Spondylolisthesis

1. SPONDYLOLISTHESIS AND DLIF/XLIF
PRESENTED BY
ANKIT JAIN

2. DEFINITION
“Spondylolysis” – defect in pars interarticularis
“Spondylolisthesis” - heterogeneous group of disorders
characterized by forward displacement of one vertebra on
another
SPONDYLO meaning spine
LISTHESIS meaning to slip

3. 0 0% (spondylosis)
I < 25%
II 25-50%
III 50-75%
IV 75% - complete
V >100% (spondyloptosis)
MEYERDING GRADING OF SPONDYLOLISTHESIS

4. WILTSE, NEWMANN CLASSIFICATION

5. Spinal Deformity Study Group (SDSS)
Classification

6. Sacral Slope (SS)
The angle between the horizontal line and the sacral upper endplate .
Pelvic Tilt (PT)
The angle between the vertical line and the line joining the midpoint of the sacral upper endplate
and the axis of the femoral heads .
Pelvic Incidence (PI)
The angle between the line joining the center of the upper endplate of S1 to the axis of the
femoral heads and a line perpendicular to the upper endplate .
Correlation Between Anatomical Pelvic Parameters

7. Table 1. Criteria for surgery in spondylolisthesis
Group Definition Indications for surgery
I-A
Children and
adolescents
with low-grade
spondylolisthe
sis
Failure to respond to prolonged conservative management. Indications include progressive slip,
intractable back and leg pain and neurological deterioration
I-B
Children and
adolescents
with high-
grade slips
Slips greater than 50%. Neurological symptoms, progression and mechanical deterioration of
deformity
II-A
Adults with
low-grade
spondylolisthe
sis
Failure of nonoperative treatment
II-B
Adults with
high-grade
spondylolisthe
sis
Symptomatic patients with low back pain and/or radicular pain in high-grade slips
III-A and B
Adults older
than 40 y with
low-grade
spondylolysis
and
degenerative
spondylolisthe
sis
Persistent or recurrent back or leg pain or neurogenic claudication and failure of conservative
trial of treatment, along with progressive neurology or bladder or bowel symptoms

8. SURGICAL OPTIONS
 DECOMPRESSION WITHOUT FUSION
Simple laminectomy and /or foraminotomy
 NONINSTRUMENTED FUSION
 INSTRUMENTED FUSION
 Purely posterior approach with pedicle screw rod
fixation
 Interbody fusion (ALIF, PLIF , TLIF AND LLIF )
 360 degree fusion
 MINIMALLY INVASIVE APPROACHES
 REDUCTION OF SPONDYLOLISTHESIS

12. Advantages of interbody fusions over posterolateral fusion
• higher fusion rates,
• the possibility of achieving better sagittal alignment
• possibly better outcomes
Anterior lumbar interbody fusion (ALIF) provides a theoretical
advantage over posterior methods of interbody fusion by allowing
• a greater extent of discectomy,
• avoiding entry in to the spinal canal and subsequent scarring adjacent to the
neural elements
• sparing of the posterior elements of exposure related damage

13. ALIF approach is also associated with several serious complications including
• visceral and ureteral injury
• vascular injury
• sexual dysfunction

14. • Patients who presented with
• axial low back pain without severe central canal stenosis were
considered candidates for this surgery if they failed at least 6
months of conservative,traditional nonoperative management.
• Contraindications
• significant central canal stenosis,
• significant rotatory scoliosis, and
• moderate to severe spondylolisthesis.

18. • A small incision will be created for insertion of atraumatic tissue dilators
and an expandable retractor, which will be the working portal
• A second mark is made posterior to this first mark at theborder between
the erector spinae muscles and the abdominal obliques. At this second
mark, a longitudinal incision of about 2 cm is made to accommodate the
surgeon’s index finger which is inserted anteriorly through the muscle
layers to identify the retroperitoneal space.
• The index finger, which is already in the retroperitoneal space, is used
to escort the dilator safely from the direct lateral incision to the psoas muscle,
protecting the intra-abdominal contents

19. • The fibers of the psoas muscle are then gently separated with the initial dilator
using blunt dissection and neuromonitoring
• The psoas should be parted between the middle and anterior third of the
muscle,ensuring that the nerves of the lumbar plexus are located
posteriorly and outside the operative corridor.
• In the posterior one-third of the psoas muscle lie the descending nerves of the
lumbar plexus.
• As the dilator is advanced through the psoas muscle, the stimulus necessary to
elicit an EMG response will vary with distance from the nerve

20. • The dissection continues, delicately spreading the midportion
of the psoas muscle fibers laterally, while avoiding the
genitofemoral nerve, until the surface of the disc is reached
• Subsequent dilators are introduced, gradually spreading the
psoas muscle until the MaXcess retractor is inserted over the
final dilator

22. • Subsequent dilators are introduced, gradually
spreading the psoas muscle until the MaXcess
retractor is inserted over the final dilator.
• A rigid articulating arm is attached to both the
retractor and the surgical table to provide hands-free
retraction. The retractor blades are expanded in a
cranio-caudal direction to the desired aperture by
squeezing the retractor handles. Anterior-posterior
exposure is achieved by turning the knobs on the
sides of the retractor

23. • Discectomy done with the posterior annulus left
intact, with the annulotomy window centered in the
anterior half of the disc space and wide enough to
accommodate a large implant.
• Disc removal and release of the contralateral annulus
using a Cobb dissector provides the opportunity to
place a long implant that will rest on both lateral
margins of the epiphyseal ring, maximizing end plate
support.
• Interbody distraction and implant placement in this
anterior and bilateral epiphyseal position provides
strong support for disc height restoration, and
sagittal and coronal plane imbalance correction.

24. • The patient is then placed prone for
placement of percutaneous pedicle screws or
done later at a second stage.

26. LLIF
 Drawbacks:
 risk to retroperitoneal structures
(ureter, psoas muscle, genitofemoral nerve). A high incidence
of transient numbness along the genitofemoral nerve
has been reported after retraction of the psoas muscle
 exiting nerve root may cross the target disc space
(intraoperative monitoring can guide dissection)
 require supplementation via posterolateral fusion via
separate incision if 360 degree fusion is required

27. THANK YOU