This document discusses the treatment of high grade spondylolisthesis. It considers whether reduction is necessary or if in situ fusion is preferable. Reduction carries risks of neurologic injury but may provide biomechanical advantages. The ideal treatment depends on factors like sagittal and pelvic balance, the presence of symptoms, and L5 transverse process size. For balanced sacropelvises with balanced spines, in situ fusion without reduction is often sufficient. Unbalanced cases may require reduction or circumferential fusion. The case presented involved a balanced patient who was treated successfully with in situ fusion using posterior instrumentation alone.

1. High Grade
Spondylolisthesis
DR SUMIT SINHA

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

3. Preop X Ray

4. Preop CT

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

8. Spondylolisthesis
MARCHETTI- BARTOLOZZI
CLASSIFICATION

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

11. High grade listhesis
Fusion Levels
• Most recommend to include L4 for in situ fusion

12. High grade listhesis
Need to fuse L4??

13. High grade listhesis
Need to fuse L4??

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

18. High grade listhesis
Is Reduction necessary?
• Sagittal Spino-Pelvic alignment

19. High grade listhesis
Is Reduction necessary?

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

25. High grade listhesis
In Situ Fusion with posterior instrumentation
Post Op X Ray

26. High grade listhesis
Post op CT

27. High grade listhesis
Post op CT

28. Post op Sagittal Profile X Ray
PI= 55◦
SS= 30◦
PT= 25◦
C7PL falls behind femoral heads
BALANCED SACROPELVIS WITH
BALANCED SPINE

29. THANK YOU