The Challenge of Creating Lordosis in High-Grade Dysplastic Spondylolisthesis

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Key points

  • High-grade dysplastic spondylolisthesis (HGDS) is secondary to dysplastic lumbosacral morphology and frequently results in sagittal imbalance secondary to kyphosis of L5 relative to S1.

  • Reduction at the time of fusion improves sagittal balance and decreases the rate of pseudarthrosis.

  • As the lumbosacral kyphosis, rather than translation, drives the pelvis and spine into imbalance, the foremost focus in any reduction must be to restore lumbosacral lordosis.

  • Most techniques for reduction achieve

Sagittal alignment in high-grade dysplastic spondylolisthesis

High-grade dysplastic spondylolisthesis (HGDS) results in significant deformity and compromise of the normal sagittal profile of the spine. Patients with HGDS have altered sacral and spinopelvic morphology with an increased pelvic incidence compared with the general population.3 High-grade spondylolisthesis typically results in kyphosis of the L5 vertebra relative to S1. These patients first compensate through increased intervertebral segmental lumbar lordosis (LL) leading to an overall

Evidence favoring reduction

Principal to the argument in favor of reduction is that the patient’s sagittal parameters can be improved, as compared with an in situ fusion in which the sagittal malalignment is maintained. The authors’ clinical experience has shown some patients with in situ fusions present decades later with severe global sagittal imbalance and pain, and subsequent surgical management is exceptionally challenging (Fig. 2). In addition, multiple studies have shown a lower rate of pseudarthrosis with

Surgical reduction techniques

Multiple techniques have been described to aid in the reduction of HGDS. Most contemporary studies have used an interbody fusion, with many investigators describing an all-posterior approach, performing a transforaminal interbody fusion (TLIF) at L5-S1. Descriptions of each reduction technique will be detailed in the following section. Details of the sagittal correction reported by investigators using these techniques can be found in Table 1.

Complications

The primary complications related to surgical management of HGDS are new neurologic deficits and pseudarthrosis.

Summary

A modern understanding of the impact of HGDS on overall sagittal parameters helps to inform us as to which patients will benefit most from reduction at the time of fusion. Patients classified as Labelle types 5 or 6 merit strong consideration for reduction, as an in situ fusion will commit them to the unbalanced sagittal contour they rest in preoperatively. During reduction, the emphasis must be placed on restoration of lordosis, rather than focusing on translation. A cantilever reduction of

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      In fact, patients tend to compensate for spondylolisthesis by adjusting several pelvic parameters. The patient compensates for focal kyphosis at the level of slip by increasing their lumbar lordosis, retroverting the pelvis, and increasing the pelvic tilt.3 As the slip progresses and these parameters can no longer fully compensate, the patient develops positive global sagittal balance.

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      Tsirikos and Garrido (2010) state treatment options depend on the age, remaining development, degree of spondylolisthesis, and severity of symptoms of the patient.10 Many surgical techniques have been suggested from simple laminectomy to complete reduction and fusion.11,12 However, lack of instrumentation result in apparition of pain and progression of the slippage, even if some studies gave a similar quality of life for surgical treatment of high-grade spondylolisthesis compared to the surgical preoperatively group.13

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    Disclosure Statement: No industry conflicts of interest. Dr D.W. Polly has been a clinical investigator in a clinical trial sponsored by SI-Bone, but has not received any financial remuneration. No funding was received for this work.

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