Harry Shufflebarger MD

Spondylolisthesis: To Reduce or NotCase discussion: Early Onset Scoliosis

•Chief, Division Spinal SurgeryMiami Children’s Hospital

•Interests•All pediatric spinal deformity•Spondylolisthesis•Writing and research

•Enjoys•Big game fishing•Boating •Grandkids

Spondylolisthesis: To Reduce or Not?

S.P.I.N.E 2010June 24-26Beirut , Lebanon

Harry L Shufflebarger MDMiami Children’s HospitalMiami, Florida, USA

Disclosures:

•Consultant DePuy Spine•Speaker’s Bureau DePuy Spine•Royalties DePuy Spine

High Dysplastic Spondylolisthesis

Grade 3 or morewith lysis or elongation of parsupper sacrum dysplasticL5 arch poorly formed

Marchetti PC & Bartolozzi P (1997)Classification of spondylolisthesis as a guidelinefor treatment. In Bridwell KH, DeWald RL (eds)The Textbook of Spinal Surgery. 2nd edn. Lippincott-Raven, Philadelphia, pp1211-1254

Classification andterms

Sagittal Spinopelvic Balancelocal & global

relationship ofpelvic incidencepelvic tiltsacral slope

low or high grade

Mac-Thiong JM, LaBelle H. A proposal for a surgical classification of pediatric lumbosacral spondylolisthesis.Eur Spine J, 2006

Classification and terms

Dysplastic Changes in L5-Sacropelvic Complex

Primary changesPosterior elements

laminafacets

Deficiency of posterior hook…pars

Secondary changesmonosegmental kyphosiswedged L5domed sacrumpelvic retroversiondegeneration of lumbosacral disc Dysplastic changes &

spinopelvic balance related

Compensatory Mechanisms—maintain global sagittalbalance

Increasing lordosis…segmental or adding lordotic segments to maximal attainable lordosis

Pelvic retroversion

PI fixed—SS decreasesPT increases

Decompensation occursusually forward leanof trunk

High Grade Spondylolisthesis

Elements •Deformity •Instability & Progression•Neurological impairment

Partial Treatment•Expose to failure•Further deterioration•Worse situation

Surgical Treatment…address pathomechanics

Goals of treatment…DeWald..Textbook of Spinal Surgery

1. Minimal segments fused 2. Interbody arthrodesis3. Restore sagittal vertical axis = reduction

•Balanceforces•Restore spinopelvicbalance

Reduction of High Grade SpondylolisthesisReduce What?

Lumbo-sacral kyphosisinterbody releaseinterbody structural graftrestores sagittal balance

Translation of L-5secondary effect

High Grade Spondylolisthesis…treatment challenge

“Extremely demanding and potentially dangerous”Schoenecker et al. Cauda equina syndrome after in-situ arthrodesis

for severe spondylolisthesis. J Bone Joint Surg Am 1990; 72:369

Multiple authors reportcatastrophic neurologic injurynerve root deficitsnon-unionsprogressive slippageneed for revision surgery

L-5 injury 5-35%

Spondylolisthesis Reduction-----why?

Direct canal decompressionCorrection of lumbosacral

kyphosis--cosmesisDecrease tension on fusion

biomechanical advantage Prevent risk of acute cauda

equina syndrome

Decrease pseudo-arthrosis ratePrevent slip progressionImprove quality fusion

Goal of surgery—restoration spinopelvic balance

Correction lumbosacralkyphosis—requires reduction (partial)

Maintain correctionrequires posterior instrumentationstructural L5-S1 implant

Spondylolistheis Reduction

Posterior shortening….Posterior tension bandstructural interbody graft = fulcrum for reduction

and lumbosacral lordosis production

Shufflebarger H, Geck M. High grade isthmicdysplastic spondylolisthesis: monosegmentalsurgical treatment. Spine 2005, 30 (6S):S42-49

• 25 patients

• Age 13.5 (10-16)

• Symptoms > 1year

– Back or leg pain

– Postural abnormality

• 96% follow-up

• Mean follow-up 5 yrs (4-9)

Neurologymotor deficit—11/25 10 L5 root, 1 incomplete cauda equinaSLR < 450 in most

All > 50% displacement L5

Percent Listhesis Slip Angle

Results

Neurology: all motor deficits cleared by 3 monthsSLR > 750 by 6 monthsNo new deficits

Sacral Inclination Sagittal Alignment LineC7 to post sacrum vertical

Results

Complications: no neurologic, infectious, reoperations, orpseudo-arthrosis. UTI, ileus common

Complications major 8%• bending of sacrum• 150 increase slip angle, then stable

Index Procedure

Harms et al, Textbook of Spinal Surgery---112 patients, 90%correction, 1 pseudo, 3 transient neurological deficits

Personal series---approximately 85 patients (15 years), data as reported for 25 patients. 6% implant complications, butno re-operations, one transient L-5 neuropathy

Mono-segmental surgery for spondylolisthesissurgical sequence

•Gill procedure & exposure L5 and S1 roots•Screw placement—reduction in L5•+/- temporary distraction•Discectomy •Sacral dome excision•Anterior graft—autogenous •Reduction—gradual with screws•Distraction •Cage placement•Compression •Postero-lateral graft

4 hour procedure, 650cc blood lossSacrum Dura

Role & Technique of Sacral Dome Resection inHigh Grade Spondylolisthesis

Pedicle subtraction osteotomy..Indications

Significant correction of sagittal imbalance

Production of 30+ degrees oflordosis from a single osteotomy

Role & Technique of Sacral Dome Resection inHigh Grade Spondylolisthesis

High grade spondylolisthesis

“problem in kyphosis, nottranslation”

Sacral dome resectionequivalent

PSO more proximal

Role & Technique of Sacral Dome Resection inHigh Grade Spondylolisthesis

High grade spondylolisthesis

“problem in kyphosis, nottranslation”

Sacral dome resection posterior shorteningdecrease L5 stretchfacilitates reduction

90% Slip…Large kyphosis

13 year old female…L-5 root weak

MRI

S1-S2Segmented

90% slip, high degree kyphosis---reduction withreduction screws L4 & L5 + S1 and iliac fixation

Reduction screws

Iliac screws

Reduction with iliac screws, S1 screws distaland L4 and L5 screws proximal

Reduction screws

High dysplastic spondylolisthesisreduction and fixation L4 to ilium

Happy Girl

Spondyloptosis

14 y/o otherwise normal

Spondyloptosis

Errors in Surgical Treatment of High Grade Spondylolisthesis

•Failure to identify L5 roots•Inadequate proximal fixation

•Poor L5 pedicles•Inadequate distal fixation

•Tri-cortical S1•S2-alar or iliac screws

•Lack of anterior column support•Inadequate correction of LS kyphosis

10 y/o female..back and leg pain

10 y/o girl

3 mos afterspondyreduction

Resolving caudaequinasyndrome

6 mos after initial surgery

Posterior revision•Explant implants•Expose L5•Screws placed•Distraction •Sacral osteotomy•Gradual reduction

•4.5mm rod•Cage placement•Compression •PL fusion

Reduction of High Grade Spondylolisthesis Indicated

Successful Uncomplicated Surgery

Partial reduction Posterior tension band Spinopelvic Kyphosis correction Anterior column support balance

Identify & protect neural structures

Thank You