Current Evidence Regarding the Treatment of Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee

Clinical and radiological outcomes of gradual reduction and circumferential fusion of high-grade spondylolisthesis in adolescents: a prospective cohort study of 29 young patients

AIM

The objective of this study was to evaluate the safety and efficacy of a novel technique of formal reduction and circumferential fusion for pediatric high-grade spondylolisthesis (HGS).

PURPOSE

The safety and efficacy of formal reduction for high-grade spondylolisthesis (HGS) has never been thoroughly examined. This study reports the outcomes of 29 children with HGS who underwent a procedure of gradual reduction and circumferential fusion.

METHODS

29 children (13 males, 16 females) were recruited between 2006 and 2010. Radiographic measurements (including % of slip, lumbosacral angle-LSA, pelvic incidence-PI, pelvic tilt-PT, sacral slope-SS, and proximal femoral angle-PFA) and quality of life assessment (SRS-22 questionnaire) were prospectively obtained at baseline and at the last post-operative follow-up (> 2 years post-op). Radiological measurements were used to classify patients according to the Spine Deformity Study Group (SDSG) classification.

RESULTS

Mean baseline slip % was 69.9 ± 16.5%. There were 13 patients with a balanced pelvic (SDSG Type 4) and 16 with an unbalanced pelvis (SDSG Type 5 and 6). On average, a reduction of 45.5 ± 15.3% (range 20-86%) was achieved safely with no major complication. In particular, of the 29 patients, only 3 had a L5 radiculopathy postoperatively that was self-resolved at follow-up. From a radiological standpoint, we observed a mean improvement of LSA from 80.3 ± 17.9° to 91.7 ± 13.6°. We also observed a statistically significant improvement in global HRQOL, and in the function and body image domains.

CONCLUSION

This prospective study suggests that formal reduction of HGS followed by circumferential fusion is safe when using a standardized surgical technique based on gradual reduction. Performing this intervention could also help improve QOL in some patients.

A Surgical Treatment Algorithm for Restoring Pelvic Balance and Health-related Quality of Life in High-grade Lumbosacral Spondylolisthesis: Prospective Multicenter Cohort of 61 Young Patients

STUDY DESIGN

Retrospective multicenter cohort-study.

OBJECTIVE

We propose an evidence-based surgical algorithm for achieving normal pelvic balance while optimizing health-related quality of life (HRQoL) in high-grade spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The principles of surgical treatment for young patients with high-grade L5-S1 spondylolisthesis remain unclear. There is a growing body of evidence supporting the central role of pelvic balance in the postural control and biomechanics of subjects with high-grade spondylolisthesis.

METHODS

This retrospective study assessed a multicenter cohort of 61 patients with high-grade L5-S1 spondylolisthesis. Classification and regression tree analysis was used to identify objective criteria associated with pelvic balance and HRQoL after surgery.

RESULTS

The most important predictor of a postoperative balanced pelvis was a postoperative L5 incidence ≤63.5 degrees. With postoperative L5 incidence ≤63.5 degrees,a residual slip percentage 9% and performing an L5-S1 posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) increased the likelihood of achieving a balanced pelvis postoperatively. When L5 incidence was 63.5 degrees,a balanced pelvis was most likely achieved with fusion limited to L5 proximally, residual slip percentage ≤40%, and residual lumbosacral angle 98 degrees. Predictors of postoperative HRQoL were the preoperative HRQoL score, L5 incidence and slip percentage.

CONCLUSIONS

A surgical algorithm is proposed to achieve normal pelvic balance, while optimizing HRQoL. The first step during surgery is to assess L5 incidence and if L5 incidence is <65 degrees, the next step depends on the pelvic balance. With a preoperative balanced pelvis, it is important not to reduce completely the slip percentage by leaving a slip percentage ≥10%. When the preoperative pelvis is unbalanced, a TLIF/PLIF at L5-S1 is recommended to facilitate correcting the angular deformity at L5-S1. If L5 incidence is ≥65 degrees,a TLIF/PLIF at L5-S1 should be performed to correct the angular deformity at L5-S1, and fusion should ideally end at L5 proximally, in addition to performing gradual reduction of the slip percentage. If fusion up to L4 is required, a lumbosacral angle ≥100 degrees is key.

Management of High-Grade Dysplastic Spondylolisthesis

The Meyerding classification grades the degree of slippage in the sagittal plane on lateral standing neutral imaging: 0% to 25% Grade I, 25% to 50% Grade II, 50% to 75% Grade III, 75% to 100% Grade IV, and greater than 100% Grade V (Spondyloptosis). Grades I and II are considered low-grade and Grades III-V are considered high-grade. There are several etiologies of spondylolisthesis. A classification system of the most common causes: Type I - Dysplastic, Type II - Isthmic (including subtypes: A - Lytic, B - Elongation, and C - Acute fracture), Type III - Degenerative, Type IV - Traumatic, Type V - Pathologic, and Type VI - Iatrogenic. Dysplastic spondylolisthesis is a type of spondylolisthesis that occurs at L5-S1 when dysplastic lumbosacral anatomy is present, and is associated with high-grade slip and spina bifida occulta.

Clinical Practice Patterns of Isthmic Spondylolysis in Young Athletes: A Survey of Pediatric Research in Sports Medicine Members

ABSTRACT

Isthmic spondylolysis is a common cause of back pain in young athletes. The condition presents to numerous medical providers who employ a variety of different practices in diagnosis and management. The purpose of this study was twofold: to review the literature of diagnosis and management of the young athlete with isthmic spondylolysis and to survey Pediatric Research in Sports Medicine (PRiSM) members during the 2021 PRiSM Annual Meeting on practice patterns of diagnosis and management of the young athlete with isthmic spondylolysis. The response rate was 27%. Per respondents: 24% obtain oblique radiographs; 90% use magnetic resonance imaging as the advanced imaging modality; 60% treat with bracing; 57% recommend rest prior to physical therapy (PT); 53% prescribe return to sport activity restrictions. Although there are similarities in the diagnosis of isthmic spondylolysis in young athletes, this survey confirmed variability in management, especially bracing, timing of PT and return to sport activity restrictions.

A delayed diagnosis of high-grade spondylolisthesis

ABSTRACT

Spondylolysis, or pars defect, occurs in nearly half of children with back pain. Despite the marked prevalence, diagnosis of spondylolysis with spondylolisthesis often is delayed or missed secondary to referred pain and uncharacteristic presentation. This article describes an 8-year-old patient with 15 months of right heel pain who was initially treated by her primary care provider for presumed Sever disease before being referred to orthopedics. After orthopedic consultation, she was diagnosed with a high-grade spondylolisthesis with L5 nerve root compression. Although spondylolysis is an infrequent diagnosis, particularly in a patient this young, missing the diagnosis can significantly reduce a patient's quality of life.

Surgical outcomes with anatomic reduction of high-grade spondylolisthesis revisited: an analysis of 101 patients

OBJECTIVE

The ideal strategy for high-grade L5-S1 isthmic spondylolisthesis (HGS) remains controversial. Critical questions include the impact of reduction on clinical outcomes, rate of pseudarthrosis, and postoperative foot drop. The scope of this study was to delineate predictors of radiographic and clinical outcome factors after surgery for HGS and to identify risk factors of foot drop.

METHODS

This was a single-center analysis of patients who were admitted for HGS, defined as grade III or greater L5 translation according to the Meyerding (MD) classification. Complete postoperative reduction was defined as MD grade I or less and L5 slip < 20%. Forty-six patients completed health-related quality-of-life questionnaires (Oswestry Disability Index, Physical Component Summary of SF-36, and visual analog scale) and ≥ 2 years' follow-up (average 105 months). A 540° approach was used in 61 patients, a 360° approach was used in 40, and L5 corpectomy was used in 17. Radiographic analysis included measures of global spinopelvic balance (e.g., pelvic incidence [PI], lumbar lordosis) and measurement of lumbosacral kyphosis angle (LSA), L4 slope (L4S), L5 slip (%), and postoperative increase of L5-S1 height.

RESULTS

The authors included 101 patients with > 1 year of clinical and radiographic follow-up. The mean age was 26 years. Average preoperative MD grade was 3.8 and average L5 slip was 81%; complete reduction was achieved in 55 and 42 patients, respectively, according to these criteria. At follow-up, LSA correlated with all clinical outcomes (r ≥ 0.4, p < 0.05). Forty patients experienced a major complication. Risk was increased in patients with greater preoperative deformity (i.e., LSA) (p = 0.04) and those who underwent L5 corpectomy (p < 0.01) and correlated with greater deformity correction. Thirty-one patients needed revision surgery, including 17 for pseudarthrosis. Patients who needed revision surgery had greater preoperative deformity (i.e., MD grade and L5 slip) (p < 0.01), greater PI (p = 0.02), and greater postoperative L4S (p < 0.01) and were older (p = 0.02), and these patients more often underwent L5 corpectomy (p < 0.01). Complete reduction was associated with lower likelihood of pseudarthrosis (p = 0.08) and resulted in better lumbar lordosis correction (p = 0.03). Thirty patients had foot drop, and these patients had greater MD grade and L5 slip (p < 0.01) and greater preoperative LSA (p < 0.01). These patients with foot drop more often required L5 corpectomy (p < 0.01). Change in preoperative L4S (p = 0.02), LSA (p < 0.01), and L5-S1 height (p = 0.02) were significantly different between patients with foot drop and those without foot drop. A significant risk model was established that included L4S change and PI as independent variables and foot drop as a dependent variable (82% negative predictive value and 71% positive predictive value, p < 0.01).

CONCLUSIONS

Multivariable analysis identified factors associated with foot drop, major complications, and need for revision surgery, including degree of deformity (MD grade and L5 slip) and correction of LSA. Functional outcome correlated with LSA correction.

Intraoperative Use of Robotics With Navigation for Pedicle Screw Placement in Treatment of Pediatric High-grade Spondylolisthesis: A Preliminary Report

BACKGROUND

Accurate pedicle screw placement is critical to surgically correct pediatric high-grade spondylolisthesis (HGS). The recent advent of robotics coupled with computer-assisted navigation (RAN) may represent a novel option to improve surgical outcomes of HGS, secondary to enhanced pedicle screw placement safety. This series presents the HGS-RAN technique adopted by our site, describing its surgical outcomes and feasibility.

METHODS

Consecutive patients with a diagnosis of HGS (Meyerding grade III to V), operated on using RAN from 2019 to 2020 at a single-center were reviewed. Demographics, screw accuracy, sagittal L5-S1 parameters, complications, and perioperative outcomes were described. All patients were treated with instrumentation, decompression, posterior lumbar interbody fusion, and reduction. Robotic time included anatomic registration to end of screw placement. Screw accuracy-defined as a screw placed safely within the planned intrapedicular trajectory-was characterized by the Gertzbein-Robbins system for patients with additional 3-dimensional imaging.

RESULTS

Ten HGS patients, with an average age of 13.7 years old, were included in the series. All 62 screws were placed without neurological deficit or complication. Seven patients had additional 3-dimensional imaging to assess screw accuracy (42 of 62 screws). One hundred percent of screws were placed safely with no pedicle breaches (Gertzbein-Robbins-grade A). Thirty screws (48%) were placed through separate incisions that were percutaneous/transmuscular and 32 screws (52%) were inserted through the main incision. There were statistically significant improvements in L5 slippage (P=0.002) and lumbosacral angle (P=0.002), reflecting successful HGS correction. The total median operative time was 324 minutes with the robotic usage time consuming a median of 72 minutes. Median estimated blood loss was 150 mL, and length-of-stay was a median 3 days.

CONCLUSIONS

This case-series demonstrates that RAN represents a viable option for HGS repair, indicated by high screw placement accuracy, safety, and L5-S1 slippage correction. Surgeons looking to adopt an emerging technique to enhance safety and correction of pediatric HGS should consider the RAN platform.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

What is the Optimal Surgical Method for Achieving Correction and Avoiding Neurological Complications in Pediatric High-grade Spondylolisthesis?

BACKGROUND

Controversy persists in the treatment of high-grade spondylolisthesis (HGS). Surgery is recommended in patients with intrusive symptoms and evidence debates the competing strategies. This study compares the radiologic outcomes and postoperative complications at a minimum of 2 years follow-up for patients with HGS treated with instrumented fusion with partial reduction (IFIS) with those treated with reduction, decompression, and instrumented fusion (RIF). We hypothesize that IFIS leads to a lower rate of complication and revision surgery than RIF.

METHODS

A retrospective comparative methodology was used to analyze consecutive HGS treated surgically between 2006 and 2017. Patients diagnosed with ≥grade 3 spondylolisthesis treated with arthrodesis before the age of 18 years with a minimum of 2 years follow-up were included. Patients were excluded if surgery did not aim to achieve arthrodesis or was a revision procedure. Cases were identified through departmental and neurophysiological records.

RESULTS

Thirty patients met the inclusion criteria. Mean follow-up was 4 years. Ten patients underwent IFIS and the remaining 20 underwent RIF. The 2 groups showed no difference in demographics, grade of slip, deformity or presenting symptoms. Of 10 treated with IFIS, the SA reduced by a mean of 10 degrees and C7 sagittal vertical line changed by 31 mm. In the RIF cohort, SA reduced by 16 degrees and C7 sagittal vertical line reduced by 26 mm. PT was unchanged in both groups. In IFIS cohort, 2 patients showed postoperative weakness, resolved by 2 years. None required revision surgery. In the RIF group, 4 sustained dural tears and 1 a laminar fracture, 7 showed postoperative weakness or dysaesthesia, 3 of which had not resolved by 2 years. Eight patients underwent unplanned further surgery, 3 for pseudarthrosis.

CONCLUSIONS

RIF and IFIS show similar radiologic outcomes. RIF shows a higher rate of unplanned return to surgery, pseudarthrosis and persisting neurological changes.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Restoration of normal pelvic balance from surgical reduction in high-grade spondylolisthesis

PURPOSE

To investigate the effectiveness of surgical reduction in high-grade spondylolisthesis in maintaining or restoring a normal pelvic balance, as related to the QoL.

METHODS

It is a retrospective analysis of prospectively collected data of 60 patients (17 males, 43 females) aged 15 ± 3.1 years who underwent surgery for high-grade spondylolisthesis and were followed for a minimum of 2 years after surgery. Patients with a residual high-grade slip following surgery were referred to the postoperative high-grade (PHG) group, while patients with a residual low-grade slip were referred to the postoperative low-grade (PLG) group. Pelvic balance was assessed from pelvic tilt and sacral slope, in order to identify patients with a balanced pelvis or unbalanced pelvis. The SRS-22 questionnaire was completed before surgery and at last follow-up.

RESULTS

Postoperatively, there were 36 patients with a balanced pelvis and 24 patients with an unbalanced pelvis. The improvement in QoL was better in patients with a postoperative balanced pelvis. There were 14 patients in the PHG group and 46 patients in the PLG group. Four of seven patients (57%) in the PHG group and 21 of 26 patients (81%) in the PLG group with a preoperative balanced pelvis maintained a balanced pelvis postoperatively (P = 0.1). None of the patients in the PHG group and 11 of 20 patients (55%) in the PLG group improved from an unbalanced to a balanced pelvis postoperatively (P < 0.05).

CONCLUSIONS

Surgical reduction in high- to low-grade slip is more effective in maintaining and restoring a normal pelvic balance postoperatively. These slides can be retrieved under Electronic Supplementary Material.

Expectations for Postoperative Improvement in Health-Related Quality of Life in Young Patients With Lumbosacral Spondylolisthesis: A Prospective Cohort Study

STUDY DESIGN

Prospective multicenter study of the changes in Scoliosis Research Society Outcome Questionaire 22 (SRS-22) scores for 78 patients younger than 25 years old surgically treated for lumbosacral spondylolisthesis OBJECTIVE.: Report the change of health-related quality of life (HRQOL) in patients younger than 25 years after surgical treatment of lumbosacral spondylolisthesis.

SUMMARY OF BACKGROUND DATA

There is a paucity of data with regard to the influence of surgical treatment on the HRQOL of patients with lumbosacral spondylolisthesis. Large prospective studies are needed to clearly define the benefits of surgery in the young patient population.

METHODS

A prospective multicenter cohort of 78 patients younger than 25 years (14.8 ± 2.9, range: 7.9-23.6 yr) undergoing posterior fusion for lumbosacral spondylolisthesis were enrolled. There were 17 patients with low-grade (<50%) and 61 with high-grade (≥50%) slips. SRS-22 scores calculated before surgery and after 2 years of follow-up were compared for all patients using two-tailed paired t tests. Subanalyses for low- and high-grade patients were done using two-tailed Wilcoxon signed ranked and paired t tests, respectively. The level of significance was set at 0.05.

RESULTS

HRQOL was significantly improved 2 years after surgery for all domains and for the total score of the SRS-22 questionnaire. The individual total score was improved in 66 patients (85%), and 52 patients (67%) improved by at least 0.5 point. All domains and the total score of the SRS-22 questionnaire were significantly improved for high-grade patients, whereas only pain, function, and total score were improved for low-grade patients.

CONCLUSION

This is the largest study comparing the HRQOL before and after surgery in young patients with low- and high-grade lumbosacral spondylolisthesis. HRQOL significantly improves after surgery for the majority of patients, especially for high-grade patients. This study helps clinicians to better counsel patients with regard to the benefits of surgery for lumbosacral spondylolisthesis.

LEVEL OF EVIDENCE

2.

A systematic review of clinical outcomes in surgical treatment of adult isthmic spondylolisthesis

BACKGROUND CONTEXT

A variety of surgical methods are available for the treatment of adult isthmic spondylolisthesis, but there is no consensus regarding their relative effects on clinical outcomes.

PURPOSE

To compare the effects of different surgical techniques on clinical outcomes in adult isthmic spondylolisthesis.

DESIGN

A systematic review was carried out.

PATIENT SAMPLE

A total of 1,538 patients from six randomized clinical trials (RCTs) and nine observational studies comparing different surgical treatments in adult isthmic spondylolisthesis.

OUTCOME MEASURES

Primary outcome measures of interest included differences in pre- versus postsurgical assessments of pain, functional disability, and overall health as assessed by validated pain rating scales and questionnaires. Secondary outcome measures of interest included intraoperative blood loss, length of hospital stay, surgery duration, reoperation rates, and complication rates.

METHODS

A search of the literature was performed in September 2017 for relevant comparative studies published in the prior 10-year period in the following databases: PubMed, Embase, Web of Science, and ClinicalTrials.gov. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed and studies were included or excluded based on strict predetermined criteria. Quality appraisal was conducted using the Newcastle-Ottawa scale (NOS) for observational studies and the Cochrane Collaboration risk of bias assessment tool for RCTs. The authors received no funding support to conduct this review.

RESULTS

A total of 15 studies (six RCTs and nine observational studies) were included for full-text review, a majority of which only included cases of low-grade isthmic spondylolisthesis. One study examined the effects of adding pedicle screw fixation (PS) to posterolateral fusion (PLF) and two studies examined the effects of adding reduction to interbody fusion (IF)+PS on clinical outcomes. Five studies compared PLF, four with PS and one without PS, with IF+PS. Additionally, three studies compared circumferential fusion (IF+PS+PLF) with IF+PS and one study compared circumferential fusion with PLF+PS. Three studies compared clinical outcomes among different IF+PS techniques (anterior lumbar IF [ALIF]+PS vs. posterior lumbar IF [PLIF]+PS vs. transforaminal lumbar IF [TLIF]+PS) without PLF. As per the Cochrane Collaboration risk of bias assessment tool, four RCTs had an overall low risk of bias, one RCT had an unclear risk of bias, and one RCT had a high risk of bias. As per the NOS, three observational studies were of overall good quality, four observational studies were of fair quality, and two observational studies were of poor quality.

CONCLUSIONS

Available studies provide strong evidence that the addition of reduction to fusion does not result in better clinical outcomes of pain and function in low-grade isthmic spondylolisthesis. Evidence also suggests that there is no significant difference between interbody fusion (IF+PS) and posterior fusion (PLF±PS) in outcomes of pain, function, and complication rates at follow-up points up to approximately 3 years in cases of low-grade slips. However, studies with longer follow-up points suggest that interbody fusion (IF+PS) may perform better in these same measures at later follow-up points. Available evidence also suggests no difference between circumferential fusion (IF+PS+PLF) and interbody fusion (IF+PS) in outcomes of pain and function in low-grade slips, but circumferential fusion has been associated with greater intraoperative blood loss, longer surgery duration, and longer hospital stays. In terms of clinical outcomes, insufficient evidence is available to assess the utility of adding PS to PLF, the relative efficacy of different interbody fusion (IF+PS) techniques (ALIF+PS vs. TLIF+PS vs. PLIF+PS), and the relative efficacy of circumferential fusion and posterior fusion (PLF+PS).