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Sacroiliac Joint Fusion System for High-Grade Spondylolisthesis Using “Reverse Bohlman Technique”: A Technical Report and Overview of the Literature
Technical Note
Sacroiliac Joint Fusion System for High-Grade Spondylolisthesis Using “Reverse Bohlman Technique”: A Technical Report and Overview of the Literature Mayur Sharma1, Zaid Aljuboori1, Jared William Clouse2, Richard Rodgers2, Thomas Altstadt1
OBJECTIVE/BACKGROUND: High-grade spondylolisthesis (HGS) is a complex clinical problem that poses significant challenges to the treating physician. Contentious debate has continued regarding the most optimal surgical approach for these patients. A variety of transsacral and transvertebral techniques have been described in reported studies.
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METHODS AND RESULTS: We present 2 cases of low back pain and radicular symptoms. Our 2 patients were a 35year-old woman and a 26-year-old white woman. The computed tomography and magnetic resonance imaging scans revealed progressive HGS (grade III) that had not been relieved by conservative measures. Both patients underwent transsacral fixation using the reverse Bohlman technique (RBT) at L5-S1 and L4-L5 anterior lumbar interbody fusion combined with posterolateral fusion. At the 9- and 10-month follow-up visits, the patients reported minimal back pain with no radicular symptoms, and the imaging studies showed satisfactory fusion in both patients.
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CONCLUSIONS: To the best of our knowledge, this is the first report to demonstrate the utility of the sacroiliac joint fusion cage using RBT in patients with HGS with successful clinical outcome. The RBT is safe, feasible, and effective in carefully selected patients.
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INTRODUCTION
I
n the current era of global spinal alignment, it is imperative for patients to have spinopelvic parameters within an ageappropriate normal range to experience good health-related
Key words High-grade spondylolisthesis - Novel technique - Reverse Bohlman technique -
Abbreviations and Acronyms ALD: Activity of daily living ALIF: Anterior lumbar interbody fusion CT: Computed tomography HGS: High-grade spondylolisthesis PLF: Posterolateral fusion POD: Postoperative day QOL: Quality of life RBT: Reverse Bohlman technique
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quality of life (QOL).1 A multitude of surgical approaches have been described for high-grade spondylolisthesis (HGS), including instrumented posterolateral fusion (PLF) with or without decompression, interbody fusion (i.e., posterior lumbar interbody fusion, transforaminal lumbar interbody fusion) with decompression, reduction and PLF, circumferential fusion, transsacral fibular dowel graft with PLF, and spondylectomy for spondyloptosis.2-7 Direct anterior approaches are often not feasible in these patients owing to the severity of slippage and an inability to access the disc space.8,9 In 1938, Speed10 first described the anterior approach for L5S1 spondylolisthesis using an in situ tibial autograft strut. In 1982, Bohlman and Cook11 first described the technique of transsacral fusion using a fibular autograft across S1 into the L5 vertebral body with decompression and noninstrumented L4eS1 PLF (Bohlman technique). The early results with this technique resulted in complications such as fibular graft fracture, graft resorption, slip progression, and pseudoarthrosis.12 Since then, several modifications of the technique (modified Bohlman techniques) have been described, including transsacral transvertebral screw fixation, transvertebral interbody cage fixation, intrasacral rods, a variety of screws, including the S1 pedicle screw, and, recently, the axial lumbar interbody fusion bolt.6,13-21 Recently, a modification of the transsacral technique, the reverse Bohlman technique (RBT) has been described. The RBT is performed through the anterior cephalad portion of the L5 vertebral body angled across the spondylolisthetic disc space into the sacral vertebral body using an anterior abdominal transperitoneal approach with or without instrumented PLF.5 A paucity of reports has described this technique in neurosurgical studies. In the present report, we describe 2 interesting cases of L5-S1 HGS managed with L4-L5 anterior lumbar interbody fusion (ALIF), L5-S1 RBT, and L5-S1 decompression with instrumented
rhBMP-2: Recombinant human bone morphogenetic protein-2 SI: Sacroiliac From the 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky; and 2Department of Neurological Surgery, Indianapolis University School of Medicine, Indianapolis, Indiana, USA To whom correspondence should be addressed: Thomas Altstadt, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 124:331-339. https://doi.org/10.1016/j.wneu.2019.01.041 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
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PLF. To the best of our knowledge, ours is the first report describing the use of a sacroiliac (SI) joint fusion cage (Rialto [Medtronic, Dublin, Ireland]) for HGS. Our results have demonstrated the safety and feasibility of using this cage as an alternative option for RBT in patients with HGS.
CASE REPORT Patient 1 A 35-year-old white woman presented with a history of low back pain, left leg pain, and left foot numbness. Her symptoms had been gradual in onset and progressive in nature and had worsened during the 6 months before her presentation. Her low back pain was deep and aching in nature, aggravated with activity, and relieved by lying down. Her left leg pain was radiating along the left L5 and S1 nerve distribution, with numbness along the left foot (S1 distribution). Her pain level was 8 of 10 at its worst using a visual analog scale. The motor examination revealed intact
Figure 1. (A, B) Computed tomography scans and (C, D) T2-weighted magnetic resonance imaging lumbosacral spine images showing L5-S1 high-grade spondylolisthesis (grade III) with severe neuroforaminal
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function in the bilateral upper extremities, with 5 of 5 strength (Medical Research Council grade22). The lower extremity examination showed left tibialis anterior strength of 4þ of 5 and left external hallucis longus strength of 4 of 5; at rest, the finding was 5 of 5. Her reflexes were 2þ throughout, and the sensory examination findings were positive for minimal numbness along the left S1 distribution in the left foot. The remaining findings of the systemic examinations were normal. We found minimal tenderness in the midline low back on palpation. CT and magnetic resonance imaging studies of the lumbosacral spine showed L5-S1 HGS (grade III) with severe neuroforaminal stenosis, sclerotic endplate changes, loss of disc height, loss of fat around the exiting bilateral L5 nerve roots, and a chronic bilateral L5 pars defect (Figure 1). Interval worsening of her HGS was present secondary to the pars defect, and lumbar flexion/extension films revealed 2.2-cm fixed anterolisthesis of L5 over S1. The preoperative spinopelvic parameters were as follows: lumbar lordosis, 83 ; pelvic incidence, 82.6 ; pelvic tilt, 3.1 ; sacral slope, 85.7 ; slippage, 60.27%; and Dubousset
stenosis, sclerotic endplate changes, loss of disc height, loss of fat around the exiting bilateral L5 nerve roots, and chronic bilateral L5 pars defect, with a trapezoid appearance of the L5 vertebral body.
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Table 1. Preoperative and Postoperative Spinopelvic Parameters Patient 1 Parameter
Preoperative Postoperative Preoperative Postoperative
Lumbar lordosis ( )
83
56.8
60
75
Pelvic incidence ( )
82.6
75.9
78
79
3.1
30.5
22
25
Sacral slope ( )
85.7
45.2
50
50
Slippage (%)
60.27
50
58.8
45
Dubousset lumbosacral angle ( )
121.8
100.2
97
104
Pelvic tilt ( )
Figure 2. Preoperative T2-weighted magnetic resonance imaging study showing high-grade spondylolisthesis of the L5 vertebra, a pars interarticularis defect, degenerative disc changes at L4-L5, and a steep sacral slope.
lumbosacral angle, 121.8 . Various conservative treatments (e.g., physical therapy, nerve root blocks) had failed and the patient was severely symptomatic, which had affected her QOL. Thus, surgical decompression with reduction and instrumented fusion was offered after discussion with the patient and her family. The procedure was performed in 2 stages: anterior fusion (modified RBT), followed by posterolateral fusion. The rationale for performing this procedure in 2 stages over 2 days was to assess the symptomatic improvement achieved after anterior alignment. Also, the 2-day procedure decreased the longer anesthesia time required for a single-stage procedure and the risks associated with transitioning the patient from the supine to prone position.
Patient 2
Her preoperative spinopelvic parameters were as follows: lumbar lordosis, 60 ; pelvic incidence, 78 ; pelvic tilt, 22 ; sacral slope, 50 ; slippage, 58.8%; and Dubousset lumbosacral angle, 97 (Table 1). Because of the steep sacral slope and the severe nature of the L5 vertebral slippage, it was decided that anterior and posterior fixation would be required to provide adequate stability. The patient underwent L4-L5 ALIF with L5-S1 transvertebral cage fixation and L5-S1 posterolateral instrumented fusion.
SURGICAL TECHNIQUE The procedure was performed in 2 stages: anterior fusion (modified RBT), followed by posterolateral fusion.
Patient 2 A 26-year-old woman had presented with a 7-month history of left hip and lower extremity pain. The radicular pain was reproducible with changes in her body position and was exacerbated when she was lying supine or prone, holding her 4-month-old child, and sitting or standing for an extended period (range, 10e15 minutes). The patient did not report any paresthesia or motor deficits with the pain. The pain had begun as a stabbing sensation in the left hip after a fall in the shower when the patient was 7 months’ pregnant with her first child. At delivery of her infant 6 weeks later, the patient had complaints of radicular pain to her mid-thigh and persistent hip pain. The radicular pain had progressively worsened, and the patient had sought care after she had begun to experience the radicular pain in her toes. A plain radiograph revealed HGS of the L5 vertebra, and the patient was referred to us for further evaluation. On physical examination, she had sciatic notch tenderness on the left with subtle weakness of dorsiflexion on the ipsilateral side. Otherwise, the findings from her neurologic examination were unremarkable. Magnetic resonance imaging confirmed grade III spondylolisthesis of the L5 vertebra and additionally showed a pars interarticularis defect, degenerative disc changes at the L4-L5 level, and a steep sacral slope (Figure 2). The patient had exhausted the conservative management options and had decided to pursue surgical repair because of her worsening pain and impairment of her activities of daily living (ADLs).
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Patient 1 Stage 1. With the patient under endotracheal general anesthesia, the patient was placed supine on the operating table with her arms outstretched. The lower abdominal region was prepared and draped in the usual sterile fashion. An experienced vascular surgeon performed the anterior approach and provided exposure to the L4-L5 and L5-S1 region. Intraoperative navigation was not feasible owing to the patient’s position on the table. The midline was defined using fluoroscopy (anteroposterior and lateral views). The superior portion of the L5 vertebral body was then identified, and a pilot hole was drilled. Using fluoroscopic guidance, a trajectory was drilled through the L5 vertebral body across the L5eS1 interspace into the sacrum (to w50 mm). The trajectory was then tapped. After confirming the absence of cortical breaches, a 12- 50-mm size Rialto SI fusion system cage (Medtronic) packed with recombinant human bone morphogenetic protein-2 (rhBMP-2) and cancellous bone chips was implanted through the L5 vertebral body across the L5eS1 interspace into the sacrum with fluoroscopic guidance. This maneuver reduced the spondylolisthesis from grade III to grade I, with no changes in the electromyographic monitoring findings or spontaneous firing of the L5 nerve root. After satisfactory placement of the cage, the L4eL5 disc space with incised and aggressive discectomy was performed using Cobb instruments, curettes, and pituitary rongeurs. The endplates were prepared for
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Figure 3. Intraoperative (A) fluoroscopic view and (B) computed tomography (CT) scan showing satisfactory placement of the anterior L4-L5 interbody implant and L5-S1 transsacral transvertebral Rialto (Medtronic)
arthrodesis by removing the cartilaginous endplates using a curette. We then implanted a 12-mm-high, 14 lordotic evolution spacer filled with rhBMP-2 and cancellous bone chips in the L4eL5 interspace using lateral fluoroscopic guidance. Next, 20mm screws were placed cephalad and caudal to the cage and locked to the Integra plate. The final lateral radiograph demonstrated satisfactory a graft and hardware position with reduction of the spondylolisthesis. No complications developed throughout the procedure, and the wound was closed in the usual manner after drain placement.
Stage 2. Intravenous anesthesia, followed by general endotracheal anesthesia, was induced. She was positioned prone with appropriate padding of all pressure points. The lumbar spine was maintained in the neutral position. A midline skin incision
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cage. Intraoperative (C) sagittal CT and (D) axial CT scans showed satisfactory placement of bilateral posterior L4-L5-S1 pedicle and iliac bolts, with satisfactory reduction.
was made, and the transverse processes of L4, L5, and sacral ala, with the bilateral iliac crest were dissected in a subperiosteal manner using monopolar cautery. We next attached a spinous process clamp on the spinous process of the sacrum with an attached fiducial marker. We then draped the patient to obtain an intraoperative CT scan using the BrainLab AIRO intraoperative navigation system (Brainlab AG, Munich, Germany) for patient 1 and the Medtronic O-arm for patient 2. We then used the BrainLAB navigation system to place bilateral pedicle screws at the L4, L5, sacrum, and iliac bolts. After satisfactory placement of the pedicle screws, the transverse processes at L4, L5, and sacral ala were decorticated. Next, appropriately sized titanium rods were used to connect the pedicle screws and iliac bolts (using side connectors) on each side and locked in place using locking screws. An intraoperative CT scan was obtained to confirm the proper placement of the
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anteriorly and posteriorly to promote bone growth and fusion. Bone grafting materials and ALIF and posterior hardware were chosen in accordance with the primary surgeon’s preference. The wound was then closed in layers in the usual manner after drain placement. The patient withstood the procedure well without complications (Figures 3 and 4).
POSTOPERATIVE COURSE Patient 1 Our first patient recovered well during the postoperative period, with improvement in her radiculopathy symptoms after anterior realignment. Her left external hallucis longus and tibialis anterior motor weakness had improved to normal during the postoperative course. Numbness along the left S1 dermatome had also improved. However, she had developed right meralgia paresthetica (likely due to the operative position), which had gradually improved during the follow-up period. Postoperative imaging revealed a satisfactory position of the implant (Figure 5). She was gradually mobilized with physical therapy on postoperative day (POD)2 with an external orthosis and was discharged to home on POD6. She underwent repeat evaluation 10 days later because of a superficial infection of the abdominal wound, which was managed conservatively with antibiotics (Figure 6). At the most recent follow-up examination at 9 months postoperatively, the patient reported minimal back pain with markedly improved right thigh numbness. Her preoperative symptoms had resolved completely, with well-healed incisions. Her motor function was 5 of 5 throughout, with no new sensory deficits. She was independent in her ADLs, and radiographs showed a satisfactory position of the hardware and a reduction of spondylolisthesis (Figure 7). The postoperative spinopelvic parameters were as follows: lumbar lordosis, 56.8 ; pelvic incidence, 75.9 ; pelvic tilt, 30.5 ; sacral slope, 45.2 ; slippage, 50%; and Dubousset lumbosacral angle, 100.2 .
Patient 2 Figure 4. Illustration showing placement of L4-L5 interbody implant, L5S1 transsacral transvertebral Rialto cage (Medtronic) and posterolateral pedicle screws.
hardware. After satisfactory placement of the hardware, the wound was copiously irrigated with antibiotic solution. rhBMP-2 with cancellous bone chips was placed over the L4 and L5 transverse processes and sacral ala to achieve posterolateral arthrodesis.
Patient 2 Stage 1. The anterior RBT procedure for patient 2 was similar to that described for patient 1.
Stage 2. In the second patient, after placing her patient in the prone position, a midline incision was taken, with subperiosteal dissection of the muscles and exposure of L4-L5, S1, and the sacral alar region. Posterolateral fusion with decompression of the left L5-S1 intervertebral foramen was performed because of the presence of substantial stenosis. Pedicle screws were placed in the L4 and S1 vertebrae, skipping the L5 level because fixation at that level was not possible owing to the severity of the slippage. Demineralized bone matrix and rhBMP-2 were used both
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Our second patient reported immediate resolution of her radicular symptoms in the postanesthesia care unit. The patient was discharged from the hospital on POD2 without complications. After discharge, the patient continued to improve and at the 6week, 3-month, and 6-month follow-up examinations remained pain free. In addition, she had been able to resume all ADLs, including carrying her child. A CT scan at 10 months postoperatively showed complete fusion from L4 to S1 (Figure 8). The postoperative spinopelvic parameters were as follows: lumbar lordosis, 75 ; pelvic incidence, 79 ; pelvic tilt, 25 ; sacral slope, 50 ; slippage, 45%; Dubousset lumbosacral angle, 104 .
DISCUSSION HGS is a challenging clinical problem that has often been associated with a retroverted pelvis and >50% slippage.23 Also, the spinopelvic balance will frequently be abnormal in these patients and, thus, affect their overall QOL.1,24,25 Surgical management is often considered for children and adolescent patients with HGS, regardless of their symptoms, owing to high risk of progression of slippage.26,27 The optimal management of HGS in adult patients has been more controversial. However, surgery is indicated for severely symptomatic patients for whom a trial of conservative management has failed.4 Surgical treatment should focus on pain relief, neural decompression, correction of the spinopelvic parameters, and achievement of solid arthrodesis.
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Figure 5. Postoperative (A) anteroposterior radiograph and (B) computed tomography scan showing the satisfactory position of the anterior and posterior
A contentious debate has continued regarding the type of surgical procedure and consideration of reduction in these patients with HGS.4,28 In the absence of high-quality evidence,28 partial reduction has often been recommended to achieve a
Figure 6. (A) Sagittal and (B) axial computed tomography scans showing superficial subcutaneous collection and wound infection 10 days after surgery.
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instrumentation with adequate reduction of high-grade spondylolisthesis.
satisfactory fusion surface area and also to improve the spinopelvic and global alignment.4,29 Anterior column support plays a critical role in achieving reduction and interbody fusion in patients with significant dysplasia of posterior elements to
The infection was managed conservatively with antibiotics.
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Figure 7. Postoperative lateral radiographs at (A) 1 month, (B) 5 months, (C) 7 months, and (D) 9 months showing satisfactory position of anterior and posterior instrumentation with adequate reduction of high-grade spondylolisthesis.
achieve satisfactory arthrodesis.4,30 However, anterior column support is not always feasible in patients with significant slippage, which precludes entry into the affected disc space. In these patients, various transsacral transvertebral body techniques, as originally describe by Bohlman and Cook,11 combined with PLF without reduction, should be considered. RBT is a modification of the original Bohlman technique, in which transsacral instrumentation is achieved via an anterior approach, thus providing anterior column support. This technique avoids the risk of injuring the dural sac or nerve roots with associated cerebrospinal fluid leakage and the morbidity associated with harvesting an autologous fibular graft, as described in original technique.5 However, RBT also involves the risks associated with an anterior approach such as injury to the iliac vessels, sympathetic plexus with retrograde ejaculation, retroperitoneal
hematoma, ileus, incisional hernia, and wound infection.31 Also, this technique requires a vascular access surgeon for the approach. Nevertheless, the incidence of complications has been low (15.8%) across all studies (anterior and posterior) using transsacral fixation techniques.7 Given the rarity of HGS and the use of various transsacral techniques, no study has compared the use of the fibular graft versus other implants in terms of complications and outcomes. Also, we found no comparison of anterior versus posterior transsacral techniques. Macagno et al.5 used this technique in 6 patients (5 with HGS with L4-L5 instability and 1 with L5-S1 grade I spondylolisthesis with L4-L5 spondylolisthesis), with satisfactory outcomes at a mean follow-up point of 20 months (range, 9e34). Macagno et al.5 used a 1-cm diameter Pyramesh cage (AccessGUDID, Memphis, Tennessee, USA) or fibular dowel allograft, which were precut according to the dimensions of the reamer (10.5-mm
Figure 8. (A) Axial, (B) coronal, and (C) sagittal computed tomography scans at 10 months postoperatively showing complete fusion at the L4eL5 disc space and L5-S1 interbody implant.
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TECHNICAL NOTE diameter and 40e50-mm depth). Similarly, we used a 12 50mm size Medtronic Rialto SI Fusion System cage packed with rhBMP-2 in our patients. We were also able to achieve distraction across the L5eS1 disc space using this technique (Figures 3 and 4), which might have contributed to the improvement in radiculopathy symptoms. Macagno et al.5 reported satisfactory improvement in slippage (from 62.3% to 49.6%), slip angle (11 of kyphosis to 2 of lordosis), and lumbar lordosis (from 49 to 57.5 ), as determined from the preoperative and postoperative lumbar images, using a Pyramesh cage or fibular dowel for RBT. Similarly, Hire et al.6 reported an improvement in lumbar lordosis (from 83 to 80 ), pelvic incidence (from 38 to 90 ), and pelvic tilt (from 38 to 31 ) using a modified Bohlman technique (axial lumbar interbody fusion bolt) in a 15-year-old boy with grade IV dysplastic HGS. Similarly, we noted an improvement in slippage (from 60.3% to 50%), lumbar lordosis (from 83 to 56.8 ), pelvic incidence (from 82.6 to 75.9 ), and pelvic tilt (from 3.1 to 30.5 ) using RBT. A recent systematic review analyzing various transsacral techniques for L5-S1 HGS (n ¼ 9 studies) reported excellent fusion rates (100%; no pseudoarthrosis) with no progression of slippage at a mean follow-up period of 30.1 months (range, 2e58).7 All the patients had some improvement in pain, and 95% of patients had at least average function postoperatively.7 Only 15.8% of patients had developed perioperative complications in that study.7 Macagno et al.,5 in their series using RBT, reported that 2 patients experienced interbody graft failure and 1 had
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developed L5-S1 pseudoarthrosis. One patient with interbody graft failure in their study had undergone PLF only at L4-L5 and fracture of the titanium cage and L5 pedicle screw had occurred 1 year after RBT.5 That patient underwent extension of the instrumentation to the ilium and replacement of the titanium cage along the original tract using a posterior approach and the original Bohlman technique. Given the shear forces present at L5-S1 in our first patient with HGS, we placed bilateral pedicle screws at L4, L5, and S1 and iliac bolts to achieve a biomechanically sound construct and facilitate fusion. Our patient had improved at her last follow-up evaluation with no complications. Finally, the mean preoperative anterolisthesis had improved from 62.3% to 49.6% (P ¼ 0.003), and the slip angle had improved from 118 of kyphosis to 28 of lordosis (P ¼ 0.005). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively. The lumbar lordosis had improved from 498 to 57.58 postoperatively (P ¼ 0.049).
CONCLUSIONS To the best of our knowledge, the present study is the first to demonstrate the utility of the SI joint fusion cage (Medtronic Rialto) using RBT in 2 patients with HGS. Our results have shown that this technique is safe, feasible, and effective and avoids the risks of injury to the dural sac and nerve roots, infection, and morbidity associated with the Bohlman or modified Bohlman technique using a fibular autograft or allograft. This technique can be considered instead of traditional surgical techniques for patients with HGS to achieve a satisfactory clinical outcome.
8. 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;14:91-99. 9. Remes V, Lamberg T, Tervahartiala P, et al. Longterm 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;31:2491-2499. 10. Speed K. Spondylolisthesis: treatment by anterior bone graft. Arch Surg. 1938;37:175-189. 11. Bohlman HH, Cook SS. One-stage decompression and posterolateral and interbody fusion for lumbosacral spondyloptosis through a posterior approach: report of two cases. J Bone Joint Surg Am. 1982;64:415-418. 12. Smith JA, Deviren V, Berven S, Kleinstueck F, Bradford DS. Clinical outcome of trans-sacral interbody fusion after partial reduction for highgrade L5-S1 spondylolisthesis. Spine (Phila Pa 1976). 2001;26:2227-2234.
15. Lakshmanan P, Ahuja S, Lewis M, Howes J, Davies PR. Transsacral screw fixation for highgrade spondylolisthesis. Spine J. 2009;9:1024-1029. 16. 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; 30:505-513. 17. Bollini G, Jouve JL, Launay F, Glard Y, Jacopin S, Blondel B. High-grade child spondylolisthesis: a custom-made canulated screw to treat the socalled double instability. Orthop Traumatol Surg Res. 2011;97:179-185. 18. Sasso RC, Shively KD, Reilly TM. Transvertebral transsacral strut grafting for high-grade isthmic spondylolisthesis L5-S1 with fibular allograft. J Spinal Disord Techn. 2008;21:328-333. 19. Laurent LE, Osterman K. Operative treatment of spondylolisthesis in young patients. Clin Orthop Relat Res. 1976;117:85-91.
13. Bozkus H, Dickman CA. Transvertebral interbody cage and pedicle screw fixation for high-grade spondylolisthesis: case report. J Neurosurg. 2004; 100(1 suppl spine):62-65.
20. Smith MD, Bohlman HH. Spondylolisthesis treated by a single-stage operation combining decompression with in situ posterolateral and anterior fusion: an analysis of eleven patients who had long-term follow-up. J Bone Joint Surg Am. 1990;72:415-421.
14. 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;19:710-715.
21. Hart RA, Domes CM, Goodwin B, et al. Highgrade spondylolisthesis treated using a modified Bohlman technique: results among multiple surgeons. J Neurosurg Spine. 2014;20:523-530.
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27. Pizzutillo PD, Hummer CD III. Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. J Pediatr Orthop. 1989;9:538-540.
23. Labelle H, Mac-Thiong JM, Roussouly P. Spinopelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J. 2011;(suppl 5): 641-646.
28. Transfeldt EE, Mehbod AA. Evidence-based medicine analysis of isthmic spondylolisthesis treatment including reduction versus fusion in situ for high-grade slips. Spine (Phila Pa 1976). 2007;32(suppl):S126-S129.
24. Labelle H, Roussouly P, Berthonnaud E, Dimnet J, O’Brien M. The importance of spino-pelvic balance in L5-S1 developmental spondylolisthesis: a review of pertinent radiologic measurements. Spine (Phila Pa 1976). 2005;30(suppl):S27-S34.
29. Bartolozzi P, Sandri A, Cassini M, Ricci M. Onestage posterior decompression-stabilization and trans-sacral interbody fusion after partial reduction for severe L5-S1 spondylolisthesis. Spine (Phila Pa 1976). 2003;28:1135-1141.
25. Passias PG, Poorman CE, Yang S, et al. Surgical treatment strategies for high-grade spondylolisthesis: a systematic review. Int J Spine Surg. 2015;9:50.
30. Pawar A, Labelle H, Mac-Thiong JM. The evaluation of lumbosacral dysplasia in young patients with lumbosacral spondylolisthesis: comparison with controls and relationship with the severity of slip. Eur Spine J. 2012;21:2122-2127.
26. Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. J Am Acad Orthop Surg. 2006;14:488-498.
lumbar interbody fusion: results of a combined spine and vascular surgical team. Global Spine J. 2016;6:147-154.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 25 November 2018; accepted 2 January 2019 Citation: World Neurosurg. (2019) 124:331-339. https://doi.org/10.1016/j.wneu.2019.01.041 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
31. Mobbs RJ, Phan K, Daly D, Rao PJ, Lennox A. Approach-related complications of anterior
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Sacroiliac Joint Fusion System for High-Grade Spondylolisthesis Using “Reverse Bohlman Technique”: A Technical Report and Overview of the Literature Mayur Sharma1, Zaid Aljuboori1, Jared William Clouse2, Richard Rodgers2, Thomas Altstadt1
OBJECTIVE/BACKGROUND: High-grade spondylolisthesis (HGS) is a complex clinical problem that poses significant challenges to the treating physician. Contentious debate has continued regarding the most optimal surgical approach for these patients. A variety of transsacral and transvertebral techniques have been described in reported studies.
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METHODS AND RESULTS: We present 2 cases of low back pain and radicular symptoms. Our 2 patients were a 35year-old woman and a 26-year-old white woman. The computed tomography and magnetic resonance imaging scans revealed progressive HGS (grade III) that had not been relieved by conservative measures. Both patients underwent transsacral fixation using the reverse Bohlman technique (RBT) at L5-S1 and L4-L5 anterior lumbar interbody fusion combined with posterolateral fusion. At the 9- and 10-month follow-up visits, the patients reported minimal back pain with no radicular symptoms, and the imaging studies showed satisfactory fusion in both patients.
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CONCLUSIONS: To the best of our knowledge, this is the first report to demonstrate the utility of the sacroiliac joint fusion cage using RBT in patients with HGS with successful clinical outcome. The RBT is safe, feasible, and effective in carefully selected patients.
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INTRODUCTION
I
n the current era of global spinal alignment, it is imperative for patients to have spinopelvic parameters within an ageappropriate normal range to experience good health-related
Key words High-grade spondylolisthesis - Novel technique - Reverse Bohlman technique -
Abbreviations and Acronyms ALD: Activity of daily living ALIF: Anterior lumbar interbody fusion CT: Computed tomography HGS: High-grade spondylolisthesis PLF: Posterolateral fusion POD: Postoperative day QOL: Quality of life RBT: Reverse Bohlman technique
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quality of life (QOL).1 A multitude of surgical approaches have been described for high-grade spondylolisthesis (HGS), including instrumented posterolateral fusion (PLF) with or without decompression, interbody fusion (i.e., posterior lumbar interbody fusion, transforaminal lumbar interbody fusion) with decompression, reduction and PLF, circumferential fusion, transsacral fibular dowel graft with PLF, and spondylectomy for spondyloptosis.2-7 Direct anterior approaches are often not feasible in these patients owing to the severity of slippage and an inability to access the disc space.8,9 In 1938, Speed10 first described the anterior approach for L5S1 spondylolisthesis using an in situ tibial autograft strut. In 1982, Bohlman and Cook11 first described the technique of transsacral fusion using a fibular autograft across S1 into the L5 vertebral body with decompression and noninstrumented L4eS1 PLF (Bohlman technique). The early results with this technique resulted in complications such as fibular graft fracture, graft resorption, slip progression, and pseudoarthrosis.12 Since then, several modifications of the technique (modified Bohlman techniques) have been described, including transsacral transvertebral screw fixation, transvertebral interbody cage fixation, intrasacral rods, a variety of screws, including the S1 pedicle screw, and, recently, the axial lumbar interbody fusion bolt.6,13-21 Recently, a modification of the transsacral technique, the reverse Bohlman technique (RBT) has been described. The RBT is performed through the anterior cephalad portion of the L5 vertebral body angled across the spondylolisthetic disc space into the sacral vertebral body using an anterior abdominal transperitoneal approach with or without instrumented PLF.5 A paucity of reports has described this technique in neurosurgical studies. In the present report, we describe 2 interesting cases of L5-S1 HGS managed with L4-L5 anterior lumbar interbody fusion (ALIF), L5-S1 RBT, and L5-S1 decompression with instrumented
rhBMP-2: Recombinant human bone morphogenetic protein-2 SI: Sacroiliac From the 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky; and 2Department of Neurological Surgery, Indianapolis University School of Medicine, Indianapolis, Indiana, USA To whom correspondence should be addressed: Thomas Altstadt, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 124:331-339. https://doi.org/10.1016/j.wneu.2019.01.041 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
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PLF. To the best of our knowledge, ours is the first report describing the use of a sacroiliac (SI) joint fusion cage (Rialto [Medtronic, Dublin, Ireland]) for HGS. Our results have demonstrated the safety and feasibility of using this cage as an alternative option for RBT in patients with HGS.
CASE REPORT Patient 1 A 35-year-old white woman presented with a history of low back pain, left leg pain, and left foot numbness. Her symptoms had been gradual in onset and progressive in nature and had worsened during the 6 months before her presentation. Her low back pain was deep and aching in nature, aggravated with activity, and relieved by lying down. Her left leg pain was radiating along the left L5 and S1 nerve distribution, with numbness along the left foot (S1 distribution). Her pain level was 8 of 10 at its worst using a visual analog scale. The motor examination revealed intact
Figure 1. (A, B) Computed tomography scans and (C, D) T2-weighted magnetic resonance imaging lumbosacral spine images showing L5-S1 high-grade spondylolisthesis (grade III) with severe neuroforaminal
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function in the bilateral upper extremities, with 5 of 5 strength (Medical Research Council grade22). The lower extremity examination showed left tibialis anterior strength of 4þ of 5 and left external hallucis longus strength of 4 of 5; at rest, the finding was 5 of 5. Her reflexes were 2þ throughout, and the sensory examination findings were positive for minimal numbness along the left S1 distribution in the left foot. The remaining findings of the systemic examinations were normal. We found minimal tenderness in the midline low back on palpation. CT and magnetic resonance imaging studies of the lumbosacral spine showed L5-S1 HGS (grade III) with severe neuroforaminal stenosis, sclerotic endplate changes, loss of disc height, loss of fat around the exiting bilateral L5 nerve roots, and a chronic bilateral L5 pars defect (Figure 1). Interval worsening of her HGS was present secondary to the pars defect, and lumbar flexion/extension films revealed 2.2-cm fixed anterolisthesis of L5 over S1. The preoperative spinopelvic parameters were as follows: lumbar lordosis, 83 ; pelvic incidence, 82.6 ; pelvic tilt, 3.1 ; sacral slope, 85.7 ; slippage, 60.27%; and Dubousset
stenosis, sclerotic endplate changes, loss of disc height, loss of fat around the exiting bilateral L5 nerve roots, and chronic bilateral L5 pars defect, with a trapezoid appearance of the L5 vertebral body.
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Table 1. Preoperative and Postoperative Spinopelvic Parameters Patient 1 Parameter
Preoperative Postoperative Preoperative Postoperative
Lumbar lordosis ( )
83
56.8
60
75
Pelvic incidence ( )
82.6
75.9
78
79
3.1
30.5
22
25
Sacral slope ( )
85.7
45.2
50
50
Slippage (%)
60.27
50
58.8
45
Dubousset lumbosacral angle ( )
121.8
100.2
97
104
Pelvic tilt ( )
Figure 2. Preoperative T2-weighted magnetic resonance imaging study showing high-grade spondylolisthesis of the L5 vertebra, a pars interarticularis defect, degenerative disc changes at L4-L5, and a steep sacral slope.
lumbosacral angle, 121.8 . Various conservative treatments (e.g., physical therapy, nerve root blocks) had failed and the patient was severely symptomatic, which had affected her QOL. Thus, surgical decompression with reduction and instrumented fusion was offered after discussion with the patient and her family. The procedure was performed in 2 stages: anterior fusion (modified RBT), followed by posterolateral fusion. The rationale for performing this procedure in 2 stages over 2 days was to assess the symptomatic improvement achieved after anterior alignment. Also, the 2-day procedure decreased the longer anesthesia time required for a single-stage procedure and the risks associated with transitioning the patient from the supine to prone position.
Patient 2
Her preoperative spinopelvic parameters were as follows: lumbar lordosis, 60 ; pelvic incidence, 78 ; pelvic tilt, 22 ; sacral slope, 50 ; slippage, 58.8%; and Dubousset lumbosacral angle, 97 (Table 1). Because of the steep sacral slope and the severe nature of the L5 vertebral slippage, it was decided that anterior and posterior fixation would be required to provide adequate stability. The patient underwent L4-L5 ALIF with L5-S1 transvertebral cage fixation and L5-S1 posterolateral instrumented fusion.
SURGICAL TECHNIQUE The procedure was performed in 2 stages: anterior fusion (modified RBT), followed by posterolateral fusion.
Patient 2 A 26-year-old woman had presented with a 7-month history of left hip and lower extremity pain. The radicular pain was reproducible with changes in her body position and was exacerbated when she was lying supine or prone, holding her 4-month-old child, and sitting or standing for an extended period (range, 10e15 minutes). The patient did not report any paresthesia or motor deficits with the pain. The pain had begun as a stabbing sensation in the left hip after a fall in the shower when the patient was 7 months’ pregnant with her first child. At delivery of her infant 6 weeks later, the patient had complaints of radicular pain to her mid-thigh and persistent hip pain. The radicular pain had progressively worsened, and the patient had sought care after she had begun to experience the radicular pain in her toes. A plain radiograph revealed HGS of the L5 vertebra, and the patient was referred to us for further evaluation. On physical examination, she had sciatic notch tenderness on the left with subtle weakness of dorsiflexion on the ipsilateral side. Otherwise, the findings from her neurologic examination were unremarkable. Magnetic resonance imaging confirmed grade III spondylolisthesis of the L5 vertebra and additionally showed a pars interarticularis defect, degenerative disc changes at the L4-L5 level, and a steep sacral slope (Figure 2). The patient had exhausted the conservative management options and had decided to pursue surgical repair because of her worsening pain and impairment of her activities of daily living (ADLs).
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Patient 1 Stage 1. With the patient under endotracheal general anesthesia, the patient was placed supine on the operating table with her arms outstretched. The lower abdominal region was prepared and draped in the usual sterile fashion. An experienced vascular surgeon performed the anterior approach and provided exposure to the L4-L5 and L5-S1 region. Intraoperative navigation was not feasible owing to the patient’s position on the table. The midline was defined using fluoroscopy (anteroposterior and lateral views). The superior portion of the L5 vertebral body was then identified, and a pilot hole was drilled. Using fluoroscopic guidance, a trajectory was drilled through the L5 vertebral body across the L5eS1 interspace into the sacrum (to w50 mm). The trajectory was then tapped. After confirming the absence of cortical breaches, a 12- 50-mm size Rialto SI fusion system cage (Medtronic) packed with recombinant human bone morphogenetic protein-2 (rhBMP-2) and cancellous bone chips was implanted through the L5 vertebral body across the L5eS1 interspace into the sacrum with fluoroscopic guidance. This maneuver reduced the spondylolisthesis from grade III to grade I, with no changes in the electromyographic monitoring findings or spontaneous firing of the L5 nerve root. After satisfactory placement of the cage, the L4eL5 disc space with incised and aggressive discectomy was performed using Cobb instruments, curettes, and pituitary rongeurs. The endplates were prepared for
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Figure 3. Intraoperative (A) fluoroscopic view and (B) computed tomography (CT) scan showing satisfactory placement of the anterior L4-L5 interbody implant and L5-S1 transsacral transvertebral Rialto (Medtronic)
arthrodesis by removing the cartilaginous endplates using a curette. We then implanted a 12-mm-high, 14 lordotic evolution spacer filled with rhBMP-2 and cancellous bone chips in the L4eL5 interspace using lateral fluoroscopic guidance. Next, 20mm screws were placed cephalad and caudal to the cage and locked to the Integra plate. The final lateral radiograph demonstrated satisfactory a graft and hardware position with reduction of the spondylolisthesis. No complications developed throughout the procedure, and the wound was closed in the usual manner after drain placement.
Stage 2. Intravenous anesthesia, followed by general endotracheal anesthesia, was induced. She was positioned prone with appropriate padding of all pressure points. The lumbar spine was maintained in the neutral position. A midline skin incision
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cage. Intraoperative (C) sagittal CT and (D) axial CT scans showed satisfactory placement of bilateral posterior L4-L5-S1 pedicle and iliac bolts, with satisfactory reduction.
was made, and the transverse processes of L4, L5, and sacral ala, with the bilateral iliac crest were dissected in a subperiosteal manner using monopolar cautery. We next attached a spinous process clamp on the spinous process of the sacrum with an attached fiducial marker. We then draped the patient to obtain an intraoperative CT scan using the BrainLab AIRO intraoperative navigation system (Brainlab AG, Munich, Germany) for patient 1 and the Medtronic O-arm for patient 2. We then used the BrainLAB navigation system to place bilateral pedicle screws at the L4, L5, sacrum, and iliac bolts. After satisfactory placement of the pedicle screws, the transverse processes at L4, L5, and sacral ala were decorticated. Next, appropriately sized titanium rods were used to connect the pedicle screws and iliac bolts (using side connectors) on each side and locked in place using locking screws. An intraoperative CT scan was obtained to confirm the proper placement of the
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anteriorly and posteriorly to promote bone growth and fusion. Bone grafting materials and ALIF and posterior hardware were chosen in accordance with the primary surgeon’s preference. The wound was then closed in layers in the usual manner after drain placement. The patient withstood the procedure well without complications (Figures 3 and 4).
POSTOPERATIVE COURSE Patient 1 Our first patient recovered well during the postoperative period, with improvement in her radiculopathy symptoms after anterior realignment. Her left external hallucis longus and tibialis anterior motor weakness had improved to normal during the postoperative course. Numbness along the left S1 dermatome had also improved. However, she had developed right meralgia paresthetica (likely due to the operative position), which had gradually improved during the follow-up period. Postoperative imaging revealed a satisfactory position of the implant (Figure 5). She was gradually mobilized with physical therapy on postoperative day (POD)2 with an external orthosis and was discharged to home on POD6. She underwent repeat evaluation 10 days later because of a superficial infection of the abdominal wound, which was managed conservatively with antibiotics (Figure 6). At the most recent follow-up examination at 9 months postoperatively, the patient reported minimal back pain with markedly improved right thigh numbness. Her preoperative symptoms had resolved completely, with well-healed incisions. Her motor function was 5 of 5 throughout, with no new sensory deficits. She was independent in her ADLs, and radiographs showed a satisfactory position of the hardware and a reduction of spondylolisthesis (Figure 7). The postoperative spinopelvic parameters were as follows: lumbar lordosis, 56.8 ; pelvic incidence, 75.9 ; pelvic tilt, 30.5 ; sacral slope, 45.2 ; slippage, 50%; and Dubousset lumbosacral angle, 100.2 .
Patient 2 Figure 4. Illustration showing placement of L4-L5 interbody implant, L5S1 transsacral transvertebral Rialto cage (Medtronic) and posterolateral pedicle screws.
hardware. After satisfactory placement of the hardware, the wound was copiously irrigated with antibiotic solution. rhBMP-2 with cancellous bone chips was placed over the L4 and L5 transverse processes and sacral ala to achieve posterolateral arthrodesis.
Patient 2 Stage 1. The anterior RBT procedure for patient 2 was similar to that described for patient 1.
Stage 2. In the second patient, after placing her patient in the prone position, a midline incision was taken, with subperiosteal dissection of the muscles and exposure of L4-L5, S1, and the sacral alar region. Posterolateral fusion with decompression of the left L5-S1 intervertebral foramen was performed because of the presence of substantial stenosis. Pedicle screws were placed in the L4 and S1 vertebrae, skipping the L5 level because fixation at that level was not possible owing to the severity of the slippage. Demineralized bone matrix and rhBMP-2 were used both
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Our second patient reported immediate resolution of her radicular symptoms in the postanesthesia care unit. The patient was discharged from the hospital on POD2 without complications. After discharge, the patient continued to improve and at the 6week, 3-month, and 6-month follow-up examinations remained pain free. In addition, she had been able to resume all ADLs, including carrying her child. A CT scan at 10 months postoperatively showed complete fusion from L4 to S1 (Figure 8). The postoperative spinopelvic parameters were as follows: lumbar lordosis, 75 ; pelvic incidence, 79 ; pelvic tilt, 25 ; sacral slope, 50 ; slippage, 45%; Dubousset lumbosacral angle, 104 .
DISCUSSION HGS is a challenging clinical problem that has often been associated with a retroverted pelvis and >50% slippage.23 Also, the spinopelvic balance will frequently be abnormal in these patients and, thus, affect their overall QOL.1,24,25 Surgical management is often considered for children and adolescent patients with HGS, regardless of their symptoms, owing to high risk of progression of slippage.26,27 The optimal management of HGS in adult patients has been more controversial. However, surgery is indicated for severely symptomatic patients for whom a trial of conservative management has failed.4 Surgical treatment should focus on pain relief, neural decompression, correction of the spinopelvic parameters, and achievement of solid arthrodesis.
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Figure 5. Postoperative (A) anteroposterior radiograph and (B) computed tomography scan showing the satisfactory position of the anterior and posterior
A contentious debate has continued regarding the type of surgical procedure and consideration of reduction in these patients with HGS.4,28 In the absence of high-quality evidence,28 partial reduction has often been recommended to achieve a
Figure 6. (A) Sagittal and (B) axial computed tomography scans showing superficial subcutaneous collection and wound infection 10 days after surgery.
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instrumentation with adequate reduction of high-grade spondylolisthesis.
satisfactory fusion surface area and also to improve the spinopelvic and global alignment.4,29 Anterior column support plays a critical role in achieving reduction and interbody fusion in patients with significant dysplasia of posterior elements to
The infection was managed conservatively with antibiotics.
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Figure 7. Postoperative lateral radiographs at (A) 1 month, (B) 5 months, (C) 7 months, and (D) 9 months showing satisfactory position of anterior and posterior instrumentation with adequate reduction of high-grade spondylolisthesis.
achieve satisfactory arthrodesis.4,30 However, anterior column support is not always feasible in patients with significant slippage, which precludes entry into the affected disc space. In these patients, various transsacral transvertebral body techniques, as originally describe by Bohlman and Cook,11 combined with PLF without reduction, should be considered. RBT is a modification of the original Bohlman technique, in which transsacral instrumentation is achieved via an anterior approach, thus providing anterior column support. This technique avoids the risk of injuring the dural sac or nerve roots with associated cerebrospinal fluid leakage and the morbidity associated with harvesting an autologous fibular graft, as described in original technique.5 However, RBT also involves the risks associated with an anterior approach such as injury to the iliac vessels, sympathetic plexus with retrograde ejaculation, retroperitoneal
hematoma, ileus, incisional hernia, and wound infection.31 Also, this technique requires a vascular access surgeon for the approach. Nevertheless, the incidence of complications has been low (15.8%) across all studies (anterior and posterior) using transsacral fixation techniques.7 Given the rarity of HGS and the use of various transsacral techniques, no study has compared the use of the fibular graft versus other implants in terms of complications and outcomes. Also, we found no comparison of anterior versus posterior transsacral techniques. Macagno et al.5 used this technique in 6 patients (5 with HGS with L4-L5 instability and 1 with L5-S1 grade I spondylolisthesis with L4-L5 spondylolisthesis), with satisfactory outcomes at a mean follow-up point of 20 months (range, 9e34). Macagno et al.5 used a 1-cm diameter Pyramesh cage (AccessGUDID, Memphis, Tennessee, USA) or fibular dowel allograft, which were precut according to the dimensions of the reamer (10.5-mm
Figure 8. (A) Axial, (B) coronal, and (C) sagittal computed tomography scans at 10 months postoperatively showing complete fusion at the L4eL5 disc space and L5-S1 interbody implant.
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TECHNICAL NOTE diameter and 40e50-mm depth). Similarly, we used a 12 50mm size Medtronic Rialto SI Fusion System cage packed with rhBMP-2 in our patients. We were also able to achieve distraction across the L5eS1 disc space using this technique (Figures 3 and 4), which might have contributed to the improvement in radiculopathy symptoms. Macagno et al.5 reported satisfactory improvement in slippage (from 62.3% to 49.6%), slip angle (11 of kyphosis to 2 of lordosis), and lumbar lordosis (from 49 to 57.5 ), as determined from the preoperative and postoperative lumbar images, using a Pyramesh cage or fibular dowel for RBT. Similarly, Hire et al.6 reported an improvement in lumbar lordosis (from 83 to 80 ), pelvic incidence (from 38 to 90 ), and pelvic tilt (from 38 to 31 ) using a modified Bohlman technique (axial lumbar interbody fusion bolt) in a 15-year-old boy with grade IV dysplastic HGS. Similarly, we noted an improvement in slippage (from 60.3% to 50%), lumbar lordosis (from 83 to 56.8 ), pelvic incidence (from 82.6 to 75.9 ), and pelvic tilt (from 3.1 to 30.5 ) using RBT. A recent systematic review analyzing various transsacral techniques for L5-S1 HGS (n ¼ 9 studies) reported excellent fusion rates (100%; no pseudoarthrosis) with no progression of slippage at a mean follow-up period of 30.1 months (range, 2e58).7 All the patients had some improvement in pain, and 95% of patients had at least average function postoperatively.7 Only 15.8% of patients had developed perioperative complications in that study.7 Macagno et al.,5 in their series using RBT, reported that 2 patients experienced interbody graft failure and 1 had
REFERENCES 1. Harroud A, Labelle H, Joncas J, Mac-Thiong JM. Global sagittal alignment and health-related quality of life in lumbosacral spondylolisthesis. Eur Spine J. 2013;22:849-856. 2. Meyerding HW. Spondylolisthesis; surgical fusion of lumbosacral portion of spinal column and interarticular facets; use of autogenous bone grafts for relief of disabling backache. J Int Coll Surg. 1956;26(5 Pt 1):566-591. 3. Stoker GE, Buchowski JM, Zebala LP, Lenke LG, Bridwell KH. High-grade spondylolisthesis: surgical management in the pediatric and young adult patient. ArgoSpine News J. 2011;23:33-42. 4. Kasliwal MK, Smith JS, Kanter A, et al. Management of high-grade spondylolisthesis. Neurosurg Clin North Am. 2013;24:275-291. 5. Macagno AE, Hasan S, Jalai CM, et al. "Reverse Bohlman" technique for the treatment of high grade spondylolisthesis in an adult population. J Orthop. 2016;13:1-9. 6. Hire JM, Jacobs JM, Bundy JV, DeVine JG. A modified Bohlman technique using a novel implant for treatment of high-grade spondylolisthesis. J Neurosurg Spine. 2015;22:80-83. 7. Rindler RS, Miller BA, Eshraghi SR, et al. Efficacy of transsacral instrumentation for high-grade spondylolisthesis at L5-S1: a systematic review of the literature. World Neurosurg. 2016;95: 623.e611-623.e619.
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developed L5-S1 pseudoarthrosis. One patient with interbody graft failure in their study had undergone PLF only at L4-L5 and fracture of the titanium cage and L5 pedicle screw had occurred 1 year after RBT.5 That patient underwent extension of the instrumentation to the ilium and replacement of the titanium cage along the original tract using a posterior approach and the original Bohlman technique. Given the shear forces present at L5-S1 in our first patient with HGS, we placed bilateral pedicle screws at L4, L5, and S1 and iliac bolts to achieve a biomechanically sound construct and facilitate fusion. Our patient had improved at her last follow-up evaluation with no complications. Finally, the mean preoperative anterolisthesis had improved from 62.3% to 49.6% (P ¼ 0.003), and the slip angle had improved from 118 of kyphosis to 28 of lordosis (P ¼ 0.005). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively. The lumbar lordosis had improved from 498 to 57.58 postoperatively (P ¼ 0.049).
CONCLUSIONS To the best of our knowledge, the present study is the first to demonstrate the utility of the SI joint fusion cage (Medtronic Rialto) using RBT in 2 patients with HGS. Our results have shown that this technique is safe, feasible, and effective and avoids the risks of injury to the dural sac and nerve roots, infection, and morbidity associated with the Bohlman or modified Bohlman technique using a fibular autograft or allograft. This technique can be considered instead of traditional surgical techniques for patients with HGS to achieve a satisfactory clinical outcome.
8. 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;14:91-99. 9. Remes V, Lamberg T, Tervahartiala P, et al. Longterm 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;31:2491-2499. 10. Speed K. Spondylolisthesis: treatment by anterior bone graft. Arch Surg. 1938;37:175-189. 11. Bohlman HH, Cook SS. One-stage decompression and posterolateral and interbody fusion for lumbosacral spondyloptosis through a posterior approach: report of two cases. J Bone Joint Surg Am. 1982;64:415-418. 12. Smith JA, Deviren V, Berven S, Kleinstueck F, Bradford DS. Clinical outcome of trans-sacral interbody fusion after partial reduction for highgrade L5-S1 spondylolisthesis. Spine (Phila Pa 1976). 2001;26:2227-2234.
15. Lakshmanan P, Ahuja S, Lewis M, Howes J, Davies PR. Transsacral screw fixation for highgrade spondylolisthesis. Spine J. 2009;9:1024-1029. 16. 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; 30:505-513. 17. Bollini G, Jouve JL, Launay F, Glard Y, Jacopin S, Blondel B. High-grade child spondylolisthesis: a custom-made canulated screw to treat the socalled double instability. Orthop Traumatol Surg Res. 2011;97:179-185. 18. Sasso RC, Shively KD, Reilly TM. Transvertebral transsacral strut grafting for high-grade isthmic spondylolisthesis L5-S1 with fibular allograft. J Spinal Disord Techn. 2008;21:328-333. 19. Laurent LE, Osterman K. Operative treatment of spondylolisthesis in young patients. Clin Orthop Relat Res. 1976;117:85-91.
13. Bozkus H, Dickman CA. Transvertebral interbody cage and pedicle screw fixation for high-grade spondylolisthesis: case report. J Neurosurg. 2004; 100(1 suppl spine):62-65.
20. Smith MD, Bohlman HH. Spondylolisthesis treated by a single-stage operation combining decompression with in situ posterolateral and anterior fusion: an analysis of eleven patients who had long-term follow-up. J Bone Joint Surg Am. 1990;72:415-421.
14. 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;19:710-715.
21. Hart RA, Domes CM, Goodwin B, et al. Highgrade spondylolisthesis treated using a modified Bohlman technique: results among multiple surgeons. J Neurosurg Spine. 2014;20:523-530.
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22. Vanhoutte EK, Faber CG, van Nes SI, et al. Modifying the Medical Research Council grading system through Rasch analyses. Brain. 2012;135: 1639-1649.
27. Pizzutillo PD, Hummer CD III. Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. J Pediatr Orthop. 1989;9:538-540.
23. Labelle H, Mac-Thiong JM, Roussouly P. Spinopelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J. 2011;(suppl 5): 641-646.
28. Transfeldt EE, Mehbod AA. Evidence-based medicine analysis of isthmic spondylolisthesis treatment including reduction versus fusion in situ for high-grade slips. Spine (Phila Pa 1976). 2007;32(suppl):S126-S129.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 25 November 2018; accepted 2 January 2019 Citation: World Neurosurg. (2019) 124:331-339. https://doi.org/10.1016/j.wneu.2019.01.041 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
31. Mobbs RJ, Phan K, Daly D, Rao PJ, Lennox A. Approach-related complications of anterior
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