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 Table of Contents  
SPINE CLINIC
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 89-98

The spine clinics: Spondylolisthesis


Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Date of Submission01-Oct-2020
Date of Decision27-Dec-2020
Date of Acceptance03-Jan-2021
Date of Web Publication28-Jan-2021

Correspondence Address:
Sahil Batra
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ISJ.ISJ_79_20

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  Abstract 

This section of the symposium draws the reader’s attention to various types of spondylolisthesis that are commonly encountered in daily routine practice on the basis of the Spinal Deformity Study Group (SDSG) classification. Each clinical scenario underlines the workup required for such cases along with various technical tips.

Keywords: Sacral dome osteotomy, SDSG, spondylolisthesis, TLIF


How to cite this article:
Batra S, Garg B. The spine clinics: Spondylolisthesis. Indian Spine J 2021;4:89-98

How to cite this URL:
Batra S, Garg B. The spine clinics: Spondylolisthesis. Indian Spine J [serial online] 2021 [cited 2021 Feb 26];4:89-98. Available from: https://www.isjonline.com/text.asp?2021/4/1/89/308210




  Introduction Top


“Spondylolisthesis” is defined as the translation of one vertebral body over the other. Various etiologies have been described, such as degenerative, isthmic, trauma, tumor, or congenital dysplasia. Degenerative dysplasia is the most common variety seen in adults and is usually of a low grade.[1],[2],[3],[4],[5] High-grade spondylolisthesis (HGS) is far less common and it usually occurs as an end result of progressive pediatric or adolescent spondylolisthesis.[6] Clinical presentation ranges from lower back pain to unilateral or bilateral radiculopathy on the basis of severity of the disease. Various classification systems have been used to measure spondylolisthesis and observe its progression; these are based on slip grade, etiology, dysplasia, and spino-pelvic parameters. By far, the SDSG classification takes into account global sagittal balance and local pathology and it is the most promising one. Six types of classification are described[7]: Type 1, 2, and 3 are low grade (<50% translation) spondylolisthesis and Type 4, 5, and 6 are high grade (>50%) spondylolisthesis. The goal of the surgical management of spondylolisthesis is decompression, stabilization, arthrodesis, and reduction wherever applicable.


  CASE 1 Top


History

A 35-year-old overweight female presented to the outpatient department (OPD) with a history of dull aching low back ache without any radiculopathy. The pain increased in severity on prolonged walking and was relieved to some extent on bending forward. She described her pain on a scale of 10 as 8, and Oswestry Disability Index (ODI) score was 56%.

Examination

There was tenderness in the lower back. The passive straight-leg test was negative, with no distal neurovascular deficit.

Prior treatment

Conservative treatment with physiotherapy had yielded limited relief in her symptoms. The mechanical back pain continued to hamper the activities of daily living (ADL).

Pretreatment images

  • Myerding grade: 1 (<25%)


  • Pelvic incidence (PI): 40


  • Pelvic tilt (PT): 20


  • Sacral slope (SS): 20


  • Lumbar lordosis (LL): 40


Flexion and extension dynamic films of the lumbar spine showed a stable isthmic spondylolisthesis at L5-S1, with facet sclerosis and end-plate degenerative changes. The patient was classified as Type 1 SDSG.

The MRI revealed grade 1 spondylolisthesis with facet effusion and central canal stenosis of grade A.

Management

The patient was counseled about the need for surgery, as conservative measures had failed. Various surgical options for low-grade spondylolisthesis include:

  1. Decompression without fusion


  2. Decompression with fusion


  3. Decompression with instrumented fusion


Decompression alone can be offered to patients who present with low-grade spondylolisthesis with no/ minimal loss of segmental lordosis. Decompression of nerve roots can be achieved by the direct or indirect method. Direct decompression includes foraminotomies to decompress exiting nerve roots or Gill laminectomy. Indirect decompression is achieved with the help of interbody fusion by restoring disc space height.[8] In patients with predominant radicular symptoms, decompression alone would be inappropriate as large laminectomy will predispose to secondary/ postsurgical instability.[9],[10],[11] The authors are of the opinion that the addition of interbody fusion will decrease the rate of pseudoarthrosis.

There has been debate whether to perform fusion alone or fusion with instrumentation. A meta-analysis comparing posterolateral fusion with Posterior Lumbar Interbody Fusion (PLIF) found a higher fusion rate in patients undergoing PLIF, but there was no significant difference in clinical outcome.[12] The authors’ opinion is that achieving stabilization will decrease radicular symptoms by preventing motion-related irritation of nerve roots.

Clinically, this patient had back pain so decompression alone would not have sufficed in this patient and loss of disc space would require an interbody cage to restore the disc space height and achieve the lordosis. Explaining all the due risks, consent was taken and a single-level TLIF was planned for the patient.

The patient was positioned prone with all pressure points padded on a standard Jackson table, which allows the abdomen to hang free, resulting in less epidural bleeding and the hips were extended to maximize lumbar lordosis. Fluoroscopy was used to mark the level and side of decompression, as wrong-level surgery is a known complication. A standard posterior midline approach was used from L4 to S2. The L4-L5 facet joint capsule needed to be preserved to avoid iatrogenic instability. Pedicle screws were inserted in L5 and S1 with bicortical purchase under fluoroscopic guidance. Decompression was done on symptomatic side through Kambin’s triangle. Annulotomy was created, and disc material was removed by sequentially increasing the diameter of shavers. End-plate curettage was done. A bone graft was placed just posterior to the anterior longitudinal ligament (ALL) by using a funnel. Polyetheretherketone (PEEK) or a titanium cage filled with morsellized graft was placed (size of cage can be determined preoperatively from MRI). Contoured rods were placed. A postero-lateral graft was placed to enhance fusion. [Figure 1]A & B
Figure 1: Case 1. (A) Preoperative radiograph showing Type 1 SDSG. (B) Postoperative radiograph showing TLIF in Type 1 SDSG

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The patient showed substantial relief in dragging pain at the first follow-up visit at 15 days and continued to be symptom free at the latest follow-up of two years. The ODI score improved to 20% at the latest follow-up.

Technical tip

TLIF is the preferred mode in our setting, as it involves less retraction of nerve roots and lesser amount of damage to the posterior longitudinal ligament (PLL) than PLIF and it is a unilateral procedure. The preservation of the posterior tension band allows the interbody body cage to be placed in compression. Anterior Lumbar Interbody Fusion (ALIF) has been shown to be the most effective in achieving segmental sagittal balance, but TLIF is associated with fewer complications.[13]


  CASE 2 Top


History

A 67-year-old female presented with a history of severe mechanical back ache and left lower limb radiculopathy. The patient complained of difficulty in walking and inability to climb stairs due to severe left thigh and calf pain, especially on the side of the back with a dragging sensation. Her pain was relieved to some extent on bending forward. She rated her pain on a scale of 10 as 8, and the ODI score was 56%.

Examination

The patient had associated depressive disorder. She had a bilateral positive straight-leg raise at 50° in bilateral lower limbs; 5/5 muscle strength in hip, knee, ankle, and Extensor Hallucis Longus (EHL) bilaterally. Paresthesia was present in L5-S1 dermatomal distribution on the left side.

Prior treatment

Conservative treatment with physiotherapy and activity of daily living modification yielded no relief in symptoms.

Pretreatment images

  • Myerding Grade: 2 (25–50%)


  • PI: 56


  • PT: 30


  • SS: 26


  • LL: 39


Flexion and extension dynamic film of the lumbar spine revealed an unstable low-grade spondylolisthesis at L5-S1.

The MRI showed a grade 2 spondylolisthesis with facet effusion and grade 2 foraminal stenosis with L5 nerve root impingement on the left side.

Management

This was a case of Type 2 SDSG, and surgical options similar to Type 1 were discussed with the patient.

This patient had back pain along with radicular symptoms with loss of lumbar lordosis, so decompression along with instrumented fusion is required to decrease risk of pseudoarthrosis and prevent further slippage of deformity. Explaining all the due risks, the consent was taken and a single-level TLIF was planned for the patient. The surgical steps were similar to Type 1 SDSG, with decompression being done from the left side [Figure 2]A and [B].
Figure 2: Case 2. (A) Preoperative radiograph showing Type 2 SDSG. (B) Postoperative radiograph showing TLIF in Type 2 SDSG

Click here to view


The patient showed substantial relief in low back ache at the first follow-up visit at 15 days and was symptom free at the latest follow-up of two years. The ODI score improved to 24% at the final follow-up and rated pain on a scale of 2 out of 10.

Technical tip

A surgical tip for this case is that end plates in young adults are thin and curettage to the level of oozing cortical bone is adequate for sufficient vascularization of the grafts whereas in older patients, end plates are mature so decortication needs to be done. In old age, osteoporosis workup is mandatory before taking up such patients for surgical intervention to prevent pullout of screws and nonunion.


  CASE 3 Top


History

The patient was a 35-year-old office worker with a three-year history of lower back pain with radiation to the right lower limb. His symptoms had become progressive since the past few months. The patient had to sit for long hours on a chair during office hours, and the symptoms were interfering with his professional life due to persistent back pain and stiffness. The patient was a nonsmoker and did not consume alcohol. No other comorbidities were present. He rated his pain on a scale of 8 out of 10, and the ODI score was 52%.

Examination

Pain aggravated on extension of the spine:

  • Tenderness was present in the L5 region.


  • Positive right straight leg rise to 40degrees. Hyperalgesia in the dorsum of the right foot +


  • Limping gait +.


Prior treatment

Despite nonsteroidal anti-inflammatory drugs, pain medications, physical therapy, and epidural injections for the initial few weeks, the patient’s symptoms persisted.

Pretreatment images

X ray LS Spine: AP and lateral

  • Myerding Grade: 2 (25–50%)


  • PI: 64


  • SS: 44


  • PT: 20


  • LL: 30


  • MRI: The MRI shows a grade 2 spondylolisthesis and central disc herniation and grade 2 foraminal stenosis with L5 nerve root impingement.


Management

The patient was classified under Type 3 SDSG classification. This patient had complaints similar to a Type 2 SDSG case, so decompression along with instrumented fusion (mono-segmental) was planned for this patient as the cage is required to achieve lordosis comparable to PI. [Figure 3]A and [B]
Figure 3: Case 3. (A) Preoperative radiograph showing Type 3 SDSG. (B) Postoperative radiograph showing TLIF in Type 3 SDSG

Click here to view


On follow-up, six months after surgery, the patient’s back pain and radiation were completely resolved. At the end of two years, the patient was pain free. The ODI score was 24%, and pain was rated on a scale of 3 out of 10.

Technical tip

A surgical tip while performing decompression is to cauterize epidural venous plexus over the dorsal annulus by using bipolar cautery to achieve hemostasis. It decreases intraoperative blood loss, and it allows good visualization of the dorsal annulus and spinal floor canal.


  CASE 4 Top


History

The patient was a 25-year-old male who worked as a farmer. He was 5’-11” tall and complained of lower back pain and right lower limb radiculopathy, which had got worse with activities for the past two years. He was actively involved in sports before the symptoms. He rated his pain as 8 on a 10-point scale, and the ODI score was 56%.

Prior treatment

All conservative treatment had failed.

Examination

Passive SLR positive (right = 30° and left = 60°)

  • Bilateral knees and ankles power: Normal


  • Palpable step +


  • There was no vascular insufficiency to his legs.


Exaggerated lumber lordosis with heart-shaped buttocks

Pretreatment imaging

X-ray LS Spine: AP and lateral

  • Myerding Grade: 3 (50–75%)


  • PI: 72


  • SS: 24


  • PT: 48


  • LL: 50


  • Spine and pelvis were balanced.


  • MRI: The MRI showed grade 3 spondylolisthesis and grade 3 foraminal stenosis with L5 nerve root impingement on the right side [Figure 4]A and [B].
Figure 4: Case 4. (A) Preoperative sagittal (T2 weighted) MRI showing high-grade spondylolisthesis. (B) Preoperative axial MRI (T2 weighted) showing grade 3 foraminal stenosis on right side. (C) Preoperative radiograph showing Type 4 SDSG. (D) Postoperative radiograph showing TLIF in Type 4 SDSG

Click here to view


Management

Based on the clinical and radiological parameters, the patient was classified under Type 4 SDSG classification.

Various surgical options for high-grade spondylolisthesis include:

  1. In situ fusion


  2. Partial reduction with fusion


  3. Complete reduction


There is controversy regarding whether the reduction of slip angle should be performed or not in the wake of neurological damage. Reduction maneuvers should be attempted when there is sagittal imbalance, and the focus should be the correction of slip angle rather than the complete correction of translation. Reduction also aids in the improvement of surface area for fusion and the distribution of forces till sacrum prevents screw pullout and late failure.[6] In a systematic review, the authors reported encouraging results (lower rate of pseudoarthrosis) with partial reduction and fusion as compared with in situ fusion.[14] Cantilever is the most common method used to aid in reduction. In situ fusion can be considered in cases with high-grade spondyolisthesis with balanced spino-pelvic parameters and a large L5 transverse process.

The spino-pelvic sagittal balance was maintained in this case; there was no need to extend the construct to one level higher and, hence, mono-segmental TLIF was planned and executed for the patient. Pedicle screws were inserted in L5 and S1. A contoured rod was placed on the left side after distraction. Decompression was done on the right side after removal of the facet joint, and an inter-body cage was placed to achieve fusion and stability [Figure 4C] and [D].

On follow-up, six months after surgery, the patient’s back pain and radiation were completely resolved. At two years after follow-up, the ODI score was 24% and the pain rating was 3 out of 10. His limping gait was improved, with no disability in his professional life/personal life.

Technical tip

Distraction across the pedicle screw before decompression allows the disc space to be opened up and moves the exiting nerve root superior from the working area, avoiding damage to neural structures. Injury to the dorsal root ganglion must be avoided at all cost, as its damage may result in neuropathic pain that is resistant to all modalities. Compression is done at the final stages to increase lumbar lordosis and optimize graft compression.


  CASE 5 Top


History

This patient was a 35-year-old female who complained of mechanical lower back pain, which had increased in the severity over the past few years. She had tried all the conservative methods, which included physiotherapy, anti-inflammatory medications, and facet injection blockade. For the past six months, she had decreased sensations on the dorsal aspect of both feet and the first web space area involving L5 and S1 dermatomes.

She rated her pain as 9 on a 10-point scale. Bed rest provided relief. Her symptoms interfered with all of her activities of daily living. The patient was a known case of hypertension and diabetes controlled with oral medications. Her ODI score was 60%.

Examination

Exaggerated lumber lordosis with heart-shaped buttocks

  • Hamstring tightness+


  • Waddle-like gait+


  • Paraspinal muscle spasm+


  • Palpable step +


  • Passive SLR positive (left = 30° and right = 60°)


  • Bilateral knee flexion and extension = 5/5 and EHL = 3/5


  • There was no vascular insufficiency.


Pretreatment images

X-ray LS Spine: AP and lateral

  • PI: 85


  • SS: 35


  • PT: 50


  • LL: 80


  • Grade of listhesis: >75% (grade 4)


  • Spine was balanced but pelvis was unbalanced (Low SS/ High PT)


  • MRI: The MRI showed grade 4 spondylolisthesis and central disc herniation and grade 4 foraminal stenosis with L5 nerve root impingement.


Management

Based on clinical and radiological parameters (Type 5 SDSG), the patient was counseled regarding the need for surgery and various surgical options similar to Type 4 were discussed with the patient. High-grade spondylolisthesis needs CT scan evaluation to look for the morphology of L5 and S1 pedicle. Global and segmental sagittal alignment is fundamental in determining the location and extent of fusion.[15] The objective parameter as defined by Claudio et al. includes an unstable zone. The unstable zone is defined on a standing lateral lumbar radiograph. A square whose area is defined by a horizontal line that passes through the center of S2 and the vertical limit is defined by a gravity line (line passing through the middle of the inferior end plate of L5) and ground reaction force (line passing through the center of femoral heads). All the vertebrae coming in this square should be included in fixation while performing the reduction of L5 vertebrae in high-grade spondylolisthesis.[16] Since the patient’s pelvis was unbalanced, reduction screws were required in this case to decrease the pelvic tilt. This patient did not require an extension of construct, as the deformity was reduced intraoperatively with the help of reduction screws [Figure 5]A and [B].
Figure 5: Case 5. (A) Preoperative radiograph showing Type 5 SDSG. (B) Postoperative radiograph in Type 5 SDSG

Click here to view


On follow-up, at six months postsurgery, the patient’s back pain had resolved partially and limping gait was improved, with no disability in professional or personal life. At the end of two years, the symptoms were completely resolved. The ODI score at the end of two years was 28%.

Technical tip

Graft placement at a different level causes different types of fusion: L5-S1 in the transverse process fusion and L4-L5 in facet fusion for L5-S1 HGS. This mass counteracts the shear forces at the lumbosacral junction. Bone graft placement can be extended till L4 level in a horizontal manner to have a vertical graft that heals better in compression.


  CASE 6 Top


History

A 35-year-old female complained of mechanical lower back pain that had increased in severity over the past few years. The pain was dull aching in nature and it got worse when rising up from the bed in the morning. All the conservative methods had been palliative for a very short term. The patient complained of paraesthesia in her right lower limb and foot.

She rated her pain as 9 on a 10-point scale. Bed rest provided relief. Her symptoms interfered with all of her activities of daily living. Her ODI score was 68%.

Examination

Exaggerated lumber lordosis with heart-shaped buttocks

  • Hamstring tightness+


  • Waddle-like gait+


  • Paraspinal muscle spasm+


  • Short torso with low rib cage and high iliac crest


  • Transverse abdominal crease+


  • B/L knee and hips FFD 10 degree


  • Palpable step +


  • Passive SLR positive (right = 30° and left = 60°)


  • Bilateral knee flexion and extension = 5/5 and EHL = 3/5


  • There was no vascular insufficiency.


Pretreatment images

X-ray LS Spine: AP and lateral

  • PI: 64


  • SS: 34


  • PT: 30


  • LL: 47


  • Grade of listhesis: >75% (grade 4)


  • Spine and pelvis was unbalanced (low SS/high PT)


  • MRI showed grade 4 spondylolisthesis and central disc herniation and grade 4 foraminal stenosis and grade C spinal stenosis with L5 nerve root impingement.


Management

Based on clinical and radiological parameters (Type 6 SDSG), the patient was counseled about the surgery.

Various surgical options are available:

  1. In situ fusion


  2. Sacral dome osteotomy


  3. Circumferential 360-degree fusion


  4. Gaines vertebrectomy


  5. Posterior-only fusion with interbody cage


Sacral dome osteotomy is a single-stage posterior approach procedure.[17] After decompression of L5 and S1 nerve roots, it involves the removal of the cranial surface of S1 vertebrae and the creation of a flat surface for the fusion of L5 vertebrae over S1. In situ fixation involves the use of trans-discal fibula and trans-pedicular fixation across L5 and S1.

Gaines vertebrectomy is a two-stage procedure. The first stage involves L5 corpectomy with the removal of an adjacent intervertebral disc through the anterior approach; the second stage entails the removal of posterior elements of L5 after the distraction and reduction of L4 over the S1 body.[18],[19]

In this case, the standard posterior approach was used and exposure was conducted from L4 to S2. Polyaxial pedicle screws were inserted under EMG monitoring to avoid the breach of pedicle walls in L5 and S1 vertebrae. Reduction screws were placed at the proximal level, that is, L5. A screw–rod construct was used to achieve lumbar lordosis of PI ± 10degrees (measured preoperatively). Alternatively, tower reducers can be used to reduce screw to the rod. After thorough decompression of L5 and S1 nerve roots, a cantilever mechanism was used for reduction. Using the Cobb elevator placed in the disc space after the removal of the disc and cartilaginous material, it can also be used as a lever to reduce L5 vertebrae over S1 and this can be done under fluoroscopy. An interbody cage was placed after the removal of disc material. Sacral dome osteotomy can be performed, as these high-grade cases usually have a dysplastic sacral dome [Figure 6]A and [B].
Figure 6: Case 6. (A) Preoperative radiograph showing Type 6 SDSG. (B) Postoperative radiograph in Type 6 SDSG

Click here to view


On follow-up, at six months postsurgery, the patient’s back pain had resolved partially, and the rate of pain was 4 on a 10-point scale. Limping gait had improved, with no disability in professional or personal life. At the end of two years, symptoms were completely resolved and ODI score was 36%.

Technical tip

In high-grade spondylolisthesis with an unbalanced spine, the steps to correct the deformity involve the correction of lumbosacral kyphosis with the distraction technique and gradual reduction of the deformity by using reduction screw/ towers and maintenance and correction of sagittal parameters of the reduction with the interbody cage.


  Conclusion Top


All the cases just cited highlight the common clinical scenario seen in the spondylolisthesis group of patients. The planning involved in these cases is discussed, and technical tips to minimize the chances of complications are mentioned.

Financial support and sponsorship

This study does not receive any funding of any nature.

Conflicts of interest

There are no conflicts of interest.

Compliance with ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.



 
  References Top

1.
Frymoyer JW Degenerative spondylolisthesis: Diagnosis and treatment. J Am Acad Orthop Surg 1994;2:9-15.  Back to cited text no. 1
    
2.
Jones TR, Rao RD Adult isthmic spondylolisthesis. J Am Acad Orthop Surg 2009;17:609-17.  Back to cited text no. 2
    
3.
Vibert BT, Sliva CD, Herkowitz HN Treatment of instability and spondylolisthesis: Surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006;443:222-7.  Back to cited text no. 3
    
4.
Steiger F, Becker HJ, Standaert CJ, Balague F, Vader JP, Porchet F, et al. Surgery in lumbar degenerative spondylolisthesis: Indications, outcomes and complications. A systematic review. Eur Spine J 2014;23:945-73.  Back to cited text no. 4
    
5.
Matsunaga S, Sakou T, Morizono Y, Masuda A, Demirtas AM Natural history of degenerative spondylolisthesis. Pathogenesis and natural course of the slippage. Spine (Phila Pa 1976) 1990;15:1204-10.  Back to cited text no. 5
    
6.
Beck AW, Simpson AK High-grade lumbar spondylolisthesis. Neurosurg Clin N Am 2019;30:291-8.  Back to cited text no. 6
    
7.
Labelle H, Mac-Thiong JM, Roussouly P Spino-pelvic sagittal balance of spondylolisthesis: A review and classification. Eur Spine J 2011;20(Suppl 5):641-6.  Back to cited text no. 7
    
8.
Bhalla A, Bono CM Isthmic lumbar spondylolisthesis. Neurosurg Clin N Am 2019;30:283-90.  Back to cited text no. 8
    
9.
Deguchi M, Rapoff AJ, Zdeblick TA Posterolateral fusion for isthmic spondylolisthesis in adults: Analysis of fusion rate and clinical results. J Spinal Disord 1998;11:459-64.  Back to cited text no. 9
    
10.
Möller H, Hedlund R Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis–a prospective randomized study: Part 2. Spine (Phila Pa 1976) 2000;25:1716-21.  Back to cited text no. 10
    
11.
Zdeblick TA A prospective, randomized study of lumbar fusion. Preliminary results. Spine (Phila Pa 1976) 1993;18:983-91.  Back to cited text no. 11
    
12.
Luo J, Cao K, Yu T, Li L, Huang S, Gong M, et al. Comparison of posterior lumbar interbody fusion versus posterolateral fusion for the treatment of isthmic spondylolisthesis. Clin Spine Surg 2017;30:E915-22.  Back to cited text no. 12
    
13.
Wang SJ, Han YC, Liu XM, Ma B, Zhao WD, Wu DS, et al. Fusion techniques for adult isthmic spondylolisthesis: A systematic review. Arch Orthop Trauma Surg 2014;134:777-84.  Back to cited text no. 13
    
14.
Longo UG, Loppini M, Romeo G, Maffulli N, Denaro V Evidence-based surgical management of spondylolisthesis: Reduction or arthrodesis in situ. J Bone Joint Surg Am 2014;96:53-8.  Back to cited text no. 14
    
15.
Guigui P, Ferrero E Surgical treatment of degenerative spondylolisthesis. Orthop Traumatol Surg Res 2017;103:11-20.  Back to cited text no. 15
    
16.
Lamartina C A square to indicate the unstable zone in severe spondylolisthesis. Eur Spine J 2001;10:444-8.  Back to cited text no. 16
    
17.
Min K, Liebscher T, Rothenfluh D Sacral dome resection and single-stage posterior reduction in the treatment of high-grade high dysplastic spondylolisthesis in adolescents and young adults. Eur Spine J 2012;21(Suppl 6):S785-91.  Back to cited text no. 17
    
18.
Gaines RW, Nichols WK Treatment of spondyloptosis by two stage L5 vertebrectomy and reduction of L4 onto S1. Spine (Phila Pa 1976) 1985;10:680-6.  Back to cited text no. 18
    
19.
Gaines RW L5 vertebrectomy for the surgical treatment of spondyloptosis: Thirty cases in 25 years. Spine 2005;30(6 Suppl):S66-70.  Back to cited text no. 19
    


    Figures

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



 

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Abstract
Introduction
CASE 1
CASE 2
CASE 3
CASE 4
CASE 5
CASE 6
Conclusion
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