CHAPTER
66
High-Grade Spondylolisthesis:
Posterior Decompression and
Spanning/Dowel Fibula
BACKGROUND
First described by Herbiniaux in 1782, spondylolisthesis is
defined as the slippage of one vertebra upon another. With
regard to the pediatric population, the L5-S1 articulation is the
most common site of slippage. In children and adolescents, the
cause of listhesis is dysplastic changes of the posterior elements
of L5 and superior articular facets of S1 and/or isthmic defects
of the posterior elements of L5 (usually the pars interarticu-
laris). The overall incidence of spondylolysis in the American
population is approximately 6%, with a male to female ratio of
2:1. It has been found that a predisposition toward spondyloly-
sis is higher in the Caucasian population than in the African-
American population and may be found in up to 50% of the
Eskimo populations of North America.4,18
From an etiologic standpoint, spondylolisthesis is a multifacto-
rial disease with heredity and environmental factors being most
important.4 Recent studies conclusively demonstrate that isthmic
spondylolisthesis is not present at birth. Although spondylolysis is
more commonly found in males, the propensity for slip progres-
sion appears to be higher in females. The etiology for these gen-
der differences is unknown. Spondylolysis is more common among
those engaged in activities involving hyperextension of the lower
spine such as gymnastics, football (linemen), wrestling, etc.
Meyerdings definition of degree of slippage, Wiltses etiologic
classification, and Marchettis and Bartolozzis descriptive classifi-
cation to define surgical parameters are the most commonly
used classification schemes to categorize spondylolisthesis.9,1922
Along with these classifications, various other risk factors for slip
progression include slip angle of greater than 55, female gen-
der, early age of diagnosis, and degree of slip at presentation
(50% slip).20 From these radiographic parameters and classifi-
cation schemes, a useful algorithm to direct nonsurgical and
surgical management of patients with spondylolisthesis has been
developed.
TREATMENT
More than 30 years ago, Wiltse and Jackson defined treatment
algorithms for pediatric spondylolisthesis based upon percent-
646
LWBK836_Ch66_p646-659.indd 646
Rick C. Sasso
James E. Lashley
age slip as well as degree of symptoms.20 To this day, these treat-
ment pathways have remained relatively unchanged. For
low-grade (Meyerding 1 and 2) slips, treatment consists of activ-
ity modification, bracing, physical therapy, and a return to nor-
mal activity once symptoms subside. Surgical intervention is
reserved for those patients in whom symptoms are not relieved
by nonoperative means. In contrast, for patients presenting
with high-grade slips (Meyerding 3, 4, and 5); surgical interven-
tion is recommended regardless of the magnitude or duration
of symptoms. This is true for children due to the high potential
for these high-grade slips to progress before skeletal maturity;
however, treatment recommendations for adults with a high-
grade slip are less clear.
Several surgical options currently exist for the treatment of
high-grade isthmic spondylolisthesis.57 The one common ele-
ment to all surgical interventions remains arthrodesis: in situ
posterolateral fusion, posterolateral fusion and decompression,
posterolateral instrumented fusion, and posterolateral fusion
combined with interbody fusion. Traditional techniques of pos-
terolateral fusion, with or without decompression or instru-
mentation, have been utilized in the treatment of high-grade
slips, but only with moderate success.10 The unfavorable biome-
chanical environment places the posterior graft bed under ten-
sion; this, in turn, leads to increased potential for nonunion,
postoperative progression of slip angle, and translation. Hanson
et al have shown that the addition of an interbody fusion utiliz-
ing a spanning fibula dowel not only leads to increased fusion
rates but also decreases postoperative slip progression.5
Unfortunately, the abnormal morphology of the lumbosacral
junction prevents the use of traditional trapezoidal anterior
and posterior interbody grafts. To overcome this abnormal
offset of the L5 and S1 end plates, a technique utilizing trans-
vertebral interbody fibular dowel grafts has met with great
success.5,17
The advantage of this technique is the ability to achieve a
circumferential construct to maximize the fusion rate without
the necessity of a complete translational reduction of L5 on S1,
which is required for traditional block-type interbody devices.
The most compelling reason not to attempt a complete transla-
tional reduction is the extremely high incidence of L5 nerve
root deficit. Cadaveric studies demonstrate a relatively low
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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula 647

planning is required. This includes planning for radiographic

Surgical Technique for
guidance of instruments and implants, neurophysiologic moni-
High-Grade Isthmic
toring, determination of anterior/posterior or posterior-only
Spondylolisthesis with approach as well as levels of instrumentation, and use of bone
TABLE 66.1
Associated Complications, graft extenders to enhance fusion.
Fusion Rate, and Complexity* Placement of instrumentation is a technically demanding
skill that requires intraoperative imaging to effect perfect place-
L5 Nerve Fusion Surgical ment of guidewires and screws. Image-guided navigation and
Technique Injury Rate Complexity real-time fluoroscopy are two methods used to visualize place-
Partial reduction with Rare High Low ment of instrumentation. At our institution, we utilize image-
fibular strut graft and guided navigation for placement of pedicle screws, as well as
posterior pedicle choosing the direction of and determining the depth for guide-
screws wire placement. After the right-sided buttock is sterilely
Vertebrectomy (Gaines More High Highest prepped, a reference antenna is percutaneously placed into the
procedure) common right posteriorsuperior iliac spine and preoperative scans are
Complete reduction of More High High acquired in the operating room (Fig. 66.1). This provides the
translational common ability to simultaneously visualize AP, lateral, and axial views in
component real time during the procedure and visualize our instrumenta-
*
tion in a virtual fashion on the computer screen (Fig. 66.2).
Posterior instrumented rare lower. Fusion in situ lowest. Pedicle screw length, reaming depth, and appropriate guide-
wire placement are all readily determined. In contrast to real-
time fluoroscopy, the surgeon, assistant, and operative field are
not crowded by two separate fluoroscopic machines; radiation
strain on the L5 nerve root with the first 25% translational exposure to personnel is dramatically reduced; and less time is
reduction of L5; however, this nerve root stretch increases spent by avoiding the numerous single fluoroscopic images
exponentially with the final 50% reduction.11 This technique with each step of instrumentation placement.
allows for the achievement of a partial reduction of the slip. Neurophysiologic monitoring is an extremely useful tool to
The most important aspect of this deformity correction is the help avoid catastrophic intraoperative nerve damage by surgi-
sagittal angle. The lumbosacral kyphosis reduction is easily cal instruments (i.e., drills, taps, and probes) and instrumenta-
achieved with positioning on the operating table, and partial tion (e.g., pedicle screws). Continuous electromyogram (EMG)
reduction of the translational deformity also frequently occurs monitoring helps prevent nerve root damage during pedicle
with this procedure. It is important, however, not to attempt a screw placement, interbody cannulation, and fibular allograft
forceful reduction of the translation to limit the chance of neu- placement. During the posterior-only approach, preparation of
ral deficit (Table 66.1). the channel for the fibular allograft requires retraction of the
S1 nerve root laterally and the dura medially to provide enough
space for passage of the reamers. Continuous EMG monitoring
PREOPERATIVE PLANNING is also utilized during preparation and placement of pedicle
screws. In addition, each pedicle screw is independently tested
In order to increase the likelihood of successful fusion as well with direct electrical stimulation via a direct monopolar nerve
as prevent intraoperative nerve damage, careful preoperative stimulator to assess pedicle wall integrity.

Figure 66.1. Intraoperative fluoro-

navigation scan outlining sagittal, coro-
nal, and axial views of a slip.

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 648 Section VI Spondylolisthesis
A B
C
Determination of the optimal surgical approach is a deci-
sion to be made between surgeon and patient. Benefits of a
posterior-only approach are that it spares a separate anterior
incision, avoids complications of the anterior approach (e.g.,
retrograde ejaculation in a male), and limits the arthrodesis to
only one level (L5-S1) if appropriate. On the other hand, a
miniopen anterior lumbar interbody fusion approach can be
utilized to gain access to the L4-L5 interspace, with placement
of the fibular dowel graft from L5 to S1 in an antegrade fash-
ion. Advantages of the anterior approach are that it avoids the
potential risks of S1 nerve root damage due to excessive retrac-
tion and reamer contact with the nerve (Table 66.2).
The successful outcome of this circumferential fusion tech-
nique is predicated upon the ability to achieve and maintain a
rigid construct composed of instrumentation and graft mate-
rial. A stable biomechanical environment reduces micromo-
tion at the fusion interface and increases the likelihood of a
successful arthrodesis. This is achieved with both fibular
allograft, as well as posterior pediclescrew/rod instrumenta-
LWBK836_Ch66_p646-659.indd 648
Figure 66.2. Intraoperative fluoronavigation scan
with projected trajectory of transsacral transvertebral
fibular dowel graft through S1 into L5 body. (A) Intraop-
erative picture with the navigation probe demonstrating
the projected trajectory. (B) Coronal view of the intraop-
erative image navigation with the probe across the L5-S1
disc into the L5 vertebral body. (C) Sagittal view of the
intraoperative image navigation showing the probe
extending from the sacrum across the high-grade spon-
dylolisthesis docking into the L5 vertebral body.
tion. Classically, it has been taught that a high-grade spon-
dylolisthesis is best treated with posterior instrumentation
spanning L4 to S1. In the past, L5 pedicle fixation was difficult
to achieve due to the challenging local anatomy (translated
and rotated L5 vertebra), and the tendency of the L4 and L5
pedicle screws heads to abut. With our current technique, it is
now possible to include the L5 pedicle screw in an L4-S1 poste-
rior construct. This is made possible through indirect reduc-
tion of L5 on S1 by patient positioning (reducing the kyphosis
of L5 on S1), the use of modern polyaxial screw heads, and
image-guided navigation (Fig. 66.3). The addition of L5 pedi-
cle fixation results in much stronger biomechanical construct
and provides an excellent environment for fusion. Furthermore,
if the L5 pedicle is considered to be strong enough and is eas-
ily accessible, it may be the most cephalad point of fixation in
the posterior fusion, thereby changing the treatment to a one-
level fusion (Fig. 66.4).
To date, iliac crest autograft is still considered the gold stan-
dard for achieving solid fusion of any posterior lumbar fusion.
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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula 649

Circumferential Versus Posterior-Only Surgical Technique

TABLE 66.2 for High-Grade Isthmic Spondylolisthesis with Associated
Advantages and Disadvantages

Potential for Retrograde Ability to Place Strong

Ejaculation in Young and Large Interbody Potential for S1
Technique Incisions Male Construct in L4-5 Disc Nerve Irritation
Posterior-only 1 No No Yes
Anterior and 2 Yes Yes No
posterior

Over the last decade, innovations in bone graft extenders and
recombinant bone morphogenic protein (BMP) have enabled us
to enhance fusion mass while potentially avoiding the morbidity
of iliac crest bone graft harvesting. We use a combination of
biphasic calcium phosphate with BMP-2 as the graft material for
the posterior fusion mass. The local autograft bone from the Gill
laminectomy is also cut into small pieces and mixed into the graft.
It must be understood that this is considered an off-label use of
these products in the treatment of high-grade spondylolisthesis.
TECHNIQUE
POSTERIOR APPROACH
The patient is placed under general endotracheal anesthesia
on the hospital bed. Once asleep, a Foley catheter is placed,
EMG leads are placed upon the lower extremities, and thigh-
high compression stockings and sequential compression devices
upon the calves. The patient is then placed into a prone posi-
tion on the Jackson table with care taken to place pads across
the chest (above nipples) and at the anterior-superior iliac
spines, while the legs are suspended in the leg sling. This
position allows the abdomen to be freely suspended and
achieves an indirect reduction of the slip by extension of the
hips. Arms are placed upon egg crate mattresses cushioning
the ulnar nerves with elbows flexed and glenohumeral joints
forward flexed 90. Likewise, the common peroneal nerves are
padded with egg crate mattresses.
After placement of the percutaneous image-guided naviga-
tion reference antenna into the posterior superior iliac spine
(PSIS), a scan is acquired (Fig. 66.1). A preoperative antibiotic
is administered, and the patient is then prepped and draped in
a sterile fashion to allow an operative field from L1 to the supe-
rior gluteal crease. A standard midline exposure is made from
the L3-L4 facet joints to the sacrum. Great care is taken during
exposure over the sacrum due to the well-established associa-
tion of spondylolisthesis and spina bifida occulta. Once
exposed, a standard Gill laminectomy of L5 is performed.
Fibrous tissue from the nonhealed pars defects are debrided
(in cases with associated spondylolysis) and both L5 nerves are
completely decompressed. Standard posterior pedicle screw
instrumentation is then placed from the L4 to S1 pedicles.
Laminectomy of S1 is performed to expose the S1-S2 interspace
and overlying dural sac, the S2 pedicles, as well as the S1 and S2
nerve roots. Next, the dural sac is retracted medially, between
the S1 nerve root and S2 pedicle, to reveal the entry site into
the body of the sacrum. The entry site is centered 1 cm lateral
to the midline of the S1 body at the level of the hypoplastic
S1-S2 disc. The planned depth of the channel to be reamed is
approximately 80% of the posterioranterior length from the
entry site at the S1 body to the anterior cortex of L5. This

Figure 66.3. An anteriorposterior circumferential fusion, which

includes the L5 pedicle screws in the posterior instrumented Figure 66.4. A posterior-only approach construct with L5 pedicle
construct. screws allowing a one-level fusion.

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 650 Section VI Spondylolisthesis
length avoids inadvertent penetration of the anterior aspect of
the L5 body.
With use of fluoroscopic control or computer navigation, a
standard 2-mm guidewire is advanced from the entry site
through the S1 body across the L5-S1 interspace into the ante-
rior cortex of the L5 body (taking care not to penetrate the
anterior L5 cortex). At our institution, we utilize image naviga-
tion for placement of pedicle screws and for determining the
path of guidewire placement from S1 into L5. In addition,
image navigation is used to determine the appropriate length
of the fibular allograft. Next, a fibular allograft, roughly cylin-
drical in shape, is cut to the appropriate length with a saw. This
length is 1 to 2 mm shorter than the depth of the reamed
channel. This allows the graft to be recessed below the level of
the reamed channel at the entry point in the posterior sacral
wall. The cut allograft is shaped with a burr to remove the
sharp edges at either end and along the axis to fashion the
graft into a cylindrical shape. The fashioned graft is then mea-
sured with the ACL (Anterior Cruciate Ligament) graft sizer to
obtain the most accurate diameter (see Fig. 66.14). The lead-
ing edge of the graft is carefully tapered to allow easy entry
into the reamed channel. Standard ACL reamers are passed
over the guidewire in sequential fashion to ream a channel 1
mm less than the cross-sectional diameter of the fibular strut
allograft (Fig. 66.5). The guidewire is removed, and the fibular
strut dowel is then driven into the reamed channel. The dowel
is gently tapped into the channel with use of a small tamp and
mallet until the posterior aspect of the dowel is recessed 1 to 2
mm below the entry point of the reamed channel; this will pre-
vent impingement of the anterior aspect of dura and nerve
roots upon a protruding graft. The process is repeated on the
contralateral aspect of the sacrum to place a second S1-L5
interbody dowel graft, and the dura is then retracted over the
first reamed channel and graft. Two rods are then placed into
their corresponding pediclescrew heads on each L4-S1 (or
L5-S1) construct, set screws are placed, and final tightening of
set screws is performed to hold the position of L5-S1.
Decortication of transverse processes (at L4 and L5) and sacral
alae is carried out; BMP-2 sponges, bone graft extender, and
local autogenous bone graft (from laminectomy) are placed in
the lateral gutters; and appropriate hemostasis is obtained.
Figure 66.5. Reaming of the channel for placement of the fibular
dowel graft.
LWBK836_Ch66_p646-659.indd 650
The wound is then closed in layers. The patient is placed into
supine fashion onto the hospital bed and awakened from gen-
eral anesthesia.
ANTERIORPOSTERIOR APPROACH
The patient is placed under general endotracheal anesthesia
on the hospital bed. Once asleep, a Foley catheter is placed;
EMG leads are placed upon the lower extremities as are thigh-
high compression stockings and sequential compression
devices upon the calves. The patient is then transferred supine
to a radiolucent table. A percutaneous image-guided naviga-
tion antenna is placed into the anterior-superior iliac spine
under sterile technique, and a preoperative scan is acquired.
A preoperative antibiotic is administered, and the patient is
then prepped and draped in sterile fashion. In the supine
position, the hips are allowed to be in an extended position
(do not place pillows under the thighs) to obtain positional
correction of the sagittal deformity at L5-S1. A standard, left-
sided, paramedian, rectus-sparing, miniopen, retroperitoneal
approach is performed to expose the L4-L5 interspace
through a transverse skin incision. This is a routine approach
to the L4-5 disc, and the L5-S1 disc is not even visualized. This
is important because the high-grade slip makes the anatomy
at L5-S1 very abnormal and impossible to expose through a
retroperitoneal approach. Exposing the L5-S1 disc in a high-
grade slip requires a transperitoneal approach, which is elim-
inated in the present technique by accessing the L5-S1 disc
through the L4-5 disc space. The L4-L5 disc is carefully
excised, and the cartilaginous end plates of L4 and L5 are
removed down to the strong subchondral bone. A 2-mm
guidewire is placed in the midportion of the cephalad L5 end
plate. The guidewire is then drilled through the cephalad L5
end plate, into the L5 body, across the L5-S1 interspace, into
the S1 body and docking at the hypoplastic S1-S2 interspace.
Sequential reaming is then performed to prepare a channel 1
mm less than the cross-sectional diameter of the fibular dowel
graft. The guidewire is removed, and the dowel graft is placed
into the channel. The graft is then carefully advanced, with a
tamp and mallet, until the proximal end of the graft is recessed
approximately 1 mm less than the entry point of the cephalad
L5 end plate. A trapezoidal femoral ring allograft packed with
a BMP-soaked sponge is then placed in the L4-L5 interspace.
As in the posterior procedure autograft reamings from the
drill are saved and mixed with the bone graft. Appropriate
hemostasis is obtained, all vascular structures are checked,
and the wound is closed in layers.
Next, the patient is placed in the prone position on a Jackson
frame (as described in the posterior approach, above). A stan-
dard midline exposure is made from the L3-L4 facet joints to
the sacrum. Great care is taken during exposure over the
sacrum due to the well-established association of spondylolis-
thesis and spina bifida occulta. Once exposed, a standard Gill
laminectomy of L5 is performed. Fibrous tissue from the non-
healed pars defects are debrided, and both L5 nerves are com-
pletely released. Standard posterior pedicle screw instrumenta-
tion is then placed from the L4 to S1 pedicles, including the L5
pedicles if possible. Rods are inserted and set screws placed and
tightened, as described above. Decortication is carried out;
bone graft and graft extenders (if used) are placed in the pre-
pared lateral gutters. Hemostasis is obtained, and the wound is
closed in layers (Figs. 66.6 and 66.7).
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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula
Figure 66.6. Lateral radiograph of an anteriorposterior
approach circumferential fusion with L4-S1 screws, posteriorly, and
L4-L5 interbody graft overlying the entry point for the fibular dowel
graft (outlined in black).
POSTOPERATIVE CARE
The patient is advanced to standing at bedside with physical
therapy on the same day of surgery. If the patient underwent an
anteriorposterior approach, they are kept NPO until passing
flatus, and then diet is advanced slowly. Otherwise, if posterior-
only approach is utilized, diet is started right away. Patient-con-
trolled analgesia is utilized for pain control. By postoperative
Figure 66.7. Anteroposterior radiograph depicting the same ante-
riorposterior approach circumferential fusion.
LWBK836_Ch66_p646-659.indd 651
651
day 1, the Foley catheter is discontinued, the wound is checked,
and pain control is slowly transitioned to oral analgesics. The
patient is progressively ambulated with assistance by physical
therapy and then discharged to home once ambulating satisfac-
torily, usually 3 to 4 days after surgery.
RESULTS
Circumferential fusion with posterolateral graft and inter-
body fibular strut grafting has a long history of success.1,3,5,10,15,16
Bohlman and Cook first described the posterior-only
approach in two patients in 1982.1 Short-term follow-up of
both patients showed resolution of preoperative pain and
neurologic deficits with solid arthrodesis at 2 years. A subse-
quent study by Smith and Bohlman evaluated 11 skeletally
mature patients with high-grade slips who underwent a sin-
gle-stage posterior approach interbody arthrodesis with pos-
terolateral fusion for up to 12 years.16 Once again, a solid
arthrodesis was obtained with improvement of preoperative
neurologic deficits in all patients. Esses et al assessed the out-
comes of nine patients who underwent a single-stage poste-
rior approach circumferential arthrodesis with fibular strut
grafts.3 In addition to showing solid fusion at 1 year, all nine
patients had significant reductions in their back pain Visual
Analog Scale (VAS) scores. Molinari et al conducted a retro-
spective comparison of three different treatments of high-
grade spondylolisthesis slips: (1) posterolateral in situ fusion
without decompression, (2) posterolateral fusion with instru-
mentation and decompression, and (3) decompression,
reduction, and circumferential fusion (both anteriorposte-
rior approach and posterior-only approach).10 The pseudart-
hrosis rates for the three groups were 45%, 29%, and 0%,
respectively. Although no significant differences regarding
pain, function, and satisfaction were found among the three
groups, the third group scored highest in all parameters.
Sasso et al reported the results of 25 patients undergoing
posterior decompression and circumferential fusion with
both techniques (anteriorposterior and posterior-only). All
25 patients achieved solid arthrodesis, with no progression of
slip, and 96% extremely satisfied/satisfied on SRS functional
outcome scoring.13
When it comes to allograft versus autograft, Hanson et al
showed no difference in rates of remodeling between the two
grafts. Therefore, they recommended that allograft is an accept-
able treatment option for strut grafting (Table 66.3).5
COMPLICATIONS
In the treatment of high-grade spondylolisthesis, numerous
complications have been outlined in the literature. In regard to
in situ posterolateral fusion, high rates of pseudarthrosis, pro-
gression of slip despite solid fusion, cauda equina syndrome,
and neurologic complications are most notable.8,14 Posterior
fusion supplemented with posterior instrumentation alone has
been further complicated by failure of instrumentation, subse-
quent pseudarthrosis, and progression of slip.2,10
It has been postulated that the biomechanical stability
afforded by an interbody graft may reduce not only the rate of
pseudarthrosis, but also reduce the chance of postfusion slip
progression. High success rates are reported throughout the
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 652 Section VI Spondylolisthesis

Details of the Literature on the Surgical Outcome of

TABLE 66.3
High-Grade Isthmic Spondylolisthesis

Study Author Patients Fusion Rate Reduction Complications Clinical Success

Sasso 25 100% No loss of Translation No neurologic 96% Extremely
correction improved 0.2 deficits satisfied/
grades. Slip satisfied
angle
improved 10
Hanson 17 100% No loss of Translation No neurologic Excellent
correction improved 1.4 deficits
grades
Slip angle
improved 14
Smith 9 100% No neurologic Excellent
deficits
Esses 9 100% Excellent based
No permanent
on VAS scores
deficits
One dural tear
Two infections at
fibular
autograft
harvest site

VAS, Visual Analog Scale.

literature when high-grade slips are treated with circumferen-
tial fusion.13,5,10,1416 As evidenced by the comparative study of
Molinari et al, circumferential fusion was associated with the
lowest rate of pseudarthrosis (0%).10 This relevant and impor-
tant comparative study clearly supports the performance of a
circumferential fusion for this difficult condition of a high-
grade isthmic spondylolisthesis. Without an interbody con-
struct, a high rate of complications and pseudarthrosis can be
expected. As with any spinal fusion procedure, there is always
the potential for failure of instrumentation and loss of fixa-
tion/reduction. Variable rates of loss of fixation have been
observed even in circumferential fusion procedures, but at a
lower rate than that seen in posterolateral fusion with pedicu-
lar fixation alone.2,10
The most concerning complication remains postoperative
neurologic deficit. Most cases of deficit involve the L5 nerve
root manifesting as postoperative foot drop and are believed
to be due to overzealous reduction of the L5-S1 level. Petraco
et al performed a cadaveric study to examine L5 nerve strain
with reduction maneuvers of slipped L5-S1 constructs.11 They
found that the initial 50% of anatomic reduction of L5 upon
S1 was associated with only 21% of nerve strain, and that the
second half of reduction was associated with 79% strain of
the L5 nerve. In addition, they found that less strain occurred
when only slip angle was reduced when compared with ana-
tomically translating L5 upon S1. Certain measures may be
taken to diminish the chance of postoperative L5 dysfunc-
tion. These include intraoperative continuous EMG monitor-
ing, and indirect partial reduction of spondylolisthesis by
patient positioning with the hips in extension, prior to inci-
sion. Although many cases of postoperative L5 dysfunction
are reported to resolve, some are permanent. It is the authors
opinion that reduction of L5 on S1 is best gained through
positional indirect partial reduction as opposed to vigorous
attempts to obtain an anatomic reduction of L5-S1 transla-
tion prior to fixation and fusion. In this instance, partial
reduction of L5 on S1 to correct the sagittal imbalance is
more important than obtaining a full translational reduction
of L5 on S1. To date, there is no literature supporting
improved outcomes with full reduction of the translation of
L5 onto S1. The most important goal to achieve a good out-
come is to achieve a solid fusion. This is appropriately accom-
plished with a solid circumferential fusion utilizing a fibular
dowel strut graft and posterolateral fusion mass with pedicle
screw instrumentation.
Other complications reported are those associated with spi-
nal fusion procedures in general. These include durotomy,
infection, deep venous thrombosis, and retrograde ejaculation
associated with anterior approaches to the lumbosacral
spine.7,12

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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula
CASE 66.1
JB is a 13-year-old competitive high school tennis player
with low back pain. Eight months prior to presentation,
the patient had a short episode of low back pain follow-
ing a basketball game, which resolved spontaneously.
Approximately 3 weeks prior to presentation, JB experi-
enced an exacerbation of low back pain with worsening
gait disturbance following a tennis match. At the time of
presentation, the patient described the presence of dyses-
thesias in the left leg and foot. The history was otherwise
unremarkable.
Physical examination is notable for hamstring tight-
ness, a vertical pelvis, an abdominal crease, hyperlordosis
above the lumbosacral junction, and a gait disturbance
consisting of flexed hips and knees with ambulation
(Figs. 66.8 and 66.9). Examination revealed the lower
extremity myotomes and dermatomes to be intact without
loss of strength. Radiographic examination displays a
high-grade slip (Meyerding 4) at the lumbosacral junc-
tion, with dysplastic changes of the sacral dome and trap-
ezoidal L5 body (Figs. 66.10 and 66.11).
With continued pain, having previously failed non-
operative management, and most notably the high
degree of slip in this young individual, operative inter-
vention was discussed. Surgical options were discussed
including interbody fusion with fibular strut grafts
(anterior vs. posterior approach) with posterolateral
fusion and instrumentation. Attendant complications
and expected outcomes were also discussed. Because of
the potential for retrograde ejaculation with an ante-
rior approach and desire to spare the normal L4-5
motion segment (Fig. 66.12) the patient/family decided
upon posterior-only approach. This approach also
allowed the potential for a limited L5-S1 arthrodesis
since the L4-5 disc was normal on magnetic resonance
imaging (MRI).
A posterior-only approach was used to obtain fixation
and fusion of this high-grade slip. The patient was
placed prone on a Jackson table, providing partial indi-
rect reduction of the slip through maximal hip extension.
A percutaneous reference antenna, for image-guided
navigation, was placed under sterile technique. An
LWBK836_Ch66_p646-659.indd 653
653
intraoperative image-guided scan was acquired (Fig.
66.1). The patient was then prepped and draped in ster-
ile fashion. A standard midline incision was made, and
great care taken during deeper dissection because of
suspected spina bifida occulta as visualized on preopera-
tive radiographs. The L5 and S1 vertebrae were identi-
fied, and dissection was carried out laterally to visualize
the transverse process of L5 as well as sacral ala at S1. In
this case, it was possible to place pedicle screws at L5
and S1 under image-guided navigation. Based upon the
large transverse processes of L5 (as a bone grafting sur-
face), good sagittal alignment of L5 on S1, and excel-
lent pedicle fixation into L5, it was decided that L5
would be the highest level included in the posterior
fusion construct. A Gill laminectomy of L5 with subse-
quent decompression of the L5 nerves was performed,
and then a laminectomy of S1 to visualize the S1 and S2
nerve roots and S2 pedicle. Sequential reaming of the
channel for the left fibular strut graft was performed to
an ACL reamer diameter of 10 mm, and depth of chan-
nel measured (Fig. 66.13). For this patient, the length
of the strut was 30 mm, and the diameter was 11 mm
(Fig. 66.14). The fibular strut graft was then carefully
fashioned such that the length of the graft was 2 mm
shorter than the depth of reamed channel. This process
was repeated for placement of the right fibular strut
graft. Decortication in the lateral gutters was performed,
and Infuse, Mastergraft, and local autograft were
placed in the lateral gutters. The patient was awakened
from general anesthesia and then transferred to PACU
and then to the floor. The postoperative course was
uneventful with the exception of 4/5 strength of left
ankle dorsiflexors. Immediately after surgery, the
patients gait was markedly improved. Two months post-
operatively, the ankle dorsiflexion weakness had
resolved and the patient was pain-free. Radiographs dis-
play early fusion and JB is currently engaged in nonim-
pact aerobic activities without difficulty. (Figs. 66.15 and
66.16) At 4 months after surgery, patient is back to play-
ing competitive tennis.
8/26/11 10:41:51 PM
 654 Section VI Spondylolisthesis

Figure 66.10. Upright lateral radiograph depicting characteristics

of high-grade spondylolisthesis including trapezoidal L5 body and
rounded sacral dome, junctional kyphosis at lumbosacral junction,
and a Meyerding grade 4 translation.

Figure 66.8. Typical posture of high-grade spondylolisthesis

depicting kyphosis of lumbosacral junction, vertical position of the
sacrum, and flexion of hips and knees in upright standing.

Figure 66.9. Scaphoid abdomen of a high-grade spondylolisthesis

patient with characteristic abdominal crease. Figure 66.11. Close-up lateral radiograph of grade 4 slip.

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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula 655

Figure 66.14. Lateral radiograph for final reduction and circum-

ferential fusion of grade 4 slip.

Figure 66.12. Sequential reaming over guidewire preparing chan-

nel for fibular dowel graft.

Figure 66.15. Anteroposterior radiograph of final reduction and

circumferential fusion of grade 4 slip.

Figure 66.13. Prepared fibular graft measuring 30 mm (2 mm

less than reamed depth of prepared channel) adjacent to ACL
(Anterior Cruciate Ligament) graft measuring tool.

LWBK836_Ch66_p646-659.indd 655 8/26/11 10:41:51 PM

 656 Section VI Spondylolisthesis

A B

Figure 66.16. Posture of high-grade slip depicting junctional kyphosis of lumbosacral junction, vertical positioning
of pelvis, and hamstring tightness with flexed knees and flexed hips.

CASE 66.2

JG is a 14-year-old competitive soccer player referred
from an outside team physician for a chief complaint of
hamstring tightness. Evaluation revealed a high-grade
L5-S1 spondylolisthesis. The patient presented with the
insidious onset of hamstring tightness. The patient did
not remember any inciting event or history of back pain.
Physical examination is notable for hamstring tightness,
an abdominal crease, and hyperlordosis above the lum-
bosacral junction (Fig. 66.17). Neurologic examination of
the lower extremities reveals intact myotomes and der-
matomes with 5/5 muscle strength. Radiographic examina-
tion revealed a grade 4 slip (Figs. 66.17 and 66.18).
Surgical options including circumferential fusion with fib-
ular dowel graft and posterolateral graft with instrumentation
were discussed. After careful consideration, the patient chose
to undergo surgical treatment via a posterior approach.
The operation consisted of a posterior-only approach as
described above. The patient was placed into a prone posi-
tion upon the Jackson table, a percutaneous image-guided
antenna placed into the PSIS with sterile technique, intra-
operative scan acquired, and then prepped and draped in
sterile fashion. The standard midline incision was made,
deep dissection carried out to visualize the L4 to S1.
During placement of pedicle screws, it was felt that the L5
pedicles were neither accessible nor strong enough to provide
sufficient pedicle screw fixation. Therefore, the pedicle screw
instrumentation and subsequent graft material spanned the
distance of L4 to S1. A Gill laminectomy of L5 was performed,
and both L5 nerve roots were decompressed. Laminectomy of
S1 was carried out, and careful retraction of the left S1 nerve
root laterally and the dura medially was performed to visual-
ize the entry point for the guidewire. Sequential reaming was
carried out; a fibular dowel graft was fashioned and then
advanced through the prepared channel. This process was
then repeated on the contralateral side. Once the fibular
grafts were placed, decortication of the transverse processes
and sacral alae was performed. Care was taken to decorticate
the transverse processes of the L5 body so that they would be
included in the posterolateral fusion mass. Local autograft,
biphasic calcium phosphate, and BMP-2 were placed in the
lateral gutters. Hemostasis was obtained and the wound closed
in layers. Postoperative radiographs were obtained (Figs. 66.19
and 66.20). After surgery, hamstring tightness resolved. At 2
years after surgery, the graft has healed and the patient is now
competing in soccer at a national level (Figs. 66.21
to 66.23).

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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula 657

Figure 66.19. Final lateral radiograph of this posterior-only

approach circumferential fusion including instrumentation from
L4-S1 and fibular dowel graft.

Figure 66.17. Lateral radiograph depicting grade 4 slip character-

istics including a trapezoidal L5 body, domed sacrum, and kyphosis of
the lumbosacral junction.

Figure 66.18. Anteroposterior radiograph depicting the Napo-

leon Hat sign of this grade 4 slip.

Figure 66.20. Final anteroposterior radiograph of this posterior-

only approach circumferential fusion.

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 658 Section VI Spondylolisthesis

Figure 66.21. Lateral radiograph of circumferential fusion at Figure 66.22. Clinical picture at 2 years postoperatively; note
2 years postoperatively; note incorporation of fibular dowel graft in improvement in posture as compared with preoperative picture
interbody fusion mass (compared to Fig. 66.23). (Fig. 66.19).

Figure 66.23. JG participating in world-class competitive soccer match 2 years after surgery.

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 Chapter 66 High-Grade Spondylolisthesis: Posterior Decompression and Spanning/Dowel Fibula
CONCLUSIONS
This technique of driving a fibular strut allograft across the
disc of a high-grade spondylolisthesis at the lumbosacral junc-
tion to afford an interbody fusion in combination with poste-
rior instrumentation is a very successful strategy. Partial
reduction is obtained with specific attention to the sagittal slip
angle. This is the preferred method for the surgical treatment
of high-grade isthmic spondylolisthesis because of the very
high fusion rate, low L5 nerve root deficit rate, low incidence
of complications, and high patient satisfaction. This is also a
reasonable technique to use in a salvage situation where the
patient has already undergone surgical treatment for a high-
grade spondylolisthesis but failed due to nonunion and defor-
mity progression. This strategy is useful in adults as well as the
pediatric population. This procedure, however, requires a
Meyerding grade 3 or higher spondylolisthesis. If the slip is a
grade 2 or less then the trajectory of the fibular strut is very
difficult to achieve. The path of the strut graft in a high-grade
situation is perpendicular to the incision, as the slip becomes
less than grade 3; the course of the reamer becomes more par-
allel to the longitudinal axis of the patient. Grade 2 and less
deformity, however, allows application of more traditional
trapezoidal interbody grafts.
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