General Session: Pediatric Spine
Presented by: P. Sudarshan - View Audio/Video Presentation (Members Only)
P. Sudarshan(1), P. Aditya Prasad(1), P. Aghilavendan(1), V. Vamsi Krishna(1), K. Sajan Hegde(1)
(1) Apollo Hospital, Orthopedics, Chennai, India
Introduction: Surgical management of high grade spondylolisthesis in the young is not only challenging but also controversial, from in-situ fusion to complete reduction. It is fraught with dangers such as neurological injury, pseudoarthrosis and progressive deformity with subsequent global sagittal imbalance. We describe our experience of progressive reduction technique and restoration of lumbosacral alignment.
Materials and Methods: A retrospective review of patients who underwent surgery between 1998 and 2012. The surgical technique involved positioning the hips in extension with traction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction manoeuvre, wide decompression, and gradual reduction of the deformity and maintenance of reduction with interbody fusion. All patients were serially assessed at 1, 3, 6 months and yearly thereafter with clinical, radiological and outcome measures (ODI and VAS).
Results: 27 patients with high grade spondylolisthesis at L5-S1 (3 cases Grade 3, 7 Grade 4, 17 Grade 5) with an average age of 13.9 yrs were reviewed. Mean follow-up was 120 months (range 24-192). All patients presented a solid fusion at the 6 month visit; mean slip percentage was reduced from 89% to 23%, with all cases reduced to grade 2 or less. The slip angle improved from 45° to 3° postoperatively, with improvement in sacral slope from 13° to 35°. 4 spondyloptosis patients had concomitant scoliosis which corrected spontaneously after the surgery and did not need further intervention. All but one patient (96.2%) had good functional outcomes and returned to their full normal activities. One patient developed a deep infection necessitating implant removal, with eventual deformity progression leading to a poor outcome. Three patients (11.1%) suffered partial drop foot that resolved in full by 12 weeks.
Conclusion: Our technique demonstrated a significant reduction of high grade spondylolisthesis, with restoration of global sagittal balance via correction of the lumbosacral kyphosis. Though surgically demanding, it is safe and reproducible.
Summary: In spite of many published reviews on the subject, surgical options for management of high grade spondylolisthesis in the young remains a controversy. A retrospective review of 27 patients who underwent surgery at our center by a progressive reduction technique showed good functional and radiological outcomes and demonstrated a significant reduction of high grade spondylolisthesis, with restoration of lumbosacral alignment. Our technique of reduction gives satisfying outcomes in correction of this difficult spinal deformity.