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Grade IV Spondylolisthesis

History

The patient is an active 14-year-old male with progressive back pain and difficulty with gait. He has radicular pain in his buttocks and posterior thighs.

Examination

He has an obvious lumbosacral deformity.

The patient had a bilateral positive straight leg raise, and EHL weakness 4/5 on the right.

Pre-treatment Images

 Fig 1 Lewis Grade IV Spondylolisthesis Pre-op AP Radiograph.jpgFigure 1:  AP radiograph showing Napolean Hat Sign

 

Fig 2 Lewis Grade IV Spondylolisthesis Showing Grade IV Dysplastic Spondylolisthesis.jpgFigure 2:  Spot L5-S1 showing Grade IV dysplastic spondylolisthesis

 

Fig 3 Lewis Grade IV Spondylolisthesis Pre-op Lateral Standing Radiograph.jpgFigure 3:  Lateral standing radiograph demonstrating Grade IV dysplastic spondylolisthesis with compensatory lordosis and retroverted pelvis

 

Fig 4 Lewis Grade IV Spondylolisthesis Pre-op 3D Reconstruction.jpgFigure 4:  3D reconstruction demonstrating deformity

 

Fig 5 Lewis Grade IV Spondylolisthesis Pre-op Axial CT Scan.jpgFigure 5:  Axial CT scan demonstating deformity

 

Fig 6 Lewis Grade IV Spondylolisthesis Pre-op Axial CT Scan.jpgFigure 6:  Axial CT scan demonstrating deformity

 

Fig 7 Lewis Grade IV Spondylolisthesis Pre-op Sagittal CT Scan.jpgFigure 7:  Sagittal CT scan demonstrating right foramen

 

Fig 8 Lewis Grade IV Spondylolisthesis Pre-op Sagittal CT Scan.jpgFigure 8:  Sagittal CT demonstrating midline deformity

 

Fig 9 Lewis Grade IV Spondylolisthesis Pre-op Sagittal CT Scan.jpgFigure 9:  Sagittal CT scan demonstrating left foramen

 

Fig 10 Lewis Grade IV Spondylolisthesis Pre-op Midline MRI.jpgFigure 10:  Midline MRI showing complete obliteration of right L5 foramen

 

Fig 11 Lewis Grade IV Spondylolisthesis Pre-op Left Foraminal Cut MRI.jpgFigure 11:  Left foraminal cut MRI showing midline compression

 

Fig 12 Lewis Grade IV Spondylolisthesis Pre-op Right Foraminal Cut MRI.jpgFigure 12:  Right foraminal cut MRI showing complete obliteration of left L5 foramen

Diagnosis

Grade IV spondylolisthesis

Suggest Treatment

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Selected Treatment

The patient underwent an instrumented L4-pelvis fusion with partial reduction and decompression and interbody support.

Reduction was chosen because the patient was decompensated, as noted by the vertical sacrum and lordotic lumbar and thoracic spines.  Gill laminectomy and decompression of both L5 nerve roots through the pars defects was performed with central and far lateral discectomy to decompress the foramens.  Instrumentation was carried out from L4 to the pelvis with reduction of the translational and angular deformities of L5.  Interbody support with a PEEK cage was used to maintain the angular correction and load share the construct.

Post-treatment Images

Figures 13-14:  X-rays showing instrumentation from L4 to the pelvis with partial reduction of translational and angular deformites at L5.  These also show the PEEK TLIF cage in place.  These images are from 1-week after surgery.

Fig 13 Lewis Grade IV Spondylolisthesis Post-op X-ray 1-week.jpgFigure 13

 

Fig 14 Lewis Grade IV Spondylolisthesis Standing Post-op X-ray 1-week.jpg Figure 14

 

Fig 15 Lewis Grade IV Spondylolisthesis Standing Post-op X-ray 18-months
Figure 15:  Pre-op and 18-months post-op standing lateral radiographs 

Outcome

The straight leg raise improved, and the patient made a full recovery in neurologic function.

Case Discussion

This is a very challenging case. It appears that the patient is suffering from grade IV isthmic spondylolisthesis on Meyerding classification.

The measurements on the 3 foot-standing x-rays provided are:
Pre-op (Figures 1 and 3):
SVA: 8.85 cm
TK: 4
LL (L1-L4): 32
SS: 7
PT: 27
PI: 36

1-week Post-op (Figure 14):
SVA: 8.55 cm
TK: 1
LL (L1-L4): 13
SS: 16
PT: 21
PI: 35

According to these measurements, the patient’s global sagittal balance is positive (approximately 8 to 9 cm). It appears that after the surgical procedure—despite adequate partial reduction of the spondylolisthesis—and after 18 months follow up, the patient continues to be in sagittal imbalance and sustained good clinical outcome with no evidence of hardware failure.

The author is to be commended in this case in that he was able to provide significant opening and distraction  of the L5-S1 interspace. This can be difficult in these severe spondylolisthesis cases.

 

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