The axial cage. a pilot study for interbody fusion in higher-grade spondylolisthesis

Instrumented L5-S1 interbody graft with IFUSE implant using the reverse Bohlman technique

BACKGROUND

In case of high sacral slope, anterior lumbosacral fusions can be performed by retroperitoneal or transperitoneal approach using a reversed Bohlman technique with an autologous corticocancellous fibular graft. The use of a trans-lumbosacral implant can avoid the iatrogenic effects but currently, there is no implant specifically designed for this fusion technique. Could the IFUSE implant from SI BONE replace a fibular graft to avoiding the iatrogenic effect induced by sampling during a Reverse Bohlman technique?

PATIENTS AND METHODS

We present the case of a 38-year-old woman with L5S1 interbody pseudarthrosis after posterior fixation for grade 2 L5-S1 spondylolisthesis with isthmic lysis of L5, and that of a 69-year-old woman who underwent a posterior T4 fusion to the pelvis for degenerative scoliosis. Both required a trans-lumbosacral instrumented fusion via an anterior approach using the reverse Bohlman technique. Surgical technique was described.

RESULTS

There were no perioperative or postoperative complications. At 6 months, the patients reported a decrease in lumbar and radicular symptomatology. There were no infectious, neurological or vascular complications. CT-scans confirmed the good position and stability of the IFUSE implant.

DISCUSSION

We present an innovative interbody grafting technique adapted to spines with high pelvic incidence. The surgical technique is safe, minimally invasive, and reduces surgical iatrogeny. The short and medium-term results are positive but require longer-term follow-up and a larger cohort.

Long term outcome and fusion rate of transdiscal fixation for L5-S1 high grade spondylolisthesis

OBJECTIVE

High grade spondylolisthesis (HGS) is a quite rare entity and many techniques are available to address this condition. In 1994 Abdu et al. proposed a transdiscal fixation approach that achieved a good clinical outcome. We analyse outcome and fusion achieved in patients treated by transdiscal fixation after 1-year follow-up.

METHODS

We reviewed patients operated through transdiscal fixation since 2014 with a follow-up of at least 1 year, and compared preoperative and postoperative clinical measures (ODI, VAS and EQ-5D) and postoperative complications. Also, we analyzed the degree of fusion on CT scan with Lenke and Birdwell criteria.

RESULTS

Twelve patients were included in the study with a mean follow-up of 49.4 months (range 12.8-84.1 months). Three cases presented a Meyerding grade IV spondylolisthesis and 9 cases grade III. At 1-year follow-up mean postoperative ODI, VAS and EQ5D scores improved (ODI 13.2 (range 0-30) vs 49.83 (range 15-71.1); p = .005). Equally this improvement was seen in the last follow-up (ODI 9.28 (range 0-35) vs 49.83 (range 15-71.1); p = .005). CT scan showed fusion grade A in 5 patients (41.6%), another 5 as grade B (41.6%) in Lenke classification. According to the Birdwell criteria 4 patients were classified as grade I (33.3%), 7 patients grade II (58.3%). None showed complications postoperatively or radiolucency in follow-up.

CONCLUSIONS

Transdiscal fixation shows a good clinical outcome that is maintained throughout a long time period and provides a reliable and suitable fusion.

Biomechanical comparison of 3 types of transdiscal fixation implants for fixing high-grade L5/S1 spine spondylolisthesis

BACKGROUND CONTEXT

There are several options for the stabilization of high-grade lumbosacral spondylolisthesis including transdiscal screws, the Bohlman technique (transdiscal fibular strut) and the modified Bohlman technique (transdiscal titanium mesh cage). The choice of an optimum construct remains controversial; therefore, we endeavoured to study and compare the biomechanical performance of these 3 techniques.

PURPOSE

The aim of this study was to compare 3 types of transdiscal fixation biomechanically in an in vitro porcine lumbar-sacral spine model.

STUDY DESIGN/SETTING

Porcine cadaveric biomechanical study.

METHODS

18 complete lumbar-sacral porcine spines were split into 3 repair groups, transdiscal screws (TS), Bohlman technique, and a modified Bohlman technique (MBT). Range of motion (L3 - S1) was measured in an intact and repaired state for flexion, extension, left/right lateral bending, and left/right torsion. To recreate a high-grade lumbosacral spondylolisthesis a bilateral L5/S1 facetectomy, removing the intervertebral disc completely, and the L5 body was displaced 50%-60% over the sacral promontory. Results were analyzed and compared to intact baseline measurements. Standard quasi-static moments (5 Nm) were applied in all modes.

RESULTS

All range of motion (ROM) were in reference to intact baseline values. TS had the lowest ROM in all modes (p=.006-.495). Statistical difference was found only in extension for TS vs. BT (p=.011) and TS vs. MBT (p=.014). No bone or implant failures occurred.

CONCLUSION

TS provided the lowest ROM in all modes of loading compared to Bohlman technique and MBT. Our study indicates that TS results in the most biomechanically stable construct.

CLINICAL SIGNIFICANCE

Knowledge of the biomechanical attributes of various constructs could aid physicians in choosing a surgical construct for their patients.

Use of a Reverse Bohlman Technique for Low-Grade Spondylolisthesis

Background

Treatment of spondylolisthesis can be difficult with regard to patients with high sacral slopes that may prohibit placement of interbody grafts for fusions across that segment. Here, we describe placement of a reverse Bohlman technique from an anterior approach to obtain fusion across a low-grade spondylolisthesis with a high sacral slope to obtain anterior fusion.

Methods

A chart review was conducted on this single patient regarding his clinical course and outcome.

Results

A 54-year-old male presented with low-back pain associated with bilateral leg pain dating back several years. Plain films demonstrated a Grade II isthmic spondylolisthesis at L5-S1 with spinopelvic measurements of 73° sacral slope, 82° lumbar lordosis, 12° pelvic tilt, and 94° pelvic incidence. Magnetic resonance imaging showed bilateral L5 pars defects with diffuse degenerative disease from L4 through S1 and significant ligamentous and facet hypertrophy. He underwent an L4-5 anterior lumbar interbody fusion and an L5-S1 reverse Bohlman placement of a transvertebral transsacral titanium mesh cage. This was supplemented with a posterior decompression and instrumentation from L4-ilium. He had resolution of his radiculopathy and has maintained a good clinical outcome at 3 years follow up.

Conclusions

We present here a patient with low-grade spondylolisthesis and a steep sacral slope who underwent a successful reverse Bohlman approach with long-term follow up. This report highlights the potential utility of this method as a viable alternative for patients with low-grade spondylolisthesis.

Level of Evidence

IV.

Clinical Relevance

Technical description of surgical technique.

Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population

BACKGROUND/AIMS

Surgical techniques for treatment of high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate both radiographic and clinical outcomes in patients with HGS treated with the "modified Bohlman" and Reverse Bohlman technique.

METHODS

Review of consecutive HGS patients undergoing modified Bohlman and Reverse Bohlman at a single center from 2006 to 2018. Clinical, surgical, and radiographic data were collected.

RESULTS

Six patients identified in the modified Bohlman treatment arm: and eight patients in the Reverse Bohlman group. Twelve (12) patients presented with high grade congenital spondylolisthesis at L5-S1; one patient presented with dissolution of the L5 vertebral body secondary to uncontrolled osteomyelitis that developed after a previous failed fusion; and one patient presented with iatrogenic L5-S1 spondylolisthesis after a previous L3-S1 fusion. One patient had medially placement pedicle screw and associated radiculopathy. All follow-up post = operative scans demonstrated solid fusion. Postoperatively, anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43° of kyphosis to 48.71° (p = .0139). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively except for positioning on a sacral cushion to increase lordotic angle. Lumbar lordosis improved from 65.29 to 63.86 postoperatively. Four of our fourteen patients had long-term median follow-up of 28 months (range = 19-48 months) slip angle, percentage, and lumbar lordosis all improved from the patient's pre-operative measurements. The improvement in slip angle was nearly statistically significant with a p-value of 0.065.

CONCLUSIONS

Reverse Bohlman technique for high grade spondylolisthesis is a viable option when seeking to address adjacent level instability or slip.

Two-level reverse Bohlman transsoseous approach for treatment of symptomatic pseudarthrosis

Surgical treatment for high-grade spondylolisthesis with high sacral slope remains controversial and no definitive gold standard procedure has been identified. The Bohlman technique, in which a fibular strut is reamed posteriorly across the L5-S1 disc space in an oblique, inferior to superior trajectory, has been increasingly utilized. Recently, a Reverse Bohlman technique has been described, in which a graft is reamed anteriorly across a single disc space in a superior to inferior trajectory. Case Report A 55 year-old male with complete lumbarization of S1 (referred to as L6) and previous L5-L6-S1 posterior instrumented fusion presented, with progressively worsening low back pain and lower extremity radicular pain. After failing conservative management, he underwent a 2-level Reverse Bohlman approach to place a titanium mesh interbody graft (cage) anteriorly from L5 to S1, crossing the L5-6 and L6-S1 disc spaces. Here we describe for the first time a Reverse Bohlman technique spanning two disc spaces in a patient with a transitional lumbosacral anomaly and high sacral slope. At 6 months post-operative follow up, the patient reported near complete resolution of symptoms.

"Reverse Bohlman" technique for the treatment of high grade spondylolisthesis in an adult population

BACKGROUND/AIMS

Surgical techniques for effective high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate radiographic/clinical outcomes in HGS patients treated using modified "Reverse Bohlman" (RB) technique.

METHODS

Review of consecutive HGS patients undergoing RB at a single university-center from 2006 to 2013. Clinical, surgical, radiographic parameters collected.

RESULTS

Six patients identified: five with L5-S1 HGS with L4-L5 instability and one had an L4-5 isthmic spondylolisthesis and grade 1 L5-S1 isthmic spondylolisthesis. Two interbody graft failures and one L5-S1 pseudoarthrosis. Postoperative improvement of anterolisthesis (62.3% vs. 49.6%, p = 0.003), slip angle (10 vs. 5°, p = 0.005), and lumbar lordosis (49 vs. 57.5°, p = 0.049).

CONCLUSIONS

RB technique for HGS recommended when addressing adjacent level instability/slip.

High-grade spondylolisthesis treated using a modified Bohlman technique: results among multiple surgeons

OBJECT

The ideal surgical management of high-grade spondylolisthesis remains unclear. Concerns regarding the original Bohlman transsacral interbody fusion technique with stand-alone autologous fibular strut include late graft fracture and incomplete reduction of lumbosacral kyphosis. The authors' goal was to evaluate the radiographic and surgical outcomes of patients treated for high-grade spondylolisthesis with either transsacral S-1 screws or standard pedicle screw fixation augmenting the Bohlman posterior transsacral interbody fusion technique.

METHODS

A retrospective review of patients who underwent fusion for high-grade spondylolisthesis in which a Bohlman oblique posterior interbody fusion augmented with either transsacral or standard pedicle screw fixation was performed by 4 spine surgeons was completed. Estimated blood loss, operating time, perioperative complications, and need for revision surgery were evaluated. Upright pre- and postsurgical lumbar spine radiographs were compared for slip percent and slip angle.

RESULTS

Sixteen patients (12 female and 4 male) with an average age of 29 years (range 9-66 years) were evaluated. The average clinical follow-up was 78 months (range 5-137 months) and the average radiographic follow-up was 48 months (range 5-108 months). Ten L4-S1 and 6 L5-S1 fusions were performed. Five fibular struts and 11 titanium mesh cages were used for interbody fusion. Six patients had isolated transsacral screws placed, with 2 (33%) of the 6 requiring revision surgery for nonunion. No nonunions were observed in patients undergoing spanning pedicle screw fixation augmenting the interbody graft. Six patients experienced perioperative complications including 3 iliac crest site infections, 1 L-5 radiculopathy without motor involvement, 1 deep vein thrombosis, and 1 epidural hematoma requiring irrigation and debridement. The average estimated blood loss and operating times were 763 ml and 360 minutes, respectively. Slip percent improved from an average of 62% to 37% (n = 16; p < 0.01) and slip angle improved from an average of 18° to 8° (n = 16; p < 0.01). No patient experienced L-5 or other motor deficit postoperatively.

CONCLUSIONS

The modified Bohlman technique for treatment of high-grade spondylolisthesis has reproducible outcomes among multiple surgeons and results in significant improvements in slip percent and slip angle. Fusion rates were high (14 of 16; 88%), especially with spanning instrumentation augmenting the oblique interbody fusion. Rates of L-5 motor deficit were low in comparison with techniques involving reduction of the anterolisthesis.

Management of high-grade spondylolisthesis

Management of high-grade spondylolisthesis (HGS) remains challenging and is associated with significant controversies. The best surgical procedure remains debatable. Although the need for instrumentation is generally agreed upon, significant controversies still surround the role of reduction and anterior column support in the surgical management of HGS. Complications with operative management of HGS can be significant and often dictate the selection of surgical approach. This review highlights the pathophysiology, classification, clinical presentation, and management controversies of HGS, in light of recent advances in our understanding of the importance of sagittal spinopelvic alignment and technologic advancements.

Clinical and radiological outcomes of axial lumbar interbody fusion

Axial lumbar interbody fusion is a novel percutaneous alternative to common open techniques, such as anterior, posterior, and transforaminal lumbar interbody fusion. This minimally invasive technique uses the presacral space to access the L5-S1 and L4-L5 disk space. The goal of this study was to examine outcomes following axial lumbar interbody fusion. The charts of all patients who underwent axial lumbar interbody fusion surgery at our institution between 2006 and 2008 were reviewed. Clinical outcomes included visual analog scale (VAS) and Oswestry Disability Index (ODI). Radiographs were also evaluated for disk space height, L4-L5 and/or L5-S1 Cobb angle, and fusion. Of the 50 patients (32 women, 18 men; mean age, 49.29 years) treated with axial lumbar interbody fusion, 48 had preoperative VAS scores and 16 had preoperative ODI scores available. Complete radiographic data were available at the preoperative, initial postoperative, and final postoperative time points for 46 patients (92%). At last follow-up (average, 12 months), ODI scores were reduced from 46 to 22, and VAS scores were lowered from 8.1 to 3.6. Of the 49 patients with postoperative radiographs, 47 (96%) went on to a solid fusion. There were no significant differences between pre- and postoperative disk space height and lumbar lordosis angle. The most common complications were superficial infection and pseudoarthrosis. Other complications were rectal injury, hematoma, and irritation of a nerve root by a screw. Overall, we found the axial lumbar interbody fusion procedure in combination with pedicle screw placement to have good clinical and radiological outcomes.

Transsacral screw fixation for high-grade spondylolisthesis

BACKGROUND CONTEXT

Symptomatic high-grade spondylolisthesis (Meyerding III-V) is usually treated by surgery. Recent literature shows that in situ fusion is better than reduction of the slip and fusion in high-grade spondylolisthesis. Furthermore, the outcome is improved if circumferential fusion is performed in severe spondylolisthesis. We have performed a new technique of circumferential fusion in high-grade spondylolisthesis using two transsacral hollow modular anchorage (HMA) screws supplemented with pedicle screw fixation and posterolateral fusion.

PURPOSE

The aim of the study is to analyze the results of circumferential fusion using transsacral HMA screws supplemented with posterolateral fusion and pedicle screw fixation.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Twelve patients with high-grade spondylolisthesis were reviewed.

OUTCOME MEASURES

Outcome was measured using short form 36 (SF-36) and the ability to return to work at the most recent follow-up.

METHODS

All patients had interbody fusion using transsacral HMA screws filled with cancellous bone graft and supplemented with pedicle screw instrumentation and posterolateral fusion.

RESULTS

The male to female ratio was 2:1 with a mean age of 31 years (range 13-54 years). Eleven of 12 patients had disappearance of leg pain. There were no neurological complications in any of them. Circumferential fusion was achieved in all of them at a mean follow-up of 21 months. The average physical function score improved from 22.50+/-10.34 to 57.50+/-17.39 (p=.001, 95% confidence interval [CI] -44.48 to -25.52), whereas the average pain score improved from 22.22+/-13.40 to 61.11+/-15.35 (p=.001, 95% CI -51.12 to -26.66).

CONCLUSIONS

HMA screws avoid the complications associated with autologous cortical fibular strut graft and also are useful to promote interbody fusion, as the hollowness in the screw can be filled with cancellous bone graft that helps in better fusion. Supplementary pedicle screw fixation is necessary to protect the HMA screws, and they together give a stable construct that can achieve a circumferential fusion in high-grade spondylolisthesis.

Cosmetic and functional outcomes following paramedian and anterolateral retroperitoneal access in anterior lumbar spine surgery

Object

In this paper, the authors review the functional and cosmetic outcomes and complications in 300 patients who underwent treatment for lumbar spine disease via either an anterior paramedian or conventional anterolateral retroperitoneal approach.

Methods

Seven surgeons performed anterior lumbar surgeries in 300 patients between August 2004 and December 2006. One hundred and eighty patients were treated with an anterior paramedian approach, and 120 patients with an anterolateral retroperitoneal approach. An access surgeon was used in 220 cases (74%). Postoperative evaluation in all patients consisted of clinic visits, assessment with the modified Scoliosis Research Society–30 instrument, as well as a specific questionnaire relating to wound appearance and patient satisfaction with the wound.

Results

At a mean follow-up of 31 months (range 12–47 months), the mean Scoliosis Research Society–30 score (out of 25) was 21.2 in the patients who had undergone the anterior paramedian approach and 19.4 in those who had undergone the anterolateral retroperitoneal approach (p = 0.005). The largest differences in quality of life measures were observed in the areas of pain control (p = 0.001), self-image (p = 0.004), and functional activity (p = 0.003), with the anterior paramedian group having higher scores in all 3 categories. Abdominal bulging in the vicinity of the surgical site was the most common wound complication observed and was reported by 22 patients in the anterolateral retroperitoneal group (18%), and 2 patients (1.1%) in the anterior paramedian group. Exposures of ≥ 3 levels with the anterolateral approach were associated with abdominal bulging (p = 0.04), while 1- or 2-level exposures were not (p > 0.05). Overall satisfaction with incisional appearance was higher in patients with an anterior paramedian incision (p = 0.001) and with approaches performed by an access surgeon (p = 0.004).

Conclusions

Patients who undergo an anterior paramedian approach to the lumbar spine have a higher quality of life and better cosmetic outcomes than patients undergoing an anterolateral retroperitoneal approach.

Prevention of epidural scarring after microdiscectomy: a randomized clinical trial comparing gel and expanded polytetrafluoroethylene membrane

A randomized clinical trial compared two materials used to prevent epidural scarring after microdiscectomy. To determine whether ADCON-L Gel (ALG) or Preclude Spinal Membrane (PSM) was more effective in preventing scarring, reducing pain, and improving quality of life postoperatively. Postdiscectomy syndrome may result from epidural scarring. Various materials have been used in attempts to prevent this problem, but none have provided optimal results. Previous laboratory and clinical studies have found ALG and PSM to be effective, but none compared the two materials. Thirty-one patients undergoing primary microdiscectomy were randomly assigned to receive either ALG or PSM. Postoperatively, patients were evaluated by magnetic resonance imaging (MRI), with contrast, for volume and rostral-caudal extent of scar tissue and nerve root involvement. Back and leg pain and quality of life were assessed by neurologic examinations and standardized patient surveys. Findings at any reoperations were recorded. Results in the PSM (n = 18) and ALG (n = 13) groups were compared statistically. No operative or postoperative complications occurred. Two patients in each group required reoperation. MRI at 6 months showed no, mild or mild-moderate scarring in most patients, with no significant differences between the ALG and PSM groups in scar volume and extent or nerve root involvement. Neurologic examinations and patient surveys showed substantial reductions in pain over time in both groups but no significant differences between groups. PSM was easy to see and remove at reoperation. PSM and ALG are equally effective in preventing epidural scarring associated with postdiscectomy syndrome.

A novel minimally invasive presacral approach and instrumentation technique for anterior L5-S1 intervertebral discectomy and fusion: technical description and case presentations

OBJECT

The authors describe a new paracoccygeal approach to the L5-S1 junction for interbody fusion with transsacral instrumentation. The purpose of this technical note is to demonstrate a novel surgical approach, technique, and instrumentation system for the treatment of L5-S1 instability in degenerative disc disease and spondylolisthesis.

METHODS

This technical note highlights the AxiaLif (TranS1) transsacral system as an alternative method to transforaminal lumbar interbody fusion or posterior lumbar interbody fusion. Via a novel presacral approach corridor, a truly percutaneous L5-S1 discectomy, interbody distraction, and fixation are achieved, and retroperitoneal viscera and dorsal neural elements are avoided. Percutaneous pedicle screw fixation is then used to provide additional stabilization at the treated level.

CONCLUSIONS

This novel technique of interbody distraction and fusion via a truly percutaneous approach corridor allows for circumferential treatment of the lower lumbar segments with minimal risk to the anterior organs and dorsal neural elements.

Computer-guided percutaneous interbody fixation and fusion of the L5-S1 disc: a 2-year prospective study

BACKGROUND

The clinical outcomes of lumbar fusion are diminished by the complications associated with the surgical approach. Posterior approaches cause segmental muscular necrosis and anterior approaches risk visceral and vascular injury. This report details a two-year prospective study of a percutaneous method which avoids the major problems associated with existing approaches.

METHODS

Seventeen patients underwent percutaneous, trans-sacral fusion and fixation of L5-S1 with the assistance of computer guidance. Each patient was followed for a minimum of two years post surgery. SF-36 questionnaires and radiographs were obtained preoperatively and at two years post-operatively. Fusion was assessed with post-operative radiographs and/or CT scan.

RESULTS

Ninety-three percent of the people fused as judged by plain AP films, Ferguson's view radiographs, and/or CT scans at the two year follow-up. Prospective health and functional SF-36 scores showed significant improvement from the preoperative to the postoperative period. There were no significant complications related to the approach or to the placement of the implants.

CONCLUSION

Percutaneous fusion of the lumbosacral spine appears safe and provides excellent clinical results with a minimal amount of associated tissue trauma.

Evaluation and management of high-grade spondylolisthesis in adults

STUDY DESIGN

A retrospective review was performed on 21 adult patients surgically treated with high-grade spondylolisthesis (Grade III, IV, or V). Additionally, the natural history, classification, and surgical alternatives for high-grade spondylolisthesis in the adult are discussed through literature review.

OBJECTIVES

The purpose of this article is to review the clinical and radiographic outcomes of surgical treatment of high-grade spondylolisthesis in the adult from a single institution. The natural history and treatment options for these adults are described in this review.

SUMMARY OF BACKGROUND DATA

High-grade spondylolisthesis is typically diagnosed and treated in the child or adolescent. Most patients with high-grade spondylolisthesis received surgical treatment during their adolescence. Some patients, however, remain minimally symptomatic for life without surgery. Little has been written on the natural history or treatment of adults with high grades of spondylolisthesis. Most of the published reports on the surgical treatment of high-grade spondylolisthesis pertain to skeletally immature patients and maybe include a few adults in their series. Nonetheless, the different techniques of surgical treatment for high-grade spondylolisthesis that have been described in these studies can help the spinal surgeon in treatment options for this rare but difficult spinal deformity.

METHODS

A literature review of the published manuscripts on the treatment of high-grade spondylolisthesis was performed with particular attention to the natural history and surgical treatment involving adult patients. Adult patients (older than 21 years) with high-grade spondylolisthesis treated surgically were retrospectively reviewed. Patients' clinical charts and radiographs were reviewed before and after surgery. Determination of fusion success, clinical outcome, and complications were performed.

RESULTS

Twenty-one consecutive adults with high-grade spondylolisthesis who underwent lumbar spinal surgery were review retrospectively between 1990 and 2004. There were 13 females and 8 males with an average age of 35 years (range, 21-68 years). The average follow-up was 6.6 years. There were 11 Grade III, 6 Grade IV, and 4 Grade V slips, including 4 acquired and 17 developmental spondylolistheses. There were no pseudarthroses or significant instrumentation failures. There was 1 case of a complete cauda equina syndrome on a patient with preoperative symptoms of an incomplete cauda equina syndrome.

CONCLUSIONS

Adult patients with high-grade spondylolisthesis not responding to nonoperative treatment can be stabilized in situ with posterior instrumentation from L4 to S1. The use of adjunctive fixation with iliac screws and/or transvertebral screws is recommended for the adult patient, particularly in revision or unstable cases. Reduction of the slipped vertebrae remains controversial for all grades of spondylolisthesis and more so for the adult patient. Partial reduction of the slip angle, decreasing the lumbosacral kyphosis, should be considered if significant sagittal malalignment is present or to improve arthrodesis success. Anterior column support should be performed, particularly when reduction has been obtained. Anterior column support can be performed, anteriorly or posteriorly, either by using inter vertebral body structural strut support or with a transsacral fibular dowel to improve stability and success of arthrodesis.