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A. Type I: Isthmic-lytic form:
1. Screw fixation and direct bone material repair of the spondylolysis
This operation can be carried out in cases in which lytic spondylolisthesis is recognized at an early stage. Studies show an expected rate of about 50 to 60% for the successful healing of the defect. This operation is only possible if there is little or no slippage and in particular if no damage has been done to the intervertebral disc (MRT).
2. Repositioning spondylodesis using the TLIF or ALIF method
If the process of slippage worsens, increasing degenerative damage to the intervertebral disc (overload), repositioning spondylodesis is then indicated. Repositioning spondylodesis can be carried out using both the TLIF or ALIF methods. Dorsal instrumentation and dorsolateral fusion alone seem insufficient to us, since the pseudoarthrosis rate is much higher after such procedures.
B. Type II: Isthmic-dysplastic form
The range of surgical indication is much wider with this form than with the isthmic-lytic form. In contrast to the isthmic-lytic form, the isthmic-dysplastic form can in many cases cause considerable suffering even in early childhood (beginning at age 3 or 4), which may then require surgical intervention. By the same token, surgery is clearly indicated if progression is observed in the isthmic-dysplastic form. We know cases involving progression often reach the full-blown clinical stage called spondyloptosis and that this can be a source of severe problems. In our view, surgical repositioning and fusion of L5/S1 should be done even in early childhood in the presence of even mild progression or symptoms, in view of the fact that repositioning is fairly easy to accomplish in children. Starting at age 12 or 13, in the presence of pronounced lumbosacral kyphoses, repositioning surgery is much more difficult and, above all, it is associated with a much higher rate of neurological
complications (paralysis of the L5 nerve). .
In general, 3 different surgical options are available:
1. Sole dorsal repositioning spondylodesis with temporary or permanent instrumentation of L4
2. Combined ventrodorsal repositioning, also with instrumentation of L4
3. Corporectomy of L5 and fusion of L4 in relation to S1 (Gaines procedure)
The most important objective of this operation is not only the repositioning of L5 in relation to S1, but also the elimination of the lumbosacral kyphosis and of pelvic retroversion. This can only be done in childhood or early adolescence. Such results are hardly feasible in adults, or at best involve a much more complicated procedure.
