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308
J.G. Khalil et al.
The role of anterior column support in the surgical management of spondylolisthesis has been
debated. Anterior column support can be provided by a posterior lumbar interbody fusion
(PLIF), a transforaminal lumbar interbody fusion
(TLIF), or an anterior lumbar interbody fusion
(ALIF). Newer techniques using lateral transpsoas or anterior oblique approaches are also
being utilized. Possible choices for interbody
fusion device materials are metallic cages, carbon fiber cages, polyetheretherketone (PEEK)
cages, or bone [1]. Anterior column support can
be used for treatment of isthmic spondylolisthesis as well as degenerative spondylolisthesis
[136–140]. Proposed advantages of using interbody fusion with PLIF or TLIF as compared to
posterior instrumented fusion without an interbody fusion includes an increased likelihood of
fusion, better indirect foraminal decompression,
better reduction of the spondylolisthesis, and better restoration of lordosis [137, 138, 140]. Oda
et al. reported that when anterior column support
was deficient, the addition of posterior stabilization with pedicle screws alone provided inadequate stability and resulted in a high level of
implant strain. In these situations, the addition of
an interbody cage significantly increased the construct stiffness and decreased hardware strain,
although it resulted in increased motion at the
adjacent segment [141].
The Spine Patient Outcomes Research Trial
(SPORT) performed a cost-effectiveness analysis
of conservative to surgical treatment of spondylolisthesis at 2-year follow-up [142]. The study
found that surgery significantly improved the
quality of life in surgical patients compared with
non-operative treatment. Two-year follow-up
surgery was not deemed cost effective; however
at longer follow-up, the procedure is likely to
meet current cost-effectiveness standards [142].
Surgical Technique
Patient Positioning
The patient is placed in the prone position on
the Jackson table with hips fully extended to
improve lumbar lordosis. This position also
minimizes epidural venous distention from
abdominal compression; additionally it can aid
in the reduction of spondylolisthesis. A partial
correction of both the slip angle and the spondylolisthesis can be occasionally seen with
patient positioning alone. The patient should
have padding over all areas. Once positioning is
satisfactory, neuromonitoring signals should be
checked for baseline comparisons. The intraoperative neurophysiologic monitoring (IONM)
techniques that are commonly used during surgery include both upper and lower SSEPs
(somatosensory evoked potentials) as well as
continuous and triggered EMG activity [143].
Pedicle Screw Placement
We prefer to place the pedicle screws prior to performing the decompression. Dissection should
provide full exposure of the transverse process
with meticulous removal of the soft tissues in the
region of the segment to be fused. Once the external landmarks of the pedicles have been identified, fluoroscopic confirmation can be obtained
for pedicle identification, hole preparation, and
proper screw placement. There are two wellknown methods for pedicle screw placement, the
Roy-Camille method and the Magerl method.
Roy-Camille’s screw entrance point is situated at
the crossing of two lines on a typical bony crest
with the horizontal line passing through the middle of the transverse process and the vertical line
given by the articular process 1 mm under the
facet joint [
cle screw is 10–20° convergent toward the sagittal plane [
axis of the pedicle, indicated by the intersection
of the two lines with the vertical line touching the
lateral border of the superior articular process
and the horizontal line bisecting the base of the
transverse process [
cation of the facet complex can be accomplished
by using a towel clamp to move the spinous process and identify the facet joint and then removal
of the soft tissues from the surface of the superior
facet. For the external landmarks of the first
sacral pedicle, the inferolateral portion of the
superior S1 facet can be utilized. There are two
144]. Magerl’s direction of the pedi-
145]. The point of entry is in the central
145]. Confirmatory identifi-
24 Surgical Management of Lumbar Spondylolisthesis
309
common sacral screw placements: anterolaterally
into the ala and anteromedially into the promontory. Each pedicle screw is placed beginning with
the burr, providing a localization screw for the
curved pedicle probe, starting with the curve
directed laterally and then positioned medially
once the probe is in the vertebral body. The continuous tactile confirmation, using a pedicle
feeler, prevents breaching of the lateral and
medial wall cortex. The depth of the channel can
be established with a depth gauge. Tapping the
pedicles for subsequent insertion of the screw
also requires tactile confirmation of wall stock in
the pedicles. Pedicle screw size can be determined on preoperative CT scans, but intraoperative modifications are common. Placement of the
screw along the same trajectory as the pedicle
probe and the tap are vital to prevent breaching of
the lateral and, more importantly, the medial wall
of the pedicle. The optimal length of the screw is
one in which about 75% of the depth of the vertebral body is obtained, with a critical understanding of not penetrating the anterior portion of the
vertebral body to avoid injury to both vascular
and visceral structures in the retroperitoneum.
After all of the appropriate pedicle screws are
placed, verification of their exact position can be
done intraoperatively with fluoroscopy.
Decompression
Decompressive laminectomy alone is mostly recommended in patients without spondylolisthesis,
yet it is also a choice in patients with a low-grade,
static spondylolisthesis [146]. In order to attain a
successful decompression, there are three stages
suggested that are most often seen as a continuous procedure intraoperatively. Central laminectomy is performed and extended pedicle to
pedicle. The lateral recess is then decompressed,
confirming thorough bony removal of the medial
part of the facet joint complex, and the hypertrophied ligamentum is then detached.
Foraminotomies are performed to safeguard full
decompression of the exiting and traversing
nerve roots, while preserving most of the facet
joint and at least 8 mm of pars interarticularis
[147]. An aggressive decompression can result in
iatrogenic disruption of the facet joint or pars,
which could lead to accelerated degeneration or
instability, respectively [148]. In patients with
advanced age or comorbid conditions that preclude an extended surgical procedure, we recommend decompression of only the levels with
critical stenosis. In patients presenting with unilateral symptomatology, particularly radicular
instead of claudication, a hemilaminectomy can
be a viable option [149].
Spondylolisthesis Reduction
Surgical techniques for reduction of spondylolisthesis are dependent upon the understanding of
biomechanics, implant materials, and the goal of
the surgery. Being mindful not to over- or undertreat the patient requires an understanding of the
approach and proper techniques to accomplish a
reduction that is satisfactory with the appropriate
construct and planning. Figure 24.9 shows the
preoperative, intraoperative, and postoperative
images from a patient with an L5-S1 isthmic
spondylolisthesis that had a grade III slip. An
L4-S1 posterolateral arthrodesis was performed
with L4-S1 posterior instrumentation with pedicle screws and an L5-S1 Gill laminectomy. In
this case, a rod persuader was used with a cantilever method to carefully reduce the spondylolisthesis so not to lose the lordosis and cause a
subsequent flat-back deformity.
Correction of high-grade isthmic spondylolisthesis poses several challenges. In order to minimize complications, proper understanding of the
correct and altered anatomy must be mastered
150]. We recommend full decompression (Gill
[
type laminectomy) prior to any active reduction
attempt. Special attention should be turned to
removing all “Gill fragment” pieces from the
foramen and ensuring full decompression of the
exiting nerve root; i.e., in a case of L5-S1 isthmic
spondylolisthesis, we focus our attention to
obtaining full decompression of the L5 nerve
root. This nerve root is visualized from takeoff,
all the way to the extraforaminal region. In cases
of high-grade L5-S1 isthmic spondylolisthesis,
310
J.G. Khalil et al.
we recommend placing bicortical screws in the
sacrum. Alternatively, iliac screws can be placed.
In cases where the L5 pedicles are dysplastic and
rigid fixation is not assured, we recommend placing pedicle screws in L4.
Posterolateral Fusion
A posterolateral fusion is considered standard in
cases of posterior arthrodesis. Once the proper
placement of the pedicle screws and rods has
been achieved, with reduction being noted on
intraoperative fluoroscopic imaging, and an interbody cage/implant has been placed, posterolateral fusion can be started with decortication.
Decortication promotes the fusion process, offers
a source of vascular supply from the underlying
cancellous bone, and allows access to pluripotent
stem cells within the marrow [151]. In posterolateral intertransverse process fusions, the transverse processes and lateral facets are essential
areas to be decorticated, whereas the pars interarticularis is less beneficial [151]. After the fusion
sites have been properly decorticated, the graft
should be placed directly on the sites so as to create a fusion mass between the selected levels.
Recommended grafts to use are maximization of
the local bone that is properly prepared with
removal of soft tissues and crushed cancellous or
demineralized bone matrix (DBM). DBM in the
form of fiber “boats” filled with local bone and/or
crushed cancellous grafts can be used to contain
the graft and allow for exact placement.
TLIF
fixation or decompression where a minimally
invasive technique would not be advantageous
with time, visualization, or high grade of spondylolisthesis. As stated previously in an earlier
paragraph, the possible choices for interbody
fusion device materials are metallic cages, carbon fiber cages, polyetheretherketone (PEEK)
cages, or bone [1].
Open TLIF Technique
It is the author’s preference to perform TLIF
after screws are placed and the decompression is
completed. The inferior articular process of the
cephalad vertebra is removed with an osteotome
or burr. The superior portion of the superior
articular process of the caudal vertebrae is then
resected. The exiting and traversing nerve roots
are identified and protected. We prefer to use a
Penfield dissector to protect the exiting root
superiorly and a Love nerve root retractor to protect the traversing nerve root medially. After
complete removal of disc material, cartilaginous
end plates are scraped using curets, ensuring
removal of as much cartilage as possible. It is
important to make sure the cortical bone surface
is not breach to minimize the occurrence of end
plate fracture and cage subsidence. We recommend packing of graft material prior to cage
insertion; it should be noted here that graft volume is of utmost importance in obtaining adequate fusion, and the authors recommend
packing of at least 15 cc of graft material.
Following that, the interbody cage is inserted
and its position checked with fluoroscopy.
Transforaminal lumbar interbody fusion (TLIF)
techniques have a learning curve that can be
overcome with experience. Depending on the
surgeons’ comfort level, training, and expertise
in performing TILF, there are two main choices
of either open TLIF or MIS TLIF. Open TLIF
indications vary, depending on the surgeon’s
experience, comfort level, and training. Open
TLIF has the benefit of broader exposure with
multilevel disease that requires multiple levels of
Minimally Invasive Techniques
Minimally invasive techniques have recently
gained popularity in the treatment of spondylolisthesis with the growing technology that allows
the percutaneous placement of instrumentation.
The appeal for minimally invasive surgery stems
from evidence showing lower rates of complications, diminished blood loss, and faster return to
function [
152]. Minimally invasive transforami-
24 Surgical Management of Lumbar Spondylolisthesis
Fig. 24.6 Standing AP
and lateral radiograph.
Degenerative lumbar
spondylolisthesis
311
nal lumbar interbody fusion (MIS TLIF) has
been popularized as an alternative to open posterior fusion techniques. This approach seems particularly useful in cases of degenerative as well
as isthmic spondylolisthesis.
MIS Technique
[153–156]
MIS TLIF surgery makes use of rigid or expandable tubular retractors. The patient is positioned on
a Jackson frame with hips extended and knees
flexed to 20–30°. Fluoroscopic guidance allows
localization of the disc space and corresponding
facet joint. It is our preference to place guidewires
prior to decompression and TLIF. After adequate
placement of guidewires is verified, a 22 mm tubular retractor is docked on the ipsilateral facet joint.
Although loupe magnification and headlight can
be used, we prefer to utilize the operating microscope for the remainder of the procedure.
Facetectomy is performed using a high-speed burr.
The interval between thecal sac, exiting and traversing nerve roots, is then identified. Disc preparation is then performed followed by bone grafting
and insertion of an interbody device. If a bilateral
laminectomy needs to be performed, we prefer to
do so after the spacer is inserted. The table is tilted
and a series of burr and Kerrison rongeurs can be
used to achieve full bilateral decompression.
Screws and rods can then be placed.
The majority of the fusion (contralateral facet
can be decorticated and grafted) occurs within
the intervertebral disc space. For this reason,
meticulous discectomy and preparation of the
cartilaginous surfaces on both end plates is critical. Bone grafting is the cornerstone of a successful MIS TLIF procedure. Care must be taken to
place a maximum amount of bone graft within
the disc space. We prefer to pack 20–30 cc of
bone graft material prior to cage insertion.
Although the learning curve is steep, proficiency offers the advantage of faster surgical
time, diminished blood loss, and lower infection
rate. Multiple case series have demonstrated
shorter hospital stay and faster return to function
153, 154, 157–160]. In the setting of spondylo-
[
listhesis, minimally invasive technique can be
used for the treatment of degenerative (Figs.
24.6,
24.7, and 24.8) as well as isthmic (Fig. 24.9)
variants [
161, 162]. Active reduction is usually
not recommended, and it is the authors’ prefer-
312
Fig. 24.7 Sagittal and
axial MRI. Degenerative
lumbar spondylolisthesis
Fig. 24.8 Intraoperative
fluoroscopy. MIS TLIF
for degenerative lumbar
spondylolisthesis
J.G. Khalil et al.
ence not to perform active reduction, whether in
an open or minimally invasive setting.
Illustrative Case
History and Physical Examination
The patient is a 45-year-old male who presents to
our clinic with a history of chronic bilateral L5
radiculopathy. Symptoms are worsened by standing and walking and are relieved by lying down. He
had undergone physical therapy for 6 months and
numerous epidural steroid injections (both interlaminal and foraminal). On a physical exam, the
patient was noted to be obese, with calculated BMI
of 39. The patient had a normal sensory examination, and a normal motor examination in all major
muscle groups with intact reflexes; overall neurovascularly intact.
24 Surgical Management of Lumbar Spondylolisthesis
313
Fig. 24.9 Radiographic images from L5-S1 isthmic spondylolisthesis, grade III slip. Preoperative standing AP, flexion,
and extension. Intraoperative lateral. Postoperative lateral
Pre-operative Radiographic Imaging (Fig. 24.10)
Outcome: Follow-up with Postoperative Radiographic Imaging
(Fig. 24.10)
Standing AP and lateral radiographs as well as
flexion-extension radiographs show a sacralized
L5 vertebra with a dynamic grade II/III isthmic
spondylolisthesis at L5-S1.
Treatment
The patient underwent MIS TLIF with expandable cage at L5-S1.
Patient’s follow-up at 6 months states he is
doing well, no complaints of pain with activity
or mechanical instability. Radiographic imaging at follow-up shows proper placement of
cage without subsidence or shifting, no hardware loosening or lucency around hardware.
The patient was pleased with his outcome and
was able to resume his activities with no persistent symptoms.
314
Fig. 24.10 Standing AP and lateral radiographs, preoperative, and postoperative imaging of sacralized L5 vertebra
with an isthmic spondylolisthesis at L5-S1 treated with MIS TLIF and an expandable cage
J.G. Khalil et al.
Technical Pearls
• The use of the prone Jackson frame allows lordosis restoration and partial reduction of
spondylolisthesis. Maximal lordosis should be
achieved on the table through the use of thigh
and hip pads and leg boards.
• Good clinical outcomes can be obtained with
partial reduction and fusion in the adult isthmic spondylolisthesis patients.
• If active reduction is desired, we recommend
extensive decompression of the exiting and
traversing nerve roots through a Gill
laminectomy.
• Active reduction can be achieved by locking
the distal screws and reducing the rod into the
proximal screws.
• MIS TLIF can achieve similar outcomes to
open procedures; however the technique
requires a learning curve estimated to be
between 30–40 cases [163–165].
• We recommend the use of a 22 mm rigid tube
and use of the microscope for the MIS TLIF.
• Arthrodesis in minimally invasive fusions is
largely depended on interbody fusion; therefore, we recommend thorough disc preparation and bone grafting of at least 15 cc. We
typically use demineralized bone matrix to
pack the disc space and local bone graft (harvested from facet joint and morcellized) to
pack the interbody spacer.
Complications and Strategies for Avoidance
The most common complication seen in any
lumbar fusion surgery is pseudarthrosis, with
rates that vary from 0% to 39% [166–170]. The
frequency of pseudarthrosis increases in
fusions performed for the type IIA (lytic) spondylolisthesis [171]. Radiographic evidence of
pseudarthrosis includes a lack of bridging
bone, lucency around the pedicle screws,
instrumentation failure, the progression of slip
angle, or an increased vertebral displacement
1]. There have been accounts of postoperative
[
worsening of spondylolisthesis even with a
non-instrumented solid arthrodesis [
106, 169, 172, 173]. The majority of these
reports utilized radiographs and not CT to
assess the fusion mass; therefore, pseudarthroses might have been attributed to many of these
cases. An increase in the olisthesis has been
reported in non-instrumented fusions, providing a sound argument for instrumented fusion.
10, 39,
24 Surgical Management of Lumbar Spondylolisthesis
315
Radiculopathy and neurapraxia are common
complications. The Scoliosis Research Society
reported the percentage of neurologic
complications that occurred with lytic spondylolisthesis surgery is 3.1% [174]. The most common surgical complication following reduction is
a radiculopathy. The manipulation during surgery
can cause direct dural trauma and damage to multiple sacral and lumbar nerve roots, resulting in
postoperative neurological deficit [1]. The most
commonly involved nerve roots are the L5 nerve
roots, with reports showing variable rates of
recovery. The highest risk of nerve root injury
appears to be associated with aggressive reductions of high-grade listhesis [175–177]. We recommend wide decompression and Gill
laminectomy in cases of isthmic spondylolisthesis. As previously mentioned, it is important in
these cases to ensure full decompression of not
only the traversing but also of the exiting nerve
root.
Dural tears are also a common surgical complication [157, 178]. Although small durotomies
can usually be addressed with placement of fibrin
sealant, larger durotomies need to be addressed
by primary closure. In our experience, the occurrence of persistent dural leaks is relatively
infrequent.
Conclusion
The optimal surgical management of lumbar
spondylolisthesis is highly dependent upon the
symptomatology, radiographic anatomy, and surgeon’s comfort level. The goals of surgical treatment are to alleviate neurologic symptoms from
nerve impingement and to stabilize spinal segments that exhibit abnormal motion.
Decompression typically relies on laminectomy, the removal of all bony and ligamentous
structures causing stenosis; decompression can
also be achieved by indirect means through vertebral segment height restoration with interbody
device insertion.
Stabilization is achieved through arthrodesis
of unstable motion segments. Arthrodesis can be
achieved through anterior or posterior means.
The use of instrumentation has been standard
since multiple reports emerged in the past two
decades showing superior outcomes. The addition of interbody grafting and support has gained
popularity with reports showing increased fusion
rates when interbody grafting was added.
Although it was shown to achieve higher fusion
success and foraminal height decompression,
clinical studies have not consistently shown
superior clinical results.
We recommend that surgeons be familiar with
more than one treatment modality. Careful examination of the specifics of each case should point
toward the most appropriate technique.
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