R Vialle1, L Miladi, P Wicart, J Dubousset. 1. Service de Chirurgie Orthopédique Pédiatrique, Hôpital Saint-Vincent de Paul, 82, avenue Denfert-Rochereau, 75014 Paris.
Abstract
PURPOSE OF THE STUDY: This retrospective analysis involved a continuous series of twenty cases of lumbosacral spondylolisthesis with major displacement treated before maturity. We compared our experience using a non-instrumented lumbosacral fusion technique with the results of other techniques proposed in the literature. MATERIAL AND METHODS: We reviewed the cases of twenty children and adolescents who underwent surgery in our unit. For each case, we recorded the clinical history and course to last follow-up. X-rays were studied and manual measurements taken of the different parameters used to analyze the spine. Data were recorded in a database for statistical analysis. Sixteen of the twenty cases showed spinal deformation causing lumbalgia, generally associated with radiculalgia. Mean age at surgical treatment was 13 years 3 months, range 7 years 2 months to 17 years 6 months. All of the children has Meyerding stage 3 or 4 displacement associated with lumbosacral kyphosis. Surgical treatment followed a period of progressive reduction by traction and suspension in lordosis using a hammock. All twenty patients underwent posterolateral arthordesis using a cancellous graft between L4 and the sacrum. The fusion was performed after fashioning a thoraco-lumbo-pelvic cast including both thighs in the position of reduction. A complementary time for anterior arthodesis was needed for eight patients. RESULTS: The postoperative period was uneventful in twelve patients. Two children developed intestinal obstruction with a peritoneal bridle. Three children had an L5 radicular deficit and three sphincter disorders. All neurological disorders resolved in a few months. At mean postoperative follow-up of 5 years 3 months, the arthrodesis appeared to be fused in 19/20 cases. Only one patient presented a lucent line in the zone of the bone graft suggesting possible fibrous nonunion. Eighteen patients were symptom free and led a normal life. Two patients complained of moderately bothersome lower back pain. DISCUSSION: Many of the children in our series had major lumbosacral dysplasia with a verticalized sacrum, aggravating the lumbosacral kyphosis. This led to an increased pelvic tilt and decreased sacral slope. Progressive preoperative reduction of the lumbosacral kyphosis allowed conducting the lumbosacral fusion under favorable conditions. We did not open the spinal canal and avoided the mid line in order to protect as much as possible posterior spinal stability and preserve all the bone surfaces receiving the posterolateral graft. We reserved indications for complementary anterior lumbosacral arthrodesis to the most exaggerated cases of lumbosacral kyphosis. The therapeutic program is long due to the progressive preoperative reduction and the strict period of immobilization after surgery. In our experience, this approach allows quality lumbosacral fusion with good correction of the lumbosacral kyphosis. Neurological complications remain frequent and can occur during even slow progressive reduction.
PURPOSE OF THE STUDY: This retrospective analysis involved a continuous series of twenty cases of lumbosacral spondylolisthesis with major displacement treated before maturity. We compared our experience using a non-instrumented lumbosacral fusion technique with the results of other techniques proposed in the literature. MATERIAL AND METHODS: We reviewed the cases of twenty children and adolescents who underwent surgery in our unit. For each case, we recorded the clinical history and course to last follow-up. X-rays were studied and manual measurements taken of the different parameters used to analyze the spine. Data were recorded in a database for statistical analysis. Sixteen of the twenty cases showed spinal deformation causing lumbalgia, generally associated with radiculalgia. Mean age at surgical treatment was 13 years 3 months, range 7 years 2 months to 17 years 6 months. All of the children has Meyerding stage 3 or 4 displacement associated with lumbosacral kyphosis. Surgical treatment followed a period of progressive reduction by traction and suspension in lordosis using a hammock. All twenty patients underwent posterolateral arthordesis using a cancellous graft between L4 and the sacrum. The fusion was performed after fashioning a thoraco-lumbo-pelvic cast including both thighs in the position of reduction. A complementary time for anterior arthodesis was needed for eight patients. RESULTS: The postoperative period was uneventful in twelve patients. Two children developed intestinal obstruction with a peritoneal bridle. Three children had an L5 radicular deficit and three sphincter disorders. All neurological disorders resolved in a few months. At mean postoperative follow-up of 5 years 3 months, the arthrodesis appeared to be fused in 19/20 cases. Only one patient presented a lucent line in the zone of the bone graft suggesting possible fibrous nonunion. Eighteen patients were symptom free and led a normal life. Two patients complained of moderately bothersome lower back pain. DISCUSSION: Many of the children in our series had major lumbosacral dysplasia with a verticalized sacrum, aggravating the lumbosacral kyphosis. This led to an increased pelvic tilt and decreased sacral slope. Progressive preoperative reduction of the lumbosacral kyphosis allowed conducting the lumbosacral fusion under favorable conditions. We did not open the spinal canal and avoided the mid line in order to protect as much as possible posterior spinal stability and preserve all the bone surfaces receiving the posterolateral graft. We reserved indications for complementary anterior lumbosacral arthrodesis to the most exaggerated cases of lumbosacral kyphosis. The therapeutic program is long due to the progressive preoperative reduction and the strict period of immobilization after surgery. In our experience, this approach allows quality lumbosacral fusion with good correction of the lumbosacral kyphosis. Neurological complications remain frequent and can occur during even slow progressive reduction.