to the pelvis.…”

Surgical treatment of spondylolisthesis using long arm screw: A literature review

“…Other studies also reported using posterior arthrodesis in-situ in children, although it was also resulted in pseudoarthrosis rates up to 40% which allowed progression of spondylolisthesis. Goals of reduction technique is to restore global spinal balance by correction of abnormal degree in lumbosacral joint [ 11 , 12 ].…”