2. High Grade Spondylolisthesis
• VJ- 65 Yr old lady
• c/o Low Backache since 3-4years
• Radiation of pain to both lower limbs while walking
• Intermittent claudication
• O/E- power 5/5 B/l LL
• Numbness in L5,S1 dermatomes b/l
6. PI= 40◦
PT= 20◦
SS= 20◦
C7 PL falls behind the femoral heads
SS
PIPT
C7PL
Preop Sagittal Profile X Ray
7. Treatment ???
• Conservative
• In situ fusion only
• IS instrumented fusion with decompression
• Reduction with decompression and instrumented fusion posteriorly
or AP or Circumferentially
9. Spondylolisthesis
Type Comments
Dysplastic/. Congenital Underdevelopment of L5 arch/ L5-S1 Facet joint
Isthmic Pars defect
Degenerative Disk and facet degeneration; intact neural arch
Traumatic # of posterior columns b/l
Pathologic Underlying metabolic disorder
WILTSE
CLASSIFICATION
10. High grade listhesis
• Ideal treatment- controversial
• Questions need to be answered-
• Need for reduction
• Levels to include in fusion
• Need for decompression
• Use of instrumentation
• Surgical approach
14. High grade listhesis
Is Reduction necessary?
Advantages
• Fusion mass has biomechanical
advantage- fusion rate better
• Less fusion segments
• Sagittal balance restored
• ASD reduced
• Canal stenosis treated
Disadvantages
• Risk of neurologic injury- upto
75%
15. High grade listhesis
Is Reduction necessary?
• What the evidence says?- Mixed literature
• Main concern in RE- postop neurologic deficit- dt-
• Direct pressure on root
• Extradural pressure on roots in reduced position
• Impingement of roots on iliolumbar ligaments
• Disc extruded in canal
16. High grade listhesis
Is Reduction necessary?
Author No of pts Neurologic
deficit
Nonunion Conclusions
Burkus et al (1992) 29 adoloscents (12 IS, 17 RE) IS- 3/12; 2/17 RE Similar clinical results-
IS- more nonunion/
progression
Muschik et al (1997) 59 adoloscents (29 IS ALIF, 30 RE
PA Fusion)
24% IS, 7% RE No clinical
improvement in RE vs IS
Molinari et al (1999) 32 adoloscents (11 IS postrly, 7
decomp, redn and postr
instrumented fusion, 19 decomp,
redn and AP instrumented fusion
IS- 0%
Redn- 15%
45%, 29%, 0% Similar clinical results at
last fU
Poussa et al (1993) 22 adoloscents (11 IS, 11 decomp,
instrumented AP fusion and RE)
IS-3; RE-1 IS preferred in
adoloscents
Poussa et al (2006) -Do- All united at fU 15 yr fU- IS has better
ODI and SRS scores
17. High grade listhesis
Is Reduction necessary?
Ideal candidates for in situ fusion
• No gait disturbances
• No postural abnormalities
• No radicular symptoms/ deficits
• Large L5 TP >2 cm2
• Balanced pelvis (Low PT, high SS)
• Preserved C 7 plumbline
20. High grade listhesis
Is Reduction necessary?
High PI-
Greator shear
and more risk of
progression
Circumferential
fusion with
instrumentation
Low PI-
Less risk of
progression
Pars repair/ IS
fusion +/-
instrumentation
*Hresko MT et al. Classification of high grade spondylolisthesis based
on pelvic version and spine balance: possible rationale for reduction.
Spine 2007;32:2208-13
21. High grade listhesis
Is Reduction necessary?
High SS/Low PT
Low SS/ High PT
C7PL over/ behind femoral heads
C7PL in front of femoral heads
Complex
reduction not
reqd
Complex
reduction
reqd
*Mac-Thiong JM et al. Relability and development of a new classification of lumbosacral spondylolisthesis.
Scoliosis 2008;3:19
22. High grade listhesis
Is Reduction necessary?
A- Balanced Sacropelvis
B- Unbalanced Sacropelvis with balanced Spine
C- Unbalanced Sacropelvis with unbalanced spine
23. High grade listhesis
Is Reduction necessary?
I II III IV
Grade of slip Sacro-pelvic
Balance
Spino-pelvic
Balance
Clinical Relevance
High grade
(3,4,5)
Balanced Balanced Can be fused in situ- no attempts at reduction-
circumferential fusion if highly dysplastic
Unbalanced Balanced Attempt reduction, but fuse in situ if reduction
difficult, 360 fusion preferable if highly dysplastic
Unbalanced Reduction mandatory; 360 fusion if highly
dysplastic
Proposed Algorhithm for surgical treatment of high grade spondylolisthesis
24. PI= 40◦
PT= 20◦
SS= 20◦
C7 PL falls behind the femoral heads
SS
PIPT
C7PL
BALANCED SACROPELVIS WITH
BALANCED SPINE
Preop Sagittal Profile X Ray