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Fortis lecture High Grade Spondylolisthesis
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- 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
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- 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
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- 9. Spondylolisthesis Type Comments Dysplastic/. CongenitalUnderdevelopment 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 FusionLevels • Most recommend to include L4 for in situ fusion
- 12. High grade listhesis Needto fuse L4??
- 13. High grade listhesis Needto fuse L4??
- 14. High grade listhesis IsReduction 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 IsReduction 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 IsReduction 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 IsReduction 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 IsReduction necessary? • Sagittal Spino-Pelvic alignment
- 19. High grade listhesis IsReduction necessary?
- 20. High grade listhesis IsReduction 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 IsReduction 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 IsReduction necessary? A- Balanced Sacropelvis B- Unbalanced Sacropelvis with balanced Spine C- Unbalanced Sacropelvis with unbalanced spine
- 23. High grade listhesis IsReduction 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 InSitu Fusion with posterior instrumentation Post Op X Ray
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- 28. Post op SagittalProfile X Ray PI= 55◦ SS= 30◦ PT= 25◦ C7PL falls behind femoral heads BALANCED SACROPELVIS WITH BALANCED SPINE
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