Surgical management of high-grade spondylolisthesis: Current recommendations

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.