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[Surgical treatment of high-grade spondylolisthesis].

OBJECTIVE: Establishment of a physiological profile of the spine via reduction of the kyphotic slipped vertebra in the transverse and sagittal planes. Achieving solid fusion. Improvement of preoperative pain symptoms and prevention or elimination of neurological deficits.

INDICATIONS: High-grade spondylolisthesis (Meyerding grade 3 and 4) as well as spondyloptosis after conservative treatment and corresponding symptoms. Serious neurological deficits, hip-lumbar extensor stiffness, are emergency indications.

CONTRAINDICATIONS (CI): Individual risk assessment must be made. Absolute CI are infections with the exception of serious neurological deficits. Multiple abdominal operations or interventions on the large vessels can be a relative contraindication for ventral intervention.

SURGICAL TECHNIQUE: For spondylolistheses of grade 3 according to Meyerding, we recommend a one-stage dorso-ventro-dorsal procedure with radicular decompression, correction and fusion in the index segment. From grade 4 according to Meyerding, reduction of the fifth lumbar vertebral body in the index segment L5/S1 is preceded by resection of the sacral dome. In cases of spondyloptosis, a two-stage procedure is often indicated. In this case, a screw-rod system spanning the index segment is implanted in the first step, which is used to distract the index segment for several days. Ventrodorsal reduction is performed in the second step.

POSTOPERATIVE MANAGEMENT: Axis-appropriate full mobilization from postoperative day 1. We recommend a light diet until the first defecation. Dorsal suture removal after 12 days if the wound is dry and free of irritation. Lifting and carrying heavy loads and also competitive or contact sports should be avoided for 12 weeks.

RESULTS: From January 2000 to December 2020, a total of 43 patients with high-grade spondylolisthesis were treated in our clinic in the manner described. The Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) improved significantly during the observation period of 3 months and 1 year. The 1‑year radiological data in 28 of the 36 patients showed complete reduction of the slipped vertebra, in 6 grade 1, and in 2 patients grade 2 according to Meyerding. Also, the kyphosis of the index vertebra was significantly corrected from a mean of 15° (0-52°) preoperatively to a lordotic profile of a mean of 4° (0-11°). No complications requiring revision were observed. One patient with preoperative cauda equina syndrome was left with right radicular sensorimotor S1 syndrome.

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