Decompressing and Fixing Symptomatic High Grade Dysplastic

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Decompressing and Fixing Symptomatic High Grade
Dysplastic spondylolisthesis with S1 pedicular
screws crossing into the inferior portion of L5
Case report.

• Khalil I Issa M.D
• Spine-Ortho. Nablus-Palestine
• UWO-London-ON-Canada
• T.Carey FRCS(C), C.Bailey FRCS(C)

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Introduction

• Spondylolisthesis is a radiographic/anatomic
  description which describes the anterolisthesis
  ( slip ) of a vertebra on the one
  immediately caudal (inferior) to it.
• The degree of anterolisthesis can be defined by
  grade ranging from 1 to 5 with each additional
  grade representing an additional 25 of the
  distance from normal alignment to the stage of
  spondyloptosis (grade 5 or complete slip).

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Introduction

• Spondylolisthesis is usually classified by its
  etiology.
• The most common classification is that by Wiltse
  Dysplastic, Isthmic (Spondylolysis, lytic defect
  of the pars), Degenerative, Traumatic,
  Pathologic, and Post-Surgical.

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Discussion

• Dysplastic Spondylolisthesis is due to congenital
  dysplastic change of the facet producing the
  anterolisthesis.
• This usually occurs at L5-S1.
• The facet dysplasia can occur in the axial or
  sagital plane, or can be due to an elongation of
  the facets (Wiltse sub classification).

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Discussion

• The L5-S1 facet joint is oblique to the sagital
  and axial plane. The facets of the upper lumbar
  spine most closely parallel the sagital plane.
  As we descend caudally down the lumbar spine the
  facets close to the sagital plane.
• Normally, the S1 superior facet is approximately
  45 degrees to the sagital plane. The S1 facet is
  also oblique to the coronal and axial plane.
  Therefore, dysplasia in the sagital or axial
  plane implies the S1 facet is more parallel to
  the sagital or axial plane respectively, allowing
  the L5 inferior facet to slide anterior because
  the S1 facet is no longer acting like a buttress.

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Discussion

• Of all the spondylolisthesis types, congenital is
  most likely to produce neurological deficit by
  virtue of the anterolisthesis alone.
• This is because the grade of the listhesis can
  often progresses greater than two and the
  posterior ring of L5 remains attached to its
  anteriorly displaced body.
• The canal becomes narrowed between the
  posterior, superior corner of S1 and the
  anteriorly displaced L5 posterior elements
  resulting in subacute or acute cauda equina
  syndrome.

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Discussion

• Congenital spondylolisthesis is relatively rare.
• It typically presents in children, adolescents,
  or young adults.
• It more commonly presents with neurological
  symptoms or leg pain as opposed to back pain.
• May require urgent treatment if it presents as
  cauda equina syndrome.
• Some sort of decompression of the L5 lamina is
  required in association with a fusion, possible
  instrumentation procedure.

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Case Presented as

• 11-year-old girl
• A lot of growth over the last year
• Tightness in her lower extremities.
• Toe walking, particularly on the left
• Underwent some stretching and massage-type
  exercises in an effort to address this.
• Her symptoms didnt resolve.
• Referred on for assessment.

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Presentation

• She has been continuing to be active in sports
  including skating and hockey with discomfort.
• Clinical examination showed a very dramatic
  picture with a standing position with flexion at
  the knee and the hip on the left side.
• Unable to fully straighten her left leg without
  discomfort.

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Presentation

• She has an obvious step-off at the lumbosacral
  region with a flattened appearance to her
  buttocks.
• Significant tightness in her lower extremities.
• Straight leg raising on the left side was about 5
  or 10 degrees and on the right side about 40
  degrees with crossover pain onto her left leg

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X-Ray

• Full length as well as focused spine views.
• Confirmed the clinical suspicion of a
  spondylolisthesis.
• She had a dysplastic spondylolisthesis with a
  significant forward displacement of at least
  grade 3.
• She had the changes associated with a dysplastic
  spondylolisthesis with a dome shaped top of S1
  and a trapezoidal L5.
• She had a significant slip angle of 24 degrees.
• No other abnormalities are detected.

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MRI

• MRI showed an extremely tight stenosis.

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Assessment

• This young lady has a high-grade
  spondylolisthesis of the dysplastic variety.
• She is getting compression of the nerve root at
  this area that accounts for her lower extremity
  symptoms.
• She didnt seem to have a frank radiculopathy at
  the moment but thought that it is certainly
  headed that way.

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Assessment

• She denied any bowel or bladder issues.
• Assessed to need a fairly urgent intervention for
  this.
• Requiring a posterior decompression followed by
  an in situ fusion likely from L4 to S1.
• The necessity for careful monitoring of cauda
  equina syndrome.

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Operative TechniqueDecompression

• Jackson frame on the OSI table, prone.
• We exposed from L4 to S1 there appeared to be a
  significant deformity with a marked forward
  displacement of L5/S1.
• laminectomy of L5 and of L4 for decompression,the
  neural elements identified and followed out.
• Significant tightness of both the L5 and S1 roots
  was seen.

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Operative TechniqueDecompression

• It was felt that it would be necessary to do an
  anterior decompression and therefore, by careful
  retraction of the thecal sac, we were able to do
  a removal of the posterior aspect of the sacral
  dome which resulted in a decreased pressure over
  the thecal sac.
• It was felt that a reduction of this lip would
  be ill-advised due to the moderate tightness
  noted at the L5 root.

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Operative TechniqueFixation

• We used 5.5mm polyaxial screws and we ensured
  pedicle screws in L4 pedicles bilaterally.
• We then placed 6.5 mm screws into S1 pedicle.
  Image intensification was used to help with the
  placement of the screws and we were able to place
  the S1 screws through the superior endplate of S1
  across the 5-1 disc space into the inferior
  portion of the body of L5.
• Then rods were contoured to appropriately fit
  between the screws and they were locked into
  place.
• Allograft bone inserted.
• She had neuromonitoring performed throughout the
  case and this was maintained within normal ranges
  at all times.

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Post Operative Course

• She did well postoperatively.
• She was held over night in ICU and did quite
  well.
• She was discharged to the floor the following day
  and gradually mobilized. She was seen by
  Physiotherapy and did well with mobilization.
• She was discharged home on 4 days post
  operatively.

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Post Operative2 weeks

• Improving from a neurological point of view, and
  has less abnormal gait according
• She still had some tightness
• Physiotherapy to work on her hamstrings and heel
  cords.
• TLSO with a hip extension to support her surgical
  site in an effort to ensure she does not get in
  to a pseudoarthrosis type situation.

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Post Operative2 Months

• Her incision is well healed.
• Overall she is quite comfortable.
• She has been working on trying to regain range of
  motion as she had quite tight hamstrings and heel
  cords.
• 5 degrees above dorsiflexion on her right heel
  cord and about 5 below on her left side.

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Post Operative2 Months

• Her straight leg raising is about 50 to 60
  degrees on the right and about 45 to 50 on the
  left, and she has popliteal angles about -45.
• On and to continue TLSO to keep her restricted in
  her activities.
• X-rays were obtained today and these show
  maintenance of the instrumentation with no
  interval changes since her postoperative films.

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Post Operative4 Months

• Doing quite well ,continued to attend
  physiotherapy once every two weeks but does
  physiotherapy approximately three times a day at
  home. She has minimal to no discomfort as well.
• TLSO full time as well.
• Able to dorsiflex to about 5-10 degrees
  bilaterally. Her straight leg raise has improved
  from previous and now is up to about 70 degrees
  bilaterally.

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Post Operative4 Months

• X-rays today as though her lumbar fusion looked
  good, however it is always difficult 100 to
  accurately find this via x-ray.
• Overall she was doing quite well.
• Allowed to get back to some activity as
  tolerated.
• Allowed to ride a bike, skip and such.
• Allowed to start to discontinue the use of her
  brace.

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Results

• It secures fixation when combining L5 to S1
  keeping L5 in the construct
• It gives the ability to skip the so much
  technically difficult L5 pedicular screws
• It augments graft healing
• It is safe and stable

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Thank You