CHAPTER
64 Mauricio A. Campos Daziano
High-Grade Spondylolisthesis:
Fusion In Situ
INTRODUCTION
The ideal treatment for high-grade spondylolisthesis (slippage
50%) is still a subject of controversy.5 In contrast with low-
grade slips, high-grade spondylolisthesis is far less frequent and
most published series are a mix of children and a few adult
patients.6 Furthermore, authors frequently group together low-
grade acquired spondylolytic spondylolisthesis with higher-
grade developmental cases with pars defects, adding more
difficulty in analyzing the available evidence.
The degree of developmental dysplasia at the lumbosacral
junction and the remaining growth potential are the most
important factors affecting progression.7 Therefore, cases of
mature adults and immature children must be considered sepa-
rately because of differences with respect to remaining growth,
remodeling potential, and risk of further slippage. While
asymptomatic adults with high-grade stable slips can be treated
nonoperatively, surgery is indicated in asymptomatic skeletally
immature patients with high-grade spondylolisthesis to prevent
further progression and neurologic deficit (Fig. 64.1).
Adult patients with high-grade slips can be asymptomatic as
their deformities can stabilize and autofuse in a good sagittal
balance.6,12 Harris and Weinstein reported on the long-term
follow-up of 11 patients with grades III and IV spondylolisthesis
treated nonoperatively and 21 patients who were treated with a
posterior interlaminar fusion. The average follow-up for both
groups were 18 and 24 years, respectively. Thirty-six percent of
patients treated without surgery were asymptomatic and 55%
had mild symptoms and only one had significant symptoms
(morning stiffness). None of them became incontinent, although
45% had mild neurologic findings. All patients led an active life
with only minor modifications. Of interest, of the six patients
with spondyloptosis and no surgery, half remained asymptom-
atic. However, a higher percentage of patients treated with fusion
in situ remained asymptomatic (57%) and were able to partici-
pate in more occupational and recreational activities.8
Once surgery is indicated, several technical decisions must
be made to optimize the outcome and reduce the risk of com-
plications for a given patient. Controversial questions include
the need for reduction, levels to be included in the fusion, the
need of decompression, use of instrumentation, surgical
approach, and the necessity of a circumferential fusion. We will
review the available evidence for each of these controversies.
LWBK836_Ch64_p633-637.indd 633
Stuart Weinstein
FUSION LEVELS
Regarding fusion levels, most authors recommend to include
L4 in high-grade slips when planning for a fusion in situ.12 In
these cases, the L5 transverse processes are anterior to the
sacral ala and therefore the horizontal fusion mass would be
under shear forces that may lead to a nonunion or bending of
the fusion mass. Classic series achieving excellent fusion rates
using standard posterior techniques also support this view.18
IS REDUCTION NECESSARY?
Reduction remains controversial for high-grade adolescent
spondylolisthesis and is even more controversial for adults.
Authors advocating reduction techniques cite several advan-
tages: placing the fusion mass in a better biomechanical situa-
tion (compression rather than tension or shear), therefore
increasing fusion rates and avoiding postoperative slippage
progression; the possibility of saving mobile segments by fusing
only L5-S1; improved cosmetic results as reduction better
restores sagittal balance and gait anomalies in severe deformi-
ties; decreasing the incidence of adjacent segment disease; and
minimizing the risk of postoperative cauda equina syndrome as
canal stenosis is addressed.12,21 The theoretical advantages of
reduction must be weighted against the risk of neurologic
injury, reported in as many as 75% of cases in one series.21
Thorough assessment and consideration of the patients clini-
cal complaints are also fundamental in decision making.
The existing evidence concerning the need for reduction is
mixed, in most cases composed of noncontrolled pediatric
patient series. There are few cases of more or less direct com-
parisons between reduction and no-reduction strategies25
(Table 64.1). Burkus et al4 reported on pediatric patients with
spondylolisthesis treated either with in situ fusion alone or in
situ fusion followed by cast reduction as per the Scagliettis
method. Among the 42 patients included in the series,
29 patients had high-grade slips. Seventeen were treated with
cast reduction and 12 without reduction. Fusion in situ was
associated with increased risk of pseudoarthrosis and postop-
erative deformity progression, although this trend did not
reach statistical significance. Muschik et al16 reported on 59
adolescent patients with severe slips (considered here as 30%
633
9/2/11 7:10:03 PM
 634 Section VI Spondylolisthesis
A B
Figure 64.1. Lateral radiographs of a 14-year old boy treated for
high-grade spondylolisthesis with an L4-S1 posterior in situ arthrod-
esis. (A) Preoperative and (B) 7 years after surgery.
of slip), who were treated either with only an anterior L5-S1 in
situ interbody fusion (n 29) or with anteroposterior L5-S1
instrumented fusion with reduction (n 30). The authors
observed a decreased rate of pseudoarthrosis (7% vs. 24%),
shorter fusion time (7 months vs. 17 months) and better radio-
graphic alignment at the lumbosacral junction in the second
group.16 However, this was not reflected clinically as both
groups had similar postoperative results in terms of equivalent
proportion of postoperative asymptomatic patients, back pain,
neurologic symptoms, and satisfaction with the procedure.
Based on these results, the authors could not conclude that
reduction improves clinical outcomes.
Molinari et al15 retrospectively compared three surgical
methods for the treatment of high-grade pediatric isthmic dys-
plastic spondylolisthesis: 11 patients received an L4-S1 in situ
posterior fusion without decompression; 7 patients were treated
with decompression, reduction, instrumentation, and L4-S1
posterior fusion; and 19 patients had decompression, reduction,
and circumferential fusion. The pseudoarthrosis rate was 45%,
29%, and 0% for each group, respectively. Small dysplastic L5
transverse processes less than 2 cm2 of surface area on Ferguson
views were associated with the risk of nonunion.15 Fifteen per-
cent of the patients who were reduced (4 out of 26) had tran-
sient neurologic deficits, one case being permanent. No neuro-
logic deficit was reported for patients fused in situ. Again, there
were no significant differences in a standardized self-reported
outcome questionnaire between groups at last follow-up.15 The
authors recommended circumferential fusion to avoid non-
union and noted that patients achieved equivalent clinical out-
comes if they fused, regardless of the technique used.
Poussa et al have reported on the midterm (average 4.8 years)20
and long-term (average 14.8 years)19 follow-up comparing two
LWBK836_Ch64_p633-637.indd 634
cohorts of 11 adolescent patients with high-grade isthmic spon-
dylolisthesis treated either with noninstrumented in situ fusion
or instrumented anteroposterior fusion, decompression, and
reduction. Midterm results showed no significant difference
between groups in clinical, functional, or subjective postopera-
tive parameters. The reduction group had longer operation
times, greater intraoperative blood loss, and a higher number of
complications and reoperations.20 At long-term follow-up the in
situ group performed better on the Oswestry and Scoliosis
Research Society (SRS) questionnaires than did the reduction
group and had less adjacent disc degeneration and muscle atro-
phy on the magnetic resonance imaging (MRI). Of interest, two
patients from the group of patients fused in situ experienced
postoperative peroneal palsy, which was attributed to overdistrac-
tion caused by interbody grafting. The authors concluded that
fusion in situ should be considered the method of choice in
severe L5 isthmic spondylolisthesis.19 However, as the study was
not randomized and there were no baseline functional data, it is
unclear whether the groups of patients were entirely compara-
ble. Of note, preoperative slip was statistically greater in the
reduction group at baseline (p .037). Despite its shortcomings,
this is probably the best designed study to address the question
of reduction in high-grade slips so far.
Apart from these direct comparisons, the rest of the evi-
dence is comprised mainly by multiple series of patients treated
with a single surgical strategy, either in situ8,12 or varying tech-
niques of reduction.3,6,11,21,23 In general, all these series report
satisfactory results with the technique utilized.
If it was not for the increased morbidity potentially involved
with reduction, there would be a much lower threshold to per-
form it. Consequently, determining the direct cause of postop-
erative neural deficit is an important consideration. Hypothetical
causes for postoperative neurologic injury include direct pres-
sure on the nerve roots during decortication,13,22 impingement
of the nerve roots on the iliolumbar ligaments, extradural ten-
sion on nerve roots in the reduced position,17 and disc mate-
rial extruded into the canal.21 Of interest, Petraco et al showed
in an anatomical study that the tension on the L5 roots
increases in a nonlinear fashion, with 71% of the total nerve
strain occurring during the second half of reduction.17
Correction of L5 kyphotic slip angle slightly relaxed the ten-
sion on the nerve roots. As a result, some authors have recom-
mended partial reduction (50% of the slippage) as a safer
mean to achieve a balanced spinopelvic segment, giving more
importance to the correction of the slip angle rather than the
slippage severity.1,5,10,21,24
DECOMPRESSION
The indications for decompression of the neural elements are
motor deficit, radicular pain, and bladder or bowel dysfunc-
tion.12 Most authors agree that tight hamstrings and gait distur-
bances do not constitute neurologic signs and therefore do not
warrant decompression. It is important to remember that
decompression encompasses not only the posterior elements of
L5, but also the redundant fibrocartilaginous tissue at the pars
nonunion and the remaining pars up to the level of the
cephalad pedicle. Decompression has been associated with
increased pseudoarthrosis rates and slip progression. Some
authors do not perform decompression routinely in high-grade
slips, based on the assumption that most of the neurological
8/25/11 9:54:12 PM
 Chapter 64 High-Grade Spondylolisthesis: Fusion In Situ 635

TABLE 64.1 Comparative Series on Reduction and High-Grade Spondylolisthesis

Reference Year Sample Size and Type Nonunion Complications Main Conclusions
4
Burkus et al 1992 Twenty-nine adolescents 3/12 IS WI (two for group), L2-L3 IS fusion associated with
high-grade, 12 IS, 17 RE 2/17 RE spondylosis one each increased nonunion
group. and postoperative
progression.
Muschik et al16 1997 Fifty-nine adolescents slips 24% IS, 7% RE IS: one WI, two retrograde The study failed to
30% (29 IS ALIF, 30 RE ejaculation; RE: one demonstrate clinical
PA fusion) DVT, one irreversible improvement for RE
foot drop, one vascular despite better
injury, one ASD alignment.
Molinari et al15 1999 Thirty-two adolescents: 11 45%, 29%, and 0% Neurologic deficit in four TP area 2 cm2 was
fused posteriorly in situ cases with RE (groups 2 associated with
(group 1), 7 and 3); four nonunion; all three
decompression and instrumentation failures groups had similar
instrumented posterior in groups 2 and 3; two clinical results; solid
fusion (group 2), 19 cases of SMAS in group 1 union is associated with
reduction and AP with casting; two good results regardless
instrumented fusion transient urinary technique.
(group 3) retention in groups 2
and 3; one WI in group
3; one dural tear in
group 3
Poussa et al20 1993 Twenty-two adolescents: 11 Three cases IS; one One transient bilateral L5 IS is to be preferred in
IS, 11 RE case RE palsy in group IS; two adolescents with severe
external fixator minor spondylolisthesis
complications; higher
intraoperative blood loss
and reoperations for RE.
Poussa et al19 2006 Twenty-two adolescents: 11 All patients united Same as above At longer f/u (15 y)
IS, 11 RE at f/u patients in the IS group
had better ODI and
SRS scores, and less
adjacent segment
changes on MRI.

ALIF, anterior lumbar interbody fusion; ASD, adjacent segment disease; DVT, deep venous thrombosis; IS, in situ fusion; MRI, magnetic
resonance imaging; PA, posteroanterior; ODI, Oswestry Disability Index; RE, reduction; SMAS, superior mesenteric artery syndrome; SRS,
Scoliosis Research Society; WI, wound infection.

complications are caused by increased extraforaminal tension
on the nerve roots17 and that preservation of the posterior ele-
ments at L5 would increase the fusion success rate. Sailhan
et al21 reported on 44 patients with high-grade spondylolisthe-
sis who were treated with partial reduction and instrumented
posterior fusion without decompression. After a minimum 5
years of follow-up, they observed a 9.1% neurologic complica-
tion rate, with only a 2.3% rate of permanent motor deficit.
Five cases developed a nonunion. They reported 90.0% of good
or fair clinical results. Of interest, two of the patients com-
plained of postoperative leg pain that could have been related
to residual stenosis, but no preoperative or postoperative MRI
was available in this cohort.
INSTRUMENTATION
structs across the lumbosacral junction, as compared with non-
segmental instrumentation. On bovine specimens, McCord et
al14 compared 10 different lumbosacral instrumentation tech-
niques. They found that the greatest resistance to flexural
moments across the lumbosacral junction was given by the use
of medially directed S1 pedicle screws and iliac screws extend-
ing anteriorly between the ilium tables and the acetabulum.
From the clinical perspective, comparisons between groups 1
and 2 in the study done by Molinari et al15 supports the use of
instrumentation. The incidence of pseudoarthrosis was 45% in
the noninstrumented group and 29% in the group with decom-
pression and instrumentation. However, 29% of patients from
this second group had instrumentation failure (i.e., pullout or
breakage).15 The authors recommended the use of sacral screws
protected by a structural graft placed anteriorly and supple-
mented with bilateral iliac screws.

The addition of instrumentation appears to increase the suc-

cess rate of the fusion, permits reduction maneuvers, allows CIRCUMFERENTIAL FUSION
early mobilization, and reduces or obviates the need of postop-
erative immobilization. Biomechanical testing in calf-spine Most authors agree on the need of performing some form of
models has suggested increased rigidity with pedicle screw con- anterior intercorporeal or circumferential fusion in high-grade

LWBK836_Ch64_p633-637.indd 635 8/25/11 9:54:13 PM

 636 Section VI Spondylolisthesis
Ideal Candidate for In Situ
TABLE 64.2 Fusion in High-Grade
Spondylolisthesis
No gait disturbances
No postural anomalies
No radicular symptoms or deficit (no decompression required)
Large L5 transverse processes (2 cm2)15
Balanced pelvis (low PT and high SS, assuming high PI in high-
grade slips)10
Preserved C7 plumb line
PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope.
spondylolisthesis.3,23 Boos et al2 reported on the surgical results
of 10 patients with high-grade slips and spondyloptosis who
were treated with decompression, reduction, and instrumented
posterolateral fusion with pedicle screws. Eighty-three percent
of the patients treated only with posterolateral fusion devel-
oped pseudoarthrosis despite the use of instrumentation.2 The
results of the study by Molinari et al15 are interpreted in the
same manner: none of the patients receiving a circumferential
fusion developed a pseudoarthrosis. Of interest, 5 out of 19
patients comprising this group were failures from group 1 (in
situ noninstrumented fusion) that were revised circumferen-
tially. More recently, Helenius et al retrospectively compared
three groups of adolescents (n 70) with high-grade spon-
dylolisthesis treated surgically through posterior, anterior, or
circumferential in situ fusions without instrumentation.9 At an
average follow-up of 17.2 years, the circumferential group fared
better than the other groups in terms of postoperative progres-
sion of the lumbosacral kyphosis, SRS score, and Oswestry Dis-
ability Index (ODI) score. In summary, the addition of
interbody fusion either posteriorly or anteriorly based seems to
increase the success of fusion and prevents postoperative pro-
gression or recurrence of the lumbosacral kyphosis.
Based on the evidence outlined above, Table 64.2 contains
the characteristics of an ideal candidate for in situ fusion in
high-grade slips.
AUTHOR PREFERRED METHOD
Once surgery has been indicated, preoperative planning can-
not be overemphasized. The degree of lumbosacral kyphosis
both in standing radiographs and on supine hyperextension
films over a bolster may give an estimate of the degree of flex-
ibility of the deformity and the amount of reduction achieved
by positioning the patient on the table. A rigid nonreducible
kyphosis may warrant the use of alternative techniques such as
transsacral fixation techniques.1 Other factors to be considered
before surgery are the size of the L5 pedicles, which are fre-
quently dysplastic and small, sometimes precluding the inser-
tion of even small screws. However, most of the time it is possible
to at least insert one pedicle screw as a fixation point in L5,
especially with the aid of intraoperative fluoroscopy; other
aspects to consider are the presence of spina bifida occulta to
avoid injuries to the dural sac during the approach; small L5
transverse processes (2 cm2) on Ferguson views have been
correlated with the risk of nonunion and maybe hard to iden-
tify during the exposure.15
LWBK836_Ch64_p633-637.indd 636
After general anesthesia induction, neuromonitoring is set in
a standard manner with lower extremities electromyography and
motor evoked potentials. Albeit rare, neurologic deficit may
occur even in the absence of reduction maneuvers (see below).
The patient is then placed prone over a well-padded four-poster
frame or Jackson table. Thighs and hips can be hyperextended to
further reduce the L5 slip angle. In our opinion, most pediatric
cases are flexible enough to reach almost a normal angle by
doing this maneuver. Knees should be flexed to avoid excessive
tension on L5 roots.21 A posterior or posterolateral fusion can be
performed in a standard fashion through a single midline skin
and fascial incisions or through the paraspinal muscle-splitting
approach as popularized by Watkins and Wiltse.26 The use of sur-
gical loupes and headlight illumination is strongly recommended,
especially with the paraspinal approach. Advantages cited for the
paraspinal approach are to provide a direct route to the trans-
verse processes to be fused by using the natural plane between
the multifidus medially and the longissimus muscles laterally.
Using this dissection plane can allow posterolateral fusion to
occur in cases where trauma to midline structures is to be avoided,
as patients with prior laminectomies for instance. It also provides
an easy working plane for pedicle screw insertion. Disadvantages
are two separate fascial closures, less familiar anatomy, difficulty
to perform a formal decompression, and more difficulty with
placing retractors. The posterior elements of L3 down to S1 are
exposed subperiosteally from one transverse process to the other
on the opposite side. Careful dissection must preserve the facet
at the level of the top pedicle to avoid future cephalad adjacent
segment problems. Thorough hemostasis is maintained through-
out. Decompression is performed as needed as described above.
If instrumentation is used, anatomical landmarks must be clearly
identified and dissected as guidance for proper pedicle screw
insertion. Description of screw insertion techniques is beyond
the scope of this chapter. However, every surgeon must tailor the
safest screw insertion technique in his or her hands including the
use of anatomical landmarks, palpation of the pedicles through
the decompression, and the use of intraoperative imaging as
needed. Once screw positioning is checked, iliac crest bone graft
is harvested through the same skin incision and placed over the
properly decorticated transverse processes and sacral ala. Rods
are placed and secured. Although there is some evidence advo-
cating the use of iliac screws, in our experience this has not been
necessary if good purchase on S1 was achieved. Closure is per-
formed in the standard fashion. Postoperatively the patient is
placed in a single pantaloon brace for 6 to 8 weeks followed by a
brace with no leg extension for a similar period. However, we
recognize that in light of the use of current segmental instrumen-
tation, this may be not fundamental.
COMPLICATIONS
Pseudoarthrosis is probably the most common complication
after an intended in situ fusion for a high-grade spondylolisthe-
sis.5 Addition of instrumentation is recommended to increase
fusion rates and allow early mobilization.6 In high-grade slips
monosegmental fusion should include some form of interbody
fusion.23 It is recommended to include L4 in the fusion if one was
to perform only a posterolateral fusion in a high-grade slip. Risk
factors for nonunion are preoperative neurological compromise
requiring wide decompression, lumbosacral hypermobility,5 and
anatomic elements indicating high dysplasia such as small L5
8/25/11 9:54:13 PM

transverse processes (2 cm2),15 domed and vertical sacrum,
trapezoidal L5 vertebral body, spina bifida, and kyphotic slip
angle (50). Patients with pseudoarthrosis with persistent
symptoms require revision of the fusion mass, with or without
reduction of the slip angle, addition of interbody fusion, and
reinstrumentation.5 For the rare cases of solid fusion and neu-
rologic complaints, decompression and sacral dome osteoto-
mies may be necessary.
Postoperative cauda equina syndrome can be derived from
several factors. As previously noted it can occur without reduc-
tion or apparent reason. Numerous explanations have been
sought: vascular phenomenon, transient anterior displacement
of L5 during exposure, and hyperextension during position-
ing.22 Gentle retraction of the dura during interbody tech-
niques cannot be overstated. In delayed-onset postoperative
deficit, epidural hematoma is always a possibility. Emergent
MRI or computed tomography (CT) myelogram and timely
decompression are imperative.
Transitional problems at the cephalad level can be the result
of direct injury to the adjacent facet, iatrogenic pars fracture
due to excessive decompression, or adjacent segment disease.
As adjacent segment disease is still somewhat controversial and
long-term studies are sparse, minimizing the segments to be
fused and preservation/restoration of the sagittal alignment
are theoretically desirable.
REFERENCES
1. Boachie-Adjei O, Do T, Rawlins BA. Partial lumbosacral kyphosis reduction, decompres-
sion, and posterior lumbosacral transfixation in high-grade isthmic spondylolisthesis:
clinical and radiographic results in six patients. Spine 2002;27(6):E161E168.
2. Boos N, Marchesi D, Zuber K, Aebi M. Treatment of severe spondylolisthesis by reduction
and pedicular fixation. A 46-year follow-up study. Spine 1993;18(12):16551661.
3. Bradford DS, Boachie-Adjei O. Treatment of severe spondylolisthesis by anterior and pos-
terior reduction and stabilization. A long-term follow-up study. J Bone Joint Surg Am
1990;72(7):10601066.
4. Burkus JK, Lonstein JE, Winter RB, Denis F. Long-term evaluation of adolescents treated
operatively for spondylolisthesis. A comparison of in situ arthrodesis only with in situ arthr-
odesis and reduction followed by immobilization in a cast. J Bone Joint Surg Am
1992;74(5):693704.
5. Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in
children and adolescents: II. Surgical management. J Am Acad Orthop Surg 2006;14
(8):488498.
6. DeWald CJ, Vartabedian JE, Rodts MF, Hammerberg KW. Evaluation and management of
high-grade spondylolisthesis in adults. Spine 2005;30(6 Suppl):S49S59.
LWBK836_Ch64_p633-637.indd 637
Chapter 64 High-Grade Spondylolisthesis: Fusion In Situ 637
7. Hammerberg KW. New concepts on the pathogenesis and classification of spondylolisthe-
sis. Spine 2005;30(6 Suppl):S4S11.
8. Harris IE, Weinstein SL. Long-term follow-up of patients with grade-III and IV spondylolis-
thesis. Treatment with and without posterior fusion. J Bone Joint Surg Am 1987;69
(7):960969.
9. Helenius I, Lamberg T, Osterman K, et al. Posterolateral, anterior, or circumferential
fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation
using the Scoliosis Research Society questionnaire. Spine 2006;31(2):190196.
10. Hresko MT, Labelle H, Roussouly P, Berthonnaud E. Classification of high-grade spon-
dylolistheses based on pelvic version and spine balance: possible rationale for reduction.
Spine 2007;32(20):22082213.
11. Hu SS, Bradford DS, Transfeldt EE, Cohen M. Reduction of high-grade spondylolisthesis
using Edwards instrumentation. Spine 1996;21(3):367371.
12. Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine
1999;24(24):26402648.
13. Maurice HD, Morley TR. Cauda equina lesions following fusion in situ and decompres-
sive laminectomy for severe spondylolisthesis. Four case reports. Spine 1989;14(2):
214216.
14. McCord DH, Cunningham BW, Shono Y, Myers JJ, McAfee PC. Biomechanical analysis of
lumbosacral fixation. Spine 1992;17(8 Suppl):S235S243.
15. Molinari RW, Bridwell KH, Lenke LG, Ungacta FF, Riew KD. Complications in the surgical
treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of
three surgical approaches. Spine 1999;24(16):17011711.
16. Muschik M, Zippel H, Perka C. Surgical management of severe spondylolisthesis in chil-
dren and adolescents. Anterior fusion in situ versus anterior spondylodesis with posterior
transpedicular instrumentation and reduction. Spine 1997;22(17):20362042; discussion
2043.
17. Petraco DM, Spivak JM, Cappadona JG, Kummer FJ, Neuwirth MG. An anatomic evalua-
tion of L5 nerve stretch in spondylolisthesis reduction. Spine 1996;21(10):11331138; dis-
cussion 1139.
18. Pizzutillo PD, Mirenda W, MacEwen GD. Posterolateral fusion for spondylolisthesis in ado-
lescence. J Pediatr Orthop 1986;6(3):311316.
19. Poussa M, Remes V, Lamberg T, et al. Treatment of severe spondylolisthesis in adolescence
with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome.
Spine 2006;31(5):583590; discussion 591592.
20. Poussa M, Schlenzka D, Seitsalo S, Ylikoski M, Hurri H, Osterman K. Surgical treatment of
severe isthmic spondylolisthesis in adolescents. Reduction or fusion in situ. Spine
1993;18(7):894901.
21. Sailhan F, Gollogly S, Roussouly P. The radiographic results and neurologic complications
of instrumented reduction and fusion of high-grade spondylolisthesis without decompres-
sion of the neural elements: a retrospective review of 44 patients. Spine 2006;31(2):161
169; discussion 170.
22. Schoenecker PL, Cole HO, Herring JA, Capelli AM, Bradford DS. Cauda equina syndrome
after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction. J Bone
Joint Surg Am 1990;72(3):369377.
23. Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis: monosegmen-
tal surgical treatment. Spine 2005;30(6 Suppl):S42S48.
24. Smith JA, Deviren V, Berven S, Kleinstueck F, Bradford DS. Clinical outcome of trans-sacral
interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis. Spine
2001;26(20):22272234.
25. Transfeldt EE, Mehbod AA. Evidence-based medicine analysis of isthmic spondylolisthesis
treatment including reduction versus fusion in situ for high-grade slips. Spine 2007;32(19
Suppl):S126S129.
26. Wiltse LL, Bateman JG, Hutchinson RH, Nelson WE. The paraspinal sacrospinalis-splitting
approach to the lumbar spine. J Bone Joint Surg Am 50(5):919926.
8/25/11 9:54:13 PM