16-Year-old with Grade 3 Spondylolisthesis

History

The patient is a 16-year-old female presenting with back pain, hamstring tightness, and increasing leg pain, with pain in the left leg greater than in the right.

Examination

Patient has normal coronal and sagittal balance, in addition to a normal neurologic exam. She has positive left straight leg raise.

Prior Treatment

Previously, the patient has tried physical therapy.

Images

Featured below are preoperative standing (Figures 1-3) and bending (Figures 4-6) pictures; anterior (Figure 7) and lateral (Figures 8-9) radiographs; and lateral (Figure 10) and axial (Figure 11) MRIs.

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Figure 10

Figure 11

Diagnosis

The patient was diagnosed with Grade 3 isthmic spondylolisthesis.

Selected Treatment

The patient underwent an L4-S1 posterior spinal fusion with reduction, bilateral L5-S1 TLIF, and supplemental pelvic fixation using S2-alar screws.

Postoperative anterior (Figure 12), lateral (Figure 13-14) radiographs and patient photos (Figures 15-16) are featured.

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Outcome

The patient reports complete relief of back and leg pain. There are no neurologic deficits.

Case Discussion

Neel Anand, MD, Mch Orth
Director, Orthopaedic Spine Surgery
Co-Director, Spine Fellowship
Cedars-Sinai Institute for Spinal Disorders
Los Angeles, CA

The patient has a Grade 3 lytic spondylolisthesis of L5-S1. What's concerning is the degenerative changes already present at L4-L5 with the segment in shear. The MRI does show the listhesis reduces to a Grade 1 or 2 when the patient is supine, and this is important information for me in deciding my approach.

A discogram could be done for the L4-L5 disc to ascertain if this is a pain generator. Personally, though, I would go with the MRI and decide to include L4-L5 in the fusion. I would also obtain a CT scan to specifically look at the L5 pedicle morphology for placement of pedicle screws.

My preference would be to treat this patient through a posterior only approach as the listhesis does reduce posturally. I would do a wide decompression with Gill laminectomy at L5 with decompression of the L5 nerve bilaterally at the pars defect. I would follow this with a sacral dome osteotomy to gain access to the L5-S1 disc space and help correction of the segmental kyphosis, followed with an interbody fusion with a banana shaped PEEK device placed as anteriorly as possible augmented with autogenous cancellous bone and DBM. This would help correct the kyphosis and obtain as much translational correction of the slip as allowed. I would not emphasize or attempt to completely correct the translational component. Fixation would then be achieved with pedicle screws at L4, L5, and S1 bilaterally. The ability to feel and localize the L5 pedicle, from within the spinal canal helps to place the L5 pedicle screw, which at times can be difficult. The S1 screws should be tricortical, covergent, and engaging the sacral promontory. They should also be as large as possible-usually a 7.5mm screw. If there is any concern with the sacral fixation, I would not hesitate in placing an iliac bolt or supplemental S2 or sacral alar screws. I would then perform a posterior and posterolateral fusion from L4 to S1, augmented with autogenous iliac crest cancellous bone and DBM.

The autogenous iliac crest cancellous bone can be harvested through the same incision with a small bone auger from between the tables of the iliac crest, taking care to not perform any subperiosteal stripping of the outer table of the iliac crest.