In a talk with relevance for both adult and pediatric spinal care providers, orthopedic surgeon Sigurd Berven, MD, discusses complex decisions on whether and how to treat a child with high-grade spondylolisthesis. Describing the surgical options available and the evidence on which may avert the need for later interventions, he emphasizes the value of skillful reduction, which often makes a quality-of-life difference in adulthood.
thanks to Delano Lee and Kyle for sort of just a terrific program and for a wonderful venue. Thanks to all of you for choosing to be here this afternoon when the alternatives right out the door is such a beautiful tropical paradise. I appreciate, I appreciate you being here. So there are some more, some more seats over here so we can take my seat even if people want to sit down. So I'm going to talk about uh Hispaniola thesis with a, with a focus on this plastic older thesis. And uh, I'm gonna give a focus on the pediatric aspect of this but also recognizing the transition from pediatric deformity to the adult. My practice at UCSF is primarily adult deformity, but I have the honor of taking care of a number of Children, both who are referred to me directly as well as occasionally get to operate with my partners who Lionel and Mohammed who have more of a primary pediatric practice. And I say the honor because there's no greater honor than a parent asking to take care of their child, especially with the severe deformity. These are some of my disclosures. Many of you are aware. We have a big grant from the NIH for looking at back pain. National Science Foundation's has funded somewhere work with predictive modeling. Um, the Jonah area are over the last 2-3 years. Those are actually no longer because I'm now a board member for nationals. So I'm no longer receiving any honoraria for talks. Um, and I've got some rolls with variable journals. So as an overview. I'm going to talk about pediatric conditions and recognizing That we've got a combined audience here. Many of us are dealing with primarily pediatric, many of us primarily adult spying, but learning from one another and in many cases doing both. Lionel's practices very much both. About 5050 would you say Lionel and and to that end, um, there's so much we can learn from each other and I think that's what's really special about this course. Again, thank you for putting this together and bringing together an audience where we really have the opportunity to learn from one another. Again, the focus can be on high grade Olaf thesis. We'll talk about the impact of all this thesis and health status. Why I think reduction is important. Now go through some surgical techniques for how I like to reduce uh more dis plastic prosthesis cases and then I'll just maybe wrap it up with a couple of case examples of what happens when we don't do a good job of reducing deformity. So again, with regard to pediatric spinal deformity, a lot of broad spectrum conditions. These are all some patients of mine between congenital deformity, neuro muscular problems. Different syndrome, mantises, neurofibromatosis, idiopathic deformity, certainly being the most common for scoliosis, saddle, playing mala alignments between Shermans and our focus today is going to be the oldest thesis or forward slippage of one vertebra on the subject isn't vertebra and our focus is primarily going to dis plastic today. I would like to bring up one of my mentors, john Hall who many of you recognized john hall was at Children's Hospital. I was a fellow there before I went to UCSF to do my adults buying fellowship and and one of his great quotes, I've got a lot of them. But what if it's one of the really good ones is the decision of whether or not to operate is far more important than the decision of how to do the surgery. He used to be somewhat disparage and say I could teach a monkey or I can even teach you how to put a screw in uh where he used more hooks and screws to be honest. But uh, but the idea of being that the decision of whether or not or when to do surgery is so important. And you know, some of the classic examples that I like to think about R one C versus R. Three C curves and you know, should we really be doing three C curves and adolescents versus letting that go into adulthood? I don't know, I think there's an active as an active area of controversy. I spoke about that. I think that our last meeting here and then, you know, spinal the thesis when when do we treat the patient with a display plastic college thesis to avoid a more significant deformity and lumber pelvic uh mile alignments. So again, our focus will be displaced and I still like the Wiltse Newman McNabb classification. I think the notion of understanding different forms of ischemic and degenerative. All this thesis is important. On the right hand side is pretty straightforward is Nicholas? This is typically, it's more of a nutcracker mechanism in patients who have a lower pelvic incidents and lower pelvic tilt as opposed to or degenerative. Older thesis, which is really more particular to the adult. But the display plastic college thesis. I think the marchetti embroidered Alozie classification really becomes valuable here and this is really to look into the ideology of deformity. I think it's much more descriptive and most of the time the subset of patients who are dealing with a really high grade to splash tickle a thesis. This is a developmental problem and typically we have the license or elongation of the pars and the real risk factor here mostly recognizes the subsidy patient with a very high pelvic incidents where they're both the center axis of gravity has moved forward compared to the back of the sacrum as well as the high cycle slope. And those added together create a significant share forces between L. Five and S. One and with growth that develops into a potentially high grade dcis. This is a classification that was put together by hubert Labelle and I find this quite useful. I was as part of this investigation. We classified this plastic holders are classified spawn on this thesis and the types that I'm going to focus on are really two, Type five and six. So the subset of patients who have a high grade olis thesis and they both have a spine of pelvic alignment. So between basically these patients have a high pelvic tilt. So there's a mala alignment, hubert chose the word imbalance, but now we'd use really matter alignment and that's the type five where they maintain their global alignment. But they've got a significant high pelvic tilt, spinal pelvic alignment. And then the type six is a subset of patients who have a global model alignment, who have a significant tilt to their spine, as well as a high pelvic tilt. So despite having a high pelvic tilt, despite retrofitting the pelvic still remain with a global mile alignment. You know, if she is not looking to get rid of this too, because I'm literally licking the inside of that mask, tried sean dan told me it was okay, okay, thanks. Um so, so most of you recognize the work that steve last man had done looking at the radiographic predictors of health status and really identifying the fact that it's the sagittal vertical axis of the global alignment of the spine that's most predictive. And we looked at um the location of curvature Z. Imaginative curvature Z. And the sagittal alignment was the most predictive of health status and and and analogous to that. This is work that hubert Labelle again and jean marc de ended looking at patients in this case pediatric patients with a high grade olis thesis. And what they found was a subset of patients who had a high spinal tilt and a global model alignment. That subset of patients reliably had worse health. Would quality of life scores who had worse uh self assessment of their health status um and significant and actually a higher correlation than we got with the scoliosis patients. This is a classic paper, I think it's worth spending just a moment on. It was done by the group in Minnesota and bob winter Dave Bradford were part of this looking at patients in this case, Children and adolescents with severe Alexis is in the spectrum of things that they did non operative care fusion insight to decompression with fusion site to versus reduction. The vast minority of patients. So less than a quarter of these patients actually had a fusion with the reduction. And so the question became, well, when should we do a fusion reduction? And what they found here was it pretty reliably the subset of patients who had a high slip angle to recognize the relationship between five and a poster margin of sacrum. Is there slip angle that was really most predictive of patients having neural symptoms and most predictive when high slip angle was not reduced. Those were the subset of patients who went on to progressive deformity who went on to progressive trouble and needing something done as a revision procedure today suggested that really paying attention to the slip angle is also important and that's long before the more recent references that I put in there. So here's an example of a patient minus as a 17 year old boy. And you can recognize some of the features of a high grade display. Last ecology thesis. Very high pelvic tilts. A pelvic tilt I think was over 40 degrees. You see the domain of the sacrum, the trapezoidal shape of L five and the displacement of L five, the oldest thesis or forward slippage of L five relative to the sacrum. Characteristically the patients will walk with a failing Dixon type gates, a very tight hamstrings, L five, ridiculous pain, sometimes weakness in his case. He actually did have weakness prior to surgery, heart shaped buttocks reflecting the retro version of the pelvis and a lot of different approaches we might use to this uh for this and I often say that the presence of variability, it's clear evidence of the absence of an evidence based approach. Dylan, I see you don't have a timer up here. So I'm gonna put my timer because I I will talk all night. Um and nobody wants me to do that. So to that end a broad spectrum of options and how we might treat this type of deformity. Going back to the radiographic parameters. And I think one of the real challenges we deal with. Certainly an adult performing. We talked a lot about the distribution of Lord doses and how do we restore lumbar sacral Lord doses. And uh in the pediatric world I think it's equally important the challenge of really creating LORD doses between L. Five and S. One. And I think that that creates a biomechanical environment that's much more amenable to fusion. And that's also awfully important in terms of restoring overall alignment of the spine. So um again a lot of variability whether or not we ought to reduce these high grade dcis cases or not. And some of the strongest evidence for leaving these cases insight to comes from the group in Finland. And this is uh Helenius and and uh opposed to who put together a long term follow up here. So the average follow up in these patients was over 15 years and these are patients followed into adulthood from surgery that was done as an adolescent. And what they showed here quite interestingly and importantly is relatively small number of patients who either underwent a surgical reduction infusion versus an insight to fusion. And they actually found that overall the patient with an insight to fusion had less complications and did at least as well actually by many measures slightly better when you actually look at this paper in some detail that it brings up the question of how well were they really fixating these patients. And you can see this is an example of a patient who had a reduction infusions infusions from L. Four to S. One. But you know, with these little dinky thumbtacks here in the sacrum no public fixation. So it's no wonder that constant like that is going to fail. So I'm not sure that that's really our our best argument for insight to fusion versus reduction when this is a technique of reduction. I think some of the work that Jorgen Harms has done with regard to advocating reduction of deformity, having high rates of fusion and good clinical outcomes. In his case, patients with high grade developmental developmental Asus is 23 were pain free forehead, moderate pain. But the trouble here is that a good number of them so fully um Do some quick math in my head here, but more than 20% ended up with L5 policies, most of them resolved. But having said that that certainly is a risk in these cases. So looking at the pluses and minuses, reducing the child with an older ceases. The pluses are. We get improved arthur dcis, we have better bone on bone surfaces for fixation, I think biomechanically we're not having our poster infusion put under tension and we'll get a better surface area of contact between L. Five and S. One for fusion. We also restore our global alignment and our global alignment is clearly associated with health related quality of life. Of course was the risk. Well the potential of an L5 policy compromised neural elements that might not recover if you look at games work looking at his procedure for spinal apoptosis fully. 25% of those patients did not recover their policies and also the possibility of loss of fixations. So, um when we're doing the surgical reduction, we're putting a lot of strain on our fixation and the possibility that loosening or even failing. So again, going back to this case, I'll just show you this was a patient, 17 year old boy. Uh He was a senior in high school in reno Nevada had significant weakness to L. Five bilaterally. And I want to show you this uh from pre op to post up because this isn't a perfect reduction. So if you look at this actual marketing grade here, so the grade of all this thesis, this is still a grade two older thesis. So I'm putting this up here with some humility to recognize this wasn't a perfect reduction of his old assistance. I can tell you what happened, interrupted lee is I put fixation in L. Four. Um I I was expecting his trans odysseus screws for fixation to pelvis. And as I was bringing L four back and bringing L five back onto the sacrum Every time I pulled it to less than a grade to his L5. His motor's dropped to L5. So it took down some more of the sacrum. And I'll show you this in a technique. Video. A short and sacrum tried to shorten the distance a little bit, but I really didn't feel that I could reliably get this further reduced. But I think the point here that I want to make is what I did is I did the Bollman technique and put trans Osti screws from S. One in L. Five. You see on the A. P. I put a fibula across there as well, I guess I don't have the ap there's yippee. You see a fibula that I used the A. C. L. Remember and put a 10 millimeter piece of fibula across chances are she said, well, we showed a very good fusion rate in 23 patients where we did this technique. But the point being that the improvement of his lumbar sacral infosys, so if you look at his slip angle, which is the angle between L. Five in the back of the sacrum, his slip angle is about 60 degrees Stefanik before surgery. And he's brought back into a lower idiotic posture after surgery without also a dramatic consequent improvement of his pelvic tilts. I'd argue that in terms of the goal of improving lumber pelvic alignment was done even without a perfect reduction of the older thesis and that ought to be a lesser goal than the lumber pelvic alignment. Um And just briefly we did a study with spinal deformity study group hubert Labelle was part of this as well and Pierre Roussel and and others and we showed that in adults there was a very similar correlation that adults with high grade this plastic holders thesis. Also the global alignment was the number one predictor of poor health status. And there was a modern correlation between global mala alignment and health status metrics. We also found that subset of patients who are chi fanatic in their lumber cycle infosys did worse than the subset of patients who are lord dot again, making an argument that overall these patients do better when we realign them. Um And patients as you expect with the higher grade olis thesis had worse function than the lower Grade 11 thesis. So here's a different example. This is also a 17 year old boy but a different clinical presentation. This guy was a cross country runner, a rower and he was really unable to participate in sport for his sophomore or junior year going into his senior year now. And these are his x rays. Again, showing some domain in the sacrum trapezoidal L five. This napoleon hat type appearance here on the A. P. U. C. On the advanced imaging, uh, maybe a partial reduction on the advanced imaging but significant L five pyramidal stenosis. Um, and uh, this is a technique that I tend to use as I tend to take the ecosystem and most of the time in my adolescence. My pediatric work, I tend to do this from the back, I'll shorten the dome of the sacrum and really prepare between L. Five and S. One as if I'm doing a very aggressive T lift. And in this instance with fixation into L. Five and the pelvis, you see my my dish shavers here in Austria tone coming across the top of S. One, really trying to shorten that gap and that enables me to pull back L. Five with a little bit of laxity in the L. Five routes and anytime I can get this reduced to a grade two or less or grade one or less, I'll typically put in an inner body key so I'll just do a T lip on that. If I'm a grade two or higher, then that's where I'll tend to maybe use my Transocean's fixation. So this depends a little bit on how much room I've got bone on bone. This is another 17 year old boy, but a slightly different technique rather than going trans odysseus, I got a better reduction. So I used the T. Live here And I think I'm gonna be able to show you this on a video and Dylan, if if you would just maybe show here you see in this case I'm using a paddle and taking this is a different case, but really taking that paddle and being able to use a combination of leverage and reduction screws to really pull that L. five back. Okay, you can go ahead to the next slide but that that's sort of the technique in real time of really being very aggressive about that hysterectomy and actually using my entire body tools to really pull L. Five back as I'm using reduction screws on L. Five. Um That that case I was just showing was actually an adult, but I actually it's actually a lot easier than a child. What about anterior surgery? Certainly from my ultimate goal is the assistant adults. I really like to do anterior surgery with either open or post your poster per catania's in the back. More often, to be honest, I prefer an open surgery because I find that that part is that all five, the proximal part of that part is right below the medical. I really find it that despite my my best reduction work, but if I don't take out that part is they don't find fruit. I really worry about that and I don't have much tolerance for persistence of L. Five particular opinion. I think it's a lot easier to get it the first time around. Well, what about the role of anterior surgery and a higher grade Olaf thesis and a low grade dcis has got a relatively low sacral slope that's pretty easy to get from the front. But in some of these just plastic cases, it can be a little more challenging. Uh This is actually an adult who's got a display plastic Alexis's again, L. Five S. One significant dominated sacrum. She's had progressive al-5 particular paying a lot of a lot of um a lot a lot of both pain and deformity this is actually I'm sorry this is a simple case here. So I like I like going entirely on the simple cases but here's a here's a dis plastic case. Again in this case an older woman decreased ability scan significant sagittal plane mal alignment. You can see the thoracic hypoxic infosys here. This is a compensatory mechanism that that's combined with the high pelvic tilt to try and get global alignment. And she's got a significant spinal pelvic mala alignment. And you see here just a closer up to see the L. five s. 1. Uh the the significant deformity of L. Five on S. One C. T. Scan showing that she's got some bridging osteo fights here in the front. This could make a reduction a little bit more difficult. But she truly did complain of a satchel mile alignment. So I really did want to get a realignment on her And anytime you C2 vertebra on the same actual cut. You know it's a significant deformity And again the severe Franco narrowing that was causing uh intolerable ridiculous pain especially when she stood there was some motion between L. five and S. one. So this is the case that I chose to do from the front just because it was so stiff. I thought I would have trouble doing it from the back and again most of the time in my pediatric world. I do these from the back but what I did here is went into the front and I actually took off that and curiosity fight at the bottom of L5. Got into that inter space. And what I did is I put my inner body cage and I put two screws up into L. Five. So I've got an L. Five. S. One antibody cage. Good fixation in L. Five and using my Cajun sucker. I just with a bit of distraction and force an occasion for a bit of bit of tapping. I always say I do nothing with more than £5 of pressure, which it really is true. And so I reduced l. five on 2 s. one. So you see here one selfies reduced on the s. One from the front really created a nice space for the frame and put a screw in the S. one. I added a plate onto this just for security and then went to the back to do my standard fixation with the back because there's there's just too much tension on this construct to leave that as a stand alone. So this is her from pre op to post up I think well maybe I won't show you that that's her reduction postoperative, so dramatic improvement of the pelvic tilt and in this case her ridiculous symptoms. So I think I don't often do this from the front and back in Children. But I think that that that that can be done. And the trick to this is really gaining fixation on the L. five and pushing your old drive back and but I would never do this as a standalone anterior. So so I'm gonna wrap wrap up here and and uh very quickly actually I just thought I'd show you a couple of cases of what happens when we don't reduce the oldest pieces. And this is a a 14 year old girl who had undergone a fusion L. Five S. One and very reasonable fixation here. L four, L. Five S. One fixation as two screws. And in this instance I would suggest that without any answer columns support. That put a lot of strain on these posterior rods and resulted in raw breakage. And I revised this with a front and back approach to an anterior and posterior to get a better better reduction of that. High grade 11 thesis. Here's another example again of high grade overseas sis that was fused from L. Four to S. One. That just puts a lot of tension on that and that's just typically not confused without good antique columns support. I think at a minimum here if you don't want to reduce it all the way to do something trans odysseus with both us one screws and perhaps with a fabulous well and I revised this one as well with a front and back approach and actually know what in this one. I think what I did is I used trans Austria screws from S. One into L. Five and I did 4 to 1. But you see the dramatic difference in the alignment from pre op and how much this fusion is under tension compared to this being under compression. And then then here's a final example of somebody. This is actually an adult who had a fusion. I think you can see it better on the ct scan. This plastic overseas is that L. Five and S. One initially had a fusion from L. Four to S. One. It was standing up to L. Three to S. One. And then the trouble with with this type of an alignment when L. Three is actually kinda phonic then that can reliably result in progressive adjacent level problems. And somebody had the bright idea to think that maybe distraction instrumentation would be appropriate here. So now this patients actually fused from L. One down to S. One completely. Type phonic across the lumbar spine. So so I revised this with a three column Asiata me. But I think that this is the case that maybe this patient would have done better in the long run had that overseas has been reduced when he was a child and that this is just his postoperative films after his realignment. Um So in conclusion I think that lumber pelvic parameters are really important both in the ideology of bullish thesis. Again the high pelvic incidents being a risk factor for developing in this plastic bullets thesis. and also when we leave the lumber pelvic parameters mala lined this is clearly associated with compromised health status. So I think the role of reduction is important. I think it improves health status in patients and Both Hubert Labelle and I showed that in pediatric and adult patients. And I think that reducing policies as well, it can be technically difficult. I think it's really worth it, especially in our Children. We think about 15, 20 year follow up these people are still very, very young adults. Um, and I will point out that, you know, one of the things that really works well for us at UCSF is how we work as a team. It's not just an orthopedic surgery neurosurgery combination is within our divisions working together and in a lot of these high grade plastic cases will be doing these together as a team. And I think that there are certain things, you know, that, that some of us do better than others and others to better and just learning from each other. It's such an important part of working well together. And I think that my partners here lee and Lionel and and certainly, you know, Kyle's been part of our program, what we've learned from each other is incredibly valuable and, and I still treasure being able to work together in some of these complex cases. I think there's nothing more lonely than having now five calls here or even called a quite a problem when you're all by yourself. So that's maybe one message I would take from what we're, what we're doing at UCSF. That really works well, so thanks so much and I'll take maybe a couple of questions. Mm hmm.