Spondyloptosis

Spondyloptosis

GEORGE SAPKAS PROFESSOR OF ORTHOPAEDICS

Metropolitan Hospital Athens Spinal Disorders and Musculo-sceletal Unit

High grade spondylolisthesis and spondyloptosis (i.e. the complete anterior translation and inferior slippage of the L5 body below the top of the sacrum) is perhaps the most challenging pathology faced by the spinal surgeon.The ideal method of treatment of this rare situation is still a subject of controversy.

Non surgical management of the symptomatic patient with high grade spondylolisthesis is generally less successful than with low grade spondylolisthesis.

Frennered AK, et al, Spine1991

Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis - spondyloptosis regardless of symptoms

Lenke LG, et al, Instr Course Lect 2003Boxall D, et al, J Bone Joint Surg Am 1979

The goals of surgery include :

neural decompression, partial reduction and correction of the lumbo-sacral slip angle and kyphosis when present. Dysplastic type of

spondyloptosis

Many surgical techniques have been proposed in the literature including:

complete or partial reduction and instrumented fusion, in situ fusion, the Gaines procedure and posterior osteotomies.

Stoker et al are in favor of a single all-posterior operation consisting of :

wide decompression, discectomy with or without sacral dome osteotomy, postural reduction, and posterior fusion with pedicle screw instrumentation.

G.E. Stoker, et al, ArgoSpine NEWS&JOURNAL-quarterly march , 2011

Cont.

Both

in situ fusion and complete anatomic reduction and fusion

have lower fusion rates and higher associated neurologic complication rates comparing with partial reduction and fusion.

G.E. Stoker, et al, ArgoSpine NEWS&JOURNAL-quarterly march , 2011

An. La.

Problem: Low back pain – non neurologic deficit

x- rays

Isthmic Spondylolysthesis

Extensive posterior decompresion(Isola system)Allografts – Autografts Postero-laterly

Lumbar - femoral Brace for 6 months

Many different methods of reduction of spondylolisthesis – spondyloptosis and fusion have been described:

A.

Pre-operative halo-femoral traction with pelvic suspension, anterior posterior fusion and placement of a pantaloon spica cast in hyperextension

Dubousset J, Cl in Or thop Relat, 1997

Cont.

B.

Gradual intra-operative closed reduction with instrumentation and posterior fusion

Matthiass HH , et al, Clin Orthop Relat Res1986

Cont.

C.

Anterior release with partial reduction and anterior interbody fusion

Muschik M, et al. Spine 1997

Cont.

D.

Posterior decompression with postero-lateral fusion, followed by halo-skeletal traction and then by a second-stage anterior interbody fusion

Bradford DS, et al, J BoneJoint Surg Am 1990

Karampalis et al, proposed a new method of :

staged reduction and fusion of high-grade spondylolisthesis using Magerl’s external fixator.

Chr. Karampalis, et al, EurSpineJ DOI10.1007/s00586-012-2190-6

Cont.

The procedure is carried out in three stages:

Cont.

In stage 1

a wide L5/S1 posterior decompression is first carried out (Gill’s procedure) followed by discectomy. Schanz pins are inserted in the pedicles of L4 and iliac crests through stab incisions and Magerl’s external fixator is assembled on them.


Cont.

The second stage is:

the gradual and progressive reduction of the slip. The amount of distraction is monitored by daily standing radiographs and the whole process is guided by patient’s comfort and neurological status.


Cont.

After slip reduction :

an anterior retroperitoneal L5/S1 fusion is performed (stage 3)


It is suggested that this technique:

restores sagittal balance and improves a severe cosmetic deformity.


The main advantage of this technique is

that gradual reduction under subsequent assessment of patients’ neurological status allows the surgeon to detect early any neurological deterioration, reverse reduction procedure and decrease the overall incidence of dysfunction of neural elements.


C. L.F. 10(Oswestry England 1979)

x- rays

Isthmic Spondylolysis

SpondylolysthesisSpondyloptosis

Operative treatment1st stage

Posterior extensive wide decompression TractionProgressive reduction L5 – S1

2nd stageAnterior fusion with autograft L5 – S1

Ke. Br.M. 10(Oswestry England 1979)

x- rays

Isthmic Spondylolysis

SpondylolysthesisSpondyloptosis

Operative treatment

1st stagePosterior extensive wide decomperssion excision of the facet joints L5 – S1TractionProgressive reduction L5 – S1

2nd stageAnterior fusion with autograft L5 – S1Screw L5 – graft S1

Ruf et al suggest that

complete reduction should be the goal of any surgical procedure for the treatment of spondylolisthesis

Michael Ruf MD, et al, Spine Vol 31

Cont.

Complete correction of the local deformity ideally

corrects the overall sagittal spinal profile, reduces the loads at the lumbosacral junction and normalizes important parameters such as

the gravity line, the sacral inclination, thoracic kyphosis and lumbar lordosis.


Cont.

Lumbosacral angle (LSA)

For that reason they propose

a method of reduction of L5/S1 with temporary instrumentation of L4 and mono-segmental fusion of L5/S1.


The complications associated with reduction should be the primary reason to question its necessity. Reduction and instrumented fusion methods are

more technically demanding, require longer surgical time and result in higher amounts of blood loss than in situ fusion.

Poussa M, et al, Spine1993

The most serious complication of spondylolisthesis reduction is

iatrogenic neurologic injury and deficit and it has been shown that it correlates with the degree of reduction achieved

Matthiass HH, et al, Clin Orthop Relat Res1986Dick WT, et al, Clin Orthop Relat Res 1988Molinari RW, et al, Spine 1999

Petraco et al, demonstrated the extent of L5 nerve stretch in spondylolisthesis reduction.

Petraco DM, et al, Spine 1996

Cont.

Stretch injury of the L5 nerve with the reduction maneuver for high-grade spondylolisthesis –spondyloptosis

is not linear; 75% of the total nerve strain occurs during the second half of reduction.

Petraco DM, et al, Spine 1996

Cont.

Given the severity and high rate of complications of spondylolisthesis reduction, a number of safer alternatives to reduction are available. The main principal among them is improvement of slip angle alone.

Sacral slope

PI=SS+PT A. BalancedB. Unbalanced pelvis

I.In situ fusion is performed

with excision of the facets and decortication of the pars,

transverse processes and alae.

Then cortico-cancellous and cancellous autogenous iliac crest grafts are placed

at the level of or slightly anterior

to the transverse processes extending to the sacral alae.

Cont.

This graft placement creates

a large posterolateral fusion mass that is able to counteract the significant shear stresses applied at the lumbo-sacral junction.

Pizzutillo PD, et al, J Pediatr Orthop 1986

II.

Alternatively the fibular dowel technique may be used.This technique involves

three-column fusion via the insertion of a fibular dowel graft and/or elongated pedicle screws through S1 and into L5.

Given the tendency for progression of an unreduced slip, the graft is beneficially subjected to compression.

Bohlman HH, et al, J Bone Joint Surg, 1990

Mar. A.

Female20 yrs oldProblem: Low Back Pain Related to Isthmic Spondylolisthesis 4th – 5th degree

C.T. Scan

M.R.I.

Post – Op X – rays

Long-term follow-up of patients with high-grade spondylolisthesis spondyloptosis treated with

in situ fusion demonstrates that

symptom relief persists and that development of accelerated degenerative spinal arthrosis does not occur at the cephalad mobile segments

Johnson JR , et al, J BoneJoint Surg Br 1983Grzegorzewski A, et al, J Pediatr Orthop 2000

Direct comparison of

in situ fusion and fusion with reduction suggests that outcomes are similarly satisfactory, with potentially lower risk for the patient without reduction

Poussa M, et al, Spine 1993

Gaines and Nicols have described:The treatment of grade V

spondylolisthesis spondyloptosis,

the technique of L5 vertebrectomy with subsequent reduction and fusion of L4 on to the sacrum.

Gaines RW, et al, Spine 1985

The first stage of this technique involves

anterior corpectomy and adjacent two-level discectomy.

With corpectomy complete,

the patient is turned prone for removal of the corresponding posterior elements.


Cont.

Prolonged duration and increased blood loss during the anterior procedure may mandate a delay of several days to weeks before the posterior stage.

Gaines RW, et al, Spine 1985 Cont.

Second stage

The posterior operation closely resembles those indicated for lower-grade deformities;

L4 is reduced onto the sacrum and fused circumferentially.


According to a review of Gaines at 2005

mild to moderate clinical deficit in the L5 nerve root occurs to many of the patients.


Cont.

The problems from L5 root dissection

generally recover, however, and only very rarely leave the patient with permanent need for bracing.


Cont.

Relief of

back pain, leg pain, and functional rehabilitation and for several, marked and gratifying cosmetic improvement

uniformly occurs and has been permanent over the follow-up.


Iatrogenic bowel, bladder, or sexual dysfunction

does not occur with this procedure, since it does not lengthen the spine.


A Modified Gaines Approach for Lumbosacral Traumatic

Spondyloptosis: A Historical Review and Case

IllustrationEisha Christian, et al, J. Spine 2014

Unlike dysplastic spondyloptosis, traumatic spondyloptosis can be associated with variable neurologic deficits and is often times complicated by polytrauma due to the high impact force of the injury.

Even if there is no neurological deficit secondary to spondyloptosis, patients eventually have difficulty maintaining their sagittal balance, and further verticalization of the sacrum leads to

difficulty with gait and maintaining posture (hyperlordosis).

The natural history of traumatic spondyloptosis is unknown given its rare clinical manifestation.

In addition, the clinical picture is not uniform where some patients are almost asymptomatic whereas others have

severe functional disability

from posture and gait imbalances and others are complete ASIA A spinal cord injuries.

Given such a variable clinical presentation, there is considerable controversy about surgical management of spondyloptosis. In general, the goals of management are

to treat symptoms, preserve and improve neurologic status, restore and maintain sagittal balance, and obtain a solid arthrodesis while fusing as few segments as possible.

Stage I: Anterior retroperitoneal approach for L5 corpectomy

Stage 2: Posterior spinal decompression, internal reduction and fusion

Stage 3: L4-S1 interbody fusion and cage insertion

Conclusions

Treatment of high grade Spondylolisthesis – Spondyloptosis is one of the most controversial in all orthopaedics, with the

amount, timing and technique of reduction producing the controversy.

Satisfactory clinical outcomes may be achieved by

many surgical methods, including

in situ fusion with or without postural reduction, instrumented reduction and fusion, and combined anterior posterior fusion techniques.

Objectives that

reduction of the slip angle and L5 incidence

correlate with better clinical outcomes suggest that this is becoming the treatment of choice.

Current thinking appears

to favor partial reduction maintained by internal fixation as the appropriate choice to achieve neurologic safety, sagittal realignment and a high fusion rate.

The best decision for an individual patient is based on

careful analysis of the presenting symptoms, clinical deformity, neurologic function, and spinal imaging, together with the operating surgeon’s preference and experience.

Spondyloptosis

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