L5-S1 Spondylolysis/listhesis in children & adolescents: When is surgery indicated? Hubert Labelle, MD

Transcription

1 L5-S1 Spondylolysis/listhesis in children & adolescents: When is surgery indicated? Hubert Labelle, MD

2 Wiltse, Newman and Macnab Classification Clin Orthop 1976;117:23-29 Type I: Congenital spondylolisthesis Type II: Isthmic spondylolisthesis Type III: Degenerative spondylolisthesis Type IV: Traumatic spondylolisthesis Type V: Pathologic spondylolisthesis

3 Medical treatment No symptoms, no treatment! Rest PT Stretching Mild analgesics Bracing Pars infiltration?

4 Algorithm for acquired spondylolysis Type 1 Type 2 Type 3 Type 4 CT scan No Fx Incomplete Fx Complete Fx MRI,Bone scan, SPECT Complete Fx Treatment Restrict activity Restrict activity Bracing 6 months No bracing Physio + after Bracing + immediately Hollenberg, Spine 2002, 27:2 Modifier by Dick J, Annual LSRH Meeting 2016

5 Indications for surgery Grades 0,1,2 unresponsive to medical treatment (>6 months) Acquired All grades 3 and higher Dysplatic

6 HGS 2 OLD DEBATES: still hot topics! To reduce or not to reduce? To instrument or not to instrument?

7 Literature review up to 2007 No Level I or II evidence on this topic Best evidence: 5 retrospective comparative studies (Level III) Conclusion: Unable to formulate clear guidelines for treatment of HGS based on the best evidence available in the published literature.

8 Has anything changed in the last decade? Improved understanding of sagittal spino-pelvic balance Improved methods of reduction, fusion & spino-pelvic fixation Reduction Instrumentation 360 Fusion In situ PL Fusion

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10 Grade 1- Local Deformity: L5-S1 Increasing LSK is associated to a decrease in HRQoL

11 2- Regional Deformity: pelvis Sacro-pelvic unit

12 PT= Pelvic Tilt SS= Sacral Slope

13 Balanced pelvis Retroverted pelvis (Unbalanced)

14 3- Global Deformity : C7 plumbline Balanced spine Unbalanced spine

15 Type 4: Balanced pelvis High grade Slip 50% Unbalanced pelvis (vertical sacrum) Type 5: Balanced spine Subtype A: normal/moderate LSK Subtype B: severe LSK Type 6: Unbalanced spine

16 Type 4 Type 5A Type 5B Type Postural reduction Formal reduction

17 My surgical goals for L5-S1 HGS 1- Achieve adequate sagittal spino-pelvic alignment (balance) 2- Solid fusion of affected segments

18 Our current Surgical Technique Posterior approach 95% Gill resection 100% PLIF + cage 100% if reduction Dome resection occasionaly Increasing levels of stability: 1- L5-S1 bicortical screws 2- L4-L5-S1 bicortical pedicle screws 2- L4-L5-S1/iliac screws (4 point pelvic fixation) 3- L5-S1 pedicle screws + anterior column support 4- L4-L5 + 4 point pelvic fixation + anterior column support 5- L4-L5 + 4 point pelvic fixation + anterior column support The proper choice instrumentation and fusion levels needs to be individualised and depends on the amount of instability, sagittal imbalance, L4-L5/S2 MRI disc status and dysplasia present

19 Highest level of stability Courtesy K. Bridwell, MD

20 To reduce or not? Yes, if sagittal balance is abnormal What to reduce? 1- L5-S1 kyphosis most important 2- Partial slip grade reduction to allow adequate PLIF

21 Recent evidence supporting the role of reduction in HGS

22 Recent evidence supporting the role of reduction in HGS

23 Case examples

24 19 y.o. male Back pain X 6 years Pain can radiate posteriorly to both knees L>R Has had to stop all sports X one year Limited ROM (SLR 50 left, 70 right) Normal neuro exam

25 I=88 T=25 S=63 Type 4 Balanced pelvis Balanced spine

26 6 years post-op L4-S1 in situ posterior Instrumentation & fusion

27 Type 5 Retroverted pelvis (High PT, Low SS) Balanced Spine

28 Type 5 Subtype A Subtype B Subtype A (LSK 80 ) Moderate lumbosacral kyphosis Postural reduction with instrumentation & fusion acceptable Subtype B (LSK<80 ) Severe lumbosacral kyphosis Formal reduction of kyphosis recommended Instrumentation & fusion

29 15 y.o. male, type 5, subtype A Moderate LSK LSK = 85 5 years post-op In situ fusion L4-pelvis, no PLIF PI = 84 SS = 39 PT = 45 PI = 83 SS = 50 PT = 33

30 14 y.o. female, type 5, subtype B Severe LSK LSK = 60 3 years post-op L5-S1 360 fusion & instrumentation PI = 81 SS = 45 PT = 36 PI = 82 SS = 59 PT = 23

31 Pre-op standing 1 Postural reduction 2 Reduction 3 Compression

32 12 y.o. Marfanoid syndrome Severe progressive LBP X 6 months Severe ROM restriction Neuro intact Right sciatica Left sciatic scoliosis Right lasegue sign + at 20 Type 5 B MRI T1

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34 Type 5 B 2 years F-up

35 Type 6 Formal reduction mandatory with instrumentation & 360 fusion

36 12 yo female, Type 6 3 years post-op L4-L5-S1 360 fusion & instrumentation

37 Conclusions To reduce or not to reduce? Yes, reduce if spino-pelvic balance is abnormal Reduction Instrumentation 360 Fusion In situ PL Fusion To instrument or not to instrument? Yes, instrument and fuse 360 when reduction is done No cookbook recipe: the proper choice instrumentation and fusion levels needs to be individualised and depends on the amount of instability, sagittal imbalance, L4-L5/S2 MRI disc status and dysplasia present.