Indian Spine Journal

SYMPOSIUM: SPONDYLOLISTHESIS
Year
: 2021  |  Volume : 4  |  Issue : 1  |  Page : 65--76

Surgical management of high-grade spondylolisthesis: Current recommendations


Karthik Kailash1, Sudhir Ganesan1, Nalli Ramanathan Yuvaraj2, Appaji Krishnan3, Charanjith S Dhillon4, Kalale Sudarshan Pramod5, Saikrishna Gadde1,  
1 Department of Spine Surgery, Sri Ramachandra Institute of Higher Education & Research, Chennai, Tamil Nadu, India
2 Department of Spine Surgery, Rajiv Gandhi General Hospital, Chennai, Tamil Nadu, India
3 Department of Spine Surgery, SIMS Hospital, Vadapalani, Chennai, Tamil Nadu, India
4 Department of Spine Surgery, MIOT Hospital, Chennai, Tamil Nadu, India
5 Aster Hospitals, Kochi, Kerala, India

Correspondence Address:
Karthik Kailash
Department of Spine Surgery, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, Tamil Nadu.
India

Abstract

Spondylolisthesis is the slippage of one vertebra over the adjacent vertebrae and a usual cause of low back pain and spinal imbalance. High-grade spondylolisthesis (HGS) is defined as Meyerding grades III, IV, and V or greater than 50% anterior translation of vertebrae resulting in spinal canal stenosis and neural compression. Management of HGS has been varied and fraught with opinions and its spectrum of management consists of in situ fusion, fusion and reduction combination techniques and vertebrectomy. Literature review was done on the various modalities of treatment and studies showed good clinical outcomes with the procedures. This review highlights the biomechanics of HGS and spondyloptosis, description of techniques of in situ fusion, reduction and fusion and, thereby, evaluate and give current recommendations in the surgical management of HGS. A systematic search of PubMed, Cochrane, and Google Scholar for papers relevant to HGS was performed. Twenty-one articles were included after title, abstract, and full-text review and grouped to analyze the effect of surgical approach, instrumentation, reduction, and decompression on patient radiographic and clinical outcomes. The level of evidence was low in ascertaining the superiority of one technique over the other. HGS is a complex disorder that can be addressed with varying procedures for it. No single technique has been proven to be better than the other. Each of the procedures described earlier has their own advantages and disadvantages, and these have to be weighed with the clinical scenario and the individual skill level of the treating surgeon before deciding on the appropriate procedure. The ideal recommendations for doing the above procedures were enumerated. However, no single procedure can be taken as the best fit for the given condition as the literature does not show one to be better than the other.



How to cite this article:
Kailash K, Ganesan S, Yuvaraj NR, Krishnan A, Dhillon CS, Pramod KS, Gadde S. Surgical management of high-grade spondylolisthesis: Current recommendations.Indian Spine J 2021;4:65-76


How to cite this URL:
Kailash K, Ganesan S, Yuvaraj NR, Krishnan A, Dhillon CS, Pramod KS, Gadde S. Surgical management of high-grade spondylolisthesis: Current recommendations. Indian Spine J [serial online] 2021 [cited 2021 May 12 ];4:65-76
Available from: https://www.isjonline.com/text.asp?2021/4/1/65/308204


Full Text



 Introduction



High-grade spondylolisthesis (HGS) is defined as greater than 50% slippage of a spinal vertebral body relative to an adjacent vertebral body as per Meyerding classification,[1] most common location being L5/S1 followed by L4/L5 and is approximately found in 11.3% of those with spondylolisthesis. Dealing low-grade spondylolisthesis comprise of conservative measures in the form of bracing, back strengthening exercises if there are no associated symptoms of canal stenosis or root irritation. If associated with the above-mentioned situations, surgical decompression with or without instrumentation shall be the choice and reduction may need not be required as the outcome may not vary if the degree of listhesis is low. Management of HGS has been varied and fraught with opinions. The spectrum of management consists of in situ fusion, fusion and reduction combination techniques and vertebrectomy.

A literature review was done on the various modalities of treatment. Most studies showed good clinical outcomes with the procedures. However, the level of evidence was low in ascertaining the superiority of one technique over the other. The aim of this review was to evaluate and give current recommendations in the surgical management of HGS.

 Method of Literature Search



A systematic search of PubMed, Cochrane, and Google Scholar for papers relevant to HGS was performed. Twenty-one articles were included after title, abstract, and full-text review and grouped to analyze the effect of surgical approach, instrumentation, reduction, and decompression on radiographic and clinical outcomes of patients.

 Biomechanics of HGS



Spondylolisthesis is defined as slippage of one vertebra over the adjacent vertebra. HGS is an uncommon cause of low back pain. Various studies in the literature have clearly stated the importance of global spinal alignment in the treatment and outcome of high-grade listhesis.[2],[3] The sacropelvic morphology is the main determinant of the geometry and stresses at the lumbosacral junction which in turn modulates the spinopelvic alignment. Optimal spinopelvic balance is when the sagittal vertical axis falls over or behind the femoral heads. The shear and axial forces are increased if the CORA at Lumbo Sacral Junction (LSJ) is anterior to the L5-S1 disc.

The Lumbosacral Junction is a transitional zone from a mobile lumbar spine to a rigid sacrococcygeal spine. Along with the LSJ, the pelvis and hip joints play a vital role in sacropelvic orientation and the overall spinal balance. Studies have described several radiographic parameters to quantify sacropelvic and spinopelvic alignment.[4],[5],[6],[7],[8] Sacropelvic morphology refers to the anatomy which is specific to each individual and is unaffected by the three-dimensional position of the sacrum and pelvis. Sacropelvic orientation depends on the position of the individual in space and is subject to change. Pelvic incidence (PI), introduced by Duval-Beaupère et al.,[9] is a measure of sacropelvic morphology that is unique and fixed for a particular individual (increases slightly constantly during childhood and adolescence and stabilizes during adulthood[10]). It is measured by the angle between a line perpendicular to the superior endplate of S1, and a line connecting the middle of the superior endplate of S1 and the center of femoral heads. Many studies have shown that PI is significantly higher in patients with listhesis compared with normal subjects with a linear correlation of higher PI with worsening listhesis although the cause–effect relationship between PI and listhesis is not clearly understood.[3],[11],[12],[13]

The other pelvic parameters that are important in maintaining the balance are pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL). PT and SS are measures of sacropelvic orientation as they are dependent on the position of the individual in space. PI is the arithmetic sum of PT and SS. For two individuals with the same PI, the PT and SS could be different. The normal values and the correlation between these parameters in normal subjects have been studied in the Indian population[14] according to which PI has a statistically significant positive correlation with SS, PT, and LL, which means subjects with high PI tend to have high SS and LL to maintain sacro-pelvic and spinopelvic balance. As patients’ age and their spines become increasingly rigid and kyphotic, compensatory management becomes exceedingly difficult. Then the pelvis is recruited and SS is decreased. Pelvic retroversion (corresponding to an increased PT) attempts to reposition the head over the pelvis and maintain a horizontal gaze. The erector muscles then help to correct posture but are unable to maintain the tension band effect due to degeneration and fatigue. If the prior compensatory mechanisms are not capable of maintaining sagittal balance, the lower extremities are recruited to alter the alignment. If not sufficiently compensated through pelvic retroversion, hip flexion, knee flexion, and even ankle flexion attempt to retain balance at the cost of increased energy expenditure.[15]

Labelle et al.[16] have investigated sacro-pelvic and spinopelvic balance in patients with high- vs. low-grade spondylolisthesis. Patients with low-grade spondylolisthesis can be subcategorized into two groups: those with low PI (<45°) and those with high PI (>60°). It is thought that patients with high PI suffer tension failure of the pars causing spondylolysis as described earlier, while patients with low PI undergo pars failure via a “nutcracker” effect,[17] by impingement of the L5 posterior elements between L4 and S1 during extension. Hresko et al.[18] identified two subgroups for high-grade listhesis: balanced and unbalanced pelvis. The balanced group includes patients with low PT and a high SS, with a posture similar to normal individuals with high PI. The unbalanced group includes patients with high PT and low SS suggestive of retroverted pelvis and a vertical sacrum. Mac Thiong et al.[19] demonstrated a relatively normal posture in individuals with low-grade spondylolisthesis compared with high grade and the abnormal posture was more pronounced in the subgroup with unbalanced sacro-pelvis.

The SDSG has proposed a classification system based on the severity according to the complexity of surgical treatment and prognosis.[16] It is based on (1) grade of slip (low or high), (2) PI (low, normal, or high), (3) sacro-pelvic balance, and (4) spine-pelvic balance. A detailed explanation can be found in the classification section of the symposium.

 Management in Paediatric Population



In situ fusion

The optimal surgical treatment procedures for high-grade isthmic spondylolisthesis still remain controversial on whether it is essential to reduce the slippage of vertebrae or not. Modern surgical techniques and instrumentation have permitted the reduction or even removal of a severely slipped fifth lumbar vertebra. However, these operations could result in an increased risk of neurological complications from the screws and also the possibility of stretching neural elements during the corrective procedure.

Fusion in situ in severe spondylolisthesis usually implies anterior and posterior fusion to achieve solid fusion and, thus, prevent further progression of the slip. In severe slips, anterior intercorporeal fusion may be difficult to accomplish because of the incongruent bony surfaces available.

In a long-term follow-up study by Poussa et al.,[20] patients in the fusion in situ group performed better on the Oswestry Disability Index (ODI) and Scoliosis Research Society Scoring questionnaires, and had less disc degeneration and muscle atrophy on magnetic resonance imaging (MRI).

Uninstrumented In situ fusion

Various surgical procedures could be used to obtain in situ spondylodesis in children and adolescents: posterolateral fusion with or without instrumentation, posterior interbody fusion, combined anterior and posterior procedures, and circumferential 360° fusion. Circumferential uninstrumented fusion as shown by Lamberg et al. had better long-term results than isolated posterolateral fusion or anterior fusion alone. Circumferential fusion provided significantly better clinical and radiographic outcomes than posterolateral or standalone anterior fusion for pediatric high-grade spondylolisthesis.[21],[22]

Circumferential uninstrumented fusion consists of combined anterior and posterolateral fusion. The anterior fusion was performed between L5 and S1 and posterolateral noninstrumented fusion using iliac crest autogenous bone grafting was between L4 and S1. This may be performed in a single setting or as a staged procedure [Figure 1][Figure 2][Figure 3] and [Table 1].{Figure 1} {Figure 2} {Figure 3} {Table 1}

Reduction and Fusion

There is disagreement in the literature on whether to reduce or not before fusion.[23] Although in situ fusion does provide patients with symptomatic relief; on long-term observation, problems arise due to decompensation from positive global sagittal balance and show higher rates of pseudoarthrosis. The risk–benefit ratio of restoration of sagittal balance and improved spine biomechanics compared to lower neurological complications is often debated about in adults.[24] In children, however, a reduction is preferred in high-grade slips as it is shown that the realignment of the slip helps reduce the stress incurred by the growing bone at the lumbosacral junction. Some authors advocate a partial reduction of slip with circumferential fusion as an acceptable alternative to complete reduction to reduce the chances of neurological deficits.

Basis for reduction

Increased stress upon treatment of high-grade spondylolisthesis based on pelvic parameters is observed recently. Hresko et al.[18] established a classification system for categorizing lumbosacral spondylolisthesis into low vs. high slip grade and in turn into balanced (high SS/low PT) or unbalanced (low SS/high PT) types. The pelvis in high-grade spondylolisthesis can be considered to be balanced when the SS is high and PT is low, thereby the global spine balance is invariably normal and fusion without reduction is justified. In an unbalanced pelvis that shows a low SS and high PT, treatment strategies should reflect the amount of strain seen at the spinopelvic junction; therefore, reduction techniques should be considered.

Techniques described in the literature

Posterior distraction-based reduction

Although no definitive recommendations can be established, literature[25],[26] suggests that circumferential fusion with interbody support has a lower incidence of pseudarthrosis and a possibly better chance of long-term clinical success compared to those treated with posterior-only techniques in the absence of interbody support. The goals of a reduction technique are a restoration of global spinal balance by correction of kyphosis at the lumbosacral junction. When achieved with the shortest possible fusion, potential adjacent disc degeneration is avoided and reduces the functional restriction in these young patients. Compression in the state of lordosis has been biomechanically described to ensure better union.

Relying on these principles, Harms et al.[27] in his series of 112 patients reported excellent results with the technique of decompression, distraction, reduction, and posterior lumbar interbody fusion in 50 patients. Distraction was obtained using hooks in the upper lumbar spine and reduction was done using long-headed pedicle screws. A more recent description of the technique with mono segmental fusion in 27 patients has been reported where temporary instrumentation of L4 was effective in reduction. In their opinion, as the L4/L5 segment is not primarily affected, it should be preserved whenever possible.

Shufflebarger et al.[28] described the results using the same technique of wide decompression of the L5 nerve roots via Gill laminectomy, temporary distraction via sacral alar hooks and proximal lumbar hooks, lumbosacral discectomy, anterior decortications and grafting, and placement of bilateral titanium mesh cages packed with morselized autograft. Kyphosis correction is achieved by posterior compression against an anterior support and helped to restore the load-sharing ability of the anterior column.

Vialle et al.[29] used a same-day, staged posterior–anterior approach and achieved fusion in all 40 patients with a double-plate technique. However, they had intraoperative complications like iliac vein lesions and implant complications like broken screws and five late infections. The authors consider the risk-reward ratio to be unacceptable and indicate the approach-related complications in transperitoneal exposure.

Sacral dome osteotomy and reduction

Bouyer et al.[30] used the cantilever maneuver to aid in reduction whereby after the pedicle screws are placed in L4, L5, and S1, reduction was then obtained gradually by transsacral vitallium rod insertion pushed down through S2 vertebral body and applied at the anterior part of S2. Then, the rods were gradually pushed down and locked in L4 and L5 pedicular screws by means of two persuaders enacting a reduction via retroversion of the sacrum. Additional fixation of the rod to the sacrum allows for the distribution of forces during reduction and preventions of screw pull-out and failure. This anterior fusion and lumbosacral correction by a posterior approach using this modification of Jackson’s intrasacral fixation seems to be an effective treatment for pediatric high-grade isthmic spondylolisthesis. Min et al.[31] also described the sacral dome osteotomy technique which is a posterior single-stage procedure involving a wide decompression of L5-S1, an osteotomy of the cranial sacrum thereby creating a flat surface for L5 reduction and fusion. Their study showed good clinical outcomes with no neurological deficits.

Minimally invasive techniques

Though the usual techniques described are essentially open, a recent report by Tian et al.[32] showed posterior reduction and mono segmental fusion of L5-S1 assisted by intraoperative three-dimensional navigation as an effective technique for managing high-grade dysplastic spondylolisthesis. The computer-assisted navigation system provided real-time three-dimensional images, giving surgeons the chance to dynamically select screw entry points and directions. In addition, the osteotomy procedures were performed under the navigation system to identify the position and direction of the bone drill in their series.

Quraishi et al.[33] recently used the minimal access surgery approach and published a case report on Grade III spondylolisthesis. They concluded that for selected patients with a mobile high-grade spondylolisthesis, it is a feasible, safe, and clinically effective technique, with the added benefit of reduced soft-tissue disruption.

The authors preferred technique[34]

This involves positioning the hips in extension with traction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction maneuver, wide decompression, and gradual reduction of the deformity and maintenance of reduction with interbody fusion. The results of this technique with long-term follow-up have been published in literature; demonstrating a significant reduction of high-grade spondylolisthesis, with restoration of global sagittal balance via correction of the lumbosacral kyphosis. Though surgically demanding, the technique proved to be safe and reproducible with low rates of neurological complications and high fusion rates with excellent clinical outcomes in long term [Table 2] and [Figure 4][Figure 5][Figure 6][Figure 7][Figure 8][Figure 9][Figure 10].{Table 2} {Figure 4} {Figure 5} {Figure 6} {Figure 7} {Figure 8} {Figure 9} {Figure 10}

 Spondyloptosis



Spondyloptosis is defined as a condition where L5 vertebral body is completely dislocated from the sacrum anteriorly.[35] It usually is the result of HGS left untreated.[36] Unlike low-grade slips, whose manifestations are typically limited to painful segmental instability or neural compromise at the affected level, high-grade slips and spondyloptosis invariably provoke secondary changes in the regional pelvic anatomy and thus produce global sagittal deformity.[37],[38] It is this global deformity that makes the surgical management of spondyloptosis complex and challenging.

Biomechanics

Spondyloptosis represents the most severe variant of HGS. In spondyloptosis, the L5 vertebra not just slips anteriorly over the superior sacral endplate but also descends inferiorly, anterior to the sacrum, into the pelvis. This descent of the lumbar spine anterior to the sacrum can be quantified numerically as Newman’s score as shown in [Figure 11].[39] The descent of L5 from its original position leads to foreshortening of the spinal column, locking the L5 vertebrae anterior to the sacrum thus making the reduction difficult. There can also be a variable degree of rotation of L5 along the horizontal axis that leads to worsening of lumbosacral kyphosis. Lumbosacral kyphosis leads to a regional sagittal imbalance which is usually compensated by retroversion of the pelvis and exaggerated LL[38],[40] [Figure 12]. As lumbosacral kyphosis increases and the upper limit of compensation by lumbar hyperlordosis and pelvic retroversion are reached, a global sagittal imbalance is prevented by flexion at the knee in an attempt to balance the spine. With further decompensation, a positive sagittal imbalance may render ambulation difficult. In more severe cases, the inferior endplate of L5 may directly lie in contact with the anterior surface of S1 and there can be attempts at auto-stabilization by forming bony osteophytes between these apposing L5 inferior endplate and S1 anterior surface.[41]{Figure 11} {Figure 12}

Treatment

There is a limited role for conservative management of spondyloptosis since most cases have a sagittal imbalance. Spontaneous fusion of the body of spondyloptotic L5 vertebrae to the anterosuperior aspect of the sacrum has been reported by Martino et al.[41] However, such a scenario occurring spontaneously is extremely rare and most authors agree that surgical fusion of unstable lumbosacral region is warranted to thwart instability encountered in spondyloptosis. However, opinions differ on whether reduction should be attempted. There are two schools of thought. On one extreme are conservative surgeons who recommend posterior in situ fusion with no attempt at reduction.[42],[43],[44],[45] while on the other extreme are adventurous surgeons who recommend a partial or complete reduction of spondyloptosis and correction of abnormal sagittal alignment with instrumentation.[46],[47],[48],[49],[50]

Decompression and in situ fusion

Posterior decompression and in situ fusion is the most common surgical intervention for spondyloptosis by virtue of the simplicity of the surgical technique and its relatively lower perioperative morbidity.[43] The advantages of in situ fusion include a lower risk of neurological deficit, shorter operative times, and blood loss.[42],[44] However, it is associated with an unacceptably high rate of pseudoarthrosis[51] (up to 40%) especially if wide decompression of nerve roots is combined with in situ fusion since laminectomy reduces the graft bed available for fusion. Also, tensile forces acting on posterior fusion mass may lead to the progression of the deformity.[51] Attempts have been made to reduce pseudoarthrosis rates by augmenting posterolateral fusion with trans-vertebral sacral fixation using screws or fibular strut graft [Figure 3] which provides additional anterior column support.[44],[45] This is reported to reduce the chance of progression of slip and pseudoarthrosis. However, persistent sagittal imbalance due to uncorrected biomechanics remains a serious drawback of in situ fusion [Figure 13].[51]{Figure 13}

Reduction and fusion

Reduction of the spondylolisthesis is preferred in adolescent spondyloptosis as the realignment of the slip helps reduce the stress incurred by the growing bone at the lumbosacral junction. In adults, however, there is controversy with regards to the need for reduction. The proponents of reduction suggest numerous advantages[46],[47],[48],[49],[50],[51],[52] favoring reduction as mentioned below:

The reduction places the fusion mass in a biomechanical advantage of compression rather than tension, thus resulting in lower pseudoarthrosis rates.[25],[47]

The reduction maneuver increases the surface areas in contact, proving a larger fusion bed for a successful union.[46]

The reduction of slip improves the sagittal alignment, improving the cosmetic deformity frequently associated with such severe slips. There is an improvement in the gait pattern and reduction in the hamstring spasm with correction of the pelvic retroversion.

The first successful attempt at complete reduction was reported by Gaines in 1976[25] wherein he popularized a two stage surgical technique for reduction of the spondyloptosis. In the first stage, L5 vertebral body was excised up to the base of pedicles through an anterior approach. The second stage under separate anesthesia was performed a few days later wherein the loose neural arch and pedicle of L5 were removed from a posterior approach with gradual reduction and docking of L4 over S1 achieving bone-on-bone contact, stabilized by transpedicular instrumentation. Kalra et al.[48] in 2010 reported a modified Gaines technique for the case of spondyloptosis (a patient with modified Newman’s criteria score of 10+6), where they performed partial L5 corpectomy and reduced the deformity. Dhillon et al.[49] reported a modified three-stage Gaines procedure for symptomatic adult manual laborer with spondyloptosis with modified Newman’s criteria score of 10+10 with successful outcomes [Figure 14].{Figure 14}

The most feared risks of complete reduction include a higher chance of neurological deficit and this frequently occurs in the terminal 50% of slip reduction.[50],[51] This observation has resulted in some authors advocating a partial reduction of slip with circumferential fusion as an acceptable alternative.[31],[52] Partial reduction has a lower risk of developing neurological deficit by avoiding a significant stretch of the L5 and L4 nerve roots.[46],[52] The sacral dome can cause significant anterior impingement of the dural sac in which case, partial sacral dome resection can be performed to further decompress the neural elements through a posterior approach.[31]

While complete reduction is desirable, even partial reduction of the slip angle and lumbosacral kyphosis is sufficient to achieve acceptable biomechanical alignment.

Recommendation

The consensus appears to be that partial reduction offers overwhelming biomechanical advantages and that in situ fixation will inevitably provide an inferior result due to persistent physical deformity or construct failure.[31],[51],[52] Expert opinion notwithstanding, the question of which is clinically superior—reduction or in situ fusion—cannot be decided until a well-designed prospective cohort study is performed and long-term follow-up data are obtained.

 Management in Adult Population



Apart from the above-mentioned reduction maneuvers, additional techniques of in situ fusion are discussed below.

Additional options for in situ fusion in high-grade listhesis

A few posterior surgical techniques could be used to achieve in situ circumferential stabilization and fusion, including (1) transvertebral transdiscal pedicle screw fixation, (2) posterior transsacral transdiscal interbody fusion using a cortical bone graft with pedicle screw instrumentation, and (3) posterior interbody cage and pedicle screw fixation.

Transvertebral transdiscal screws-delta fixation

To avoid the neurologic risks associated with reduction procedures and the high pseudarthrosis rates seen with posterior in situ arthrodesis without instrumentation, it has been generally accepted that posterior spinal fusion with instrumentation has become the standard for adults with higher-grade spondylolisthesis. However, placing pedicle screws into L5 vertebrae can be very difficult without at least a partial reduction of the spondylolisthesis. Thus, to provide additional fixation, transvertebral screws have been described. The sacral S1 pedicle screws are extended across the sacral promontory into the listhetic L5 vertebral body where L5 has slipped directly anterior to the sacrum. The S1screws can be angled slightly more cranially to exit the sacral promontory within the disc edge. These screws should be sufficiently long (55 to 70 mm) to penetrate and cross the posterior third of the L5 vertebral body and act as a support for the slipped L5 vertebral body to sit on.[53] Abdu et al. initially described this technique in three patients.[54] They believed that the strength of their construct was a result of the longer triangulated screws and the multiple cortical purchases through the sacral promontory and through the inferior endplate of L5. Transvertebral L5-S1 screw fixation uses the concept of three-column fixation achieved from a single posterior approach, potentially improving the resistance against the shear forces across the disc space while posterolateral fusion is occurring. This configuration, however, provides no bone substrate for interbody arthrodesis. Studies have shown that the stiffness of the transdiscal fixation was found to be equivalent to fixation with a combined interbody fusion and pedicle screw fixation.[55],[56],[57]

Transsacral cage: Augmented pedicle screw/rod fixation

Transsacral cage-augmented pedicle screw/rod fixation combined with posterolateral fusion provides immediate, circumferential rigid stabilization at the lumbosacral junction in the treatment of high-grade lumbosacral spondylolisthesis. The transsacral–transvertebral cage acts as a buttress to resist translation and angulation of L-5 relative to S-1. The fenestrations in the cage allow bone fusion to develop between the graft in the cage and the surrounding vertebrae. An autograft filled titanium mesh cage immediately provides structural stability in the anterior column, with a higher elasticity modulus to resist shear forces across the L5–S1 disc space, in contrast with fibular autograft or allograft. Furthermore, the donor site morbidity and graft-related complications associated with the use of fibular dowel graft is avoided.[58]{Table 3}

 Summary and Conclusion



HGS is a complex disorder that can be addressed with varying procedures for it. No single technique has been proved to be better than the other. The reduction is not necessary for patients with balanced sacro-pelvis because their spinopelvic balance is similar to normal individuals. On the contrary, the reduction is considered beneficial in patients with an unbalanced sacro-pelvis because these individuals have an unbalanced spinopelvic balance. To optimize the surgical treatment, biomechanical considerations have to be considered in the preoperative planning. Each of the procedures described earlier has their own advantages and disadvantages, and these have to be weighed with the clinical scenario and the individual skill level of the treating surgeon before deciding on the appropriate procedure. The ideal recommendations for doing the above procedures were enumerated. However, no single procedure can be taken as the best fit for the given condition as the literature does not show one to be better than the other.[59]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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