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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 77-88

Complications in spondylolisthesis surgery: Common, uncommon, and rare

Department of Spine Surgery, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission21-Aug-2020
Date of Decision21-Dec-2020
Date of Acceptance30-Dec-2020
Date of Web Publication28-Jan-2021

Correspondence Address:
Sameer Ruparel
Department of Spine Surgery, Jaslok Hospital and Research Centre, 15, Pedder Rd, IT Colony, Tardeo, Mumbai, Maharashtra.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ISJ.ISJ_71_20

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Spondylolisthesis is a common pathological condition caused due to numerous etiologies in young and old alike. The forward slippage of one vertebra over the other alters the biomechanics to an extent that can result in various postoperative complications. The most common complications reported are pseudoarthrosis, neurological deficits, and transitional syndrome. The rate of pseudoarthrosis varies based on etiology as well as various intraoperative factors. The authors reviewed the literature for the varying incidence rates and suggest principles of reduction and fusion based on evidence and experience. Similarly, neurological complications are a common occurrence postoperatively particularly in the treatment of high-grade slips. Percentage of reduction of slips, slip angle, and traction injury to nerve roots tend to have a complex interaction leading to neurological injuries. The authors try to decipher this co-relation based on literature. Though most neurological issues have been found reversible, recent innovations like intraoperative neuromonitoring tend to decrease its incidence even further. The development of transition syndrome is an enigma in itself. Whether increased stresses at adjacent levels are due to fusion or a part of an ongoing degenerative process is yet to be understood. On the basis of case examples, the authors suggest recommendations to avoid them. Finally, minimally invasive spine surgeries (MISS) are now being used to treat spondylolisthesis. The authors reviewed comparative studies between open and MISS and found similar complication rates between them with regards to low-grade slips with a word of caution to treat high-grade listhesis with minimally invasive surgery techniques. Last but not the least, a few unusual and rare complications have been enlisted with case examples and learning points. This manuscript aims at reviewing the common, uncommon, and rare complications of treating cases of spondylolisthesis along with enlisting the principles to avoid and treat them in day to day practice.

Keywords: Complications, neurological complications, pseudoarthrosis, spondylolisthesis, transitional syndrome

How to cite this article:
Ruparel S, Chaddha R. Complications in spondylolisthesis surgery: Common, uncommon, and rare. Indian Spine J 2021;4:77-88

How to cite this URL:
Ruparel S, Chaddha R. Complications in spondylolisthesis surgery: Common, uncommon, and rare. Indian Spine J [serial online] 2021 [cited 2021 May 12];4:77-88. Available from: https://www.isjonline.com/text.asp?2021/4/1/77/308208

  Introduction Top

Spondylolisthesis is a common pathological condition affecting young and old alike. In the young, it may occur due to dysplasia or defect in the pars interarticularis. However, in adults, it may be due to a defect in the pars, degenerative, traumatic, or pathological issues.[1],[2] Since the center of gravity of the human body is anterior to the lumbosacral junction, there is a tendency of slippage of one vertebra over the other. This may be asymptomatic or symptomatic causing mechanical back pain and/or neurological compression. Surgical intervention with reduction of slip, correction of deformity along with decompression and fusion form the standard of care when conservative treatment fails. The complex steps and caveats of surgery along with altered biomechanics of the pathology are responsible for numerous adverse events and complications. These complications may be usual, unusual, and rare. The incidence of complications varies widely in literature and depends upon numerous factors like the pathology of spondylolisthesis, its grade, type of fusion, bone graft material used, and the likes. In a large study conducted by Sansur et al.[3] encompassing 10,242 adults with spondylolisthesis, they found the overall complication rate to be 9.2%. They also reported complication rate to be higher in patients with high-grade spondylolisthesis [Table 1]. On the basis of the Scoliosis Research Society summary statement on spondylolisthesis published in 2005 by Ogilvie et al.,[4] the usual complications may be pseudoarthrosis, neurological complications, or transition syndrome. In a large meta-analysis done by Kwon et al.[5] which included 35 studies encompassing 900 patients, they found pseudoarthrosis rates ranging from 1.8% to 24.7% based on the type of surgery performed. In a study by De Wald et al.[6] for the management of adult high-grade spondylolisthesis, they documented neurological abnormalities in nine of their 20 patients postoperatively, out of which six recovered along with one instrumentation failure. Similarly, the rates of adjacent segment degeneration have been reported to be as high as 35%.[7] Some of these complications may be early (neurological) or late (pseudoarthrosis and transition syndrome) and these along with their management have been described in detail in subsequent sections. Minimally invasive spine surgeries (MISS) are being increasingly used to treat spondylolisthesis today. The challenges faced in treating spondylolisthesis primarily and their surgical complications are altogether different. The variations in symptomatology, surgical techniques, and complications raise a few questions. How to prevent such complications and what are the ways to tackle them? This manuscript focuses on usual, unusual, and rare complications of surgical intervention for spondylolisthesis and suggests principles to treat and prevent them.
Table 1: Summary of important review articles particularly with patients of high-grade spondylolisthesis

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  Usual Complications Top


Pseudoarthrosis is one of the commonest complications of spondylolisthesis surgery.[8] There is a huge discrepancy in literature with regards to nonunion rates ranging from 0 to 39%.[9],[10],[11] The reasons for this are numerous. For example, isthmic spondylolisthesis has a higher incidence of pseudoarthrosis than its degenerative counterpart.[8] In addition, the incidence of pseudoarthrosis also depends on the grade of slip, type of fusion surgery performed, and various patient dependent factors like smoking, obesity, etc.[12],[13] Only a handful of these may be symptomatic which may be the cause of decreased reported incidence in a few studies.

In spondylolisthesis, the slip of one vertebra over the other causes a drastic change in mechanics which ultimately affects the biology of fusion. Though excellent/good outcomes have been reported in patients undergoing decompression without fusion for both degenerative[14] and lytic spondylolisthesis,[15] long-term studies have shown statistically significant progression of slips[16] with chances of revision surgery in the range of 10%.[17] Since fusion surgery is more morbid, the authors recommend decompression without fusion only in the select elderly population with predominant leg pain, collapsed disc space, and stable radiographs. Thus, fusion remains the treatment of choice in most cases of spondylolisthesis. This has been echoed in numerous studies.[18],[19] Similarly, segmental instrumentation has been shown to produce a more solid arthrodesis than an un-instrumented one. In a large multicentric study of 2684 patients with spondylolisthesis, radiographic fusion was noted in 89% of patients with pedicle screw fixation as compared to 70% of those without instrumentation.[20] The authors support the use of instrumented fusion to reduce the rates of pseudoarthrosis. In cases where reduction is attempted or disc distraction is done, interbody fusion is advised to reduce the strain on the posterior construct. Reduction is recommended in cases with sagittal imbalance and those with high slip angles (>45°) as they provide a conducive environment for fusion.[21],[22] Adding an anterior interbody fusion support also increases the likelihood of fusion, provides indirect foraminal decompression, better lordosis, and good reduction.[23],[24] The authors recommend its use for isthmic spondylolisthesis, although it has been advocated in degenerative pathologies also.[23],[24] However, in cases when an in situ fusion is planned, an extension of fusion mass to L4 is advised to counteract the shear forces at the lumbosacral junction.[25] Surgeons must be watchful in patients with high-grade slips requiring wide decompression, patients with excessive mobility at L5-S1 junction, hypoplastic transverse processes, and sacral malformations as they are more prone to develop pseudoarthrosis. All in all, the instrumentation does not guarantee fusion, and fusion is not directly related to satisfactory outcomes. However, better fusion rates correlate to better functional outcomes.[26],[27] One must always keep in mind paying meticulous attention to the basics of bone fusion providing adequate immobility by stabilization, anatomical realignment, viable bed for fusion, and osteoinductive or osteoconductive source of graft material.

Neurological complications

One of the most dreaded complications after spine surgery is neurological worsening or paralysis. The incidence of neurological issues after posterior lumbar decompression and instrumented fusion surgery in cases of spondylolisthesis may be as high as 45%.[6] The logical explanation may lie in its pathology, i.e., forward slippage of one vertebra over the other. It is still unclear whether the dynamics of attempted reduction is responsible for this. According to the 2003 Scoliosis Research Society mortality and morbidity report, the fairly stabilized incidence of neurological deficits over the years increased due to greater attempts at reduction by spine surgeons, particularly with lytic spondylolisthesis.[28] This may be due to the fact that degenerative pathologies have lesser degrees of slip than their lytic counterparts due to their inherent tendency to auto-stabilize. Similarly, it has been shown in laboratory studies that the strain on the L5 nerve root is nonlinear during reduction with a small amount in the first 50% and remaining 50% reduction resulting in 71% of strain.[29] The L5 nerve root is also the most commonly affected in clinical practice.[30] Thus, greater slips with larger attempts of reduction might be one of the causes of increased neurological deficits in such cases. However, one cannot turn a blind eye to the benefits of reduction. Reduction helps in indirect neural decompression, restoration of sagittal alignment, and in addition, facilitates arthrodesis.[31] The authors have a balanced approach with attempts at reduction. They respect the proven fact that it is the correction of the slip angle rather than the percentage of translation that is important in restoring sagittal balance.[21] The authors recommend a partial reduction in presence of dynamic instability and sagittal imbalance for reversal of lumbosacral kyphosis. However, whether or not decompression plays a role in reducing these deficits is still an enigma. Kasliwal et al. did not find any association between the development of neurological deficit and performance of direct decompression.[32] This may be because the exiting nerve root rather than the traversing one is usually compressed in high-grade spondylolisthesis. Hence, the authors recommend an interbody fusion construct for the restoration of foraminal height and prevention of pseudoarthrosis in cases where reduction is attempted. Authors usually perform decompression in patients having neurological symptoms and signs preoperatively. They completely expose the exiting nerve roots beyond the foramen which permits its thorough visualization at all times during the surgery especially during reduction. Contrary to the staggering rates of neurological complications, a large number of these have been found to be reversible supporting that most of these injuries may be neuropraxic and strain related. Dewald et al.[6] found 90% of neurological issues resolved without active intervention in their cohort of postoperative spondylolisthesis patients. Similar results were found by Kasliwal et al.[32] These neuropraxic injuries are very well recognized with the help of intraoperative neuromonitoring. This technique has been found to be effective in reducing the incidence of neurological complications.[33] The authors frequently use neuromonitoring in cases of high-grade spondylolisthesis which also serves as a useful guide as to the amount of reduction to be attempted. For example, in a patient of high-grade spondylolytic spondylolisthesis [Case 1, [Figure 1]A] operated with TLIF [Figure 1]B, neuromonitoring was used which helped detect neuropraxic injury to the opposite nerve root during the final steps of cage compression [Figure 1]C. The compression was relieved and the signals returned to baseline. This is an important example since in such high-grade slips patients often complain of opposite side radicular pain after surgery, especially in cases of TLIF where unilateral facetectomy is done.
Figure 1: Case 1. (A) Preoperative X-rays AP, lateral, and dynamic showing spondylolytic spondylolisthesis. (B) Postoperative X-ray—AP and Lat—TLIF. (C) Baseline and altered neuromonitoring signals during cage compression

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Transition syndrome

Every aspect and technique of spine surgery has its advantages and disadvantages. For example, when a fusion surgery is done, there are chances of pseudoarthrosis as described above. At the same time, it has been postulated that a solid fusion increases the stresses on adjacent segments which may cause spondylolisthesis acquista or transition syndrome. Kinematic studies have shown increased disc degeneration, more stress, hypertrophy of facet joints, and hypermobility at the levels adjacent to fusion.[34] In a retrospective long-term follow-up study of 36 patients with degenerative spondylolisthesis operated with instrumented fusion, it was noted that 5 (13.89%) patients had symptomatic adjacent segment degeneration (ASD), while other 7 (19.4%) had asymptomatic radiographic ASD at the end of 6.5 years.[35] Spine surgeons across the world have not been able to decipher yet as to whether ASD is caused due to surgical intervention or as a part of the ongoing degenerative process. With this in mind, it has been recommended that in young patients with pars defect and no-slip or disc degeneration, pars repair should ideally be performed. This is thought to preserve the motion segment and thus adjacent segment stresses. This theory has also prompted the use of motion sparing technology as an effective alternative to fusion.[36] Though early results showed clinical improvement, conclusive long-term follow-up results are pending. On the contrary, Schlenzka et al.[37] found in a group of patients that the rates of ASD were the same in patients treated with pars repair or posterior–lateral fusion. Similarly, Seitsalo et al.[38] found the rates of ASD to be the same in patients operated with postero-lateral fusion or conservatively treated, thus supporting that this phenomenon may not be caused purely due to abnormal stresses after the intervention.[39] Irrespective of either theory, the authors feel the goal should be to leave as many lumbar levels unfused. Strict vigilance as to not damage the adjacent facet capsule during pedicle instrumentation is recommended as this has been shown to increase adjacent segment motion.[40] Care must be taken to maintain the integrity of pars interarticularis while performing isolated decompression at an adjacent level to fusion. Last but not the least, restoration of mechanical alignment, lumbar lordosis, slip angle, and a reduction might go a long way to reduce shear stresses across the fused and adjacent segments.

  Minimally Invasive Spine Surgery (MISS) Top

Achieving optimum surgical outcome with minimum collateral damage forms the basis of MISS. The advantages of MISS like reduced blood loss, early ambulation, shorter length of hospital stay, and better pain relief have been documented in numerous studies.[41],[42] However, the utility of MISS in spondylolisthesis surgery deserves special attention due to altered biomechanics. MISS has several advantages that may prevent ASD like preservation of posterior tension band, contralateral facet joint, and less injury to ipsilateral paraspinal musculature. Systematic reviews[43],[44] comparing open vs minimally invasive surgery (MIS) TLIF (transforaminal lumbar interbody fusion) for low-grade spondylolisthesis did not find any statistically significant difference in clinical/ radiological outcomes, complications, and re-operation rates. Also, comparative studies between isthmic and degenerative spondylolisthesis have shown nonsignificant differences in disc height restoration, slip reduction, complication, and fusion rates[45] when either pathology were operated with MISS. A 5-year follow-up study[46] of patients with low-grade spondylolisthesis operated with MIS TLIF showed 81% fusion rates and 6% of patients required intervention at adjacent levels due to transition syndrome. There were no cases of instrumentation failure. All the above studies include only low-grade slips. Grade I or II slips are usually suitable for MISS but high-grade slips can be technically challenging. There is a scarcity of literature for patients with high-grade spondylolisthesis treated with MISS. Initial reports have shown good clinical and radiological outcomes.[47] However, more studies are required to conclusively lay down complication rates in such cases. With limited experience in the treatment of high-grade slips with MIS approach authors advise that it is necessary to increase foraminal dimensions by augmenting disc height and inserting a large interbody cage, thus increasing the space available for fusion. Similarly, pedicle screws with reduction extenders can pull the proximal pedicle screws by seating the connecting rod into the tulip without causing excessive strain on implants.

Additional complications associated with MIS techniques need special attention like the increased learning curve and radiation exposure.[48],[49] This is because insertion of percutaneous pedicle screws though considered safe[50],[51] lack anatomic landmarks. Rarely, during percutaneous pedicle screw placement, the guidewire may advance through the anterior wall of the vertebral body where it might cause vascular or visceral injury. Mobbs et al.[52] reported 7 guidewire breaches of the anterior vertebral body in a retrospective series of 525 percutaneous pedicle screw (PPS) insertions. Authors recommend constant monitoring under C-arm guidance and the help of an able assistant surgeon to hold and keep a check on guidewire, especially during tapping when it tends to migrate anteriorly. Apart from these, following general principles of percutaneous screw placement like having a true anteroposterior (AP) and lateral images is a must especially in cases of spondylolytic spondylolisthesis having dysplastic anatomy. Similarly, increased superior facet joint violations have been noted with MISS.[53] This may increase the chances of ASD. We hope with recent innovations like computer-assisted navigation techniques and robotics these rates should be significantly less. The use of navigation techniques for spondylolisthesis have also shown comparable outcomes[54] with additional benefits of decreased operative times and radiation doses. Thus authors find complication rates of MISS for the treatment of low-grade slips comparable to conventional techniques and advocate its use routinely in such cases. However, surgeries for high-grade slips must be attempted only after developing enough experience and expertise. Authors feel, just like other pathologies, MISS techniques have an ever-expanding role in the treatment of spondylolisthesis.

  Unusual and Rare Complications Top

As mentioned above, one of the most common complications of spondylolisthesis surgery is pseudoarthrosis. Though most of them are asymptomatic, some may cause gross biomechanical failures. It has been rightly said, there exists a race between biology and metallurgy. Asymptomatic pseudoarthrosis does not warrant treatment apart from watchful observation. Failure of fusion may cause the failure of mechanical constructs with loosening and breakage of screws, loss of reduction, and migration of interbody cages with or without neurological compromise. Revision surgeries are usually warranted in nonunions causing mechanical back pain or neurological compromise. This is illustrated in the following unusual cases. Case 2 was a patient operated for spondylolytic spondylolisthesis [Figure 2]A with TLIF [Figure 2]B. Interval X-ray showed migration of the cage and loosening of the rod on one side [Figure 2]C coincident with the development of neurological signs and symptoms. Revision surgery was done with the removal of the interbody cage. Final X-rays showed good fusion with the maintenance of reduction [Figure 2]D. Contrary to this an elderly gentleman was operated with degenerative spondylolisthesis L4-5 [Case 3, [Figure 3]A] with TLIF [Figure 3]B. Interval X-ray showed progressive migration of cage [Figure 3]C but without any neurological issues. Since the patient was asymptomatic, after thorough counseling, no revision surgery was undertaken and watchful observation was planned. Loss of reduction is a complex problem that results from shear forces being placed across the instrumented segment.[55] The bodyweight acts as a vertical load creating a shearing moment that is generated and results in local kyphosis and anterior translation. The rigid instruments/implants minimize these forces until they finally may fail due to pseudoarthrosis. In the author’s experience, most common failures occur at the S1 screws. The reasons for this may be numerous. L5-S1 is the most common level affected by isthmic spondylolisthesis[56] which in turn is more prone for high-grade slips and non-fusions. Failure to have a tricortical/ bicortical S1 pedicle fixation might contribute to the suboptimal purchase. At the same time, one must keep in mind that a bicortical S1 screw which is not medial enough can cause L5 nerve root injury on the anterior aspect especially in the case where screw insertion is difficult because of overlapping soft tissue relevant to cases of spondylolisthesis.[57] A recent study conducted[58] showed these laterally placed screws causing injury can be reliably picked up with intraoperative neuromonitoring. It is necessary to pay meticulous attention to the optimum placement of S1 screws. Case 4 was a patient operated elsewhere for spondylotic spondylolisthesis with TLIF [Figure 4]A. Interval x-rays showed broken, loose screws with loss of reduction [Figure 4]B. Revision surgery was undertaken with the replacement of screws with larger, longer implants and extension of fusion [Figure 4]C. Eventually, fusion was achieved, however, final X-rays showed a broken S1 screw [Figure 4]D. This may happen due to solid fusion causing micromotion at the screw bone interface. Since the patient was asymptomatic the broken screw was left in situ. Broken implants after solid fusion were also seen in one more patient (Case 5) operated for spondylolisthesis [Figure 5]A with TLIF [Figure 5]B. Bilateral rods were found severed at identical points [Figure 5]C with good fusion achieved. Since the patient was asymptomatic, no intervention was planned. Irrespective of the cause it is necessary to pay meticulous attention to all factors contributing to or for prevention of pseudoarthrosis during the index surgery. In cases of failure, techniques for more extensive fusion and rigid instrumentation are called for. Apart from following the general principles to achieve fusion, authors usually resort to one or more of the following principles during such failures. These include adopting a different surgical approach, excising all dead tissue, conversion to circumferential fusion, the addition of more rigid instrumentation, and spinal realignment with the use of more efficient graft material. Recently, BMPs—rhBMP-2 and rhBMP-7—have been available and are considered to be osteoinductive with high osteogenic potential. Various studies have shown good evidence with high fusion rates using rhBMP-2 which is comparable to autograft.[59] However, the use of BMP has been controversial with potential complications (osteolysis, excessive new bone formation, risk of cancer, etc.) raising safety concerns with the use of BMP in clinical practice.[60],[61] From a general perspective, in cases of pseudoarthrosis after un-instrumented fusion, this can be managed with the postero-lateral/ posterior interbody fusion technique. Those failing after instrumented fusion are revised with the addition of interbody support. Loose and broken implants are removed and replaced with larger diameter screws and sometimes extension of fusion levels as illustrated in case 6. This was a patient who was operated with L4-5 TLIF for degenerative spondylolisthesis [Figure 6]A, [B]. Interval x-rays showed loss of reduction and loosening of screws [Figure 6]C. CT scan showed the lateral placement of the superior left screw [Figure 6]D. The screw was revised and fusion was extended above for better fixation. Follow-up X-rays showed good fusion [Figure 6]E. This case emphasizes the need for proper instrumentation and thus prevent pseudoarthrosis. The most challenging ones are those which have failed after circumferential constructs. A new approach like anterior lumbar interbody fusion (ALIF) may be helpful. Extension of fusion along with the addition of iliac screws strengthens the construct. Iliac screws are also recommended in cases of broken S1 screws with the substantial progression of failed lytic spondylolisthesis to high-grade slips. It is very much necessary to restore the sagittal alignment in these revision surgeries. Apart from broken screws and implants, there have been unusual instances of bone graft migrations leading to the bowel and visceral injuries. Garg et al.[62] reported sigmoid colon perforation after transforaminal lumbar interbody fusion (TLIF) as early as 4 days. They suspected a preoperative rent in the annulus which may have led to the migration of bone spicules causing perforation on retrospective analysis. They suggested certain factors that can potentiate such incidents like insecure placement, segmental instability, annular tears, damage to the anterior longitudinal ligament, excessive disc resorption, and curettage of disc material which are very much pertinent in cases of high-grade spondylolisthesis.
Figure 2: Case 2. (A) Preoperative X-rays AP, Lat, and dynamic showing spondylolytic spondylolisthesis. (B) Postoperative X-ray—AP and Lat—TLIF. (C) Interval X-ray AP and Lat cage migration and loosening of the rod on one side. (D) Final X-rays AP and Lat after revision surgery showing good fusion

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Figure 3: Case 3. (A) Preoperative X-rays AP and Lat showing L4-5 spondylolisthesis. (B) Postoperative X-ray—AP and Lat—TLIF. (C) Interval X-ray AP and Lat showing migration of cage

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Figure 4: Case 4. (A) Postoperative X-ray (AP and Lat) showing L4-5 TLIF. (B) Interval X-ray AP and Lat (dynamic) showing loosening of implants and loss of reduction. (C) Revision surgery performed. Postoperative X-ray (AP and Lat) showing the placement of larger screws with an extension of fusion. (D) Final X-rays (AP and Lat) showing good fusion with broken S1 screw

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Figure 5: Case 5. (A) Preoperative X-rays AP and Lat. (B) Postoperative X-rays AP and Lat. (C) Final X-rays AP and Lat showing good fusion with broken rods

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Figure 6: Case 6. (A) Preoperative AP and Lat X-rays showing L4-5 degenerative spondylolisthesis. (B) Postoperative X-rays AP and Lat. (C) Interval X-ray AP and Lat showing loosening of screws and loss of reduction. (D) Computerized tomography (CT) scan showing laterally placed screw. (E) Final X-rays AP and Lat after revision surgery and extension of fusion

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The senior author in his vast experience over the decades also shares some rare complications in the case illustrations below. Since these are rare, not much literature is available. Most of these need to be tackled on a case to case basis with falling back on basic principles from time to time.

  • Case 7: A case of degenerative mobile spondylolisthesis [Figure 7]A without neurological deficit was operated with L4-5 TLIF [Figure 7]B. The patient who was neurologically preserved postoperatively suddenly developed foot drop two and half months after surgery. At this time, the patient had no local or constitutional symptoms what so ever. The patient was admitted and Magnetic resonance imaging (MRI) was performed. It showed a suspicious foreign body or septic focus [Figure 7]C. Retrospectively also, there were no constitutional symptoms, and the wound had healed well under cover of antibiotics at 2 weeks postoperatively. The patient was immediately taken up for revision and a retained gauze piece was found and removed. Since no signs of infection/loosening of implants were found, they were retained after a thorough wash. The patient fused well at follow-up and took eight months for complete neurological recovery. In cases of spondylolisthesis, particularly in high-grade slips, there is a need to dissect far laterally which are packed by roller gauze. Authors recommend more than one count must be maintained during surgery and roller gauze must never be cut, since, if cut, the count becomes spurious. The roller gauze should always have a radio-opaque marker which can be picked up on check X-rays. As per senior authors’ experience, these are extremely rare circumstances and the above is a rather atypical clinical presentation of gossypiboma or textiloma.

  • Case 8: This is a case of transition syndrome where all causes and modalities of treatment can be learned. This was an elderly man with two-level stenosis L3-4 and L4-5 with a collapsed disc space and mobile spondylolisthesis at L4-5. The patient was operated with decompression L3-5, TLIF at L4-5, and soft stabilization with flexible rods at L3-4 [Figure 8]A. In spite of this patient developed ASD at L2-3 and revision surgery was done with rigid stabilization and decompression from L2-5 [Figure 8]B. Later, the same patient, unfortunately, developed a disc prolapse at L1-2 causing cauda equina syndrome for which third surgery was done [Figure 8]C and fusion extended to D10. A year later, collapse of adjacent D9 vertebra with cord compression was seen despite 2 years of anti-osteoporotic treatment with teriparatide. Two more revision surgeries [Figure 8]D and [E] were taken up due to Proximal Junctional Kyphosis (PJK) and construct extended to D1 and strengthened with sublaminar wires. This was a case where all causes of ASD like adjacent disc prolapse, screw back out with proximal junctional kyphosis, and vertebral body collapse were seen together despite using the adequate anti-osteoporotic treatment and soft stabilization techniques. These cases teach us that there is no fixed algorithm to treat complications and we can face such rare circumstances despite following standard treatment principles.
Figure 7: Case 7. (A) Preoperative X-rays AP, Lat, and dynamic showing spondylolisthesis. (B) Postoperative X-rays AP and Lat. (C) Postoperative MRI showing retained foreign body

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Figure 8: Case 8. (A) Preoperative X-rays, MRI, and postoperative X-rays of the first surgery. (B) Preoperative X-rays, MRI, and postoperative X-rays of the second surgery. (C) Preoperative X-rays, MRI, and postoperative X-rays of a third surgery. (D) Preoperative X-rays, MRI, and postoperative X-rays of fourth surgery. (E) Pre- and postoperative X-rays of fifth surgery

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  Conclusion Top

The biomechanics of spondylolisthesis are different from other lumbar degenerative pathologies which modify the principles of fixation and fusion. Complications like pseudoarthrosis, neurological deterioration, and transition syndromes may occur. Advances in modern medicine like interbody fusion techniques, neuromonitoring, and osteobiologics help to reduce their incidence. Failed constructs require revisions with rigid instrumentation and extensive fusion. While facing unusual and rare complications, the basic principles of biology and mechanics form the pillars of success for better patient outcomes.[64]

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  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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