|Year : 2019 | Volume
| Issue : 2 | Page : 184-189
Modified three-stage Gaines procedure for symptomatic adult spondyloptosis
Charanjit Singh Dhillon, Mithun Jakkan, Narendra Reddy Medagam
Department of Spine Surgery, MIOT Hospitals, Chennai, Tamil Nadu, India
|Date of Web Publication||23-Jul-2019|
Dr. Charanjit Singh Dhillon
Flat 2083, Appaswamy Platina Apartments, 107 Mount-Poonamallee Road, Porur, Near Saravana Stores, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Spondyloptosis or complete anterior dislocation of the L5 vertebra over S1 is a rare clinical condition. In general, the surgical management of spondyloptosis includes either posterior long-segment in situ fusion (with total disregard for altered biomechanics) or restoration of lumbosacral kyphosis by reduction of spondyloptosis using multistaged procedures. Reduction is possible in spondyloptosis only after sacral dome osteotomy or L5 corpectomy with interbody fusion of L4 over S1 as described by Robert Gaines. We present the case of a 29 year old manual laborer who presented with complaints of severe low back pain and bilateral sciatica. He was diagnosed to have spondyloptosis of L5 over S1 with modified Newman's score of 10 + 10. The patient underwent three-staged modified Gaines procedure in the form of L5 corpectomy, reduction of L4 over S1 and interbody fusion between L4 and S1. The reduction was maintained at the end of 18 months and he was able to resume his job as a manual laborer.
Keywords: High-grade lytic spondylolisthesis, modified Gaines procedure, spondyloptosis
|How to cite this article:|
Dhillon CS, Jakkan M, Medagam NR. Modified three-stage Gaines procedure for symptomatic adult spondyloptosis. Indian Spine J 2019;2:184-9
| Introduction|| |
Spondylolisthesis is slippage of all or part of one vertebra forward on the other. Meyerding, an obstetrician, described four degrees of slip in spondylolisthesis according to the slip percentage. Grades III, IV, and V (spondyloptosis) are collectively classified as high-grade spondylolisthesis (HGS) with slip percentage of more than 50%., These comprise < 5% of total spondylolisthesis with spondyloptosis being very rare (<1%)., HGS responds poorly to conservative treatment, and the treatment of choice is often operative.,,,,,
Spondyloptosis is defined as a condition where L5 vertebral body is completely dislocated from the sacrum anteriorly., It was originally described by Neugebauer. Patients usually display classical symptoms of low back pain, stiffness with hamstring tightness with or without radicular symptoms, or cauda equina syndrome.,,,, In general, the surgical management of spondyloptosis includes either posterior long-segment in situ fixation and fusion, in situ instrumented delta fixation, partial reduction and fixation using pedicle screw-rod instrumentation, or reduction of spondyloptosis using multistaged procedures. Traditional treatment by in situ posterolateral arthrodesis totally disregards the lumbosacral kyphosis and the altered lumbosacral biomechanics and has been associated with pseudarthrosis rates up to 40%. Even with successful posterolateral fusion, the graft is in an unfavorable biomechanical environment, owing to it being under tension, which can allow for progression of lumbosacral kyphosis (slip angle) and sagittal translation (slip). Open reduction of spondyloptosis after L5 corpectomy (Gaines procedure) improves the biomechanical situation by reducing lumbosacral kyphosis and restoring lumbosacral lordosis but is associated with neurologic deficits in up to 90% of patients. We present our case of a manual laborer who was treated successfully by modified three-stage Gaines procedure.
| Case Report|| |
A 29-year-old male patient, manual laborer, presented to us with complaints of severe low back pain and bilateral sciatica. The low back pain was insidious in onset and gradually progressive. The pain worsened with all activities of daily living and improved partially with rest. He was unable to walk more than 500 m at a stretch due to pain. There was no history of trauma preceding the onset of his symptoms. The Oswestry Disability Index (ODI) score at the time of initial presentation was 70. He was given a trial of conservative management in the form of analgesics, corset, and activity modification for over 6 months. However, he did not have any significant relief.
On examination, the patient was unable to stand erect until he flexed his hips and knees. He had flattened buttocks, with severe hamstring tightness and a positive step sign. Neurological examination revealed sensory blunting in bilateral L4 and L5 dermatome (50%) and weakness in the right extensor hallucis longus (EHL) and right tibialis anterior (TA) muscle (power 3/5).
X-ray revealed spondyloptosis of L5 with the L5 superior end plate lying below the S1 superior end plate [Figure 1]. The L5 vertebra has not just translated forward and dropped into the pelvis but also rotated in the sagittal plane along transverse axis so that the inferior end plate of L5 was facing the anterior surface of S1 body. His modified Newman's score was 10 + 10 [Figure 2]. Magnetic resonance imaging scan showed compression of the dural sac at L5-S1 level with severe bilateral L5 neural foraminal compression. Computed tomography scan showed unsuccessful attempts at natural fusion between inferior end plate of L5 and anterior surface of S1 in the form of developing osteophytes [Figure 3]. Dynamic flexion and extension X-rays and traction X-rays showed no mobility at L5-S1 region.
|Figure 1: (a) Preoperative X-ray showing L5 superior end plate was lying below the S1 superior end plate. (b) Preoperative X-ray with sagittal pelvic parameter measurements|
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|Figure 2: (a) Modified Newman's Score- The degree of slip is measured by two numbers; one along the sacral endplate and another along the anterior portion of the sacrum. A = 3 + 0, B = 8 + 6, C = 10 +10. (b) Sagittal CT scan of the patient with Newman score 10 + 10. [Bridwell, K. (2011). The textbook of spinal surgery. Philadelphia u.a.: Lippincott.]|
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The patient was counseled regarding various options for treatment including nonsurgical management. The option of leaving the listhesis uncorrected with possibility of further worsening of neurological status was informed to the patient. Frank discussions regarding the morbidity of surgery and the technical difficulties in obtaining reduction of spondyloptosis along with the possibility of worsening the preexisting right TA muscle weakness to complete foot drop and the possibility of retrograde ejaculation following anterior surgery were discussed with the patient and his family in his native language. After thorough discussion with the patient and after fully understanding the pros and cons of operative procedure, he consented for surgery. A three-staged anterior-posterior-anterior intervention was planned for reduction of spondyloptosis in a single session of anesthesia.
During the first stage, anterior transperitoneal approach to L5 and S1 vertebrae was done through Pfannenstiel incision. Since this was our first case of Roberts Gaines procedure and since the L5 vertebra had descended deep into the pelvis, we anticipated greater mobilization of the aorta and the inferior vena cava would be required to effectively achieve complete L5 corpectomy. Hence, we decided to do transperitoneal approach instead of classical retroperitoneal approach. Major neurovascular structures were dissected and secured by blunt dissection with the help of vascular surgeon. L5 body was identified. Complete L5 corpectomy up to the base of pedicles was done along with excision of L4-L5 and L5-S1 disc. Completeness of corpectomy was confirmed intraoperatively with an image intensifier. Wound was closed temporarily in a single layer, and sterile dressings were applied.
In the second stage, with the patient in prone position, midline subperiosteal exposure of the spine was done from L2 to S2. Polyaxial pedicle screws of 6.5 mm (Legacy™, Medtronic, Minneapolis, USA) were inserted in L3 and L4 pedicles on either side. A sacral plate (Colorado™, Medtronic, Minneapolis, USA) with pedicle screws in S1 and alar screws in S2 was used to form the base of the distal construct. All screws were inserted under fluoroscopic guidance. Posterior elements of L4 and L5 were excised and bilateral L4 and L5 nerve roots were decompressed till they exited the neural foramina. Rods were firmly secured to sacral plate, and gradual reduction of L4 over S1 was achieved without undue tension on the roots. There were two roots exiting between the pedicles of L4 and S1, and the transforaminal space was inadequate to insert an interbody cage from posterior approach. Hence, it was decided to do interbody fusion through anterior approach to avoid excessive manipulation of the nerve roots. Wound was closed in layers after complete hemostasis.
In the third stage, anterior abdominal wound was reopened. The empty corpectomy space was reconstructed with an appropriate size Harms prototype cage contoured in lordosis and filled with bone graft [Figure 4]. Since there was a significant change in the sagittal alignment of the lumbosacral region, it was decided to fuse L3-L4 level to reduce the stress on L4-S1 construct. L3-L4 disc space was identified and curetted and fused with cages filled with bone graft. The position of cage was confirmed by an image intensifier. Stability of cages was checked intraoperatively. After complete hemostasis, wound was closed in layers over drain. Total duration of the surgery was 6 h, and blood loss was approximately 850 ml.
|Figure 4: (a and b) Postoperative X-ray anteroposterior and lateral view showing contoured Harms cage in the interbody space between L4 and S1 (c) Harms cage cut obliquely to attain 20° of lordosis|
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The patient was stable and withstood the surgical procedure without any hemodynamic complication. Nevertheless, the right EHL and right TA continued to remain weak in the immediate postoperative period (preoperative right EHL and TA muscle power was 3/5). This was in spite of inspection of L4 and L5 roots during the reduction maneuver to prevent any undue nerve root tension.
The patient was mobilized after 48 h with lumbar corset. He was instructed to walk with hips and knees slightly flexed for the first 1 month to reduce the traction on L4 and L5 nerve roots. Sutures were removed after the 12th postoperative day and the patient was discharged in stable condition. He was refrained from activities such as lifting weights, sitting cross legged, and bending forwards for up to 6 months.
On regular follow-up, his right EHL and TA power improved gradually over a period of 6 weeks, and he was able to walk comfortably up to 2 km by the end of 6 months. At 18 months followup, he had a significant symptomatic improvement with postoperative ODI score of 8. Radiology showed solid fusion with maintenance of sagittal balance [Figure 5]. He was able to return to his job as a manual laborer by 6 months [Figure 6].
|Figure 5: (a and b) Follow-up X-ray at 18 months' lateral and anteroposterior view showing complete fusion. (c) Follow-up X-ray at 18 months with sagittal pelvic parameter measurements|
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|Figure 6: Follow-up at 18 months postoperative showing spine range of movements and tibialis anterior muscle recovery|
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| Discussion|| |
Spondyloptosis or complete anterior dislocation of the L5 vertebral body over S1 is a rare clinical condition. The ideal method of treatment of this rare situation is still a subject of controversy. On one extreme are conservative surgeons who recommend posterior long-segment in situ fusion with no attempt at reduction,,, while on the other extreme are adventurous surgeons who recommend partial or complete reduction of spondyloptosis and correction of abnormal sagittal alignment with instrumentation.,,, Reduction of forward translation of L5 over S1 is possible in cases where lower end plate of L5 vertebra is at or above the level of superior end plate of S1 vertebra. In severe cases, reduction can also attempted by sacral dome osteotomy. However, in our case, L5 superior end plate was lying below superior end plate of S1 vertebra into the pelvis, so reduction with sacral dome osteotomy was technically difficult.
In 1985, Gaines and Nichols popularized a two-staged surgical technique for reduction of the spondyloptosis. In the first stage, L5 vertebral body was excised up to the base of pedicles. The second stage under separate anesthesia was performed after few days wherein the loose neural arch and pedicle of L5 were removed from posterior approach with gradual reduction and docking of L4 over S1 achieving bone-on-bone contact, stabilized by transpedicular instrumentation., Kalra et al. in 2010 reported a modified Gaines technique for case of spondyloptosis (a patient with modified Newman's criteria score of 10 + 6), where they performed partial L5 corpectomy and reduced the deformity. In our patient, the L5 vertebral body was displaced below the level of superior end plate of S1 with modified Newman's score of 10 + 10; hence, reduction by partial corpectomy of L5 vertebra was difficult.
We modified Gaines procedure into three stages. The first stage was similar to that described by Gaines., In the second stage, pedicle screws were inserted in L3 and L4. For sacral fixation, we deliberately used Colorado sacral plate with S1 sacral screw and S2 alar screw to use the combined strength of S1 pedicle and S2 alar screws to enhance distal fixation. L3 and L4 vertebral bodies were sequentially reduced to the distal sacral fixation. Due care was taken to observe the L4, L5, and S1 roots and to look for any tension on the nerve roots during reduction maneuver. In this case, we were able to achieve the complete reduction of L4 over S1 while maintaining lumbosacral lordosis.
In the third stage, we had to bridge the corpectomy defect as well as we had to maintain lumbosacral lordosis of around 20° that we had achieved in posterior reduction. Since there was no such commercially available cage, we used Harms prototype cage of appropriate size which was customized to required lordosis by cutting the cage obliquely around the circular lattice to achieve desired lordosis [Figure 4].
In classical Gaines procedure, the L4 vertebral body is directly docked onto the superior end plate of S1 achieving direct bone on bone fusion between L4 and S1 vertebral bodies. As a result, there is no lordosis between L4 and S1 vertebral bodies. Furthermore, in between L4 and S1 pedicles, there are two nerve roots (L4 and L5) exiting through the common foramina which are subject to overcrowding and compression since no cage is used between L4 and S1 vertebral bodies. In our case, we did not dock L4 vertebral body directly on S1 superior end plate but left considerable gap in between the two end plates to attain wider neural foraminal height. The gap was reconstructed with a 20° lordotic cage to restore lumbosacral lordosis thus ensuring better biomechanics at lumbosacral junction compared to classical Gaines procedure.
Foot drop is the most commonly reported complication in many studies, where reduction maneuver was performed.,,, Hu et al. in 1996 mentioned the rate of neurological complications of around 25% and complications such as root injury, cauda equina syndrome, and injury to hypogastric plexus during anterior procedure., In Gaines study, 23 out of 30 patients had a clinical deficit in L5 root following their reconstruction. However, 21 out of 23 patients in Gaines study having root deficits recovered fully from 6 weeks to 3 years following their reconstruction. According to Petraco et al., 71% of strain occurs on L5 nerve root in the second half of reduction maneuver in high-grade listhesis, and correction of the lumbosacral kyphosis may be protective for L5 nerve root.
Our patient already had EHL and TA weakness over the right side before surgery. The possibility of worsening of the neurology was discussed with the patient before surgery. In spite of close intraoperative monitoring for root tension, there was no improvement in TA and EHL strength in the immediate postoperative period. Nevertheless, over a period of 6 months, the patient recovered completely and was able to resume his work as a manual laborer. At the end of 18 months of follow-up, our patient recovered clinically with ODI score of 8 from 70. Radiological parameters were measured using picture archiving and communication system software, and these parameters showed improvement to acceptable level [Table 1].
| Conclusion|| |
The modified three-stage Gaines procedure is a powerful tool to correct the deformity, attain lumbosacral lordosis and achieve sound fusion in severe spondyloptosis. The use of a wedged interbody cage instead of direct bone on bone docking of L4 over S1 (vis a vis classical Gaines procedure) helps to reinstate lumbosacral lordosis. The cage also restores adequate space in the neural foramen between L4 and S1 pedicles where the two exiting roots L4 and L5 reside in the common lateral recess. Transient postoperative L4 and L5 root neuropraxia is a possibility, and the patient needs to be counseled preoperatively. Further experience with this technique will add to the repertoire of surgical options available for spondyloptosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]