Surgical treatment of dysplastic spondylolisthesis. Results after in situ fusion

Current Evidence Regarding the Treatment of Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee

STUDY DESIGN

Structured literature review.

OBJECTIVES

The Scoliosis Research Society requested an assessment of the current state of peer-reviewed evidence regarding pediatric lumbar spondylolisthesis to identify what is known and what research remains essential to further understanding.

SUMMARY OF BACKGROUND DATA

Pediatric lumbar spondylolisthesis is common, yet no formal synthesis of the published literature regarding treatment has been previously performed.

METHODS

A comprehensive literature search was performed. From 6600 initial citations with abstract, 663 articles underwent full-text review. The best available evidence regarding surgical and medical/interventional treatment was provided by 51 studies. None of the studies were graded Level I or II evidence. Eighteen of the studies were Level III, representing the current best available evidence. Thirty-three of the studies were Level IV.

RESULTS

Although studies suggest a benign course for "low grade" (<50% slip) isthmic spondylolisthesis, extensive literature suggests that a substantial number of patients present for treatment with pain and activity limitations. Pain resolution and return to activity is common with both medical/interventional and operative treatment. The role of medical/interventional bracing is not well established. Uninstrumented posterolateral fusion has been reported to produce good clinical results, but concerns regarding nonunion exist. Risk of slip progression is a specific concern in the "high grade" or dysplastic type. Although medical/interventional observation has been reported to be reasonable in a small series of asymptomatic high-grade slip patients, surgical treatment is commonly recommended to prevent progression. There is Level III evidence that instrumentation and reduction lowers the risk of nonunion, and that circumferential fusion is superior to posterior-only or anterior-only fusion. There is Level III evidence that patients with a higher slip angle are more likely to fail medical/interventional treatment of high-grade spondylolisthesis.

CONCLUSIONS

The current "best available" evidence to guide the treatment of pediatric spondylolisthesis is presented.

LEVEL OF EVIDENCE

Level III; review of Level III studies.

Outcome of L5 radiculopathy after reduction and instrumented transforaminal lumbar interbody fusion of high-grade L5-S1 isthmic spondylolisthesis and the role of intraoperative neurophysiological monitoring

PURPOSE

To evaluate the incidence and course of iatrogenic L5 radiculopathy after reduction and instrumented fusion of high-grade L5-S1 isthmic spondylolisthesis and the role of intraoperative neurophysiological monitoring (IONM).

METHODS

Consecutive patients treated for high-grade spondylolisthesis with IONM from 2005 to 2013 were screened for eligibility. Prospectively collected clinical and surgical data as well as radiographic outcomes were analyzed retrospectively. Patients completed the multidimensional Core Outcome Measures Index (COMI) before and at 3, 12, and 24 months after surgery.

RESULTS

Seventeen patients were included, with a mean age of 26.3 (±9.5) years. Mean preoperative L5-S1 slip was 72% (±21%) and was reduced to 19% (±13%) postoperatively. Mean loss of reduction at last follow-up [mean 19 months (±14, range 3-48 months)] was 3% (±4.3%). Rate of new L5 radiculopathy with motor deficit (L5MD) after surgery was 29% (five patients). Four patients fully recovered after 3 months, one patient was lost to neurologic follow-up. IONM sensitivity and specificity for postoperative L5MD was 20 and 100%, respectively. COMI, back pain and leg pain scores showed significant (p < 0.001) improvements at 3 months postoperatively, which were retained up to 24 months postoperatively.

CONCLUSIONS

Transient L5 radiculopathy after reduction and instrumented fusion of high-grade spondylolisthesis is frequent. With IONM the risk of irreversible L5 radiculopathy is minimal. If IONM signal changes recover, full clinical recovery is expected within 3 months. Overall, patient-reported outcome of reduction and instrumented fusion of high-grade spondylolisthesis showed clinically important improvement.

Radiographic and functional outcome of posterolateral lumbosacral fusion for low grade isthmic spondylolisthesis in children and adolescents

Aims

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis.

Methods

No patient underwent spinal decompression or instrumentation placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative blood loss 200 ml (150 to 340). There was one wound infection treated with antibiotics but no other complication. Radiological assessment included standing posteroanterior and lateral, Ferguson and lateral flexion/extension views, as well as CT scans.

Results

A solid posterolateral fusion was confirmed in all patients at mean latest follow-up of 4.7 years (3.4 to 9.8) beyond skeletal maturity into early adult life. Fusion of the isthmic lesion was documented in nine patients bilaterally and eight patients unilaterally. The poor fusion rate across the spondylolysis has not affected the excellent functional results of the procedure, which in our series depended on achieving a stable lumbosacral junction.

Conclusion

Quality of life assessment demonstrated significant improvement in all functional scores and high patient satisfaction with 28 patients returning to previous sports activities at an elite competitive level. Take home message: Posterolateral arthrodesis in situ with autologous iliac crest bone without instrumentation has achieved a solid fusion between the L5 transverse processes and the sacral ala in patients with grade I to II isthmic lumbosacral spondylolisthesis and this has produced excellent clinical outcomes and high patient satisfaction. Cite this article: Bone Joint J 2016;98-B:88–96.

Uninstrumented posterolateral spinal arthrodesis: is it the gold standard technique for I degrees and II degrees grade spondylolisthesis in adolescence?

We retrospectively reviewed the outcome of uninstrumented posterolateral spinal arthrodesis in 49 patients with lumbar isthmic spondylolisthesis grades I degrees and II degrees in adolescent patients in the time of surgery, who participate at follow-up, between 1980 and 1995. The goal of our study is to analyse the clinical and radiographic imaging at long follow-up in uninstrumented posterolateral arthrodesis and to evaluate the efficiency and the validity of surgical technique in young patients (<18 years). All patients had failed previous conservative treatment. The average age at follow-up was 33.5 years (range 25-42 years) and the average follow-up time was 19.7 years (range 12-27 years). The clinical outcome measures were the Oswestry Disability Index, the SF-36, and the visual analogic score. All measures assessed the endpoint outcomes at 20 years after surgery. The outcome of spinal fusion was good with 43 (87.7%) patients attaining solid fusion, pseudoarthrosis in 6 patients (12.3%). None of our patients complained of excessive postoperative wound pain. Additionally, no complications, such as wound infection, were encountered. Satisfactory results were obtained in 94% of patients and this was closely associated with the rate of successful fusion. The results suggest that clinical outcome is closely related to the attainment of solid fusion.

The radiographic results and neurologic complications of instrumented reduction and fusion of high-grade spondylolisthesis without decompression of the neural elements: a retrospective review of 44 patients

STUDY DESIGN

A retrospective review of all cases of high-grade spondylolisthesis treated by 1 surgeon between the years 1991 and 2003.

OBJECTIVE

To report the radiographic results and neurologic complications following instrumented posterior reduction and fusion without decompression of the neural elements.

SUMMARY OF BACKGROUND DATA

Despite a large number of published reviews of the clinical results of operative intervention, controversy remains about the surgical treatment of high-grade spondylolisthesis.

METHODS

A retrospective review of the clinical charts and radiographs of all patients with L5-S1 spondylolisthesis and more than 50% anterior displacement of L5 on S1 who were treated by the same surgical team at 1 institution.

RESULTS

With this technique, an average reduction in the displacement of L5 on S1 from 64% to 38% was achieved. At a minimum 2-year follow-up (41 patients), we have detected 5 cases with evidence of pseudarthrosis or loss of reduction (11.4%). Overall, a neurologic complication rate of 9.1% occurred in this series, with a 2.3% chance of a persistent motor deficit. We did not detect any loss of bowel or bladder function after surgery. At last follow-up, and after revision procedures, we were able to achieve good or fair clinical results in 40 (90.9%) of 44 patients.

CONCLUSIONS

These data suggest that a posterior instrumented reduction and fusion of high-grade spondylolisthesis without decompression of the neural elements can be accomplished with acceptable radiographic and clinical results.

Spondylolysis and spondylolisthesis in the child and adolescent: a new classification

Spondylolysis and spondylolisthesis commonly are diagnosed in children and adolescents. The diagnostic workup and treatment plan vary widely among physicians. Although the orthopaedic literature is extensive on the topic, it is our opinion that a lack of clarity exists with regards to etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment. Important basic principles regarding spondylolysis and spondylolisthesis, with emphasis on clinical evaluation and nonsurgical treatment, serve as the basis for a new classification. We propose a new classification for pediatric spondylolysis and spondylolisthesis that is comprehensive, simple, and easily applied. This scheme is based on clinical presentation and spinal morphology and is more appropriate for the child and adolescent than the existing classification schemes of Wiltse-Newman and Marchetti-Bartolozzi. Algorithms for evaluation and treatment of spondylolysis and spondylolisthesis in children and adolescents, based on this new classification, are presented.

Combined dysplastic and isthmic spondylolisthesis: possible etiology

STUDY DESIGN

Four cases of combined dysplastic and higher-level isthmic spondylolisthesis were studied.

OBJECTIVE

To attempt to understand the possible etiology of this unreported combination.

SUMMARY OF BACKGROUND DATA

Dysplastic spondylolisthesis is thought to be hereditary. It is believed that isthmic spondylolisthesis, the more common type, is acquired. Multiple spondylolysis and spondylolisthesis have been reported, but no cases of combined dysplastic and isthmic spondylolisthesis.

METHODS

The global and segmental Cobb angles of the lumbar vertebrae and sagittal vertical alignment were measured in four patients who presented with lower back pain and varying degrees of pain radiation to the lower limb. Posteroanterior and lateral radiographs were taken with patients standing barefooted. Three of the patients underwent surgery. The fourth patient refused surgery.

RESULTS

The global and segmental Cobb angles were found significantly increased in these patients. Increased segmental extension angles were clearer at the levels above the dysplastic vertebrae and at the level of the isthmic defect. Large anterior translation of the thorax was noted in all cases.

CONCLUSIONS

The authors believe that this unusual combination may have resulted from hyperlordosis occurring above the dysplastic vertebrae, which caused increased stresses that led to the isthmic defect. This combination should be investigated in patients with dysplastic spondylolisthesis and hyperlordosis.

One-stage decompression and posterolateral and interbody fusion for severe spondylolisthesis. An analysis of 14 patients

STUDY DESIGN

A retrospective study of 14 patients with high-grade L5-S1 spondylolisthesis surgically treated with one-stage decompression and posterolateral and interbody fusion (technique of Bohlman and Cook).

OBJECTIVE

To determine the efficacy of this technique in managing severe lumbosacral spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Controversy exists over the most appropriate method for managing high-grade spondylolisthesis. Circumferential in situ fusion from a single-stage posterior approach was described in 1982, but to the current authors' knowledge, there are not many reports on clinical results in the literature. The current authors studied 14 patients (mean age, 21 years) with severe L5-S1 spondylolisthesis. The percentage of slipping averaged 77%; slip angle averaged 36 degrees. The average follow-up period was 30 months. All patients had severe back or radicular symptoms. Two patients had foot drop, and four had minor neurologic dysfunction. Four patients had extremely tight hamstrings.

METHODS

Pre- and postoperative radiographic films and computed tomography scans were reviewed. Magnetic resonance imaging was carried out in 11 patients before surgery and at follow-up examination. Patients were evaluated for fusion rate, clinical outcome, and complications.

RESULTS

All six patients with motor deficit of the nerve roots showed complete strength recovery at follow-up examination. None of the patients had tightness of hamstrings. Twelve patients demonstrated incorporation of the graft with solid fusion, one patient had a fracture of the fibular graft, and one had graft resorption. All patients but one rated the surgical result as excellent. One patient was not satisfied with the cosmetic result. Transient paresthesias in the leg of the donor graft were documented in two patients.

CONCLUSIONS

Posterior decompression of the spinal canal combined with anterior and posterior arthrodesis performed at one stage through a posterior approach is a safe and effective technique for managing severe spondylolisthesis.