The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue Supplement 2 Part 1

Surgical Techniques | March 01, 2008

Uninstrumented in Situ Fusion for High-Grade Childhood and Adolescent Isthmic Spondylolisthesis: Long-Term Outcome: Surgical Technique

Ilkka Helenius, MD, PhD¹; Ville Remes, MD, PhD²; Mikko Poussa, MD, PhD³

¹ Children's Hospital, Helsinki University Central Hospital, P.O. Box 281, 00029 HUS, Finland. E-mail address for I. Helenius: ilkka.helenius@helsinki.fi
² Peijas Hospital, Helsinki University Central Hospital, P.O. Box 900, 00029 HUS, Finland
³ Orton Orthopaedic Hospital, Tenholantie 10, FIN-00280 Helsinki, Finland

View Disclosures and Other Information

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 89-A, pp. 512-8, March 2007

DISCLOSURE: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from The Foundation for Paediatric Research, The Päivikki and Sakari Sohlberg Foundation, Instrumentarium Scientific Foundation, and Paulo Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller (biomedart@haderermuller.com).

NOTE: The authors thank Dr. Dietrich Schlenzka for valuable comments and Jarmo Nummenpää for help with intraoperative photographs.

Investigation performed at Orton Orthopaedic Hospital, Helsinki, Finland

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2008 Mar 01;90(Supplement 2 Part 1):145-152. doi: 10.2106/JBJS.G.01186

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Abstract

BACKGROUND: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements.

METHODS: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores.

RESULTS: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending.

CONCLUSIONS: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

ORIGINAL ABSTRACT CITATION: "Uninstrumented in Situ Fusion for High-Grade Childhood and Adolescent Isthmic Spondylolisthesis: Long-Term Outcome" (2007;89:512-8).

Figures in this Article

INTRODUCTION

INTRODUCTION | SURGICAL TECHNIQUE | POSTOPERATIVE TREATMENT | References

Circumferential in situ fusion has provided better long-term clinical, radiographic, and health-related outcomes than posterolateral or anterior fusion has when used for the treatment of high-grade spondylolisthesis in children^1,2. Uninstrumented circumferential in situ fusion also has provided better long-term outcomes than instrumented reduction has in the same patient population³. The surgical technique of circumferential in situ fusion will be described in detail here.

SURGICAL TECHNIQUE

INTRODUCTION | SURGICAL TECHNIQUE | POSTOPERATIVE TREATMENT | References

Preoperative Planning

Surgical treatment is often recommended for children who have high-grade spondylolisthesis (>50% slip) to prevent further progression of the slip and lumbosacral kyphosis⁴. Plain standing anteroposterior and lateral radiographs of the lumbar spine are made. Magnetic resonance imaging of the lumbar spine is the diagnostic test of choice to demonstrate compromise of the neural elements showing central spinal canal and nerve root stenosis.

Preserving the posterior midline structures appears to be important for preventing the progression of lumbosacral kyphosis. For patients with 100% slip or spondyloptosis, anterior intervertebral fusion usually cannot be performed. In those cases, transsacral spondylodesis and the Gaines procedure are alternative options. For patients with true dysplastic (type-I) high-grade spondylolisthesis, we recommend decompression of the central spinal canal and nerve roots in conjunction with circumferential instrumented fusion at the time of the primary operation; the uninstrumented technique described here is not suitable.

Posterior Approach

The patient is first placed prone on a four-poster Relton frame. A posterior midline skin incision is performed (Fig. 1-A). A space is developed bilaterally through the erector spinae muscles, 3 cm from the midline. The L5 transverse process, the L5-S1 facet joint, and the sacral ala are then identified. Through the same skin incision, the posterior iliac wing is exposed and cancellocortical autogenous bone is obtained for grafting. The L5-S1 facet joint is opened with an osteotome, and curettage and decortication of the L5 transverse process and the sacral ala are carried out. The autogenous graft is placed over the decorticated bone and is also impacted into the L5-S1 facet joint space (Fig. 1-B)⁵. The fasciae on both sides and subcutaneous tissues and skin are closed with a running absorbable suture.

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FIGS. 1-A and 1-B: Illustrations depicting the posterior paraspinal exposure (Fig. 1-A) and posterolateral fusion (Fig. 1-B) as described by Wiltse and Spencer. (Redrawn and modified, with permission, from: Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine. 1988;13:696-706.)

Anterior Approach

The patient is placed supine, with both hips extended and the lower extremities spread apart. A small bolster is placed under the lumbar spine to obtain lumbar lordosis while the surgeon is working between the legs. A Trendelenburg position of the table helps to keep the abdominal contents cephalad to the operating area. A longitudinal midline incision is made from just caudad to the umbilicus to just cephalad to the symphysis pubis. The fascia over the rectus abdominis muscle is opened, and an internervous plane is developed between the abdominal muscles. After opening the peritoneum, we extend the approach in a cephalad direction by cutting through the linea alba and packing the abdominal contents superiorly. Care is taken not to enter the dome of the bladder in the caudad direction. The posterior peritoneum is opened (Fig. 2-A), and the anatomy of the iliac vessels is assessed. Usually, the presacral intervertebral disc can be approached between the great vessels with minimal vessel mobilization. Great caution should be taken to protect the left iliac vein that runs across the L5 vertebral body and is found caudad to the aortic bifurcation. Blunt dissection with a swab held with forceps in this region exposes the L5-S1 disc. The anterior longitudinal ligament is identified, and the middle sacral artery is ligated. Two smooth Steinmann pins can be inserted on either side of the L5 vertebral body to help to retract the iliac vessels (Fig. 2-B). We attempt to preserve all parasympathetic nerve fibers in this area by approaching the disc space in the midline. The anterior longitudinal ligament is opened horizontally, just cephalad to the L5-S1 disc space (Fig. 3). To obtain better visualization into the disc space, the lower anterior lip of the L5 vertebra can be resected along with the anterior longitudinal ligament. All intervertebral disc material up to the posterior longitudinal ligament is carefully removed. Likewise, the ring apophysis on both sides is removed, and the end plates are prepared with curettage (Fig. 4). Two to three tricortical wedge-shaped bone grafts are obtained from either anterior iliac wing. The heght of the grafts is usually about 15 mm in the anterior dimension and 10 mm in the posterior dimension. The length of these grafts varies but usually is approximately 20 mm. It is essential that the autogenous grafts fit into the disc space as prepared (Figs. 5-A and 5-B). A moderate increase in the disc height is desirable and usually, in conjunction with proper patient positioning, reduces the spondylolisthesis and lumbosacral kyphosis. The use of three structural autogenous grafts will provide the best stability. In patients with a nearly 100% slip, it is sometimes necessary to increase the area for anterior spinal fusion. In these cases, a Morscher-type osteotomy of the sacrum can be performed⁶. The anterior ligament release is continued inferiorly, thus producing an osteoperiosteal flap over the S1 vertebral body. Corticocancellous bone grafts can then be applied beneath this flap, thus increasing the area for anterior intervertebral fusion. The anterior longitudinal ligament is reattached with absorbable sutures through osseous channels in the L5 vertebra, and the posterior peritoneal and laparotomy incisions are then closed (Fig. 6).

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FIGS. 2-A and 2-B: Figs. 2-A and 2-B Illustration and photograph depicting the anterior transperitoneal approach. Fig. 2-A The posterior peritoneum has been opened and the middle sacral artery has been ligated. Fig. 2-B Steinmann pins have been inserted on both sides of the disc space to expose the operative field better.

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FIG. 3: The anterior longitudinal ligament has been opened, and a small piece of bone from the lower lip of L5 has been removed.

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FIG. 4: All disc material has been carefully removed up to the posterior longitudinal ligament. The apophysis has been removed by means of curettage.

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FIGS. 5-A and 5-B: Fig. 5-A After a thorough discectomy, two or three suitably sized structural autogenous grafts are placed. Fig. 5-B Intraoperative photograph showing the tricortical autografts in place.

POSTOPERATIVE TREATMENT

INTRODUCTION | SURGICAL TECHNIQUE | POSTOPERATIVE TREATMENT | References

The patient is mobilized on the second or third postoperative day with a custom-molded thoracolumbosacral orthosis. Sports, bending, and lifting activities are restricted for three to six months or until a solid fusion is documented on follow-up radiographs (Figs. 7-A and 7-B).

CRITICAL CONCEPTSINDICATIONS:High-grade (50% to 100% slip) spondylolisthesis in a child under the age of eighteen years with or without lumbosacral kyphosisCONTRAINDICATIONS:Dysplastic high-grade spondylolisthesis requiring wide posterior decompressionCauda equina syndrome or L5 nerve root paralysis requiring nerve root decompressionSpondyloptosisPrevious abdominal surgery (relative)An overweight patientPITFALLS:Preserving posterior midline structures appears to be important; a posterior midline approach to the osseous elements should be used only if decompression of the central spinal canal is needed.Positioning of the patient is crucial for the anterior procedure. The L5-S1 disc space is usually oriented upward from an anterior vantage point. Thus, for better visualization, one should secure hyperextension of the lumbar spine and take advantage of the Trendelenburg position of the table.Orthopaedic surgeons with less experience may find it useful to enlist the assistance of a vascular or general surgeon for access through the transperitoneal approach to L5-S1 disc space.Use of special access and retractor systems helps to maintain the operative field free of abdominal contents.During removal of the disc material and ring apophysis, the osseous end plates should be preserved for structural support of the autogenous graft.Injury to the parasympathetic nerve fibers may result in retrograde ejaculation in male patients, and this risk should be discussed with them.After a thorough anterior discectomy, the intervertebral area can become rather unstable. If a too-large bone graft is inserted to increase disc height, L5 nerve root paralysis can result from excessive traction. In such an infrequent situation, a smaller graft should be inserted with or without L5 nerve root decompression.AUTHOR UPDATE:No substantial changes have been made in the technique since the publication of the original article.

CRITICAL CONCEPTS

INDICATIONS:

High-grade (50% to 100% slip) spondylolisthesis in a child under the age of eighteen years with or without lumbosacral kyphosis

CONTRAINDICATIONS:

Dysplastic high-grade spondylolisthesis requiring wide posterior decompressionCauda equina syndrome or L5 nerve root paralysis requiring nerve root decompressionSpondyloptosisPrevious abdominal surgery (relative)An overweight patient

Dysplastic high-grade spondylolisthesis requiring wide posterior decompression

Cauda equina syndrome or L5 nerve root paralysis requiring nerve root decompression

Spondyloptosis

Previous abdominal surgery (relative)

An overweight patient

PITFALLS:

Preserving posterior midline structures appears to be important; a posterior midline approach to the osseous elements should be used only if decompression of the central spinal canal is needed.

Positioning of the patient is crucial for the anterior procedure. The L5-S1 disc space is usually oriented upward from an anterior vantage point. Thus, for better visualization, one should secure hyperextension of the lumbar spine and take advantage of the Trendelenburg position of the table.

Orthopaedic surgeons with less experience may find it useful to enlist the assistance of a vascular or general surgeon for access through the transperitoneal approach to L5-S1 disc space.

Use of special access and retractor systems helps to maintain the operative field free of abdominal contents.

During removal of the disc material and ring apophysis, the osseous end plates should be preserved for structural support of the autogenous graft.

Injury to the parasympathetic nerve fibers may result in retrograde ejaculation in male patients, and this risk should be discussed with them.

After a thorough anterior discectomy, the intervertebral area can become rather unstable. If a too-large bone graft is inserted to increase disc height, L5 nerve root paralysis can result from excessive traction. In such an infrequent situation, a smaller graft should be inserted with or without L5 nerve root decompression.

AUTHOR UPDATE:

No substantial changes have been made in the technique since the publication of the original article.

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FIG. 6: The anterior longitudinal ligament is reattached through osseous channels, and the posterior peritoneal and laparotomy incisions are subsequently closed.

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FIGS. 7-A and 7-B: Fig. 7-A Standing lateral radiograph of the lumbar region of a fourteen-year-old boy with high-grade spondylolisthesis. The patient underwent uninstrumented circumferential fusion as described in the text. Fig. 7-B Radiograph made at the time of the most recent follow-up, when the patient was thirty years old, showing that the spinal fusion is solid. The patient was symptom-free.

References

INTRODUCTION | SURGICAL TECHNIQUE | POSTOPERATIVE TREATMENT | References

Lamberg T, Remes V, Helenius I, Schlenzka D, Seitsalo S, Poussa M. Uninstrumented in situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: long-term outcome. J Bone Joint Surg Am. 2007;89: 512-8.89512 2007 [PubMed][CrossRef]

Helenius I, Lamberg T, Österman K, Schlenzka D, Yrjönen T, Tervahartiala P, Seitsalo S, Poussa M, Remes V. 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. 2006;31: 190-6.31190 2006 [PubMed][CrossRef]

Poussa M, Remes V, Lamberg T, Tervahartiala P, Schlenzka D, Yrjönen T, Österman K, Seitsalo S, Helenius I. Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome. Spine. 2006;31: 583-92.31583 2006 [PubMed][CrossRef]

Hu SS, Bradford DS. Spondylolysis and spondylolisthesis. In: Weinstein SL, editor. The pediatric spine: principles and practice. 2001. Lippincott Williams & Wilkins: Philadelphia; 2nd ed. 2001. p 433-51.433 2001

Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine. 1988;13: 696-706.13696 1988 [PubMed]

Morscher E. [Two-stage reposition and fixation of spondyloptosis with Harrington instrumentation and anterior intercorporeal spondylodesis (author's transl)]. Arch Orthop Unfallchir. 1975;83: 323-34. German.83323 1975 [CrossRef]

Topics

spondylolisthesis ; decompressive incision ; isthmic spondylolisthesis

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Ilkka Helenius, Ville Remes, Mikko Poussa; Uninstrumented in Situ Fusion for High-Grade Childhood and Adolescent Isthmic Spondylolisthesis: Long-Term OutcomeSurgical Technique. The Journal of Bone & Joint Surgery. 2008 Mar;90(Supplement_2__Part_1):145-152.

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