Surgical treatment of high-grade spondylolisthesis: Technique and results

Abstract

Background: Surgical management of high-grade spondylolisthesis is not only challenging but also controversial, from in situ fusion to complete reduction. We report our results of a safe three-stage spinal procedure in a single surgical session with seven patients diagnosed high-grade spondylolisthesis.

Hypothesis: Posterior fixation combined with interbody fusion is effective on reduction, ossification and clinical outcomes in high-grade spondylolisthesis.

Patients and methods: This study is a retrospective review of patients who underwent surgery between 2016 and 2018. The surgical method involved specific installation for deformity reduction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction maneuver, wide decompression, gradual reduction of the deformity, and sometimes maintenance of the reduction with interbody fusion. Patients were checked out at 2, 6 and 12 months and yearly after the procedure. Clinical, radiological, Visual Analogic Scale (VAS) and Oswestry Disability Index (ODI) outcomes measures were collected.

Results: Seven patients with high-grade spondylolisthesis at L5-S1 (2 patients grade II, 4 patients grade IV and 1 patient grade V), with a median age of 37 years [17; 72] were included. Median follow-up was 24 months [12; 25 months]. All patients have a fused joint at 6 months except one. Median lumbosacral angle (LSA) improved from 76°[59; 85] to 94°[76; 104]. Meyerding grade of 2 cases was stable after surgery, 3 cases with loss of two ranks and 2 cases with loss of one rank. The radiological parameters showed statistically significant difference (p = 0.036) postoperatively. There was not deep infection. Medians VAS and ODI showed improved pain and disability scores.

Conclusion: This procedure allows correct reduction rate of high-grade spondylolisthesis with good clinic-radiologic outcomes. Though surgically demanding, it was safe and reproducible.

Level of evidence: IV, retrospective.

Keywords: High-grade spondylolisthesis; Lumbosacral kyphosis; Pedicle screw; Reduction; Sciatalgia; Trans-sacral.

Fig. 1

Meyerding's classification for grading the degree of spondylolisthesis. Grade I, Grade II, Grade III, Grade IV, and normal vertebra with inferior body divided into quarters used to determine measurement of slip. Adapted from Meyerding (1932). Copyright 1932 by the American College of Surgeons. Reprinted with permission.

Fig. 2

(A) Sagittal and (B) axial MRI of lumbosacral spine in a patient with grade III spondylolisthesis.

Fig. 3

(A) CT-scanner of a patient with grade 3, LSA of L5 measuring 91°. (B) The postoperative CT-scanner showing satisfactory reduction of the spondylolisthesis with the LSA corrected to 105°.

Fig. 4

Intraoperative sagittal fluoroscopic image of pedicle screws for L4-L5-S1 fixation with rod construct, showing the strut titanium mesh across L5-S1 disc space and docking into the S1 body.

Fig. 5

(A) Preoperative radiography of young girl patient with grade 4 spondylolisthesis. (B) CT-scanner and radiography showing satisfy reduction at 6 months of follow-up. (C) Beginning of back pain return at 12 months showing suspicion of pseudarthrosis. (D) Preoperative CT-scanner at 18 months of follow-up with pseudarthrosis and titanium mesh failure.

Fig. 6

Postoperative radiographies after reoperation of patient with pseudarthrosis and titanium mesh failure: extension of construct, with S2 screws and iliac screws implantation.