Fixation and Fusion Segments for High-grade Lumbar Spondylolisthesis_West China Medical Journal

Authors：

 XULian , ZHOUZhong-jie , YANGJin ,  KONGQing-quan , LIULi-min , ZENGJian-cheng , LIUHao , SONGYue-ming

Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

KONGQing-quan, Email: kqqspine@126.com

Keywords：

High-grade spondylolisthesis; Posterior approach; Reduction; Fixation and fusion segments

DOI：

10.7507/1002-0179.20150410

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Objective To explore a better segment of fixation and fusion for high-grade spondylolisthesis. Methods A total of 21 patients with high-grade spondylolisthesis who had undergone reduction and posterior instrumented fusion between July 2007 and March 2012, were retrospectively reviewed. All cases underwent posterior spinal canal decompression, Schanz screws fixation and reduction, and intervertebral and posterolateral fusion. The concept of "unstable zone" and the feature of spinal deformity helped us to identify the most appropriate segment to fuse. The pre/post-operative differences on slip percentage, pelvic incidence (PI) and lumbosacral angle were compared and analyzed. The nerve function was evaluated by physical examination and neurological Frankel grade. The Visual Analogue Scale (VAS) and Oswestry Disability Index were used to assess clinical and functional outcomes of lower limbs. Bone fusion was assessed using CT reconstruction. Results All patients were followed up between 12 and 48 months. The clinical and radiological outcomes such as VAS scores and PI angle were all improved compared with that of preoperative, and the differences were all statistically significant (P<0.05). Conclusion For children with severe spondylolisthesis, if not combined with structural scoliosis, the fixation and fusion level should be up to the upper vertebra which PI angle>60°, and try to protect the posterior longitudinal ligament complex in case adjacent segments become instability or even slip. For adults with severe spondylolisthesis, if not combined with other spinal disorders such as severe osteoporosis, only mono-segmental fusion is recommended after reduction. If the slipped vertebrae could not be reduced to Meyerding gradeⅠ, two or more segments would need to be fixed and fused.

Citation： XULian, ZHOUZhong-jie, YANGJin, KONGQing-quan, LIULi-min, ZENGJian-cheng, LIUHao, SONGYue-ming. Fixation and Fusion Segments for High-grade Lumbar Spondylolisthesis. West China Medical Journal, 2015, 30(8): 1420-1425. doi: 10.7507/1002-0179.20150410 Copy

1.	Meyerding HW. Spondylolisthesis[J]. J Bone Joint Surg Am, 1931, 13(1):39-48.
2.	Marchetti PG, Bartolozzi P. Classification of spondylolisthesis as a guideline for treatment[M]//Bridwell KH. The textbook of spinal surgery. Philidalphia:Lippincott Williams & Wilkins, 1997:1211-1254.
3.	O'brien MF, Kuklo TR, Blanke KM, et al. Spinal deformity study group radiographic measurement manual[J]. Spine (Phila Pa 1976), 2004, 30(2):222-226.
4.	Stoker GE, Buchowski JM, Zebala LP, et al. High-grade spondylolisthesis:surgical management in the pediatric and young adult patient[J]. ArgoSpine News & Journal, 2011, 23(1):33-42.
5.	König MA, Boszczyk BM. Limited access surgery for 360 degrees in-situ fusion in a dysraphic patient with high-grade spondylolisthesis[J]. Eur Spine J, 2012, 21(3):390-395.
6.	Lian XF, Hou TS, Xu JG, et al. Single segment of posterior lumbar interbody fusion for adult isthmic spondylolisthesis:reduction or fusion in-situ[J]. Eur Spine J, 2014, 23(1):172-179.
7.	Transfeldt EE, Mehbod AA. Evidence-based medicine analysis of isthmic spondylolisthesis treatment including reduction versus fusion in situ for high-grade slips[J]. Spine (Phila Pa 1976), 2007, 32(Suppl 19):S126-S129.
8.	Martiniani M, Lamartina C, Specchia N. "In situ" fusion or reduction in high-grade high dysplastic developmental spondylolisthesis (HDSS)[J]. Eur Spine J, 2012, 21 (Suppl 1):S134-S140.
9.	Ruf M, Koch H, Melcher RP, et al. Anatomic reduction and monosegmental fusion in high-grade developmental spondylolisthesis[J]. Spine (Phila Pa 1976), 2006, 31(3):269-274.
10.	Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis-Monosegmental surgical treatment[J]. Spine (Phila Pa 1976), 2005, 30(6, S):S42-S48.
11.	Mac-Thiong JM, Wang Z, de Guise JA, et al. Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis[J]. Spine (Phila Pa 1976), 2008, 33(21):2316-2325.
12.	Lamartina C, Zavatsky JM, Petruzzi MA, et al. Novel concepts in the evaluation and treatment of high-dysplastic spondylolisthesis[J]. Eur Spine J, 2009, 18(Suppl 1):S133-S142.
13.	Agabegi SS, Fischgrund JS. Contemporary management of isthmic spondylolisthesis:pediatric and adult[J]. Spine J, 2010, 10(6):530-543.
14.	Seitsalo S. Operative and conservative treatment of moderate spondylolisthesis in young patients[J]. J Bone Joint Surg Br, 1990, 72(5):908-913.
15.	Poussa M, Remes V, Lamberg T, et al. Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ:long-term clinical, radiologic, and functional outcome[J]. Spine (Phila Pa 1976), 2006, 31(5):583-590.
16.	Schoenecker PL, Cole HO, Herring JA, et al. Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction[J]. J Bone Joint Surg Am, 1990, 72(3):369-377.
17.	Hu SS, Bradford DS, Transfeldt EE, et al. Reduction of high-grade spondylolisthesis using Edwards instrumentation[J]. Spine (Phila Pa 1976), 1996, 21(3):367-371.
18.	Molinari RW, Bridwell KH, Lenke LG, et al. Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis:a comparison of three surgical approaches[J]. Spine (Phila Pa 1976), 1999, 24(16):1701-1711.
19.	Tiusanen H, Schlenzka D, Seitsalo S, et al. Results of a trial of anterior or circumferential lumbar fusion in the treatment of severe isthmic spondylolisthesis in young patients[J]. J Pediatr Orthop B, 1996, 5(3):190-194.
20.	Mac-Thiong JM, Labelle H. A proposal for a surgical classification of pediatric lumbosacral spondylolisthesis based on current literature[J]. Eur Spine J, 2006, 15(10):1425-1435.
21.	Hresko MT, Labelle H, Roussouly PA. Classification of high-grade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction[J]. Spine (Phila Pa 1976), 2007, 32(20):2208-2213.
22.	Kasliwal MK, Smith JS, Kanter A, et al. Management of high-grade spondylolisthesis[J]. Neurosurg Clin N Am, 2013, 24(2):275-291.
23.	Boxall D, Bradford DS, Winter RB, et al. Management of severe spondylolisthesis in children and adolescents[J]. J Bone Joint Surg Am, 1979, 61(4):479-495.
24.	Zhou Z, Song Y, Cai Q, et al. Spontaneous resolution of scoliosis associated with lumbar spondylolisthesis[J]. Spine J, 2013, 13(5):e7-e10.
25.	Umehara S, Zindrick MR, Patwardhan AG, et al. The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments[J]. Spine (Phila Pa 1976), 2000, 25(13):1617-1624.
26.	Akamaru T, Kawahara N, Yoon ST, et al. Adjacent segment motion after a simulated lumbar fusion in different sagittal alignments:a biomechanical analysis[J]. Spine (Phila Pa 1976), 2003, 28(14):1560-1566.
27.	Okuda S, Iwasaki M, Miyauchi A, et al. Risk factors for adjacent segment degeneration after PLIF[J]. Spine (Phila Pa 1976), 2004, 29(14):1535-1540.
28.	Zencica P, Chaloupka R, Hladíková J, et al. Adjacent segment degeneration after lumbosacral fusion in spondylolisthesis: a retrospective radiological and clinical analysis[J]. Acta Chir Orthop Traumatol Cech, 2010, 77(2):124-130.
29.	Ghiselli G, Wang JC, Bhatia NN, et al. Adjacent segment degeneration in the lumbar spine[J]. J Bone Joint Surg Am, 2004, 86(7):1497-1503.
30.	Park P, Garton HJ, Gala VC, et al. Adjacent segment disease after lumbar or lumbosacral fusion:review of the literature[J]. Spine (Phila Pa 1976), 2004, 29(17):1938-1944.
31.	Miyakoshi N, Abe E, Shimada Y, et al. Outcome of one-level posterior lumbar interbody fusion for spondylolisthesis and postoperative intervertebral disc degeneration adjacent to the fusion[J]. Spine (Phila Pa 1976), 2000, 25(14):1837-1842.
32.	Lamartina C. A square to indicate the unstable zone in severe spondylolisthesis[J]. Eur Spine J, 2001, 10(5):444-448.
33.	Panjabi MM, Goel VK, Takata K. Physiologic strains in the lumbar spinal ligaments. An in Vitro biomechanical study 1981 Volvo Award in Biomechanics[J]. Spine (Phila Pa 1976), 1982, 7(3):192-203.
34.	Asano S, Kaneda K, Umehara S, et al. The mechanical properties of the human L4-5 functional spinal unit during cyclic loading. The structural effects of the posterior elements[J]. Spine (Phila Pa 1976), 1992, 17(11):1343-1352.
35.	Yang JY, Lee JK, Song HS. The impact of adjacent segment degeneration on the clinical outcome after lumbar spinal fusion[J]. Spine (Phila Pa 1976), 2008, 33(5):503-507.
36.	Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability[J]. J Neurosurg, 1999, 90(2 Suppl):163-169.

1. Meyerding HW. Spondylolisthesis[J]. J Bone Joint Surg Am, 1931, 13(1):39-48.
2. Marchetti PG, Bartolozzi P. Classification of spondylolisthesis as a guideline for treatment[M]//Bridwell KH. The textbook of spinal surgery. Philidalphia:Lippincott Williams & Wilkins, 1997:1211-1254.
3. O'brien MF, Kuklo TR, Blanke KM, et al. Spinal deformity study group radiographic measurement manual[J]. Spine (Phila Pa 1976), 2004, 30(2):222-226.
4. Stoker GE, Buchowski JM, Zebala LP, et al. High-grade spondylolisthesis:surgical management in the pediatric and young adult patient[J]. ArgoSpine News & Journal, 2011, 23(1):33-42.
5. König MA, Boszczyk BM. Limited access surgery for 360 degrees in-situ fusion in a dysraphic patient with high-grade spondylolisthesis[J]. Eur Spine J, 2012, 21(3):390-395.
6. Lian XF, Hou TS, Xu JG, et al. Single segment of posterior lumbar interbody fusion for adult isthmic spondylolisthesis:reduction or fusion in-situ[J]. Eur Spine J, 2014, 23(1):172-179.
7. Transfeldt EE, Mehbod AA. Evidence-based medicine analysis of isthmic spondylolisthesis treatment including reduction versus fusion in situ for high-grade slips[J]. Spine (Phila Pa 1976), 2007, 32(Suppl 19):S126-S129.
8. Martiniani M, Lamartina C, Specchia N. "In situ" fusion or reduction in high-grade high dysplastic developmental spondylolisthesis (HDSS)[J]. Eur Spine J, 2012, 21 (Suppl 1):S134-S140.
9. Ruf M, Koch H, Melcher RP, et al. Anatomic reduction and monosegmental fusion in high-grade developmental spondylolisthesis[J]. Spine (Phila Pa 1976), 2006, 31(3):269-274.
10. Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis-Monosegmental surgical treatment[J]. Spine (Phila Pa 1976), 2005, 30(6, S):S42-S48.
11. Mac-Thiong JM, Wang Z, de Guise JA, et al. Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis[J]. Spine (Phila Pa 1976), 2008, 33(21):2316-2325.
12. Lamartina C, Zavatsky JM, Petruzzi MA, et al. Novel concepts in the evaluation and treatment of high-dysplastic spondylolisthesis[J]. Eur Spine J, 2009, 18(Suppl 1):S133-S142.
13. Agabegi SS, Fischgrund JS. Contemporary management of isthmic spondylolisthesis:pediatric and adult[J]. Spine J, 2010, 10(6):530-543.
14. Seitsalo S. Operative and conservative treatment of moderate spondylolisthesis in young patients[J]. J Bone Joint Surg Br, 1990, 72(5):908-913.
15. Poussa M, Remes V, Lamberg T, et al. Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ:long-term clinical, radiologic, and functional outcome[J]. Spine (Phila Pa 1976), 2006, 31(5):583-590.
16. Schoenecker PL, Cole HO, Herring JA, et al. Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction[J]. J Bone Joint Surg Am, 1990, 72(3):369-377.
17. Hu SS, Bradford DS, Transfeldt EE, et al. Reduction of high-grade spondylolisthesis using Edwards instrumentation[J]. Spine (Phila Pa 1976), 1996, 21(3):367-371.
18. Molinari RW, Bridwell KH, Lenke LG, et al. Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis:a comparison of three surgical approaches[J]. Spine (Phila Pa 1976), 1999, 24(16):1701-1711.
19. Tiusanen H, Schlenzka D, Seitsalo S, et al. Results of a trial of anterior or circumferential lumbar fusion in the treatment of severe isthmic spondylolisthesis in young patients[J]. J Pediatr Orthop B, 1996, 5(3):190-194.
20. Mac-Thiong JM, Labelle H. A proposal for a surgical classification of pediatric lumbosacral spondylolisthesis based on current literature[J]. Eur Spine J, 2006, 15(10):1425-1435.
21. Hresko MT, Labelle H, Roussouly PA. Classification of high-grade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction[J]. Spine (Phila Pa 1976), 2007, 32(20):2208-2213.
22. Kasliwal MK, Smith JS, Kanter A, et al. Management of high-grade spondylolisthesis[J]. Neurosurg Clin N Am, 2013, 24(2):275-291.
23. Boxall D, Bradford DS, Winter RB, et al. Management of severe spondylolisthesis in children and adolescents[J]. J Bone Joint Surg Am, 1979, 61(4):479-495.
24. Zhou Z, Song Y, Cai Q, et al. Spontaneous resolution of scoliosis associated with lumbar spondylolisthesis[J]. Spine J, 2013, 13(5):e7-e10.
25. Umehara S, Zindrick MR, Patwardhan AG, et al. The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments[J]. Spine (Phila Pa 1976), 2000, 25(13):1617-1624.
26. Akamaru T, Kawahara N, Yoon ST, et al. Adjacent segment motion after a simulated lumbar fusion in different sagittal alignments:a biomechanical analysis[J]. Spine (Phila Pa 1976), 2003, 28(14):1560-1566.
27. Okuda S, Iwasaki M, Miyauchi A, et al. Risk factors for adjacent segment degeneration after PLIF[J]. Spine (Phila Pa 1976), 2004, 29(14):1535-1540.
28. Zencica P, Chaloupka R, Hladíková J, et al. Adjacent segment degeneration after lumbosacral fusion in spondylolisthesis: a retrospective radiological and clinical analysis[J]. Acta Chir Orthop Traumatol Cech, 2010, 77(2):124-130.
29. Ghiselli G, Wang JC, Bhatia NN, et al. Adjacent segment degeneration in the lumbar spine[J]. J Bone Joint Surg Am, 2004, 86(7):1497-1503.
30. Park P, Garton HJ, Gala VC, et al. Adjacent segment disease after lumbar or lumbosacral fusion:review of the literature[J]. Spine (Phila Pa 1976), 2004, 29(17):1938-1944.
31. Miyakoshi N, Abe E, Shimada Y, et al. Outcome of one-level posterior lumbar interbody fusion for spondylolisthesis and postoperative intervertebral disc degeneration adjacent to the fusion[J]. Spine (Phila Pa 1976), 2000, 25(14):1837-1842.
32. Lamartina C. A square to indicate the unstable zone in severe spondylolisthesis[J]. Eur Spine J, 2001, 10(5):444-448.
33. Panjabi MM, Goel VK, Takata K. Physiologic strains in the lumbar spinal ligaments. An in Vitro biomechanical study 1981 Volvo Award in Biomechanics[J]. Spine (Phila Pa 1976), 1982, 7(3):192-203.
34. Asano S, Kaneda K, Umehara S, et al. The mechanical properties of the human L4-5 functional spinal unit during cyclic loading. The structural effects of the posterior elements[J]. Spine (Phila Pa 1976), 1992, 17(11):1343-1352.
35. Yang JY, Lee JK, Song HS. The impact of adjacent segment degeneration on the clinical outcome after lumbar spinal fusion[J]. Spine (Phila Pa 1976), 2008, 33(5):503-507.
36. Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability[J]. J Neurosurg, 1999, 90(2 Suppl):163-169.

West China Medical Journal

Fixation and Fusion Segments for High-grade Lumbar Spondylolisthesis

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