Isthmic Spondylolisthesis:

Anterior vs Posterior Fusion

• Clinical Professor, University of
California, San Diego

•Medical Director, San Diego Center

for Spinal Disorders La Jolla, California

Behrooz A. Akbarnia, MD
 Isthmic Spondylolisthesis:
Anterior vs Posterior Fusion

Behrooz A. Akbarnia, MD
Clinical Professor, University of California, San Diego
Medical Director, San Diego Center for Spinal Disorders
La Jolla, California

Society for Progress and Innovations for the Near East (SPINE)
Beirut , Lebanon, June 23, 201
Disclosures

(a) DePuy Spine, Nuvasive, K2M

(b) DePuy Spine, Nuvasive, K2M
(c) Nuvasive, K2M

a. Grants/Research Support
b. Consultant
c. Stock/Shareholder
d. Speakers’ Bureau
e. Other Financial Support
Isthmic Spondylolisthesis:
Causes

 Repetitive
hyperextension
 Gymnasts, football
linemen, rugby
 Scheuermann
disease
 Spondylolisthesis
Myerding Classification

LOW
GRADE

HIGH
GRADE

V = Spondyloptosis
 Marchetti and Bartolozzi
1982

Developmental Acquired
Due to lysis Iatrogenic
Due to elongation Pathologic
Traumatic Degenerative
Acute fx
Stress fx
RB
 Key Management Issues

 Character of Symptoms
– Pain
– Neurological dysfunction
 Deformity
 Developemental or Aquired ?
– amount of dysplasia
 Adult or Pediatric ?
 Spondylolysis & Spondylolisthesis:
Treatment
Pediatric
 Up to 50% slip, asymptomatic: observe, consider
high risk athletic restriction if >25%
 Up to 50% slip, symptomatic: activity
modification, PT, bracing
 Greater than 50% slip: consider surgery
Spondylolysis & Spondylolisthesis:
Surgical Options
Pediatric
 In-situ Posterolateral Fusion
– ―Gold Standard‖ for low grade
 Direct Repair of the Pars
 Fibular strut grafting (Bohlman)
 Transsacral Fixation
 Reduction and fusion
 In Situ fusion

 Does in situ fusion leaves any

disability behind?
DR
DR
14 years Boy
CT 1/2009
Post OP
Comparison
• 81 patients all under 20 yo
• PLF uninstrumented
• 81% no pain
– 16% required occarional salicylates, 2%
occasional narcoticzs
• 91% participated in athletics
AS 16/F spondylolisthesis
 16 years old
Pre-op

Sacroplasty, wide decompression of nerve roots, monitoring

Follow up 48 mos
 Isthmic Spondylolisthesis:
Nonoperative Treatment
Adults
 NSAIDs
 Pain Management
 Physical Therapy
 Weight loss
 ESI, facet injections
 Bracing (comfort, not for healing)

Most patients improve within 3 months

 Indications for Surgery
Adults

 Severe back/leg pain

 Progressive neurologic deficit
 Progression
 Cauda equina
 Cosmesis
 Surgical Options
Adults
 Direct repair of the pars
 Decompression alone (Gill Laminectomy)
 Decompression with in situ fusion
+/- instrumentation
 Interbody fusion and fixation
 Reduction and fixation
 Vertebrectomy
 Decompression alone
• Decompression alone is not indicated in
pediatric and adolescent patients
– Gill et al reported good early results with
decompression alone
• Gill et al. JBJS Am 1955
– Several authors later reported high rate of slip
progression and unsatisfactory results
• Osterman et al. CORR 1976
• Marmor et al. JBJS Am 1961
• Considered a possibility in elderly with
comordities
 Posterolateral fusion

 Gold standard
 Pediatric and adolescent
– Fusion rates >90%
– 75-100% good to excellent results
 Adults
– Fusion rates variable
– 33-100%
– Is it the Gold standard in adults??????
 Posterolateral fusion
• ―Fusion disease‖ – stripping paraspinal musculature
• Does not address anterior column
• Can continue to have discogenic pain
• Barrick et al.
– Pts had back pain despite solid PLF
– Improved with ALIF
• L’Heareaux et al. and La Rosa et al.
– Correction of slip angle lost over time because of disc
space collapse despite solid PLF
 Posterolateral fusion
 Instrumentation not proven to improve
results
 McGuire and Admundson Spine 1993
– 78% fusion with instrumentation
– 72% fusion without instrumentation
 Moller and Hedlund Spine 2000
– 65% fusion with
– 78% fusion without
– No difference in clinical outcome
Plain Radiographs
MRI
L4
S1
 Anterior Lumbar Interbody
Fusion
 Discectomy helps to correct slip angle
 Bone graft in compressive environment –
optimal for fusion
 Avoids stripping of paraspinal muscles
– Vessel, bowel, retrograde ejaculation
 Indirect decompression
– Direct decompression not possible
 Anterior Lumbar Interbody
Fusion
 Ishihara et al J Spinal Disord 2001
– Minimum 10 year follow up
– 83% fusion rate
 Van Rens and van Horn Acta Orthop Scand
1982
– 90% fusion rate
 Anterior and Posterior Fusion
• ALIF and PSF (360˚)
• TLIF
• PLIF

• Promote higher fusion rates

• Combines all benefits of ALIF with benefits
from PLF
• Longer operaterative times
• More complications
 A.H.

 44 yo Female
– Back pain since high-school
– Managed with activity self-regulation
 Now, increasing pain frequency/duration

 decreasing pain free periods

– Last 1 yr—also c/o RLE pain/numbness

 Which approach is better?
• Kwon et al. J Spinal Disord Tech 2005
• ―A critical analysis of the literature regarding
surgical approach and outcome for adult low-
grade isthmic spondylolisthesis‖
• 4 of 34 reports were prospective randomized
• Combine A/P (PLIF, TLIF or 360˚) fusions
better results
– Fusion rate
• 98% (A/P) vs 75% (ALIF) vs 83% (PLF)
– Cinically ―Successful‖
• 86 % (A/P) vs 79% (ALIF) vs 74% (PLF)
 ALIF vs PLIF/TLIF
• Kim et al. J Spinal Disord Tech 2009 – ―Mini-
transforaminal lumbar interbody fusion versus
anterior lumbar interbody fusion augmented by
percutaneous pedicle screw fixation: a
comparison of surgical outcomes in adult low-
grade isthmic spondylolisthesis‖ (2 year follow
up)
– ALIF vs TLIF - Fusion 95% vs 92%, clinical outcomes
similar
– ALIF significant difference – pre to post disc height,
segmental lordosis, whole lumbar lordosis
– Could potentially see clinical differences long term with
improved lordosis at instrumented levels (i.e. ASD, sag
balance)
 Coclusions
 Outcomes are significantly different between
pediatric and adult groups
 Good long term outcomes can be expected with
posterior approach in most pediatric and many
adults
 Anterior approach allows better fusion rate and
may be better correction
 Anterior and posterior approach may allow the
best alignment and fusion but carries higher risks
Thank you