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A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction
Journal of Clinical Neuroscience xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Tools and techniques
A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction Chester J. Donnally III a,⇑, Karthik Madhavan b, Alexander J. Butler a, Jonathan I. Sheu c, Dustin H. Massel a, Barth A. Green b, Joseph P. Gjolaj a a b c
University of Miami Hospital, Department of Orthopaedic Surgery, 1400 N.W. 12th Ave, Miami, FL 33136, United States University of Miami Hospital, Department of Neurosurgery, 1400 N.W. 12th Ave, Miami, FL 33136, United States The University of Miami Leonard M. Miller School of Medicine, Department of Education, 1600 NW 10th Ave #1140, Miami, FL 33136, United States
a r t i c l e
i n f o
Article history: Received 31 July 2018 Accepted 5 November 2018 Available online xxxx Keywords: Novel technique High-grade spondylolisthesis L5 spondylectomy Spino-pelvic balance Spondyloptosis
a b s t r a c t Surgical treatment of high-grade spondylolisthesis and spondyloptosis is recommended in symptomatic patients, yet there exists much debate regarding the optimal surgical approach and the need for reduction. Similar to the Bohlman technique in that fixation is achieved across two vertebral endplates, we discuss a novel technique with the advantage of using bilateral threaded pedicle screws of large diameter and length instead of a single fibula allograft. Patients underwent posterior instrumented fusion without spondylolisthesis reduction using a novel technique placing pedicle screws with a transvertebral trajectory through the two end plates involved in the spondylolisthesis. Following screw placement, patients underwent decompression ± discectomy. Screws were connected to adjacent pedicle screws either in the upper adjacent vertebrae (i.e. L5) or the more rostral adjacent vertebrae (i.e. L4) if spinal alignment or instability necessitate including additional levels of fixation. Three patients were reviewed with ages of 67, 62, 58 years, operative times of 377–790 min, estimated blood loss 400–1050 cc, and follow-up times of 478–1082 days. There were no CSF leaks, intragenic neurologic deficits post-operatively, implant failures, revisions, or other systemic events. Two patients achieve radiographic fusion assessed by CT. At the time of final follow up, all patients were satisfied and essentially pain free. This one-stage technique offers the ability to manage local malalignment with a technique that inherently minimizes risk. The minimal complications and favorable outcomes make this technique an effective, efficient and safe procedure. Additional studies will focus on long term outcomes and should include larger patient samples. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction There remains significant debate regarding the optimal management options for high-grade spondylolisthesis. It is widely agreed upon that fusion is necessary [1]. However, surgical controversy surrounds the optimal approach to fusion as well as the necessity for decompression. While it is agreed that there is a need for decompression in the setting of neurological deficits, many now support that a complete reduction of high-grade slips is likely not required and possibly dangerous [2]. While circumferential fusion procedures have higher clinical and radiographic fusion rates, the severity of many high-grade slips prevent direct anterior interbody fusion [3,4]. In such cases
⇑ Corresponding author. E-mail address: [email protected] (C.J. Donnally III).
in-situ fusion may be more feasible. Initially reported by Speed as an anterior approach for in-situ fusion using a tibial autograft strut to stabilize L5-S1 spondylolisthesis, Bohlman and Cook popularized their modification of this protocol for spondyloptosis. Using a posterior approach and a fibular autograft across the vertebral bodies of S1 to L5, they proposed performing a decompression with an uninstrumented L4-S1 posterolateral fusion, providing a three column spinal fixation [5]. Our procedure significantly diverges from the Bohlman and reverse Bohlman in that we are using 2 screws instead of one mid line screw (or strut) from front (reverse Bohlman) or from back (regular Bohlman). With advancements in instrumentation and surgeon technique, additional modalities for achieving three column fixation now include use of intrasacral rods [6], transvertebral interbody cage fixation [7], transsacral transvertebral screw fixation [8,9], and custom-made screws [10]. This study introduces a novel technique for the stabilization of high-grade spondylolisthesis via in-situ fusion of L5-S1 without reduction.
https://doi.org/10.1016/j.jocn.2018.11.001 0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
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C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
2. Methods 2.1. Indications Three symptomatic patients with high-grade L5/S1 spondylolisthesis underwent stabilization and fusion with this novel technique in 2015 at one center by one surgeon (JG). All 3 patients had severe persisting low back pain and leg pain with failure of conservative treatment for greater than six months. Blood loss, surgery time, and complications were collected for all patients. 2.2. Surgical technique The starting point at the junction of sacral ala (or transverse process) and lateral facet joint is localized at the lower vertebrae (i.e. S1 vertebrae) first using lateral fluoroscopic imaging and then confirmed with AP fluoroscopic images. A high speed pneumatic drill is used to breach the cortical bone. A pedicle-finding gearshift is used to penetrate the pedicle. Lateral fluoroscopic images are taken to confirm trajectory, aiming upwards towards the anterior portion of the vertebral body above (i.e. L5 vertebra). The gearshift is gradually directed cranial towards the rostral vertebrae approximately 20–30 degrees from the usual pedicle trajectory. Using alternating images from AP and lateral fluoroscopy, the gearshift is advanced beyond the endplates into the rostral vertebrae. This is followed by palpation of the tract using a ball-tip feeler to confirm that there has been no cortical breach. The tract is then tapped to a diameter 1 mm (mm) smaller than the proposed screw diameter and the screw is placed. A large diameter screw such as 7 or 8 mm is typically used for robust fixation to both the upper and lower vertebrae (i.e. L5-S1) (Fig. 1). The typical length of this screw is between 55 mm and 65 mm. This procedure is repeated on the opposite side for the bilateral fixation. Preoperative CT imaging with spinal reformatted images are critical to determine screw trajectory and estimate the appropriate screw size. The modified screw technique provides a strong cortical
fixation through the lower vertebra’s pedicles and the endplate and anterior body of the upper vertebra. Similar to the Bohlman technique in that fixation is achieved across two vertebral endplates, this technique has the advantage of using bilateral threaded pedicle screws of large diameter and length instead of fibula allograft. This alteration provides strong bilateral fixation of the rostral to caudal vertebrae. These transvertebral screws can be then connected to adjacent pedicle screws either in the upper adjacent vertebrae (i.e. L5) or the more rostral adjacent vertebrae (I.e. L4) if spinal alignment or instability necessitate including additional levels of fixation. Once the instrumentation is completed, the decompression is performed. When possible, a discectomy with interbody fusion may be performed at the adjacent disc level for added stability and maximum fusion potential. At L5-S1 and adjacent as needed, fusion was achieved via ample posterior-lateral bone grafting and use of BMP. 2.3. Data collection We conducted a retrospective review of all patients with highgrade spondylolisthesis (HGS) in 2015 that underwent this new procedure by a single surgeon (JG) at a single center. Included parameters were patient age, gender, presenting symptoms, pre/ post-op neurological dysfunction, history of previous surgery at the operative level, use of BMP-2, estimated blood loss (EBL), operative time, follow up time. 3. Results Three patients were reviewed, 2 females and 1 male with ages of 67 (Case 1), 62 (Case 2), 58 years (Case 3), operative times of 499, 377, 790 min, estimated blood loss of 600, 400, 1050 cc, and follow up days of 468, 927, and 1082, respectively (Table 1). All patients had high-grade L5/S1 spondylolisthesis. All patients were stenotic at L4-S1, with one patient also stenotic at L3-L4 as well. This patient had three levels decompressed and fused whereas the remaining two only underwent surgical treatment of the affected two levels. Preoperatively all patients reported lower back pain as well as radiating radiculopathy bilaterally into the ankle. No patients had motor deficits or reported bowel or bladder dysfunction. There were no CSF leaks, iatrogenic neurologic deficits postoperatively, implant failures, or systemic complications. The mean follow-up was 2.5 years (826 days) during which point there were no required revisions, no infections, and no recurrence of symptomatology. Based on CT imaging, two patients achieved fusion and one patient progressed to a pseudoarthrosis at last followup. All patients were satisfied and essentially pain free at final follow up. 3.1. Case 1
Fig. 1. In-situ transvertebral fixation of spondyloptosis at L5-S1.
A 67-year-old female presented with a several year history of low back pain with radiation to the right buttocks, posterior thigh, calf and lateral ankle. She also noted progressive subjective weakness of the bilateral lower extremities with worsening difficulty ascending and descending stairs. Clinically she was noted to have 5/5 strength in the bilateral lower extremities though inconsistent numbness in the right L5 distribution. CT demonstrated grade III spondylolisthesis at L4-L5 and grade I spondylolisthesis at L5-S1. An MRI demonstrated severe facet arthropathy at L4-S1 with associated foraminal and canal narrowing at these levels. She underwent a posterior decompression followed by posterolateral fusion at L4-5 and L5-S1 involving transvertebral S1 pedicle screws
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
3
C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx Table 1 Description, operative data, and outcomes. Case
Age (yrs) / Sex
Level
Stenotic Levels
# levels fused
LOS (days)
OR Time
EBL
Transfusion (units)
Complications (intra/post-operative)
CSF leak
DVT
PE
Fusion achieved (CT)
F/u time (days)
1 2 3 Mean
67 F 62 F 58 M 62.3
L5/S1 L5/S1 L5/S1 –
L4, L5, S1 L4, L5, S1 L3, L4, L5, S1 –
2 2 3 –
5 7 5 5.6
499 377 790 555.3
600 400 1050 683.3
2 3 2 2.3
None Post-operative hypotension None –
No No No –
No No No –
No No No –
Yes Yes No –
468 927 1082 825.7
(Yrs): Years; (#): number; (LOS) Length of Stay; (OR) Operative; (EBL) Estimated blood loss; (CSF) Cerebral spinal fluid; (DVT): Deep vein thrombosis; (PE) Pulmonary Embolism; (CT) Computed Topography; (F/u): Follow up
traversing the L5-S1 disc space to achieve fixation to the L5 endplate. Pre- and post-operative radiographs are provided (Fig. 2). At four months post-operatively she was pain free with some residual numbness in the right L5 distribution. At 14 months post-operatively an MRI and CT demonstrated stable hardware fixation without canal stenosis at the affected levels nor transitional breakdown proximally (Figs. 3 and 4). Fusion was achieved in a posterior-lateral pattern. 3.2. Case 2 A 62-year-old female presented with severe left buttock and left lower extremity pain that worsened with ambulation. On exami-
nation she was found to have relative weakness in her left extensor hallicus longus (EHL). Otherwise she did have full 5/5 strength in the bilateral lower extremities. On pre-OP CT and MRI she was noted to have grade III spondylolisthesis of L5-S1 with severe canal stenosis at this level as well as facet arthropathy and central stenosis at L4-L5 level. She underwent posterior decompression, posterior lumbar interbody fusion (PLIF) at L4-5 and posterolateral arthrodesis using the transvertebral pedicle screw technique at L5-S1, with the S1 pedicle screws traversing rostrally into the body of L5. A PLIF was used at L4-L5 to restore disc space height and to assist with fusion in that this patient was a former recent smoker. At five months postoperatively her pain had been relieved considerably, and serial imaging demonstrated stable fixation of hardware. Pre- and post-operative radiographs are provided (Fig. 5). 3.3. Case 3 A 58-year-old male presented with incapacitating lower back pain with radiation into the bilateral lower extremities. He described a gradual onset following a standing height fall onto his buttocks several years prior. He eventually became wheelchair dependent after this injury secondary to severe pain that developed within one minute of standing erect though still suffered from significant leg pain at rest. CT and MRI revealed L5-S1 spondyloptosis with a 90-degree anterior rotation of L5 off S1 resulting in a severe kyphotic deformity. He also had significant compensatory lumbar hyperlordosis and evidence of severe disc degeneration at L5-S1. He underwent posterior decompression L3-S2, and then posterior lateral fusion of L2-S2 including S2 screws extending through the anterior sacrum cortex into the severely anterolisthesed body of L5. At 1 year postoperatively he was able to walk for several minutes without any pain, and his lower extremity pain had been all but eliminated at rest. Postoperative imaging demonstrated stable fixation. Pre- and postoperative radiographs are provided (Fig. 6). 4. Discussion
Fig. 2. Case 1- Radiographs of a 67-year-old female; (A) anterior-posterior view pre-operative; (B) lateral view pre-operative; (C) anterior-posterior view postoperative; (D) lateral view post-operative.
Management of high-grade spondylolisthesis remains a debated topic in spine surgery. First described prior to the advent of modern pedicle screw fixation technique, the Bohlman procedure offers a method of achieving transsacral inter body fusion using an autologous bone graft in a single procedure to treat severe cases of spondylolisthesis. This technique has received considerable criticism due to concerns regarding the ability to adequately reduce and stabilize anterolisthesis as well as due to other documented complications including graft fracture or failure. Specifically, subsequent studies have suggested that one single fibular graft has the potential to loosen and may not ideal for fusion [11,12]. Our method overcomes the biomechanical demerits associated with the Bohlman procedure by incorporating multiple points of screw fixation. Our procedure uses 2 screws instead of one mid line screw (or strut) from front (reverse Bohlman) or from back (regular Bohlman).
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
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C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
Fig. 3. Case 1- Post-operative imaging demonstrating L5/S1 screw purchase and central decompression; (A) CT axial; (B) CT sagittal.
Fig. 4. Case 1- Post-operative imaging demonstrating L5/S1 screw purchase and central decompression; (A) MRI axial; (B) MRI sagittal; (C) MRI axial; (D) MRI sagittal.
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
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Fig. 5. Case 2- Radiographs of a 62-year-old female; (A) anterior-posterior view pre-operative; (B) lateral view pre-operative; (C) anterior-posterior view postoperative; (D) lateral view post-operative.
Fig. 6. Case 3- Radiographs of a 58-year-old male; (A) anterior-posterior view preoperative; (B) lateral view pre-operative; (C) anterior-posterior view post-operative; (D) lateral view post-operative.
In the setting of high-grade spondylolisthesis, while the need for a stabilization is almost uniformly agreed upon, the indications for reduction in a neurologically intact patient are subject to ongoing discussion. This is due to the potential risks of intragenic injuries which have been reported in 10%–25% of cases [13–15]. The most common neurologic deficit seen with reduction is a traction injury at the L5 nerve [16,17]. Cadaver studies have shown how the strain on the L5 nerve does not follow a linear pattern [18]. If the complete reduction of a 100% slippage is divided into halves, only 29% of the total strain occurs during this first half of a reduction, while the remaining 71% of strain occurred in the final 50% to 0% of slip reduction. This anatomic study also described the benefits of correcting sagittal balance in that improving lumbosacral kyphosis lessens tension at the L5 nerve. Boachie-Adjei et al. reported six cases where a posterior approach without reduction was used to improve lumbosacral kyphosis with pedicle screw fixation [19]. At final follow up, all patients achieved fusion, maintained the improvement of slip angle, and had sustained no neurological injuries. These authors argue that the goal without a reduction should be correction of the kyphotic deformity as opposed to the slippage percentage. Such studies support the concept of prioritizing lumbosacral kyphosis correction over translational reduction. At this point there are no level I or II evidence studies comparing in-situ fusions versus reduction for high-grade spondylolisthe-
sis [20]. Some have postulated that reduction is not necessary as prone patient positioning may indirectly and reduce anterolisthesis to an adequate degree [21,22]. Scheer retrospectively reports on 282 patients with degenerative spondylolisthesis undergoing minimally invasive TLIF with and without a reduction [23]. Those with a reduction had a higher fusion rate (84.5% vs. 70.8%) and increased EBL (280.2 vs. 212.6 cc). Reduction was not associated with hospital stay lengths, intraoperative complications, and post-operative complication rates. Through a limited series our study describes a new technique with favorable clinical outcomes and minimal complications (1 case of post-operative hypotension attributed to anesthesia error). Avoiding the use of a strut allograft eliminates the need for pressfit drilling and time associated with its placement. Additionally, intragenic L5 injury is reduced by avoiding intraoperative reduction. The sample size and length of follow-up is comparable to other literature presently available that describes techniques for management of high-grade spondylolisthesis.
5. Conclusion Surgical treatment of high-grade spondylolisthesis remains a challenging procedure and continued innovation will allow for
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
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C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
optimized care. This one-stage technique offers the ability to manage local malalignment with a technique that inherently minimizes risk. The minimal complications and favorable outcomes make this technique an effective, efficient and safe procedure. Additional studies will focus on long term outcomes and should include larger patient samples. Spine surgeons should be aware of this technique when considering treatment of high-grade spondylolisthesis. All authors contributed significantly to the document and have reviewed the final manuscript.
6. Conflicts of interest and source of funding The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
References [1] Ghogawala Z, Dziura J, Butler WE, et al. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 2016;374 (15):1424–34. [2] Oxland TR, Crisco 3rd JJ, Panjabi MM, Yamamoto I. The effect of injury on rotational coupling at the lumbosacral joint. A biomechanical investigation. Spine (Phila Pa 1976) 1992;17(1):74–80. [3] Ishihara H, Osada R, Kanamori M, et al. Minimum 10-year follow-up study of anterior lumbar interbody fusion for isthmic spondylolisthesis. J Spinal Disord 2001;14(2):91–9. [4] Remes V, Lamberg T, Tervahartiala P, et al. Long-term outcome after posterolateral, anterior, and circumferential fusion for high-grade isthmic spondylolisthesis in children and adolescents: magnetic resonance imaging findings after average of 17-year follow-up. Spine (Phila Pa 1976) 2006;31 (21):2491–9. [5] Bohlman HH, Cook SS. One-stage decompression and posterolateral and interbody fusion for lumbosacral spondyloptosis through a posterior approach. Report of two cases. JBJS 1982;64(3):415–8. [6] Bouyer B, Bachy M, Courvoisier A, Dromzee E, Mary P, Vialle R. High-grade lumbosacral spondylolisthesis reduction and fusion in children using transsacral rod fixation. Childs Nerv Syst 2014;30(3):505–13.
[7] Bartolozzi P, Sandri A, Cassini M, Ricci M. One-stage posterior decompressionstabilization and trans-sacral interbody fusion after partial reduction for severe L5–S1 spondylolisthesis. Spine (Phila Pa 1976) 2003;28(11):1135–41. [8] Abdu WA, Wilber RG, Emery SE. Pedicular transvertebral screw fixation of the lumbosacral spine in spondylolisthesis. A new technique for stabilization. Spine (Phila Pa 1976) 1994;19(6):710–5. [9] Lakshmanan P, Ahuja S, Lewis M, Howes J, Davies PR. Transsacral screw fixation for high-grade spondylolisthesis. Spine J 2009;9(12):1024–9. [10] Jouve JL, Blondel B, Fuentes S, Choufani E, Pesenti S, Bollini G. Circumferential fusion using a custom-made screw in the management of high-grade spondylolisthesis. Eur Spine J 2014;23(Suppl 4):S457–462. [11] Hart RA, Domes CM, Goodwin B, et al. High-grade spondylolisthesis treated using a modified Bohlman technique: results among multiple surgeons. J Neurosurg Spine 2014;20(5):523–30. [12] Hanson DS, Bridwell KH, Rhee JM, Lenke LG. Dowel fibular strut grafts for highgrade dysplastic isthmic spondylolisthesis. Spine (Phila Pa 1976) 2002;27 (18):1982–8. [13] Ruf M, Koch H, Melcher RP, Harms J. Anatomic reduction and monosegmental fusion in high-grade developmental spondylolisthesis. Spine (Phila Pa 1976) 2006;31(3):269–74. [14] Hu SS, Bradford DS, Transfeldt EE, Cohen M. Reduction of high-grade spondylolisthesis using Edwards instrumentation. Spine (Phila Pa 1976) 1996;21(3):367–71. [15] Ani N, Keppler L, Biscup RS, Steffee AD. Reduction of high-grade slips (grades III-V) with VSP instrumentation. Report of a series of 41 cases. Spine (Phila Pa 1976) 1991;16(6 Suppl):S302–10. [16] Molinari RW, Bridwell KH, Lenke LG. Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches. Spine (Phila Pa 1976) 1999;24(16):1701–11. [17] Fu KM, Smith JS, Polly Jr DW, et al. Morbidity and mortality in the surgical treatment of six hundred five pediatric patients with isthmic or dysplastic spondylolisthesis. Spine (Phila Pa 1976) 2011;36(4):308–12. [18] Petraco DM, Spivak JM, Cappadona JG, Kummer FJ, Neuwirth MG. An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction. Spine (Phila Pa 1976) 1996;21(10):1133–8 [discussion 1139]. [19] Boachie-Adjei O, Do T, Rawlins BA. Partial lumbosacral kyphosis reduction, decompression, and posterior lumbosacral transfixation in high-grade isthmic spondylolisthesis: clinical and radiographic results in six patients. Spine (Phila Pa 1976) 2002;27(6):E161–168. [20] Transfeldt EE, Mehbod AA. Evidence-based medicine analysis of isthmic spondylolisthesis treatment including reduction versus fusion in situ for highgrade slips. Spine (Phila Pa 1976) 2007;32(19 Suppl):S126–9. [21] Montgomery DM, Fischgrund JS. Passive reduction of spondylolisthesis on the operating room table: a prospective study. J Spinal Disord 1994;7(2):167–72. [22] Naderi S, Manisali M, Acar F, Ozaksoy D, Mertol T, Arda MN. Factors affecting reduction in low-grade lumbosacral spondylolisthesis. J Neurosurg 2003;99(2 Suppl):151–6. [23] Scheer JK, Auffinger B, Wong RH, et al. Minimally invasive Transforaminal Lumbar Interbody Fusion (TLIF) for spondylolisthesis in 282 patients: in situ arthrodesis versus reduction. World Neurosurg 2015;84(1):108–13.
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Tools and techniques
A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction Chester J. Donnally III a,⇑, Karthik Madhavan b, Alexander J. Butler a, Jonathan I. Sheu c, Dustin H. Massel a, Barth A. Green b, Joseph P. Gjolaj a a b c
University of Miami Hospital, Department of Orthopaedic Surgery, 1400 N.W. 12th Ave, Miami, FL 33136, United States University of Miami Hospital, Department of Neurosurgery, 1400 N.W. 12th Ave, Miami, FL 33136, United States The University of Miami Leonard M. Miller School of Medicine, Department of Education, 1600 NW 10th Ave #1140, Miami, FL 33136, United States
a r t i c l e
i n f o
Article history: Received 31 July 2018 Accepted 5 November 2018 Available online xxxx Keywords: Novel technique High-grade spondylolisthesis L5 spondylectomy Spino-pelvic balance Spondyloptosis
a b s t r a c t Surgical treatment of high-grade spondylolisthesis and spondyloptosis is recommended in symptomatic patients, yet there exists much debate regarding the optimal surgical approach and the need for reduction. Similar to the Bohlman technique in that fixation is achieved across two vertebral endplates, we discuss a novel technique with the advantage of using bilateral threaded pedicle screws of large diameter and length instead of a single fibula allograft. Patients underwent posterior instrumented fusion without spondylolisthesis reduction using a novel technique placing pedicle screws with a transvertebral trajectory through the two end plates involved in the spondylolisthesis. Following screw placement, patients underwent decompression ± discectomy. Screws were connected to adjacent pedicle screws either in the upper adjacent vertebrae (i.e. L5) or the more rostral adjacent vertebrae (i.e. L4) if spinal alignment or instability necessitate including additional levels of fixation. Three patients were reviewed with ages of 67, 62, 58 years, operative times of 377–790 min, estimated blood loss 400–1050 cc, and follow-up times of 478–1082 days. There were no CSF leaks, intragenic neurologic deficits post-operatively, implant failures, revisions, or other systemic events. Two patients achieve radiographic fusion assessed by CT. At the time of final follow up, all patients were satisfied and essentially pain free. This one-stage technique offers the ability to manage local malalignment with a technique that inherently minimizes risk. The minimal complications and favorable outcomes make this technique an effective, efficient and safe procedure. Additional studies will focus on long term outcomes and should include larger patient samples. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction There remains significant debate regarding the optimal management options for high-grade spondylolisthesis. It is widely agreed upon that fusion is necessary [1]. However, surgical controversy surrounds the optimal approach to fusion as well as the necessity for decompression. While it is agreed that there is a need for decompression in the setting of neurological deficits, many now support that a complete reduction of high-grade slips is likely not required and possibly dangerous [2]. While circumferential fusion procedures have higher clinical and radiographic fusion rates, the severity of many high-grade slips prevent direct anterior interbody fusion [3,4]. In such cases
⇑ Corresponding author. E-mail address: [email protected] (C.J. Donnally III).
in-situ fusion may be more feasible. Initially reported by Speed as an anterior approach for in-situ fusion using a tibial autograft strut to stabilize L5-S1 spondylolisthesis, Bohlman and Cook popularized their modification of this protocol for spondyloptosis. Using a posterior approach and a fibular autograft across the vertebral bodies of S1 to L5, they proposed performing a decompression with an uninstrumented L4-S1 posterolateral fusion, providing a three column spinal fixation [5]. Our procedure significantly diverges from the Bohlman and reverse Bohlman in that we are using 2 screws instead of one mid line screw (or strut) from front (reverse Bohlman) or from back (regular Bohlman). With advancements in instrumentation and surgeon technique, additional modalities for achieving three column fixation now include use of intrasacral rods [6], transvertebral interbody cage fixation [7], transsacral transvertebral screw fixation [8,9], and custom-made screws [10]. This study introduces a novel technique for the stabilization of high-grade spondylolisthesis via in-situ fusion of L5-S1 without reduction.
https://doi.org/10.1016/j.jocn.2018.11.001 0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
2
C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
2. Methods 2.1. Indications Three symptomatic patients with high-grade L5/S1 spondylolisthesis underwent stabilization and fusion with this novel technique in 2015 at one center by one surgeon (JG). All 3 patients had severe persisting low back pain and leg pain with failure of conservative treatment for greater than six months. Blood loss, surgery time, and complications were collected for all patients. 2.2. Surgical technique The starting point at the junction of sacral ala (or transverse process) and lateral facet joint is localized at the lower vertebrae (i.e. S1 vertebrae) first using lateral fluoroscopic imaging and then confirmed with AP fluoroscopic images. A high speed pneumatic drill is used to breach the cortical bone. A pedicle-finding gearshift is used to penetrate the pedicle. Lateral fluoroscopic images are taken to confirm trajectory, aiming upwards towards the anterior portion of the vertebral body above (i.e. L5 vertebra). The gearshift is gradually directed cranial towards the rostral vertebrae approximately 20–30 degrees from the usual pedicle trajectory. Using alternating images from AP and lateral fluoroscopy, the gearshift is advanced beyond the endplates into the rostral vertebrae. This is followed by palpation of the tract using a ball-tip feeler to confirm that there has been no cortical breach. The tract is then tapped to a diameter 1 mm (mm) smaller than the proposed screw diameter and the screw is placed. A large diameter screw such as 7 or 8 mm is typically used for robust fixation to both the upper and lower vertebrae (i.e. L5-S1) (Fig. 1). The typical length of this screw is between 55 mm and 65 mm. This procedure is repeated on the opposite side for the bilateral fixation. Preoperative CT imaging with spinal reformatted images are critical to determine screw trajectory and estimate the appropriate screw size. The modified screw technique provides a strong cortical
fixation through the lower vertebra’s pedicles and the endplate and anterior body of the upper vertebra. Similar to the Bohlman technique in that fixation is achieved across two vertebral endplates, this technique has the advantage of using bilateral threaded pedicle screws of large diameter and length instead of fibula allograft. This alteration provides strong bilateral fixation of the rostral to caudal vertebrae. These transvertebral screws can be then connected to adjacent pedicle screws either in the upper adjacent vertebrae (i.e. L5) or the more rostral adjacent vertebrae (I.e. L4) if spinal alignment or instability necessitate including additional levels of fixation. Once the instrumentation is completed, the decompression is performed. When possible, a discectomy with interbody fusion may be performed at the adjacent disc level for added stability and maximum fusion potential. At L5-S1 and adjacent as needed, fusion was achieved via ample posterior-lateral bone grafting and use of BMP. 2.3. Data collection We conducted a retrospective review of all patients with highgrade spondylolisthesis (HGS) in 2015 that underwent this new procedure by a single surgeon (JG) at a single center. Included parameters were patient age, gender, presenting symptoms, pre/ post-op neurological dysfunction, history of previous surgery at the operative level, use of BMP-2, estimated blood loss (EBL), operative time, follow up time. 3. Results Three patients were reviewed, 2 females and 1 male with ages of 67 (Case 1), 62 (Case 2), 58 years (Case 3), operative times of 499, 377, 790 min, estimated blood loss of 600, 400, 1050 cc, and follow up days of 468, 927, and 1082, respectively (Table 1). All patients had high-grade L5/S1 spondylolisthesis. All patients were stenotic at L4-S1, with one patient also stenotic at L3-L4 as well. This patient had three levels decompressed and fused whereas the remaining two only underwent surgical treatment of the affected two levels. Preoperatively all patients reported lower back pain as well as radiating radiculopathy bilaterally into the ankle. No patients had motor deficits or reported bowel or bladder dysfunction. There were no CSF leaks, iatrogenic neurologic deficits postoperatively, implant failures, or systemic complications. The mean follow-up was 2.5 years (826 days) during which point there were no required revisions, no infections, and no recurrence of symptomatology. Based on CT imaging, two patients achieved fusion and one patient progressed to a pseudoarthrosis at last followup. All patients were satisfied and essentially pain free at final follow up. 3.1. Case 1
Fig. 1. In-situ transvertebral fixation of spondyloptosis at L5-S1.
A 67-year-old female presented with a several year history of low back pain with radiation to the right buttocks, posterior thigh, calf and lateral ankle. She also noted progressive subjective weakness of the bilateral lower extremities with worsening difficulty ascending and descending stairs. Clinically she was noted to have 5/5 strength in the bilateral lower extremities though inconsistent numbness in the right L5 distribution. CT demonstrated grade III spondylolisthesis at L4-L5 and grade I spondylolisthesis at L5-S1. An MRI demonstrated severe facet arthropathy at L4-S1 with associated foraminal and canal narrowing at these levels. She underwent a posterior decompression followed by posterolateral fusion at L4-5 and L5-S1 involving transvertebral S1 pedicle screws
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
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C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx Table 1 Description, operative data, and outcomes. Case
Age (yrs) / Sex
Level
Stenotic Levels
# levels fused
LOS (days)
OR Time
EBL
Transfusion (units)
Complications (intra/post-operative)
CSF leak
DVT
PE
Fusion achieved (CT)
F/u time (days)
1 2 3 Mean
67 F 62 F 58 M 62.3
L5/S1 L5/S1 L5/S1 –
L4, L5, S1 L4, L5, S1 L3, L4, L5, S1 –
2 2 3 –
5 7 5 5.6
499 377 790 555.3
600 400 1050 683.3
2 3 2 2.3
None Post-operative hypotension None –
No No No –
No No No –
No No No –
Yes Yes No –
468 927 1082 825.7
(Yrs): Years; (#): number; (LOS) Length of Stay; (OR) Operative; (EBL) Estimated blood loss; (CSF) Cerebral spinal fluid; (DVT): Deep vein thrombosis; (PE) Pulmonary Embolism; (CT) Computed Topography; (F/u): Follow up
traversing the L5-S1 disc space to achieve fixation to the L5 endplate. Pre- and post-operative radiographs are provided (Fig. 2). At four months post-operatively she was pain free with some residual numbness in the right L5 distribution. At 14 months post-operatively an MRI and CT demonstrated stable hardware fixation without canal stenosis at the affected levels nor transitional breakdown proximally (Figs. 3 and 4). Fusion was achieved in a posterior-lateral pattern. 3.2. Case 2 A 62-year-old female presented with severe left buttock and left lower extremity pain that worsened with ambulation. On exami-
nation she was found to have relative weakness in her left extensor hallicus longus (EHL). Otherwise she did have full 5/5 strength in the bilateral lower extremities. On pre-OP CT and MRI she was noted to have grade III spondylolisthesis of L5-S1 with severe canal stenosis at this level as well as facet arthropathy and central stenosis at L4-L5 level. She underwent posterior decompression, posterior lumbar interbody fusion (PLIF) at L4-5 and posterolateral arthrodesis using the transvertebral pedicle screw technique at L5-S1, with the S1 pedicle screws traversing rostrally into the body of L5. A PLIF was used at L4-L5 to restore disc space height and to assist with fusion in that this patient was a former recent smoker. At five months postoperatively her pain had been relieved considerably, and serial imaging demonstrated stable fixation of hardware. Pre- and post-operative radiographs are provided (Fig. 5). 3.3. Case 3 A 58-year-old male presented with incapacitating lower back pain with radiation into the bilateral lower extremities. He described a gradual onset following a standing height fall onto his buttocks several years prior. He eventually became wheelchair dependent after this injury secondary to severe pain that developed within one minute of standing erect though still suffered from significant leg pain at rest. CT and MRI revealed L5-S1 spondyloptosis with a 90-degree anterior rotation of L5 off S1 resulting in a severe kyphotic deformity. He also had significant compensatory lumbar hyperlordosis and evidence of severe disc degeneration at L5-S1. He underwent posterior decompression L3-S2, and then posterior lateral fusion of L2-S2 including S2 screws extending through the anterior sacrum cortex into the severely anterolisthesed body of L5. At 1 year postoperatively he was able to walk for several minutes without any pain, and his lower extremity pain had been all but eliminated at rest. Postoperative imaging demonstrated stable fixation. Pre- and postoperative radiographs are provided (Fig. 6). 4. Discussion
Fig. 2. Case 1- Radiographs of a 67-year-old female; (A) anterior-posterior view pre-operative; (B) lateral view pre-operative; (C) anterior-posterior view postoperative; (D) lateral view post-operative.
Management of high-grade spondylolisthesis remains a debated topic in spine surgery. First described prior to the advent of modern pedicle screw fixation technique, the Bohlman procedure offers a method of achieving transsacral inter body fusion using an autologous bone graft in a single procedure to treat severe cases of spondylolisthesis. This technique has received considerable criticism due to concerns regarding the ability to adequately reduce and stabilize anterolisthesis as well as due to other documented complications including graft fracture or failure. Specifically, subsequent studies have suggested that one single fibular graft has the potential to loosen and may not ideal for fusion [11,12]. Our method overcomes the biomechanical demerits associated with the Bohlman procedure by incorporating multiple points of screw fixation. Our procedure uses 2 screws instead of one mid line screw (or strut) from front (reverse Bohlman) or from back (regular Bohlman).
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
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Fig. 3. Case 1- Post-operative imaging demonstrating L5/S1 screw purchase and central decompression; (A) CT axial; (B) CT sagittal.
Fig. 4. Case 1- Post-operative imaging demonstrating L5/S1 screw purchase and central decompression; (A) MRI axial; (B) MRI sagittal; (C) MRI axial; (D) MRI sagittal.
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
C.J. Donnally III et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
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Fig. 5. Case 2- Radiographs of a 62-year-old female; (A) anterior-posterior view pre-operative; (B) lateral view pre-operative; (C) anterior-posterior view postoperative; (D) lateral view post-operative.
Fig. 6. Case 3- Radiographs of a 58-year-old male; (A) anterior-posterior view preoperative; (B) lateral view pre-operative; (C) anterior-posterior view post-operative; (D) lateral view post-operative.
In the setting of high-grade spondylolisthesis, while the need for a stabilization is almost uniformly agreed upon, the indications for reduction in a neurologically intact patient are subject to ongoing discussion. This is due to the potential risks of intragenic injuries which have been reported in 10%–25% of cases [13–15]. The most common neurologic deficit seen with reduction is a traction injury at the L5 nerve [16,17]. Cadaver studies have shown how the strain on the L5 nerve does not follow a linear pattern [18]. If the complete reduction of a 100% slippage is divided into halves, only 29% of the total strain occurs during this first half of a reduction, while the remaining 71% of strain occurred in the final 50% to 0% of slip reduction. This anatomic study also described the benefits of correcting sagittal balance in that improving lumbosacral kyphosis lessens tension at the L5 nerve. Boachie-Adjei et al. reported six cases where a posterior approach without reduction was used to improve lumbosacral kyphosis with pedicle screw fixation [19]. At final follow up, all patients achieved fusion, maintained the improvement of slip angle, and had sustained no neurological injuries. These authors argue that the goal without a reduction should be correction of the kyphotic deformity as opposed to the slippage percentage. Such studies support the concept of prioritizing lumbosacral kyphosis correction over translational reduction. At this point there are no level I or II evidence studies comparing in-situ fusions versus reduction for high-grade spondylolisthe-
sis [20]. Some have postulated that reduction is not necessary as prone patient positioning may indirectly and reduce anterolisthesis to an adequate degree [21,22]. Scheer retrospectively reports on 282 patients with degenerative spondylolisthesis undergoing minimally invasive TLIF with and without a reduction [23]. Those with a reduction had a higher fusion rate (84.5% vs. 70.8%) and increased EBL (280.2 vs. 212.6 cc). Reduction was not associated with hospital stay lengths, intraoperative complications, and post-operative complication rates. Through a limited series our study describes a new technique with favorable clinical outcomes and minimal complications (1 case of post-operative hypotension attributed to anesthesia error). Avoiding the use of a strut allograft eliminates the need for pressfit drilling and time associated with its placement. Additionally, intragenic L5 injury is reduced by avoiding intraoperative reduction. The sample size and length of follow-up is comparable to other literature presently available that describes techniques for management of high-grade spondylolisthesis.
5. Conclusion Surgical treatment of high-grade spondylolisthesis remains a challenging procedure and continued innovation will allow for
Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001
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optimized care. This one-stage technique offers the ability to manage local malalignment with a technique that inherently minimizes risk. The minimal complications and favorable outcomes make this technique an effective, efficient and safe procedure. Additional studies will focus on long term outcomes and should include larger patient samples. Spine surgeons should be aware of this technique when considering treatment of high-grade spondylolisthesis. All authors contributed significantly to the document and have reviewed the final manuscript.
6. Conflicts of interest and source of funding The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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Please cite this article as: C. J. Donnally, K. Madhavan, A. J. Butler et al., A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.001