Surgical outcomes with anatomic reduction of high-grade spondylolisthesis revisited: an analysis of 101 patients

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  • 1 Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany;
  • | 2 Paracelsus Medical University Salzburg, Salzburg, Austria;
  • | 3 Research Office (biostatistics), Paracelsus Medical University Salzburg, Salzburg, Austria;
  • | 4 Spine Center, Werner-Wicker-Clinic, Bad Wildungen, Germany;
  • | 5 Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria;
  • | 6 Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria; and
  • | 7 Department for Orthopedic Surgery, Schoen Clinic Vogtareuth, Vogtareuth, Germany
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OBJECTIVE

The ideal strategy for high-grade L5–S1 isthmic spondylolisthesis (HGS) remains controversial. Critical questions include the impact of reduction on clinical outcomes, rate of pseudarthrosis, and postoperative foot drop. The scope of this study was to delineate predictors of radiographic and clinical outcome factors after surgery for HGS and to identify risk factors of foot drop.

METHODS

This was a single-center analysis of patients who were admitted for HGS, defined as grade III or greater L5 translation according to the Meyerding (MD) classification. Complete postoperative reduction was defined as MD grade I or less and L5 slip < 20%. Forty-six patients completed health-related quality-of-life questionnaires (Oswestry Disability Index, Physical Component Summary of SF-36, and visual analog scale) and ≥ 2 years’ follow-up (average 105 months). A 540° approach was used in 61 patients, a 360° approach was used in 40, and L5 corpectomy was used in 17. Radiographic analysis included measures of global spinopelvic balance (e.g., pelvic incidence [PI], lumbar lordosis) and measurement of lumbosacral kyphosis angle (LSA), L4 slope (L4S), L5 slip (%), and postoperative increase of L5–S1 height.

RESULTS

The authors included 101 patients with > 1 year of clinical and radiographic follow-up. The mean age was 26 years. Average preoperative MD grade was 3.8 and average L5 slip was 81%; complete reduction was achieved in 55 and 42 patients, respectively, according to these criteria. At follow-up, LSA correlated with all clinical outcomes (r ≥ 0.4, p < 0.05). Forty patients experienced a major complication. Risk was increased in patients with greater preoperative deformity (i.e., LSA) (p = 0.04) and those who underwent L5 corpectomy (p < 0.01) and correlated with greater deformity correction. Thirty-one patients needed revision surgery, including 17 for pseudarthrosis. Patients who needed revision surgery had greater preoperative deformity (i.e., MD grade and L5 slip) (p < 0.01), greater PI (p = 0.02), and greater postoperative L4S (p < 0.01) and were older (p = 0.02), and these patients more often underwent L5 corpectomy (p < 0.01). Complete reduction was associated with lower likelihood of pseudarthrosis (p = 0.08) and resulted in better lumbar lordosis correction (p = 0.03). Thirty patients had foot drop, and these patients had greater MD grade and L5 slip (p < 0.01) and greater preoperative LSA (p < 0.01). These patients with foot drop more often required L5 corpectomy (p < 0.01). Change in preoperative L4S (p = 0.02), LSA (p < 0.01), and L5–S1 height (p = 0.02) were significantly different between patients with foot drop and those without foot drop. A significant risk model was established that included L4S change and PI as independent variables and foot drop as a dependent variable (82% negative predictive value and 71% positive predictive value, p < 0.01).

CONCLUSIONS

Multivariable analysis identified factors associated with foot drop, major complications, and need for revision surgery, including degree of deformity (MD grade and L5 slip) and correction of LSA. Functional outcome correlated with LSA correction.

ABBREVIATIONS

HGS = high-grade L5–S1 isthmic spondylolisthesis; H-L5-S1 = L5–S1 intervertebral distance and height; HRQOL = health-related quality of life; IONM = intraoperative neurophysiological monitoring; L4S = L4 slope; LIV = lower instrumented vertebra; LL = lumbar lordosis; LSA = lumbosacral kyphosis angle; MD = Meyerding; NPV = negative predictive value; ODI = Oswestry Disability Index; PCS = Physical Component Summary; PI = pelvic incidence; PPV = positive predictive value; PT = pelvic tilt; SRS-22 = Scoliosis Research Society–22; SS = sacral slope; SVA = sagittal vertical axis; TK = thoracic kyphosis; UIV = upper instrumented vertebra; VAS = visual analog scale.

Supplementary Materials

    • Supplemental Figs. 1-3 (PDF 9,459 KB)

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