Minimally Invasive Surgical Techniques for Spondylolisthesis Treatment
Dustin H. Massel
Benjamin C. Mayo
Krishna D. Modi
William W. Long
Philip K. Louie
Kern Singh
REBUTTAL ▪ The Case against Spondylolisthesis MIS Techniques
Christopher J. DeWald
Spondylolisthesis refers to the anterior translation of the cranial over the caudal vertebra. Many types of spondylolistheses occur:
These include developmental and acquired pathologies (degenerative, dysplastic, iatrogenic, isthmic, traumatic, and pathologic spondylolistheses).
The two most common types of spondylolisthesis are isthmic and degenerative.
Spondylolisthesis generally occurs in a bimodal age distribution, with mechanical low back and radicular leg pain as the most common presenting symptoms.1,2,6 Isthmic spondylolisthesis commonly presents at 5 to 7 years old or in the early teenage years.1,6 Degenerative changes to the intervertebral disk in the fourth and fifth decades of life result in the late presentation of degenerative spondylolisthesis.2
The severity of spondylolisthesis is described based on a combination of clinical symptoms, the stability of the spondylolisthetic vertebral segment, and the radiographically diagnosed Meyerding grade, which corresponds to the degree of anterolisthesis between vertebrae.7 Definitive surgical management of spondylolisthesis is accomplished through stand-alone anterior (ALIF), lateral (LLIF), or transforaminal (TLIF) lumbar interbody fusions.8 High-grade (grade III-IV) spondylolistheses are generally treated with an open surgical technique rather than a minimally invasive technique due to the increased risk of slip progression and need for reduction prior to fusion.
This chapter aims to highlight the indications, complications, and outcomes associated with reduction techniques and methods of definitive surgical management.
SURGICAL TECHNIQUES
Stand-Alone Anterior Lumbar Interbody Fusion (ALIF)
Indications/Contraindications
Indications include chronic back pain of discogenic origin, spinal instability due to degenerative disk disease, degenerative scoliosis, low-grade isthmic and degenerative spondylolisthesis, adjacent segment degeneration, pseudarthrosis, tumor, or infection9, 10, 11, 12, 13 (Figs. 29.1, 29.2, 29.3 and 29.4).
There are few contraindications to an ALIF; however, calcification of the aortic or iliac vessels, obesity, current infection or a diagnosis of osteoporosis precludes ALIF.10,11
 Figure 29.1 Incision site used for a stand-alone anterior lumbar interbody fusion. The patient is placed in supine position with his/her arms secured over the chest and the skin is incised lateral to midline. |
 Figure 29.2 Transverse incision and underlying rectus abdominis muscle fibers. |
 Figure 29.3 Dissection performed in order to create a surgical plane inferior to the left rectus abdominis muscle. |
 Figure 29.4 Lateral representation of the spine demonstrating proper placement of the stand-alone cage within the intervertebral space following stand-alone anterior lumbar interbody fusion. |
Complications
Most commonly reported complications include abdominal muscle, vascular, and urologic injury, superficial infection, and superior hypogastric plexus injury resulting in denervation of the bladder neck sphincter or subsequent retrograde ejaculation.10,12,13
Additional risks include peritoneal perforation, major vessel injury or thrombosis, ureteral, lymphatic, and neurologic injury, cage dislodgement, and subsidence.12,13
Several studies have reported pseudarthrosis as a complication, which may require subsequent posterior instrumentation and completion of circumferential fusion.9
Outcomes
Lateral Lumbar Interbody Fusion (LLIF)
Indications/Contraindications
Indications include low-grade spondylolisthesis, segmental instability, adjacent segment degeneration, spondylosis with stenosis, degenerative disk disease, and postlaminectomy kyphosis between T7 and L4 vertebral levels10,21 (Figs. 29.5, 29.6, 29.7, 29.8, 29.9, 29.10 and 29.11).
The patient’s lower ribs may limit surgical exposure to the L2 level and below.
Contraindicated in high-grade spondylolisthesis, severe spinal stenosis, and patients with abnormal vascular anatomy.
The iliac crests generally preclude surgical exposure of the L5-S1 level, but the L4-L5 vertebral level is accessible in patients with low-lying iliac crests.
Adequate vertebral access is determined by preoperative fluoroscopic imaging.
Complications
Risk of neural injury to the lumbar plexus nerve branches, superficial (genitofemoral nerve) and deep (femoral nerve) to the psoas muscle.
Care must be taken to properly retract the psoas muscle as improper retractor placement may result in psoas muscle or lumbar plexus injury, leading to the most common complication, iliopsoas weakness (L1-L3).10,21
Figure 29.5 For a lateral lumbar interbody fusion the patient is positioned on the operating table in lateral decubitus position with the operative site in line with the break in the table so when flexed the space between the iliac crest and lower ribs is maximal.
Figure 29.6 Under fluoroscopic guidance, the disk level is identified and marked. The skin incision is made, exposing the fibers of the underlying external oblique muscle.
Figure 29.7 Incision performed on the external oblique muscle, parallel to its fibers, exposing the underlying internal oblique muscle fibers.
Figure 29.8 Exposed transversalis fascia obtained following incision of the internal oblique muscle.
Figure 29.9 Blunt dissection through the transversalis fascia with a Kocher clamp, allowing entrance into the retroperitoneal space and exposure of the retroperitoneal fat.
Figure 29.10 Surgeon performing a lateral annulotomy while protecting the neural structures retracted with the psoas muscle posteriorly.
Figure 29.11 The final implant impacted into place.Related posts:
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