Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 77 ppsx

Operation times are longer and complication rates are higher (Table 7)thanwith
the other two approaches. Kwon and Albert [44] point out that solid fusion does
not always correlate with clinical success in other degenerative disorders of the
spine. While comparative objective radiographic measurements of the spine
after PLIF vs. PLF for lytic spondylolisthesis in adults show better results for
PLIF, clinical outcomes were not reported to be markedly different [47, 55, 105].
It is therefore valid to at least critically question whether the benefits engendered
by performing a combined approach stand in correlation to the longer, techni-
cally more demanding and, from a hardware standpoint, usually more expensive
procedure with a higher risk for complications.
Fusion to L4
Reduction is facilitated
by instrumenting to L4
In children with severe developmental spondylolisthesis at L5/S1 (Meyerding
Grades III–V), reduction can be extremely tedious and may be facilitated by
instrumentationtoL4(
Case Study 2, Fig. 7). This technique allows to distract
between L4 and S1, which facilitates the reduction. In selected cases, the L4
screws can be removed at the end of the operation or alternatively 12 weeks later,
which leaves the motion segment L4/5 intact [87]. However, the lateral process of
L5isoftendysplasticinchildrenanddoesnotallowforareliablefusion.There-
fore a fusion to L4 is recommended. This is particularly valid if no interbody
fusion is added.
In adults the L4/5 disc
is often degenerated
and requires inclusion
in the fusion
In adults with marked slips of L5/S1, the adjacent L4/5 segment frequently
exhibits significant degenerative changes. In these cases, a fusion of L4 to S1 is
indicated because the L4/5 segment often rapidly decompensates after the L5/S1
fusion.

Vertebrectomy
To achieve good spine realignment, surgical treatment of spondyloptosis, which
almost only affects L5/S1, may necessitate vertebrectomy of L5 (Gaines’ proce-
dure [26]). This is a two-stage procedure, first incorporating an anterior
approach with resection of the entire body of L5 back to the base of the pedicles,
as well as the intervertebral discs L4/5 and L5/S1. In a second stage, the posterior
approach allows realignment of the spine after L5 pedicles, facets and laminar
arch have been removed bilaterally. After transpedicular instrumentation from
L4 to S1 and sagittal realignment, nerve roots L5 and S1 exit the spinal canal
together over a reconstructed intervertebral foramen. Gaines, who originally
described this method in 1985, more recently reported on 30 patients treated
with this procedure [26]. Despite the fact that Gaines had a low complication rate
and good success, over two-thirds of the patients had neurapraxic injury to one
Vertebrectomy for
a high-grade slip is prone
to complications
or both L5 roots and in two this remained permanent. This procedure, which
requires a large amount of surgical experience, should only be performed at spe-
cifically equipped centers. Complication rates remain very high even in experi-
enced hands.
Sacral Dome Osteotomy
The main risk of reducing high-grade spondylolisthesis and spondyloptosis is
related to the stretching of the L5 nerve roots, which often results in neuropraxia.
The sacral dome osteotomy helps to avoid this nerve root injury by shortening of
the sacrum. This technique consists of a bilateral osteotomy of the sacral dome,
which allows the reduction of the slip without distraction (
Fig. 7). The operation
is carried out in a single stage. This demanding procedure should be carried out
754 Section Spinal Deformities and Malformations
ab

cd
ef
Figure 7. Reduction of high-grade spondylolisthesis with sacrum dome osteotomy
a The pedicles of L4, L5 and S1 are instrumented with pedicle screws. b, c The loose posterior arc of L5 is resected and the
L5 and S1 nerve root as well as the intervertebral discs are exposed. The dome of the sacrum is osteotomized with a chisel
and resected.
d A rod is inserted on both sides first connecting the S1 screws with the rods. L4 is then reduced to the rod
with a reduction forceps. L4– S1 are slightly distracted.
e L5 is pulled back and connected to the rod with a reduction for-
ceps.
f An interbody fusion is added to L5/S1 and a posterolateral fusion to L4–S1.
Spondylolisthesis Chapter 27 755
only with neuromonitoring of the L5 nerve roots. It is important to note that neu-
romonitoring is not absolutely reliable, because paresis of the nerve root can
occur even hours after the surgery. It is therefore recommended to reduce the slip
onlyfarenoughtoallowforagoodsagittalrealignmentandaninterbodybut-
tressing by a graft or cage (
Case Study 2).
Complications
Typical complications
encountered are neurologic
injuries and non-union
As with all surgical procedures, patients surgically managed for spondylolisthe-
sis must receive the best outcome with low exposure to problems and complica-
tions. It is therefore important to appreciate which complications can occur so as
to minimize the occurrence and appreciate the psychologic impact these may
have on the patient [79]. Depending on the etiology of the condition and the pro-
cedure performed, complication rates differ significantly. In situ fixation for
degenerative low-grade slippage in the adult will have a markedly lower risk of
attaining neurologic impairment than complex reconstructive surgery of the

adolescent spine in spondyloptosis. Common complications after spondylolis-
thesis surgery are:
neurologic injury (0.3–9.1%) [74, 79, 89, 93]
persistent nerve root deficits (2–3%) [15, 38, 74, 89, 102]
non-unions (0–39%) [20, 31, 38, 48, 55, 60, 67, 74, 89, 106]
progressive slippage (4–11%) [28, 82, 89, 102]
revision surgery (7.6%) [48, 67, 89]
L5nerverootisathighrisk
in high-grade spondylolis-
thesis surgery
The list of these potential complications indicates that surgery of (high-grade)
spondylolisthesis is demanding and very careful preoperative planning is neces-
sary before the procedure is performed. As with all neurologic complications,
these need to be accurately assessed and diagnostic imaging should occur rap-
idly. If there is obvious compression of neural structures, be it from hematoma or
misplacement of spinal instrumentation, immediate revision surgery should be
the consequence.
More complex are the cases where there is no radiographic evidence of com-
pression of neural structures. In cases of only minor deficit, an attentive yet
merely observational approach may be warranted. The question whether reduc-
tion was too ambitious should critically be asked. In general for any surgeon, the
decision for or against revision surgery is among the most difficult to make. It is
therefore prudent to involve a further, less biased surgeon to assess the patient as
well as the radiographic parameters and decide for or against revision together.
Adjacent segmen t instability afterinstrumentationmaybeduetoexcessive
iatrogenic destabilization of the overlying facet joint and capsule, due to exces-
sive thinning or complete removal of the overlying lamina or due to degenerative
changes to the adjacent motion segment. While the iatrogenic destabilization of
a segment certainly will lead to slippage adjacent to a stabilized segment [109],
data concerning adjacent segment degeneration are inconsistent. Incidences are

reported to range between less than 3% and 35%. The discussion remains open
as to whether these observed degenerative changes reflect the natural history of
disc disease or stand in context to the adjacent fusion [66, 83]. As Ogilvie [79]
points out, both are probably a factor and therefore as many lumbar levels should
be left unfused as are consistent with the goals of surgery.
756 Section Spinal Deformities and Malformations
Recapitulation
Epidemiology.
Lumbar spondylolisthesis can be
developmental or acquired. As most slippages are
asymptomatic, the true incidence of the condition
remains speculative. For developmental spondylo-
listhesis, rates of around 3% in the general popula-
tion have been estimated, but depending on the
ethnic group, the incidence may be significantly
higher. Among the acquired slippages, the degen-
erative type is the most frequent one.
Pathogenesis. Spondylolysis, which is a defect of
the pars interarticularis, is the main cause of devel-
opmental spondylolisthesis and results from a
stress fracture. This causes failure of the posterior
stabilizing elements and the disc is confronted with
excessive shear. The dissociation of the anterior
and posterior column therefore ultimately results
in slippage, since the disc cannot withstand the
shear forces. Acquired spondylolisthesis mostly oc-
curs on the basis of degenerative lumbar disease.
Further causes may be iatrogenic destabilization of
a motion segment, trauma, tumors, and rare syn-
dromes or systemic bone disease.

Classification. Only those classifications are of true
value that are based on anatomy or distinguish be-
tween developmental and acquired forms of the
deformity. The two systems which are clinically rele-
vant are those of Wiltse/Rothmann and Marchetti/
Bartolozzi. The Marchetti classification is self-ex-
planatory and, as it avoids complex terminology,
easier to understand.
Clinical presentation. Patients seeking medical at-
tention do so with a variety of symptoms. Back
and/or leg pain may range from merely harassing to
severe. Depending on the degree of slippage and
onset, neurologic symptoms mayoccur.Inrare
cases, spinal canal compromise may be so severe
that patients present with a cauda equina syndrome.
Adolescents with symptomatic high-grade spondy-
lolisthesis may develop a sciatic crisis known as the
Phalen-Dixon sign. Tight hamstrings and posture ab-
normalities accompany the presentation in the ado-
lescent patient. In the adult patient, mechanical low-
back pain (worse on motion, better on rest) and radi-
culopathy are the prevailing symptoms. Physical ex-
amination may show hyperlordosis of the lumbar
spine, and in high-grade slippages a step-off be-
tween spinous processes.Patientsshouldbeas-
sessed for sensory or motor deficits of nerve roots.
Diagnostic work-up. Standard anteroposterior and
lateral radiographs are the mainstay for the initial as-
sessment. Oblique X-rays may visualize a pars defect
not already visible on a lateral view. Slippage is quan-

tified by either using the method as described by Me-
yerding (Grade I–V) or of Taillard (%). Assessment of
the sagittal deformity (lumbosacral kyphosis) is cru-
cial in high-grade spondylolisthesis. A large slip angle
in conjunction with a rounded sacrum increases the
risk of slip progression in children. In case of neuro-
logic deficit or if surgery is planned, a CT scan or MRI
should always be performed.
Non-operative treatment. Treatment decision will
ultimately be based on the age of the patient,
symptoms, etiology as well as the degree of slip-
page. General objectives of treatment are to re-
lieve pain, reverse neurologic deficit and, in cases of
severe slippage, to realign the spine. The vast ma-
jority of spondylolisthesis can be treated non-oper-
atively. Acute pain should be controlled with initial
rest, anti-inflammatory and/or pain-modulating
medication as well as administration of a muscle re-
laxant. This is followed by a therapeutic exercise
program with paraspinal and abdominal muscle
strengthening. If pain does not sufficiently subside,
the use of a brace or orthoses may be beneficial.
Cast treatment may result in a healing of an acute
spondylolysis in selected cases.
Operative treatment. Surgery is justified in cases of
persistent or recurrent back and/or radicular pain,
neurologic deficit/neurogenic claudication as well
as bladder and/or bowel syndromes. Aim of all sur-
gical techniques is to decompress neural struc-
tures, prevent progression and achieve stability

with subsequent fusion. Generally there are three
methods to achieve this goal, i.e. uninstrumented
posterolateral fusion (PLF), and instrumented pos-
terolateral fusion with or without anterior or poste-
rior interbody fusion (ALIF/PLIF). Due to technical
innovations and improvement in implants, there is
an increasing trend to manage spondylolisthesis by
combined approaches. The surgical approach will
depend on familiarity with the approach, resources
andinfrastructureaswellasback-upexpertisein
case of complications. Particularly the manage-
ment of high-grade spondylolisthesis is a surgical
challenge and technically demanding. In children
with high-grade spondylolisthesis,fusiontoL4is
often required. Reduction of high-grade spondylo-
Spondylolisthesis Chapter 27 757
listhesis is still a matter of debate because of the
high complication rates associated with these pro-
cedures. Particularly, the L5 nerve root is at risk. The
primary goal in adult low-grade spondylolisthesis
is not to reduce the slip but this may be necessary in
cases with foraminal stenosis. In the latter indica-
tion, solid fusion and neural decompression are
more important. In cases where reduction and/or
distraction of the slipped vertebra was performed,
anterior buttressing by an interbody fusion is nec-
essary. Frequent complications encountered are
non-union and neural compromise.
Key Articles
Boxall DW, Bradford DS, Winter RB, Moe JH (1979) Management of severe spondylolis-

thesis (grade III and IV) in children and adolescents. J Bone Joint Surg (Am) 61:479 – 495
Patients with an L5/S1 spondylolisthesis of 50% or greater were reviewed. Four had been
treated non-operatively; 11, by spondylodesis; 18, by decompression and spondylodesis;
and 10, by reduction and spondylodesis. The angle of slippage was found to be as impor-
tant a measurement as the percentage of slippage in measuring instability and progres-
sion. Spondylodesis alone, even in the presence of minor neural deficits, tight ham-
strings, or both, gave relief of pain and resolution of neural deficits and tight hamstrings.
The study suggests that management by postoperative extension casts may achieve a sig-
nificant reduction in percentage and in angle of slippage. Progression of the spondylolis-
thesis may occur following a solid spondylodesis.
Bradford DS, Boachie-Adjei O (1990) Treatment of severe spondylolisthesis by anterior
and posterior reduction and stabilisation. A long-term follow-up study. J Bone Joint
Surg (Am) 72:1060 – 1066
Unselected patients (n=22) who had severe spondylolisthesis were treated by a first-stage
posterior decompression (Gill procedure) and a posterolateral arthrodesis, followed by
haloskeletal traction, and then by a second-stage anterior interbody arthrodesis, followed
by immobilization in a cast. At an average 5-year follow-up the corrected slip angle
remained much the same. A pseudarthrosis developed in four patients, all of whom had
a reoperation. The neurologic deficitsthat had been present in ten patients preoperatively
had completely resolved in all but one at follow-up. Alignment in the sagittal plane was
restored in most patients, and the back pain and radicular symptoms were resolved in all
patients but one.
Lenke LG, Bridwell KH, Bullis D, Betz RR, Baldus C, Schoenecker PL (1992)Resultsofin
situ fusion for isthmic spondylolisthesis. J Spinal Disord 5:433 – 442
Patients treated with in situ bilateral transverse process fusions utilizing autogenous iliac
bone graft yet without decompression or instrumentation are assessed. A surprisingly
low fusion rate was found; yet despite this overall clinical improvement was noted in
>80% of patients with preoperative symptoms of back pain, leg pain, or hamstring tight-
ness.
Boos N, Marchesi D, Zuber K, Aebi M (1993) Treatment of severe spondylolisthesis by

reduction and pedicular fixation. A 4–6-year follow-up study. Spine 18:1655 – 1661
This paper compares the surgical treatment of severe spondylolisthesis by posterolateral
fusion with and without interbody fusion. The majority of patients with single postero-
lateral fusion demonstrated loss of reduction, non-union and implant failure. The
authors suggest that pedicular fixation systems only allow permanent reduction and sta-
bilization of high-grade spondylolisthesis in conjunction with a combined interbody and
posterolateral fusion.
Moller H, Hedlund R (2000) Instrumented and noninstrumented posterolateral fusion
in adult spondylolisthesis: a prospective randomized study: part 2.Spine25:1716 – 1721
This prospective randomized study assesses whether posterolateral fusion in patients
with adult isthmic spondylolisthesis results in an improved outcome compared with an
exercise program. Pain and functional disability were quantified before treatment and at
1- and 2-year follow-up assessments by visual analog scales (VAS). The data shows that
surgical management of adult isthmic spondylolisthesis improves function and relieves
pain more efficiently than an exercise program. The results suggest that the use of supple-
758 Section Spinal Deformities and Malformations
mentary transpedicular instrumentation does not add to the fusion rate or improve clini-
cal outcome.
Molinari RW, Bridwell KH, Lenke LG, Baldus C (2002)Anteriorcolumnsupportinsur-
gery for high-g rade, isthmic spondylolisthesis. Clin Orthop Rel Res 394:109 – 120
This study compares the outcome of two techniques of surgical management of high-
grade isthmic spondylolisthesis. While reduction and circumferential fusion including
anterior structural support had no pseudarthrosis, the incidence of non-union in
patients treated with in-situ fusion or decompression and reduction with sole posterior
instrumentation was 39%. Outcomes regarding pain after treatment, function, and satis-
faction were high in those patients who achieved solid fusion regardless of the method.
Gaines RW (2005)L5 vertebrectomy for the surgical treatment of spondyloptosis. Thirty
cases in 25 years. Spine 30:66 – 70
Thirty cases of vertebrectomy are reviewed over a significant time span. Complication
review showed that 23 patients had some temporary clinical deficit in the L5 root for

6 weeks up to 3 years after reconstruction. All but two recovered fully. One patient had
retrograde ejaculation, and two patients needed revision surgery for screw breakage due
to non-union. No patient had junctional problems and overall patients were clinically sat-
isfied with the procedure.
McAfee PC, DeVine JG, Chaput CD, Prybis BG, Fedder IL, Cunningham BW, Farrell DJ,
Hess SJ, Vigna FE (2005) The indications for interbody fusion cages in the treatment of
spondylolisthesis: analysis of 120 cases. Spine 30:60 – 5
The authors review 120 cases of patients with spondylolisthesis of varying etiologies sur-
gically managed by 360° instrumentation in respect to their radiographic outcome. Also,
complications are assessed. Seven incidental durotomies and three infections were
recorded. There was an excellent rate of fusion at 98% and the authors conclude that an
important part of the success was regaining neuroforaminal height due to distraction and
the interbody spacer.
Schlenzka D, Remes V, Helenius I, Lamberg T, Tervahartiala P, Yrjonen T, Tallroth K,
Osterman K, Seitsalo S, Poussa M (2006)Directrepairfortreatmentofsymptomatic
spondylolysis and low-grade isthmic spondylolisthesis in young patients: no benefit in
comparison to segmental fusion after a mean follow-up of 14.8 years. Eur Spine J
15:1437 – 47
Clinical, radiographic and MRI assessment of the long-term clinical, functional, and
radiographic outcome of direct repair of spondylolysis using cerclage wire fixation
according to Scott in young patients with symptomatic spondylolysis or low-grade isth-
mic spondylolisthesis (n=25) as compared to the outcome after uninstrumented pos-
terolateral in situ fusion (n=23). In conclusion, the results of direct repair of the spon-
dylolysis according to Scott were very satisfactory in 76%. After direct repair, the Oswe-
stry Disability Index (ODI) deteriorated with time leading to a clinically moderate but
statistically significant difference in favor of segmental fusion. Lumbar spine mobility
was decreased after direct repair. Secondary segmental instability above the spinal
fusion was not detected. The procedure does not seem to be capable of preventing the
olisthetic disc from degeneration. The theoretical benefits of direct repair could not be
proven.

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