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How to Reduce Unbalanced Severe Isthmic Spondylolisthesis

February 19, 2016

Contributors: Angelo Toscano, MD; Raffaele Borghi, MD; Daniele Fabbri, MD; Alberto Corrado Di Martino, MD, PhD; Camilla Pungetti, MD; Mohammadreza Chehrassan, MD; Francesco Traina, MD, PhD; Cesare Faldini, MD; Cesare Faldini, MD

2016 AWARD WINNER The management of high-grade isthmic spondylolisthesis (HGIS) is a challenge for orthopaedic surgeons. In the past, HGIS has been managed via anterior, posterior, or combined approaches; however, recent studies advocate management of HGIS via posterior reduction and instrumented interbody fusion. The surgical steps shown in this video include pedicle identification via anatomic landmarks, a pedicle screw insertion technique, accurate and gentle reduction of vertebral slippage, lumbar decompression via L5 laminectomy, and intersomatic cage insertion via a posterior approach. The goal of this video is to demonstrate the surgical technique for reduction of L5 HGIS in a 36-year-old woman with chronic low back pain associated with intractable L5 bilateral radiculopathy. Graphic illustrations are included to support the video and better explain the technique. A total of 23 consecutive patients with symptomatic L5-S1 isthmic spondylolisthesis underwent surgical treatment via this technique. One of the patients is shown in the video. Each patient was evaluated with the use of Odom criteria, radiography, CT, and MRI. At the last follow-up, clinical results were excellent in 13 patients, good in 7 patients, and moderate in 3 patients. Listhesis reduction was greater than 50% in 13 patients and less than 25% in 10 patients. Arthrodesis was achieved 3 months postoperatively in 22 patients, whereas mobilization of the intersomatic cage occurred in 1 patient. Two postoperative complications, including palsy bladder and dysesthesia of the perineal region and transient unilateral paresis of the sciatic nerve from a large hematoma in the surgical site, occurred. Both complications spontaneously and completely resolved within 6 months. Posterior instrumented arthrodesis, reduction, and interbody fusion is an effective treatment option for the management of HGIS. This video may help young surgeons understand how to approach and appropriately manage HGIS.