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Patient Outcomes in the Operative and Nonoperative Management of High-Grade Spondylolisthesis in Children

Lundine, Kristopher M. MD, MSc, FRCSC*; Lewis, Stephen J. MD MSc, FRCSC*; Al-Aubaidi, Zaid MD, MB, CHB; Alman, Benjamin MD, FRCSC*; Howard, Andrew W. MD, MSc, FRCSC*

Journal of Pediatric Orthopaedics: July/August 2014 - Volume 34 - Issue 5 - p 483–489
doi: 10.1097/BPO.0000000000000133

Background: The optimal management of high-grade spondylolisthesis in the growing child is controversial. Some authors have advocated for surgery in all cases regardless of symptoms. Surgical intervention results in a >10% risk of complications with increased risk of neurological injury associated with slip reduction maneuvers. There is a paucity of literature regarding nonoperative management in this setting. This study sought to obtain outcome measures in pediatric patients with high-grade spondylolisthesis managed either operatively or nonoperatively.

Methods: Database review was performed to identify patients with a high-grade (Meyerding grade III to V) spondylolisthesis managed either operatively or nonoperatively. Retrospective radiographic and chart review was performed. Patients were then contacted by phone to obtain current quality-of-life measurements using the Scoliosis Research Society (SRS)-30 questionnaire.

Results: Fifty-three patients were identified for inclusion in the study and 49 were contacted for 92% follow-up. Twenty-four patients were treated with operative intervention, and 25 patients were initially treated nonoperatively, but 10 went on to require surgical intervention. Mean age at presentation was 12.6 years (range, 8 to 17 y) and mean age at follow-up was 20.1 years (range, 10 to 29 y). There were no outcome differences between the groups. A more kyphotic slip angle was associated with worse SRS-30 outcome scores across all groups. In the nonoperative group, the slip angle was significantly larger in patients who failed conservative treatment (34±17 degrees) than in those who remained nonsurgical at final follow-up (20±14 degrees). Slip angle in the operative group was 27±14 degrees. In surgical patients, an older age at surgery was associated with better SRS-30 outcome scores.

Conclusions: Nonoperative management or “watchful waiting” of the minimally symptomatic or asymptomatic child with a high-grade spondylolisthesis is safe and does not lead to significant problems. Operative intervention for the symptomatic patient achieves similar long-term results compared with patients whose minimal symptoms do not warrant surgery. Delayed surgical intervention does not result in worse outcomes. Regardless of treatment modality, patients with a more kyphotic slip angle tend to have a poorer prognosis.

Level of Evidence: Level III.

*Division of Orthopaedic Surgery, Hospital for Sick Children, Toronto, ON, Canada

Orthopaedic Surgery, Odense University Hospital, Odense, Denmark

None of the authors received financial support for this study.

The authors declare no conflict of interest.

Reprints: Kristopher M. Lundine, MD, MSc, FRCSC, Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Ave. Toronto, ON, Canada M5G 1X8. E-mail:

© 2014 by Lippincott Williams & Wilkins