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Spondylolysis and Spondylolisthesis in Children and Adolescents: II. Surgical Management

Dr. Cheung is Fellow, Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN. Dr. Herman is Associate Professor, Department of Orthopaedic Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA. Dr. Cavalier is Attending Orthopaedic Surgeon, Summit Sports Medicine and Orthopaedic Surgery, Brunswick, GA. Dr. Pizzutillo is Professor, Department of Orthopaedic Surgery, St. Christopher’s Hospital for Children, Philadelphia.

None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Cheung, Dr. Herman, Dr. Cavalier, and Dr. Pizzutillo.

Reprint requests: Dr. Herman, St. Christopher’s Hospital for Children, Department of Orthopaedic Surgery, Front Street at Erie Avenue, Philadelphia, PA 19134-1095.

Surgical management is indicated for children and adolescents with spondylolysis and low-grade spondylolisthesis (50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low-grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw–laminar hook fixation are surgical options. The ideal surgical management of high-grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high-grade spondylolisthesis.

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