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  • Efficacy of Transsacral Instrumentation for High-grade L5-S1 Spondylolisthesis: A Systematic Review of the Literature

    Final Number:

    Rima Sestokas Rindler MD; Brandon Andrew Miller MD PhD; Daniel Refai MD; Faiz U. Ahmad MD, MCh

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: High-grade L5-S1 spondylolisthesis is challenging to treat, with no standard recommended operative technique. The authors performed a systematic review of the literature to evaluate efficacy and safety of modern transsacral instrumentation techniques for high-grade L5-S1 spondylolisthesis. An example from their institution is provided.

    Methods: A systematic PubMED search adherent to PRISMA guidelines included relevant clinical studies (English, 1980-2015) reporting transsacral instrumentation for high-grade spondylolisthesis in adult humans. Available data on clinical and radiographic outcomes for individual patients were abstracted.

    Results: Nine of 311 studies reported a total of 38 patients (mean 32.9 years; range 18-66) treated with transsacral instrumentation. Cages (6 articles, n=23), screws (2 articles, n=12) and rods (1 article, n=3) were used. Posterior (86.8%) and combined anterior-posterior approaches were used, both with (55.2%) and without decompression, partial reduction (23.7%), posterior pedicle screw fixation (94.7%) and adjacent level inter-body fusion (42.1%). Four patients (10.5%) had a total of 6 complications (vascular, neurologic, infectious, or thrombotic), one of whom required a second operation. Mean follow-up time was 30.1 months (range 2-58; n=37). All studies with outcomes reported at least some improvement in pain in all patients (n=32) and at least average function post-operatively (94.7%; n=33/35). All reported patients had adequate fusion on follow-up imaging (n=34) and no progression of slip (n=32). Case Illustration: A 31-year-old woman with Grade IV L5-S1 spondylolisthesis presented with back pain, L5 radiculopathy, saddle anesthesia and urinary retention. She underwent L5-S2 laminectomies, L4-L5-S1-iliac instrumented fusion and L5-S1 transsacral interbody cage placement without perioperative complications. Her numbness and radiculopathy improved. Adequate bony fusion without slip progression was achieved.

    Conclusions: Operative techniques for managing high-grade L5-S1 spondylolisthesis are evolving. In this systematic review, modern transsacral instrumentation resulted in good clinical outcome and fusion rates, and acceptably high complication rates. Risks and benefits should be individualized for each patient.

    Patient Care: This systematic review provides neurosurgeons with synthesized evidence from the primary literature regarding the safety and efficacy of transsacral instrumentation for patients with high-grade L5-S1 spondylolisthesis that has not previously been explored in detail.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe various operative techniques for treating high-grade L5-S1 spondylolisthesis using modern transsacral instrumentation 2) Evaluate the safety and efficacy of transsacral instrumentation in L5-S1 spondylolisthesis in the adult population.

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