A three-year-old girl presented with primary complaint of severe low back pain with radiation to both lower limbs below the knees since 2 months following history of fall and marked restriction of her daily routine activities. After clinicoradiological evaluation she was diagnosed of having dysplastic L5-S1 spondyloptosis. A staged procedure was planned after thorough discussion with her parents. During initial stage she underwent posterior decompression along L5-S1 segment including exposure of bilateral L5 and S1 nerve roots followed by instrumented reduction (L3-S2 5.5 mm pedicle screws) utilizing a rotational-translational technique. No interbody fusion was done at L5-S1 level and inner nuts of bilateral L3, L4, and S2 screws were intentionally kept loose. Subsequently after about symptom-free three-year follow up, she presented with recurrence of symptoms and underwent revision surgery as per initial plan discussed with her parents. Removals of posterior implants were done followed by stabilization with larger diameter pedicle screws (6.5 mm) at L5 and S1 level. During the same stage through anterior transperitoneal approach L5-S1 interbody fusion was done. At one-year follow-up after second-stage definitive surgery, patient remains symptom-free and fully active without any radiological evidence of reduction loss or implant failure.
Spondyloptosis is an exceeding rare condition and more so ever publications concerning spondylolisthesis in preschool children are sparse in the existing literature, mostly in form of case reports [
A 3-year-old girl presented with primary complaints of severe back pain with radiation to both lower limbs below the knees 2 months following history of fall while playing as conveyed by her parents. Due to present problem she was able to walk only few steps and stand for about 5–10 minutes only. Her obstetric, developmental, and family history was normal. Inspection of her posture on standing revealed severe sagittal plane deformity including lumbosacral kyphosis and lumbar hyperlordosis with flexion at hips and knees (crouched position) (Figure
Crouched standing posture.
(a) Preoperative A-P radiograph lumbosacral spine. (b) Whole spine standing lateral view radiograph. (c) Flexion-extension lateral view of lumbosacral spine. (d) Sagittal reconstructed CT scan.
Sagittal T2 weighted MRI image.
In view of severe disability resulting from dysplastic L5-S1 spondyloptosis to the patient, surgical treatment was advocated to her parents after thorough discussion. Through a posterior approach exposure was done from L3-S2 level. On the basis of preoperative axial CT scan for the assessment of lumbosacral spine pedicle size, bilateral 5.5 mm diameter polyaxial pedicle screw insertion at L3, L4, S1, and S2 levels was done. Wide decompression was performed by removal of complete L5 lamina and superior portion of S1 lamina. Bilateral L5 and S1 roots wide foraminotomy was done, especially concerning far lateral exposure of L5 roots, and was followed by bilateral L5-S1 discectomy. Subsequently hip joints were placed in maximum extension position, which allowed a partial reduction of the pelvic retroversion and slip angle followed by a contoured rod attached on one side. A 5.5 mm diameter polyaxial reduction screw was inserted into contralateral L5 vertebrae pedicle and a contoured rod was inserted along this side. Tightening of L5 reduction screw nut was done slowly and gently resulting in pulling of its body to the rod between L4 and sacrum leading to anterior slippage correction. While performing this reduction maneuver, L5 and S1 roots were continuously observed for any undue tension or compression. Rod inserted on this side was secured by tightening of inner screw of L5 and S1 screws, and those of L3, L4, and S2 screws were kept loose (Figure
Intraoperative image (1st-stage surgery) showing loose inner nut of L4 pedicle screw (broad arrow) before final wound closure.
Postoperative standing lateral spine radiograph.
A-P and lateral radiograph of lumbosacral spine after 3-year follow-up.
A-P and lateral radiograph of lumbosacral spine following 2nd-stage surgery.
During the most recent follow-up of about 12 months following the subsequent surgery, patient is pain-free and fully active and on clinical evaluation her spinal alignment was found to be appropriate (Figures
A-P and lateral clinical photograph one year postoperatively.
High grade spondylolisthesis and spondyloptosis usually occur in dysplastic type involving lumbosacral region, although it has been stated in the existing literature that progression of slip beyond 25 percent is not possible without concomitant pars defect [
Generally surgical management is the accepted treatment for the high grade developmental spondylolisthesis [
Posterior in situ fusion without reduction usually performed between L4 and S1 vertebrae has low rate of neurological complication combined with minimal operative disruption [
Although there exists controversy regarding reduction for the treatment of spondyloptosis, it helps to restore segmental lordosis and correct sacral position which normalize the overall sagittal profile [
It has been suggested that reduction of slip in high grade spondylolisthesis produces a relative anterior column deficiency due to inability of abnormal lumbosacral disc to share load in the reduced position, highlighting the need of anterior column grafting [
Our decision to use pedicle instrumentation in a 3-year-old child after preoperative CT scan evaluation was based on the studies which have established their safe use in very young children without vertebral growth retardation [
The most serious complication of spondylolisthesis reduction is the iatrogenic neurological injury and it has shown to correlate with degree of reduction achieved [
On literature review concerning surgical management of L5-S1 spondyloptosis in preschool children (3–5 years), only one case report involving single case by Wild et al. was found [
Literature review regarding management of L5-S1 spondyloptosis in preschool children (3–5 years).
Authors | Number of cases | Age (year)/sex | Management |
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Wild et al. [ |
1 | 5 yr/male | During initial surgery three-stage procedure (back-front-back). L5 lamina resection and wide L5 nerve root decompression, anterior subtotal resection of inferior L5 body with interbody morcellized vertebral body graft between L5 and S1, and finally posterior instrumentation (L2-S1) with reduction of L5-S1 spondyloptosis. |
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Our case | 1 | 3 yr/female | Wide posterior decompression followed by 5.5 mm pedicle instrumentation from L3-S2 vertebrae including bilateral 5.5 mm polyaxial reduction screw for L5 vertebrae and spondyloptosis reduction via rotation translation technique. Subsequently inner nuts of bilateral L3, L4, and S2 pedicle screws were kept loose and no interbody graft was used. |
Although this is only a single case being the first to our knowledge, it highlights the strategy to tackle one of the most challenging pathologies faced by the spinal surgeons worldwide involving rare dysplastic L5-S1 spondyloptosis in a very young child. We recommend a staged procedure: first stage involving a rotation-translation technique for deformity correction to improve overall sagittal profile utilizing pedicle screw instrumentation which permits subsequent longitudinal growth of the involved spinal segments and second stage providing interbody support resulting in final fusion, thus reducing the growth potential loss and possibility of secondary deformity in the involved segments. However long term follow-up is necessary to determine effects of this surgical approach.
Vikas Tandon is the first author. The manuscript submitted does not contain information about medical device(s)/drug(s).
No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. None of the authors has any potential conflict of interests.