- Email: [email protected]
Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population
Journal of Clinical Neuroscience xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical study
Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population Aria Jamshidi, Allan D. Levi ⇑ Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
a r t i c l e
i n f o
Article history: Received 3 May 2019 Accepted 8 July 2019 Available online xxxx Keywords: Bohlman Reverse High grade Spondylolisthesis
a b s t r a c t Background/aims: Surgical techniques for treatment of high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate both radiographic and clinical outcomes in patients with HGS treated with the ‘‘modified Bohlman” and Reverse Bohlman technique. Methods: Review of consecutive HGS patients undergoing modified Bohlman and Reverse Bohlman at a single center from 2006 to 2018. Clinical, surgical, and radiographic data were collected. Results: Six patients identified in the modified Bohlman treatment arm: and eight patients in the Reverse Bohlman group. Twelve (12) patients presented with high grade congenital spondylolisthesis at L5-S1; one patient presented with dissolution of the L5 vertebral body secondary to uncontrolled osteomyelitis that developed after a previous failed fusion; and one patient presented with iatrogenic L5-S1 spondylolisthesis after a previous L3-S1 fusion. One patient had medially placement pedicle screw and associated radiculopathy. All follow-up post = operative scans demonstrated solid fusion. Postoperatively, anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43° of kyphosis to 48.71° (p = .0139). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively except for positioning on a sacral cushion to increase lordotic angle. Lumbar lordosis improved from 65.29 to 63.86 postoperatively. Four of our fourteen patients had long-term median follow-up of 28 months (range = 19–48 months) slip angle, percentage, and lumbar lordosis all improved from the patient’s pre-operative measurements. The improvement in slip angle was nearly statistically significant with a p-value of 0.065. Conclusions: Reverse Bohlman technique for high grade spondylolisthesis is a viable option when seeking to address adjacent level instability or slip. Ó 2019 Elsevier Ltd. All rights reserved.
1. Introduction Isthmic spondylolisthesis is a forward slippage of the vertebral body, its pedicles, transverse process, and upper articular process caused by a break in continuity or elongation of the pars interarticularis. This entity was first described in 1854 by Kilian, and then further characterized by Taillard in 1957 [1]. As per the Meyerding classification, high grade spondylolisthesis (Grades III-V) is defined as greater than 50% slippage of a spinal vertebral body relative to an adjacent vertebral body, and most commonly affects alignment of the L5-S1 motion segment. Patients are typically selected as surgical candidates due to their constellation of symptoms of severe axial back pain with associated neurogenic claudication, segmental
⇑ Corresponding author at: University of Miami MILLER School of Medicine, Department of Neurological Surgery, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA. E-mail address: [email protected] (A.D. Levi).
deformity, radiculopathy, or focal instability. The goals of surgical intervention are thus focused on decompressing neural structures, providing sufficient fixation, and restoring spinopelvic alignment. Surgical management of high-grade cases is a complex issue, and complications can range from pseudoarthrosis, graft site morbidity, neurological compromise, hardware failure, and progression of slip grade or angle [2–4]. Surgical options include in situ posterior fusion, oblique interbody fusion, instrumented posterior fusion, anterior or posterior interbody fusion with instrumentation, and vertebral resection with reduction and fusion [5–8]. While there’s no gold standard technique, the most widely accepted surgical approach is a posterior spinal fusion with instrumentation, either alone or in conjunction with another technique. Transsacral instrumentation through the sacrum and body of L5 has been used increasingly during the last fifteen years. Speed in 1938 was the first to use an anterior approach with an oblique tibial autograft strut for interbody fusion to stabilize a L5-S1 spondylolisthesis [9]. Bohlman and Cook proposed a modification to this
https://doi.org/10.1016/j.jocn.2019.07.044 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
2
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
protocol in 1982 using a single incision posterior approach by introducing a fibular autograft across S1 into the L5 vertebral body along with a decompression and uninstrumented L4-S1 posterolateral fusion to permit for a three column spinal fixation [10]. The benefits of this oblique interbody fusion include increasing the surface area for graft incorporation and a stabilizing effect of the graft with regards to the slip [5]. Rodriguez-Olavaerri and colleagues demonstrated that the Bohlman technique had similar outcomes with transforaminal interbody fusion, resulting in lumbosacral kyphosis improvement [11,12]. The Bohlman procedure was described prior the widespread adoption of modern pedicle screw instrumentation and consequently the technique was initially associated with several complications including fibular graft fracture, graft resorption, slip progression, and pseudoarthrosis [13–15]. Due to these problems, authors suggested using pedicle screw instrumentation to achieve complete reduction. However, this technique resulted in different issues, specifically L-5 nerve root palsies in some patients, as well as instrumentation failure particularly at the sacrum. In reaction to these findings, authors then began advocating for supplementary pelvic fixation to prevent S-1 pedicle screw failure [3,16,17]. The ‘‘modified Bohlman,” which includes addition of transsacral and pedicle screw instrumentation to supplement the Bohlman oblique interbody fusion may help address the previous complications of late graft failure and incomplete reduction of lumbosacral kyphosis [14,18]. Further, other supplementary methods to achieve threecolumn fixation have been offered including transvertebral interbody cage fixation and use of intrasacral rods and custom-made screws [19–22]. While these techniques are performed via a posterior approach for direct decompression and stabilization with pedicle screw fixation, an additional anterior approach or ‘‘reverse Bohlman” is useful in increasing fusion rates by providing an optimal graft environment, restoring sagittal alignment via anterior column reconstruction to restore disk height and reducing the slip angle [23,24]. This method precludes the need for a complete sacral laminectomy with retraction of the caudal dura, and the associated inherent risk, while also making it easier to access the L4-5 intervertebral disk from a single anterior approach as the entry points form the L4L5 and L5S1 interbody graft are juxtaposed [24]. Both techniques have been described with favorable outcomes. However, no earlier study has attempted to compare one to the other, and treatment of HGS at L-5/S-1 remains a significant challenge within spine surgery. As such, we examined radiographic and clinical outcomes in patients who underwent surgery with a single surgeon (ADL) at the same institution over the course of 12 years. We analyze outcomes in patients with HGS treated with either a ‘‘modified Bohlman” (n = 6) or ‘‘Reverse Bohlman” (RB) (n = 8) procedure consisting of a combined anterior/posterior approach with transacral and/or pedicle screw fixation and fibular graft augmented with bone morphogenetic protein-2 (BMP-2) (Medtronic, Memphis, TN) to allow for interbody fusion through an angled anterior approach. We detail the techniques employed at our institution to highlight available surgical options for treating HGS at the lumbar-sacral junction. 2. Materials and methods 2.1. Study design A retrospective review of all consecutive patients who underwent a modified reverse Bohlman (RB) procedure, as well as Reverse Bohlman for HGS was performed at a single university-based center between 2006 and 2018. Primary outcomes evaluated were occurrence of perioperative complications and the need for revision procedures.
2.2. Data collection Clinical parameters collected included patient age and sex, primary presenting symptoms, neurological dysfunction prior to or after surgery, and previous surgical procedures for spondylolisthesis. Radiographic parameters included Wiltse classification, slip percentage (grade), and slip angle. Perisurgical parameters included fusion levels, type of interbody device (fibular strut), posterior instrumentation pattern (transsacral or pedicle screws), use of BMP-2, estimated blood loss (EBL), and perioperative complications. 2.3. Modified Bohlman and Reverse Bohlman procedure 2.3.1. Modified Bohlman All procedures consisted of a posterior only approach. In the majority of cases – two levels (L4-5 and L5-S1) were performed. L4L5 was often incorporated because L5S1 only was technically not possible because pedicle screws heads would cross and would not permit rod placement. No attempt was made to reduce the spondy. L4-L5 was prepared as per regular posterior lumbar interbody fusion technique with radical discectomy and endplate preparation. At the L5-S1 level, a guide wire was initially placed under realtime fluoroscopy. The starting point was in the mid-line just caudal to the end of the dural sac between the sacrococcygeal nerve roots. The wire crosses the overlapping portion of the L5S1 disc space. Rigid cannulated reamers (10–12 mm) from the anterior cruciate ligament reconstruction tray were utilized over the guide wire to create a hole, 40–60 mm in depth, through the L5 and S1 vertebral bodies in which a carefully shaped, rounded fibular allograft would be place. BMP-2 was placed within and around the graft (BMP2.1 mg) and was then impacted into position with proximal portion recessed into S1, continuing across the L5-S1 disc space, and ending in the L5 vertebral body. The L4-5 disc space was distracted and filled with a pre-cut allograft ramps in addition to 2.1 mg of BMP. 2.3.2. Reverse Bohlman All procedures consisted of a anterior/posterior approach, with anterior access performed by an experienced vascular access surgeon. Two levels (L4-5 and L5-S1) were addressed in all cases. L4-L5 was prepared as per regular anterior lumbar interbody fusion technique with radical discectomy and endplate preparation. Prior to placement of L4-5 cage, attention was turned to the L5S1 level. Rigid cannulated reamers were utilized over a guide wire, which was placed under real-time fluoroscopy from the anterior cephalad portion of the L5 vertebral body angled across the spondylolisthetic disc space into the sacral vertebral body. The guide wire was oriented in a trajectory almost perpendicular to the L5-S1 disc space, which was typically perpendicular to the floor. With guide wire in place, a 10.5 mm reamer was passed under fluoroscopy to the desirable depth (40–60 mm) this allowed for creation of a direct channel across the disc space into the sacrum. A standard fibular allograft was used and cut to the pre-reamed length. BMP-2 was placed within and around the graft (BMP2.1 mg) and was then impacted into position with proximal portion recessed into L5, continuing across the L5-S1 disc space, and ending in the proximal sacrum. The L4-5 disc space was distracted and filled with a pre-cut femoral ring allograft containing 2.1 mg of BMP. Following closure of the anterior procedure, the patient was turned prone and an open posterior decompression and fusion from L4-S1 was performed. Iliac fixation was not used.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
3
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
2.4. Radiographic evidence Upright spine radiographs were collected pre-operatively and at the last follow-up and were evaluated by a single independent reviewer. Pelvic incidence was measured from preoperative digital radiographs. Slip percent and slip angle were measured digitally from standing pre-operative and final follow-up evaluations. All measurements were performed digitally with surgimap software. Implant and fusion status were evaluated using plain film, flexion-extension, lateral radiographs, supplemented by CT scans for selected patients at discretion of the operating surgeon.
3. Results Fourteen patients were identified (10 female, 4 male); mean age was 52 years (range: 33–83). 12 patients presented with high grade congenital spondylolisthesis at L5-S1; one patient presented with dissolution of the L5 vertebral body secondary to uncontrolled osteomyelitis that developed after a previous failed fusion; and one patient presented with iatrogenic L5-S1 spondylolisthesis after a previous L3-S1 fusion. All patients reported symptoms of spinal stenosis including severe axial pain as well as claudication symptoms relieved by flexion and exacerbated by extension. Four patients had radicular pain, and one had a unilateral lowerextremity motor deficit (foot drop). No patients presented with bladder or bowel disturbance. The measured mean pelvic incidence preoperatively was 79.1°, which is consistent with prior reports of high pelvic incidence associated with high-grade spondylolisthesis [15]. Six patients underwent the conventional Bohlman procedure with a fibular allograft from L5 to S3, followed by a conventional L4-S1 pedicle fusion in two patients, L5-S1 fusion in three patients, and L3 to Iliac fusion in one patient who had a history of a L3-S1 fusion complicated by a wound infection, osteomyelitis, and dissolution of the L5 vertebral body (Table 1). Eight patients underwent the Reverse Bohlman procedure. All eight patients had a standard ALIF at L4-L5, followed by a L5-S1 reverse Bohlman approach. This modified Bohlman stage was performed with a fibular allograft in seven patients and a titanium mesh cage packed with BMP in one patient. Standard pedicle screws were used for the posterior procedure. Seven of the eight patients were instrumented from L4-S1 and one patient from L2S1 who had a history of a prior L3-S1 fusion and pseudoarthrosis (Table 2).
There was one patient who developed left groin pain postoperatively. A CT scan was done which demonstrated a medially displaced L4 pedicle screw. The patient was taken back to the operating room for revision of the screw and thereafter did well postoperatively with resolution in her pain. At the three-month post-operative visit, five of the six patients in the conventional Bohlman group reported subjective improvement in their pain from their pre-operative state. One endorsed no change in their pain profile. Six of the eight patients in the Reverse Bohlman group reported complete resolution of their pain at the three-month post-operative visit. The two remaining patients reported improvement in their pain from their pre-operative state. Mean intraoperative blood loss was 521 cc (350–800) in this cohort. There were no intraoperative complications. Standard radiographic measurements were made on pre- and postoperative lumbar images. Mean preoperative anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43° of kyphosis to 48.71° (p = .0139) (Table 3). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively except for positioning on a sacral cushion to increase lordotic angle. Lumbar lordosis improved from 65.29 to 63.86 postoperatively (Table 4). Four of our fourteen patients had long-term median follow-up of 28 months (range = 19–48 months) slip angle, percentage, and lumbar lordosis all improved from the patient’s pre-operative measurements. The improvement in slip angle was nearly statistically significant with a p-value of 0.065 (Table 5).
4. Discussion The natural history of high-grade spondylolisthesis is not favorable [25,26]. And while there is the risk of neurological complications with surgical intervention, many authors have concluded that operative treatment is reasonable for symptomatic patients [8]. While the surgical goals of neurological decompression achieving solid arthrodesis, and reduction of lumbosacral kyphosis are all widely agree upon, the optimal surgical approach remains a controversial topic. With only a small number of patients who are affected with this disease process, retrospective comparisons of fusion and complication rates are currently the best means of evaluating treatment outcomes [14,27]. The literature is limited with respect to comparisons of treatment of isthmic spondylolisthesis with fusion in situ, reduction followed by fusion, and vertebral resection. Consequently, based on
Table 1 Characteristics, surgical technique, outcome, and complications in 6 patients with High Grade Spondylolisthesis Who Underwent the Modified Bohlman Procedure. Case #
Age/ Sex
Grade Slip
Surgery performed
FU
Fusion
Immediate FU
3 months FU
1
33/M
3
3 months
Yes
37/F
3
3 months
Yes
Medially Placed Left L4 Pedicle Screw Radiculopathy Numbness over L5 dermatome RLE
Pain Unchanged
2
L4-S1 Pedicle Fusion w/ Vertebral autograft & BMP, L5-S3 fibular allograft Bohlman L5-S1 Pedicle Fusion w/ Vertebral autograft & BMP, L5-S3 fibular allograft Bohlman
3
48/F
3
L5-S1 Pedicle Fusion w/ BMP, L5-S3 fibular allograft Bohlman
3 months
Yes
Neurounchanged
4
52/F
2
L4-S1 Pedicle Fusion w/ vertebral allograft & BMP, L5-S3 fibular allograft Bohlman
13 months
Yes
Neurounchanged
5
54/F
3
L5-S1 laminectomy pedicle fusion w/ BMP, Bohlman Fibular allograft L5-S3
3 months
Yes
Neurounchanged
6
66/M
Lumbar Spine infection w/ Osteomyelitis & L5 fx
L3-Iliac Posterior fusion w/ BMP & vertebral autograft & allograft, L4-S3 fibular allograft w/ BMP
6 months
Yes
Neurounchanged
Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
4
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
Table 2 Characteristics, surgical technique, outcome, and complications in 6 patients with High Grade Spondylolisthesis who Underwent the Reverse Bohlman Procedure. Case #
Age/ Sex
Grade
Anterior Graft
Posterior Graft
FU (months)
EBL
Fusion
Immediate
3 months
7
47/F
3
L4-5 ALIF w/ femoral ring allograft with BMP, L5-S1 Reverse Bohlman Fibular allograft with BMP
L4-S1 pedicle fusion with vertebral autograft
48
350 cc
Yes
Neurounchanged
8
63/ M
4
L4-5 ALIF w/ femoral ring allograft with BMP, L5-S1 Reverse Bohlman Fibular allograft with BMP
L4-S1 pedicle fusion with vertebral autograft
34
800 cc
Yes
Neurounchanged
9
34/F
3
L5-S1 ALIF w/ Reverse Bohlman fibular allograft w/ BMP, L4-5 ALIF w/ femoral ring allograft
L4-S1 pedicle fusion with vertebral autograft
28
600 cc
Yes
Neurounchanged
10
54/F
3
L4-S1 pedicle fusion with posterolateral bone graft
3
500 cc
Yes
Neurounchanged
11
74/F
3
300 cc
Yes
Neurounchanged
33/F
2
19
500 cc
Yes
Neurounchanged
13
83/F
2
L4-5 ALIF – femoral ring allograft with BMP, fibular structural allograft
3
600 cc
Yes
Neuro unchanged
14
74/ M
3
L4-5 ALIF – femoral ring allograft with BMP, fibular structural allograft
L2-S1 pedicle screws & L5-S1 Interbody with BMP & cadaveric allograft L4-S1 pedicle screws with BMP, vertebral autograft, allograft, supplemented posterolateral bone graft L4-S1 pedicle screws with BMP, vertebral autograft, allograft, supplemented posterolateral bone graft L4-S1 pedicle screws with BMP, vertebral autograft, allograft, supplemented posterolateral bone graft
4
12
L4-5 ALIF w/ femoral ring allograft with BMP, L5-S1 Reverse Bohlman w/ 12 mm titanium cage vertebral autograft allograft and BM L2-4 ALIF with cadaveric allograft & BMP, L4-S1 Fibular Structural allograft with BMP L4-5 ALIF – femoral ring allograft with BMP, fibular structural allograft
Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms Doing wellPain improved from Pre-op Doing wellPain improved from Pre-op
3
300 cc
Yes
Neuro unchanged
Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms
Table 3 Radiographic Measurements and Meyerding Classification of Patients Who Underwent Modified Bohlman Procedure (Patients 2, 5, & 6 excluded due to lack of preoperative films). Case #
Age/Sex
Meyerding Score
Pelvic Incidence
Slip angle Pre-op
1
33/M
3
102°
36
3
48/F
3
4
52/F
83
2
89
7
15
Slip angle Post-op
Slip % Pre-op
Slip % Post-op
Lumbar Lordosis Pre-op
66%
64%
63
52%
32%
4
5 13°
31%
Lumbar Lordosis Post-op
67
75
72
30%
103
94
Table 4 Radiographic Measurements and Meyerding Classification of Patients Who Underwent Reverse Bohlman Procedure. Case #
Age/ Sex
Meyerding Score
Pelvic Incidence
7
47/F
3
84
8
63/M
4
91
9
34/F
3
47
10
54/F
3
60
11
74/F
3
93
12
33/F
2
35
4
13
83/F
2
86
14
74/M
3
91
7
9
Slip % Post-op
Lumbar Lord Pre-op
10°
75%
61%
72
82%
68%
66
75%
72%
46
53%
23%
70
61%
55%
67
35%
28%
3
25 18°
21 10°
Slip % Pre-op
8
Slip angle Post-op
3
26
25
66
Slip angle Pre-op
59
42%
34%
77
31%
31%
68
4
78
73
44
4
Lumbar Lord Post-op
65
63
48
76
68
Table 5 Patients Who Underwent the Reverse Bohlman Procedure Who had Range Median Follow-Up of 28 Months. Case #
Age/Sex
Meyerding Score
Slip angle Pre-op
Slip angle Post-op
Slip % Pre-op
Slip % Post-op
Lumbar Lord Pre-op
7
47/F
3
35
10°
75%
56%
72
8
63/M
4
82%
58%
4
3
9
34/F
3
25
12
33/F
2
21
66
75%
51%
46
35%
28%
59
8 4
Lumbar Lord Post-op
75
68
44
48
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
the best evidence available in the literature, it is difficult to develop clear guidelines for treatment of high-grade spondylolisthesis. The use of a fibular strut for oblique interbody fusion in surgical management for high-grade spondylolisthesis is well documented in the literature [2,5]. Recurrent instability and graft failure are known complications of this procedure [3,14]. Failure of fusion is often due to the high loads encountered resulting in fatigue fracture, as well as from weakening of the graft by bone resorption following healing [28,29]. Moreover, placement of an oblique interbody strut without reduction of the slip angle fixes the spine in a position of lumbosacral kyphosis, with potential long-term deleterious effects. Several authors have recognized limitations of the Bohlman technique and have offered modifications to the procedure, including replacement of the fibular strut graft with a titanium mesh cage, and incorporation of pedicle screw or trans-sacral screw instrumentation for augmentation and reduction of the listhesis [3,20,30,31]. Complete reduction of antherolisthesis is now achievable with modern instrumentation techniques, presenting the option of incorporating interbody fusion techniques but making the incorporation of an oblique cage impossible. Advocates of reduction claim that it allows for increased surface area for fusion. However, as long as stable arthrodesis and kyphosis reduction are achieved, there is no evidence to suggest that residual antherolisthesis affects longterm outcomes. Moreover, reduction of antherolisthesis has been linked to increased rates of neurological deficits, specifically an L-5 motor deficit and associated foot drop [4]. In a retrospective review of patients who underwent posterior instrumented reduction and fusion of high grade spondylolisthesis without decompression of neural elements, the authors reported a neurologic complication rate of 9.1%, of which 2.3% represented a L5 motor deficit [32]. In addition to neurological complications, reduction has been associated with implant failures from the increased forces on instrumentation. This has resulted in the need for revision and extension of the primary construct and addition of pelvic fixation. The modified Bohlman technique for treatment of high-grade spondylolisthesis has shown promising results. Hart et al. reported significant improvements in slip percent and slip angle, with high rates of fusion (88%), and concomitantly low rates of L-5 radiculopathy (1 of 16 patients) as compared to techniques involving reduction of anterolisthesis. Our results were comparable to these
5
previously published findings. In our cohort, five of the seven patients reported subjective improvement in their pain from their pre-operative state at 3-month follow-up. Further, in the three of the six patients who had pre-operative and post-operative films to evaluate, there was radiographic improvement in both slip angle and slip percentage (Fig. 1A-D). We had one complication secondary to a medially directed pedicle screw that caused a L4 radiculopathy. The patient’s pain completely resolved after revising the screw. The reverse Bohlman approach represents a novel approach that has been described once before by Macagno et al. in a case series of six patients [24]. The technique is indicated in patients with high-grade spondylolisthesis with adjacent level instability or slippage. With an anterior approach, a standard ALIF of the adjacent segment is achieved along with placement of a fibular allograft or titanium cage through the body of L5 and S1. We used a rigid cannulated reamer in a trajectory perpendicular to the L5-S1 disk space to create passage for a cortical allograft. One of the distinct advantages of this technique is that through an anterior approach – the main access point is the L4-5 disc space and anterosuperior corner of the L5 vertebral body. In an area measuring 3 3 cm of bone working space one can prepare the L4-5 and L5-S1 disc spaces and apply the interbody graft. In contrast, the modified Bohlman requires extensive posterior tissue dissection with the skin incision extending well into the intergluteal cleft. The tip of the dural sac needs to be mobilized and retraction of the distal sacral nerve roots is required. In our case series, five of the eight patients who underwent the reverse Bohlman reported complete resolution of their preoperative pain. Further, we found that mean pre-operative anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43°to 48.71° (p = .0139). At longterm follow-up, there was improvement in slip angle (p = .065), percentage and lumbar lordosis (Fig. 2A-E). Significantly, we achieved improvement in slip angle and grade without causing any neurological complications in our series of patients. To the best of our knowledge, no other studies have been published comparing the modified Bohlman and reverse Bohlman procedures. The reverse Bohlman construct confers the advantage of a stable 3-column stabilization through a simple and safe construct. When attempted in our series, the procedure did not lead to any permanent neurological deficits. The size of this cohort and
Fig. 1. (A) Pre-operative Films From a 54-year-old Female with a Grade 2 Spondylolisthesis (Case #4). (B-C) 3-month Post-Operative Films Demonstrating Solid Fusion After Lumbar Four to Sacral One Pedicle Fusion and Lumbar Five to Sacrum Fibular Allograft. (D) 13-month Post-Operative Films Demonstrating Solid Fusion After Lumbar Four to Sacral One Pedicle Fusion and Lumbar Five to Sacrum Fibular Allograft.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
6
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
Fig. 2. (A) Pre-operative Films From a 63-year-old Male with a Grade 4 Spondylolisthesis (Case #8). (B–E) 3-month Post-Operative Films Demonstrating Solid Fusion After Lumbar Four to Sacral One Pedicle Fusion and Lumbar Five to Sacrum Fibular Allograft.
follow-up duration are comparable to those in many published series, a reflection of the rarity of high-grade spondylolisthesis. 5. Conclusions Patients with high-grade spondylolisthesis remain a rare but challenging group. A reverse Bohlman procedure that combines a traditional ALIF with placement of a fibular allograft using a rigid cannulated reamer results in satisfactorily reproducible clinical outcomes while minimizing extensive posterior tissue dissection associated with the modified Bohlman technique. Further, rates of neurological deficit appear to be reduced by limiting reduction to the lumbosacral kyphosis. Funding None. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jocn.2019.07.044. References [1] Taillard WF. Etiology of spondylolisthesis. Clin Orthop Relat Res 1976;117:30–9. [2] Helenius I, Lamberg T, Osterman K, et al. Posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation using the Scoliosis Research Society questionnaire. Spine (Phila Pa 1976) 2006;31(2):190–6. [3] Molinari RW, Bridwell KH, Lenke LG, Ungacta FF, Riew KD. 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. [4] Lehmer SM, Steffee AD, Gaines Jr RW. Treatment of L5-S1 spondyloptosis by staged L5 resection with reduction and fusion of L4 onto S1 (Gaines procedure). Spine (Phila Pa 1976) 1994;19(17):1916–25. [5] 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(3):415–21. [6] Stauffer RN, Coventry MB. Anterior interbody lumbar spine fusion. Analysis of Mayo Clinic series. J Bone Joint Surg Am 1972;54(4):756–68. [7] Suk SI, Lee CK, Kim WJ, Lee JH, Cho KJ, Kim HG. Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis. Spine (Phila Pa 1976) 1997;22(2):210–9. discussion 219-220.
[8] 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(19 Suppl):S126–9. [9] Speed K. A text-book of fractures and dislocations covering their pathology, diagnosis and treatment. fourth ed. Philadelphia: Lea & Febiger; 1942. [10] 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(3):415–8. [11] Rodriguez-Olaverri JC, Zimick NC, Merola A, et al. Comparing the clinical and radiological outcomes of pedicular transvertebral screw fixation of the lumbosacral spine in spondylolisthesis versus unilateral transforaminal lumbar interbody fusion (TLIF) with posterior fixation using anterior cages. Spine (Phila Pa 1976) 2008;33(18):1977–81. [12] Sasso RC, Shively KD, Reilly TM. Transvertebral transsacral strut grafting for high-grade isthmic spondylolisthesis L5–S1 with fibular allograft. J Spinal Disord Tech 2008;21(5):328–33. [13] Roca J, Ubierna MT, Caceres E, Iborra M. One-stage decompression and posterolateral and interbody fusion for severe spondylolisthesis. An analysis of 14 patients. Spine (Phila Pa 1976) 1999;24(7):709–14. [14] Smith JA, Deviren V, Berven S, Kleinstueck F, Bradford DS. Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis. Spine (Phila Pa 1976) 2001;26(20):2227–34. [15] 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. [16] Edwards CC, Bradford DS. Instrumented reduction of spondylolisthesis. Spine (Phila Pa 1976) 1994;19(13):1535–7. [17] Gaines RW. L5 vertebrectomy for the surgical treatment of spondyloptosis: thirty cases in 25 years. Spine (Phila Pa 1976) 2005;30(6 Suppl):S66–70. [18] 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. [19] Bozkus H, Dickman CA. Transvertebral interbody cage and pedicle screw fixation for high-grade spondylolisthesis. Case report. J Neurosurg 2004;100(1 Suppl Spine):62–5. [20] 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. [21] 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. [22] Bollini G, Jouve JL, Launay F, Glard Y, Jacopin S, Blondel B. High-grade child spondylolisthesis: a custom-made canulated screw to treat the so-called double instability. Orthop Traumatol Surg Res 2011;97(2):179–85. [23] Kwon BK, Albert TJ. Adult low-grade acquired spondylolytic spondylolisthesis: evaluation and management. Spine (Phila Pa 1976) 2005;30(6 Suppl):S35–41. [24] 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):1–9. [25] Boxall D, Bradford DS, Winter RB, Moe JH. Management of severe spondylolisthesis in children and adolescents. J Bone Joint Surg Am 1979;61 (4):479–95. [26] Harris IE, Weinstein SL. Long-term follow-up of patients with grade-III and IV spondylolisthesis. Treatment with and without posterior fusion. J Bone Joint Surg Am 1987;69(7):960–9. [27] Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis: monosegmental surgical treatment. Spine (Phila Pa 1976) 2005;30(6 Suppl): S42–8.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx [28] Jones J, Yoo J, Hart R. Delayed fracture of fibular strut allograft following multilevel anterior cervical spine corpectomy and fusion. Spine (Phila Pa 1976) 2006;31(17):E595–9. [29] Wheeler DL, Enneking WF. Allograft bone decreases in strength in vivo over time. Clin Orthop Relat Res 2005;435:36–42. [30] Blumenthal SL, Ohnmeiss DD, Nass. Intervertebral cages for degenerative spinal diseases. Spine J 2003;3(4):301–9.
7
[31] Slosar PJ, Reynolds JB, Koestler M. The axial cage. A pilot study for interbody fusion in higher-grade spondylolisthesis. Spine J 2001;1(2):115–20. [32] Sailhan F, Gollogly S, Roussouly P. The radiographic results and neurologic complications of instrumented reduction and fusion of high-grade spondylolisthesis without decompression of the neural elements: a retrospective review of 44 patients. Spine (Phila Pa 1976) 2006;31(2):161–9. discussion 170.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical study
Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population Aria Jamshidi, Allan D. Levi ⇑ Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
a r t i c l e
i n f o
Article history: Received 3 May 2019 Accepted 8 July 2019 Available online xxxx Keywords: Bohlman Reverse High grade Spondylolisthesis
a b s t r a c t Background/aims: Surgical techniques for treatment of high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate both radiographic and clinical outcomes in patients with HGS treated with the ‘‘modified Bohlman” and Reverse Bohlman technique. Methods: Review of consecutive HGS patients undergoing modified Bohlman and Reverse Bohlman at a single center from 2006 to 2018. Clinical, surgical, and radiographic data were collected. Results: Six patients identified in the modified Bohlman treatment arm: and eight patients in the Reverse Bohlman group. Twelve (12) patients presented with high grade congenital spondylolisthesis at L5-S1; one patient presented with dissolution of the L5 vertebral body secondary to uncontrolled osteomyelitis that developed after a previous failed fusion; and one patient presented with iatrogenic L5-S1 spondylolisthesis after a previous L3-S1 fusion. One patient had medially placement pedicle screw and associated radiculopathy. All follow-up post = operative scans demonstrated solid fusion. Postoperatively, anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43° of kyphosis to 48.71° (p = .0139). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively except for positioning on a sacral cushion to increase lordotic angle. Lumbar lordosis improved from 65.29 to 63.86 postoperatively. Four of our fourteen patients had long-term median follow-up of 28 months (range = 19–48 months) slip angle, percentage, and lumbar lordosis all improved from the patient’s pre-operative measurements. The improvement in slip angle was nearly statistically significant with a p-value of 0.065. Conclusions: Reverse Bohlman technique for high grade spondylolisthesis is a viable option when seeking to address adjacent level instability or slip. Ó 2019 Elsevier Ltd. All rights reserved.
1. Introduction Isthmic spondylolisthesis is a forward slippage of the vertebral body, its pedicles, transverse process, and upper articular process caused by a break in continuity or elongation of the pars interarticularis. This entity was first described in 1854 by Kilian, and then further characterized by Taillard in 1957 [1]. As per the Meyerding classification, high grade spondylolisthesis (Grades III-V) is defined as greater than 50% slippage of a spinal vertebral body relative to an adjacent vertebral body, and most commonly affects alignment of the L5-S1 motion segment. Patients are typically selected as surgical candidates due to their constellation of symptoms of severe axial back pain with associated neurogenic claudication, segmental
⇑ Corresponding author at: University of Miami MILLER School of Medicine, Department of Neurological Surgery, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA. E-mail address: [email protected] (A.D. Levi).
deformity, radiculopathy, or focal instability. The goals of surgical intervention are thus focused on decompressing neural structures, providing sufficient fixation, and restoring spinopelvic alignment. Surgical management of high-grade cases is a complex issue, and complications can range from pseudoarthrosis, graft site morbidity, neurological compromise, hardware failure, and progression of slip grade or angle [2–4]. Surgical options include in situ posterior fusion, oblique interbody fusion, instrumented posterior fusion, anterior or posterior interbody fusion with instrumentation, and vertebral resection with reduction and fusion [5–8]. While there’s no gold standard technique, the most widely accepted surgical approach is a posterior spinal fusion with instrumentation, either alone or in conjunction with another technique. Transsacral instrumentation through the sacrum and body of L5 has been used increasingly during the last fifteen years. Speed in 1938 was the first to use an anterior approach with an oblique tibial autograft strut for interbody fusion to stabilize a L5-S1 spondylolisthesis [9]. Bohlman and Cook proposed a modification to this
https://doi.org/10.1016/j.jocn.2019.07.044 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
2
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
protocol in 1982 using a single incision posterior approach by introducing a fibular autograft across S1 into the L5 vertebral body along with a decompression and uninstrumented L4-S1 posterolateral fusion to permit for a three column spinal fixation [10]. The benefits of this oblique interbody fusion include increasing the surface area for graft incorporation and a stabilizing effect of the graft with regards to the slip [5]. Rodriguez-Olavaerri and colleagues demonstrated that the Bohlman technique had similar outcomes with transforaminal interbody fusion, resulting in lumbosacral kyphosis improvement [11,12]. The Bohlman procedure was described prior the widespread adoption of modern pedicle screw instrumentation and consequently the technique was initially associated with several complications including fibular graft fracture, graft resorption, slip progression, and pseudoarthrosis [13–15]. Due to these problems, authors suggested using pedicle screw instrumentation to achieve complete reduction. However, this technique resulted in different issues, specifically L-5 nerve root palsies in some patients, as well as instrumentation failure particularly at the sacrum. In reaction to these findings, authors then began advocating for supplementary pelvic fixation to prevent S-1 pedicle screw failure [3,16,17]. The ‘‘modified Bohlman,” which includes addition of transsacral and pedicle screw instrumentation to supplement the Bohlman oblique interbody fusion may help address the previous complications of late graft failure and incomplete reduction of lumbosacral kyphosis [14,18]. Further, other supplementary methods to achieve threecolumn fixation have been offered including transvertebral interbody cage fixation and use of intrasacral rods and custom-made screws [19–22]. While these techniques are performed via a posterior approach for direct decompression and stabilization with pedicle screw fixation, an additional anterior approach or ‘‘reverse Bohlman” is useful in increasing fusion rates by providing an optimal graft environment, restoring sagittal alignment via anterior column reconstruction to restore disk height and reducing the slip angle [23,24]. This method precludes the need for a complete sacral laminectomy with retraction of the caudal dura, and the associated inherent risk, while also making it easier to access the L4-5 intervertebral disk from a single anterior approach as the entry points form the L4L5 and L5S1 interbody graft are juxtaposed [24]. Both techniques have been described with favorable outcomes. However, no earlier study has attempted to compare one to the other, and treatment of HGS at L-5/S-1 remains a significant challenge within spine surgery. As such, we examined radiographic and clinical outcomes in patients who underwent surgery with a single surgeon (ADL) at the same institution over the course of 12 years. We analyze outcomes in patients with HGS treated with either a ‘‘modified Bohlman” (n = 6) or ‘‘Reverse Bohlman” (RB) (n = 8) procedure consisting of a combined anterior/posterior approach with transacral and/or pedicle screw fixation and fibular graft augmented with bone morphogenetic protein-2 (BMP-2) (Medtronic, Memphis, TN) to allow for interbody fusion through an angled anterior approach. We detail the techniques employed at our institution to highlight available surgical options for treating HGS at the lumbar-sacral junction. 2. Materials and methods 2.1. Study design A retrospective review of all consecutive patients who underwent a modified reverse Bohlman (RB) procedure, as well as Reverse Bohlman for HGS was performed at a single university-based center between 2006 and 2018. Primary outcomes evaluated were occurrence of perioperative complications and the need for revision procedures.
2.2. Data collection Clinical parameters collected included patient age and sex, primary presenting symptoms, neurological dysfunction prior to or after surgery, and previous surgical procedures for spondylolisthesis. Radiographic parameters included Wiltse classification, slip percentage (grade), and slip angle. Perisurgical parameters included fusion levels, type of interbody device (fibular strut), posterior instrumentation pattern (transsacral or pedicle screws), use of BMP-2, estimated blood loss (EBL), and perioperative complications. 2.3. Modified Bohlman and Reverse Bohlman procedure 2.3.1. Modified Bohlman All procedures consisted of a posterior only approach. In the majority of cases – two levels (L4-5 and L5-S1) were performed. L4L5 was often incorporated because L5S1 only was technically not possible because pedicle screws heads would cross and would not permit rod placement. No attempt was made to reduce the spondy. L4-L5 was prepared as per regular posterior lumbar interbody fusion technique with radical discectomy and endplate preparation. At the L5-S1 level, a guide wire was initially placed under realtime fluoroscopy. The starting point was in the mid-line just caudal to the end of the dural sac between the sacrococcygeal nerve roots. The wire crosses the overlapping portion of the L5S1 disc space. Rigid cannulated reamers (10–12 mm) from the anterior cruciate ligament reconstruction tray were utilized over the guide wire to create a hole, 40–60 mm in depth, through the L5 and S1 vertebral bodies in which a carefully shaped, rounded fibular allograft would be place. BMP-2 was placed within and around the graft (BMP2.1 mg) and was then impacted into position with proximal portion recessed into S1, continuing across the L5-S1 disc space, and ending in the L5 vertebral body. The L4-5 disc space was distracted and filled with a pre-cut allograft ramps in addition to 2.1 mg of BMP. 2.3.2. Reverse Bohlman All procedures consisted of a anterior/posterior approach, with anterior access performed by an experienced vascular access surgeon. Two levels (L4-5 and L5-S1) were addressed in all cases. L4-L5 was prepared as per regular anterior lumbar interbody fusion technique with radical discectomy and endplate preparation. Prior to placement of L4-5 cage, attention was turned to the L5S1 level. Rigid cannulated reamers were utilized over a guide wire, which was placed under real-time fluoroscopy from the anterior cephalad portion of the L5 vertebral body angled across the spondylolisthetic disc space into the sacral vertebral body. The guide wire was oriented in a trajectory almost perpendicular to the L5-S1 disc space, which was typically perpendicular to the floor. With guide wire in place, a 10.5 mm reamer was passed under fluoroscopy to the desirable depth (40–60 mm) this allowed for creation of a direct channel across the disc space into the sacrum. A standard fibular allograft was used and cut to the pre-reamed length. BMP-2 was placed within and around the graft (BMP2.1 mg) and was then impacted into position with proximal portion recessed into L5, continuing across the L5-S1 disc space, and ending in the proximal sacrum. The L4-5 disc space was distracted and filled with a pre-cut femoral ring allograft containing 2.1 mg of BMP. Following closure of the anterior procedure, the patient was turned prone and an open posterior decompression and fusion from L4-S1 was performed. Iliac fixation was not used.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
3
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
2.4. Radiographic evidence Upright spine radiographs were collected pre-operatively and at the last follow-up and were evaluated by a single independent reviewer. Pelvic incidence was measured from preoperative digital radiographs. Slip percent and slip angle were measured digitally from standing pre-operative and final follow-up evaluations. All measurements were performed digitally with surgimap software. Implant and fusion status were evaluated using plain film, flexion-extension, lateral radiographs, supplemented by CT scans for selected patients at discretion of the operating surgeon.
3. Results Fourteen patients were identified (10 female, 4 male); mean age was 52 years (range: 33–83). 12 patients presented with high grade congenital spondylolisthesis at L5-S1; one patient presented with dissolution of the L5 vertebral body secondary to uncontrolled osteomyelitis that developed after a previous failed fusion; and one patient presented with iatrogenic L5-S1 spondylolisthesis after a previous L3-S1 fusion. All patients reported symptoms of spinal stenosis including severe axial pain as well as claudication symptoms relieved by flexion and exacerbated by extension. Four patients had radicular pain, and one had a unilateral lowerextremity motor deficit (foot drop). No patients presented with bladder or bowel disturbance. The measured mean pelvic incidence preoperatively was 79.1°, which is consistent with prior reports of high pelvic incidence associated with high-grade spondylolisthesis [15]. Six patients underwent the conventional Bohlman procedure with a fibular allograft from L5 to S3, followed by a conventional L4-S1 pedicle fusion in two patients, L5-S1 fusion in three patients, and L3 to Iliac fusion in one patient who had a history of a L3-S1 fusion complicated by a wound infection, osteomyelitis, and dissolution of the L5 vertebral body (Table 1). Eight patients underwent the Reverse Bohlman procedure. All eight patients had a standard ALIF at L4-L5, followed by a L5-S1 reverse Bohlman approach. This modified Bohlman stage was performed with a fibular allograft in seven patients and a titanium mesh cage packed with BMP in one patient. Standard pedicle screws were used for the posterior procedure. Seven of the eight patients were instrumented from L4-S1 and one patient from L2S1 who had a history of a prior L3-S1 fusion and pseudoarthrosis (Table 2).
There was one patient who developed left groin pain postoperatively. A CT scan was done which demonstrated a medially displaced L4 pedicle screw. The patient was taken back to the operating room for revision of the screw and thereafter did well postoperatively with resolution in her pain. At the three-month post-operative visit, five of the six patients in the conventional Bohlman group reported subjective improvement in their pain from their pre-operative state. One endorsed no change in their pain profile. Six of the eight patients in the Reverse Bohlman group reported complete resolution of their pain at the three-month post-operative visit. The two remaining patients reported improvement in their pain from their pre-operative state. Mean intraoperative blood loss was 521 cc (350–800) in this cohort. There were no intraoperative complications. Standard radiographic measurements were made on pre- and postoperative lumbar images. Mean preoperative anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43° of kyphosis to 48.71° (p = .0139) (Table 3). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively except for positioning on a sacral cushion to increase lordotic angle. Lumbar lordosis improved from 65.29 to 63.86 postoperatively (Table 4). Four of our fourteen patients had long-term median follow-up of 28 months (range = 19–48 months) slip angle, percentage, and lumbar lordosis all improved from the patient’s pre-operative measurements. The improvement in slip angle was nearly statistically significant with a p-value of 0.065 (Table 5).
4. Discussion The natural history of high-grade spondylolisthesis is not favorable [25,26]. And while there is the risk of neurological complications with surgical intervention, many authors have concluded that operative treatment is reasonable for symptomatic patients [8]. While the surgical goals of neurological decompression achieving solid arthrodesis, and reduction of lumbosacral kyphosis are all widely agree upon, the optimal surgical approach remains a controversial topic. With only a small number of patients who are affected with this disease process, retrospective comparisons of fusion and complication rates are currently the best means of evaluating treatment outcomes [14,27]. The literature is limited with respect to comparisons of treatment of isthmic spondylolisthesis with fusion in situ, reduction followed by fusion, and vertebral resection. Consequently, based on
Table 1 Characteristics, surgical technique, outcome, and complications in 6 patients with High Grade Spondylolisthesis Who Underwent the Modified Bohlman Procedure. Case #
Age/ Sex
Grade Slip
Surgery performed
FU
Fusion
Immediate FU
3 months FU
1
33/M
3
3 months
Yes
37/F
3
3 months
Yes
Medially Placed Left L4 Pedicle Screw Radiculopathy Numbness over L5 dermatome RLE
Pain Unchanged
2
L4-S1 Pedicle Fusion w/ Vertebral autograft & BMP, L5-S3 fibular allograft Bohlman L5-S1 Pedicle Fusion w/ Vertebral autograft & BMP, L5-S3 fibular allograft Bohlman
3
48/F
3
L5-S1 Pedicle Fusion w/ BMP, L5-S3 fibular allograft Bohlman
3 months
Yes
Neurounchanged
4
52/F
2
L4-S1 Pedicle Fusion w/ vertebral allograft & BMP, L5-S3 fibular allograft Bohlman
13 months
Yes
Neurounchanged
5
54/F
3
L5-S1 laminectomy pedicle fusion w/ BMP, Bohlman Fibular allograft L5-S3
3 months
Yes
Neurounchanged
6
66/M
Lumbar Spine infection w/ Osteomyelitis & L5 fx
L3-Iliac Posterior fusion w/ BMP & vertebral autograft & allograft, L4-S3 fibular allograft w/ BMP
6 months
Yes
Neurounchanged
Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op Doing well- Pain improved from Pre-op
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
4
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
Table 2 Characteristics, surgical technique, outcome, and complications in 6 patients with High Grade Spondylolisthesis who Underwent the Reverse Bohlman Procedure. Case #
Age/ Sex
Grade
Anterior Graft
Posterior Graft
FU (months)
EBL
Fusion
Immediate
3 months
7
47/F
3
L4-5 ALIF w/ femoral ring allograft with BMP, L5-S1 Reverse Bohlman Fibular allograft with BMP
L4-S1 pedicle fusion with vertebral autograft
48
350 cc
Yes
Neurounchanged
8
63/ M
4
L4-5 ALIF w/ femoral ring allograft with BMP, L5-S1 Reverse Bohlman Fibular allograft with BMP
L4-S1 pedicle fusion with vertebral autograft
34
800 cc
Yes
Neurounchanged
9
34/F
3
L5-S1 ALIF w/ Reverse Bohlman fibular allograft w/ BMP, L4-5 ALIF w/ femoral ring allograft
L4-S1 pedicle fusion with vertebral autograft
28
600 cc
Yes
Neurounchanged
10
54/F
3
L4-S1 pedicle fusion with posterolateral bone graft
3
500 cc
Yes
Neurounchanged
11
74/F
3
300 cc
Yes
Neurounchanged
33/F
2
19
500 cc
Yes
Neurounchanged
13
83/F
2
L4-5 ALIF – femoral ring allograft with BMP, fibular structural allograft
3
600 cc
Yes
Neuro unchanged
14
74/ M
3
L4-5 ALIF – femoral ring allograft with BMP, fibular structural allograft
L2-S1 pedicle screws & L5-S1 Interbody with BMP & cadaveric allograft L4-S1 pedicle screws with BMP, vertebral autograft, allograft, supplemented posterolateral bone graft L4-S1 pedicle screws with BMP, vertebral autograft, allograft, supplemented posterolateral bone graft L4-S1 pedicle screws with BMP, vertebral autograft, allograft, supplemented posterolateral bone graft
4
12
L4-5 ALIF w/ femoral ring allograft with BMP, L5-S1 Reverse Bohlman w/ 12 mm titanium cage vertebral autograft allograft and BM L2-4 ALIF with cadaveric allograft & BMP, L4-S1 Fibular Structural allograft with BMP L4-5 ALIF – femoral ring allograft with BMP, fibular structural allograft
Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms Doing wellPain improved from Pre-op Doing wellPain improved from Pre-op
3
300 cc
Yes
Neuro unchanged
Doing wellResolution of Preopoperative symptoms Doing wellResolution of Preopoperative symptoms
Table 3 Radiographic Measurements and Meyerding Classification of Patients Who Underwent Modified Bohlman Procedure (Patients 2, 5, & 6 excluded due to lack of preoperative films). Case #
Age/Sex
Meyerding Score
Pelvic Incidence
Slip angle Pre-op
1
33/M
3
102°
36
3
48/F
3
4
52/F
83
2
89
7
15
Slip angle Post-op
Slip % Pre-op
Slip % Post-op
Lumbar Lordosis Pre-op
66%
64%
63
52%
32%
4
5 13°
31%
Lumbar Lordosis Post-op
67
75
72
30%
103
94
Table 4 Radiographic Measurements and Meyerding Classification of Patients Who Underwent Reverse Bohlman Procedure. Case #
Age/ Sex
Meyerding Score
Pelvic Incidence
7
47/F
3
84
8
63/M
4
91
9
34/F
3
47
10
54/F
3
60
11
74/F
3
93
12
33/F
2
35
4
13
83/F
2
86
14
74/M
3
91
7
9
Slip % Post-op
Lumbar Lord Pre-op
10°
75%
61%
72
82%
68%
66
75%
72%
46
53%
23%
70
61%
55%
67
35%
28%
3
25 18°
21 10°
Slip % Pre-op
8
Slip angle Post-op
3
26
25
66
Slip angle Pre-op
59
42%
34%
77
31%
31%
68
4
78
73
44
4
Lumbar Lord Post-op
65
63
48
76
68
Table 5 Patients Who Underwent the Reverse Bohlman Procedure Who had Range Median Follow-Up of 28 Months. Case #
Age/Sex
Meyerding Score
Slip angle Pre-op
Slip angle Post-op
Slip % Pre-op
Slip % Post-op
Lumbar Lord Pre-op
7
47/F
3
35
10°
75%
56%
72
8
63/M
4
82%
58%
4
3
9
34/F
3
25
12
33/F
2
21
66
75%
51%
46
35%
28%
59
8 4
Lumbar Lord Post-op
75
68
44
48
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
the best evidence available in the literature, it is difficult to develop clear guidelines for treatment of high-grade spondylolisthesis. The use of a fibular strut for oblique interbody fusion in surgical management for high-grade spondylolisthesis is well documented in the literature [2,5]. Recurrent instability and graft failure are known complications of this procedure [3,14]. Failure of fusion is often due to the high loads encountered resulting in fatigue fracture, as well as from weakening of the graft by bone resorption following healing [28,29]. Moreover, placement of an oblique interbody strut without reduction of the slip angle fixes the spine in a position of lumbosacral kyphosis, with potential long-term deleterious effects. Several authors have recognized limitations of the Bohlman technique and have offered modifications to the procedure, including replacement of the fibular strut graft with a titanium mesh cage, and incorporation of pedicle screw or trans-sacral screw instrumentation for augmentation and reduction of the listhesis [3,20,30,31]. Complete reduction of antherolisthesis is now achievable with modern instrumentation techniques, presenting the option of incorporating interbody fusion techniques but making the incorporation of an oblique cage impossible. Advocates of reduction claim that it allows for increased surface area for fusion. However, as long as stable arthrodesis and kyphosis reduction are achieved, there is no evidence to suggest that residual antherolisthesis affects longterm outcomes. Moreover, reduction of antherolisthesis has been linked to increased rates of neurological deficits, specifically an L-5 motor deficit and associated foot drop [4]. In a retrospective review of patients who underwent posterior instrumented reduction and fusion of high grade spondylolisthesis without decompression of neural elements, the authors reported a neurologic complication rate of 9.1%, of which 2.3% represented a L5 motor deficit [32]. In addition to neurological complications, reduction has been associated with implant failures from the increased forces on instrumentation. This has resulted in the need for revision and extension of the primary construct and addition of pelvic fixation. The modified Bohlman technique for treatment of high-grade spondylolisthesis has shown promising results. Hart et al. reported significant improvements in slip percent and slip angle, with high rates of fusion (88%), and concomitantly low rates of L-5 radiculopathy (1 of 16 patients) as compared to techniques involving reduction of anterolisthesis. Our results were comparable to these
5
previously published findings. In our cohort, five of the seven patients reported subjective improvement in their pain from their pre-operative state at 3-month follow-up. Further, in the three of the six patients who had pre-operative and post-operative films to evaluate, there was radiographic improvement in both slip angle and slip percentage (Fig. 1A-D). We had one complication secondary to a medially directed pedicle screw that caused a L4 radiculopathy. The patient’s pain completely resolved after revising the screw. The reverse Bohlman approach represents a novel approach that has been described once before by Macagno et al. in a case series of six patients [24]. The technique is indicated in patients with high-grade spondylolisthesis with adjacent level instability or slippage. With an anterior approach, a standard ALIF of the adjacent segment is achieved along with placement of a fibular allograft or titanium cage through the body of L5 and S1. We used a rigid cannulated reamer in a trajectory perpendicular to the L5-S1 disk space to create passage for a cortical allograft. One of the distinct advantages of this technique is that through an anterior approach – the main access point is the L4-5 disc space and anterosuperior corner of the L5 vertebral body. In an area measuring 3 3 cm of bone working space one can prepare the L4-5 and L5-S1 disc spaces and apply the interbody graft. In contrast, the modified Bohlman requires extensive posterior tissue dissection with the skin incision extending well into the intergluteal cleft. The tip of the dural sac needs to be mobilized and retraction of the distal sacral nerve roots is required. In our case series, five of the eight patients who underwent the reverse Bohlman reported complete resolution of their preoperative pain. Further, we found that mean pre-operative anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43°to 48.71° (p = .0139). At longterm follow-up, there was improvement in slip angle (p = .065), percentage and lumbar lordosis (Fig. 2A-E). Significantly, we achieved improvement in slip angle and grade without causing any neurological complications in our series of patients. To the best of our knowledge, no other studies have been published comparing the modified Bohlman and reverse Bohlman procedures. The reverse Bohlman construct confers the advantage of a stable 3-column stabilization through a simple and safe construct. When attempted in our series, the procedure did not lead to any permanent neurological deficits. The size of this cohort and
Fig. 1. (A) Pre-operative Films From a 54-year-old Female with a Grade 2 Spondylolisthesis (Case #4). (B-C) 3-month Post-Operative Films Demonstrating Solid Fusion After Lumbar Four to Sacral One Pedicle Fusion and Lumbar Five to Sacrum Fibular Allograft. (D) 13-month Post-Operative Films Demonstrating Solid Fusion After Lumbar Four to Sacral One Pedicle Fusion and Lumbar Five to Sacrum Fibular Allograft.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
6
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx
Fig. 2. (A) Pre-operative Films From a 63-year-old Male with a Grade 4 Spondylolisthesis (Case #8). (B–E) 3-month Post-Operative Films Demonstrating Solid Fusion After Lumbar Four to Sacral One Pedicle Fusion and Lumbar Five to Sacrum Fibular Allograft.
follow-up duration are comparable to those in many published series, a reflection of the rarity of high-grade spondylolisthesis. 5. Conclusions Patients with high-grade spondylolisthesis remain a rare but challenging group. A reverse Bohlman procedure that combines a traditional ALIF with placement of a fibular allograft using a rigid cannulated reamer results in satisfactorily reproducible clinical outcomes while minimizing extensive posterior tissue dissection associated with the modified Bohlman technique. Further, rates of neurological deficit appear to be reduced by limiting reduction to the lumbosacral kyphosis. Funding None. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jocn.2019.07.044. References [1] Taillard WF. Etiology of spondylolisthesis. Clin Orthop Relat Res 1976;117:30–9. [2] Helenius I, Lamberg T, Osterman K, et al. Posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation using the Scoliosis Research Society questionnaire. Spine (Phila Pa 1976) 2006;31(2):190–6. [3] Molinari RW, Bridwell KH, Lenke LG, Ungacta FF, Riew KD. 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. [4] Lehmer SM, Steffee AD, Gaines Jr RW. Treatment of L5-S1 spondyloptosis by staged L5 resection with reduction and fusion of L4 onto S1 (Gaines procedure). Spine (Phila Pa 1976) 1994;19(17):1916–25. [5] 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(3):415–21. [6] Stauffer RN, Coventry MB. Anterior interbody lumbar spine fusion. Analysis of Mayo Clinic series. J Bone Joint Surg Am 1972;54(4):756–68. [7] Suk SI, Lee CK, Kim WJ, Lee JH, Cho KJ, Kim HG. Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis. Spine (Phila Pa 1976) 1997;22(2):210–9. discussion 219-220.
[8] 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(19 Suppl):S126–9. [9] Speed K. A text-book of fractures and dislocations covering their pathology, diagnosis and treatment. fourth ed. Philadelphia: Lea & Febiger; 1942. [10] 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(3):415–8. [11] Rodriguez-Olaverri JC, Zimick NC, Merola A, et al. Comparing the clinical and radiological outcomes of pedicular transvertebral screw fixation of the lumbosacral spine in spondylolisthesis versus unilateral transforaminal lumbar interbody fusion (TLIF) with posterior fixation using anterior cages. Spine (Phila Pa 1976) 2008;33(18):1977–81. [12] Sasso RC, Shively KD, Reilly TM. Transvertebral transsacral strut grafting for high-grade isthmic spondylolisthesis L5–S1 with fibular allograft. J Spinal Disord Tech 2008;21(5):328–33. [13] Roca J, Ubierna MT, Caceres E, Iborra M. One-stage decompression and posterolateral and interbody fusion for severe spondylolisthesis. An analysis of 14 patients. Spine (Phila Pa 1976) 1999;24(7):709–14. [14] Smith JA, Deviren V, Berven S, Kleinstueck F, Bradford DS. Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis. Spine (Phila Pa 1976) 2001;26(20):2227–34. [15] 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. [16] Edwards CC, Bradford DS. Instrumented reduction of spondylolisthesis. Spine (Phila Pa 1976) 1994;19(13):1535–7. [17] Gaines RW. L5 vertebrectomy for the surgical treatment of spondyloptosis: thirty cases in 25 years. Spine (Phila Pa 1976) 2005;30(6 Suppl):S66–70. [18] 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. [19] Bozkus H, Dickman CA. Transvertebral interbody cage and pedicle screw fixation for high-grade spondylolisthesis. Case report. J Neurosurg 2004;100(1 Suppl Spine):62–5. [20] 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. [21] 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. [22] Bollini G, Jouve JL, Launay F, Glard Y, Jacopin S, Blondel B. High-grade child spondylolisthesis: a custom-made canulated screw to treat the so-called double instability. Orthop Traumatol Surg Res 2011;97(2):179–85. [23] Kwon BK, Albert TJ. Adult low-grade acquired spondylolytic spondylolisthesis: evaluation and management. Spine (Phila Pa 1976) 2005;30(6 Suppl):S35–41. [24] 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):1–9. [25] Boxall D, Bradford DS, Winter RB, Moe JH. Management of severe spondylolisthesis in children and adolescents. J Bone Joint Surg Am 1979;61 (4):479–95. [26] Harris IE, Weinstein SL. Long-term follow-up of patients with grade-III and IV spondylolisthesis. Treatment with and without posterior fusion. J Bone Joint Surg Am 1987;69(7):960–9. [27] Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis: monosegmental surgical treatment. Spine (Phila Pa 1976) 2005;30(6 Suppl): S42–8.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044
A. Jamshidi, A.D. Levi / Journal of Clinical Neuroscience xxx (xxxx) xxx [28] Jones J, Yoo J, Hart R. Delayed fracture of fibular strut allograft following multilevel anterior cervical spine corpectomy and fusion. Spine (Phila Pa 1976) 2006;31(17):E595–9. [29] Wheeler DL, Enneking WF. Allograft bone decreases in strength in vivo over time. Clin Orthop Relat Res 2005;435:36–42. [30] Blumenthal SL, Ohnmeiss DD, Nass. Intervertebral cages for degenerative spinal diseases. Spine J 2003;3(4):301–9.
7
[31] Slosar PJ, Reynolds JB, Koestler M. The axial cage. A pilot study for interbody fusion in higher-grade spondylolisthesis. Spine J 2001;1(2):115–20. [32] Sailhan F, Gollogly S, Roussouly P. The radiographic results and neurologic complications of instrumented reduction and fusion of high-grade spondylolisthesis without decompression of the neural elements: a retrospective review of 44 patients. Spine (Phila Pa 1976) 2006;31(2):161–9. discussion 170.
Please cite this article as: A. Jamshidi and A. D. Levi, Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2019.07.044