Historical evolution, management, and outcome of surgical treatment for high-grade spondylolisthesis

J Neurosurg Spine 42:784–796, 2025

This systematic review analyzes the evolution and outcomes of surgical techniques for high-grade spondylolisthesis (HGSL). Both reduction and in situ fusion are effective, but reduction carries higher neurological risk and in situ fusion higher nonunion risk. Larger, high-quality studies are needed to guide optimal patient-specific treatment.

• High-grade spondylolisthesis (HGSL) is defined as vertebral slippage >50% (Meyerding grade 3–5) and is rare, with no consensus on optimal surgical management.

• Surgical approaches are divided into reduction and fusion versus in situ fusion, with no gold-standard technique established.

• Reduction techniques are linked to more neurological complications, while in situ fusion (especially older techniques like Bohlman’s) has higher rates of nonunion and graft failure.

• Modifications using transsacral transvertebral screws and titanium cages have reduced nonunion and graft failure rates in in situ fusion.

• Most patients, regardless of technique, report good postoperative outcomes in pain and function.

• Choice of technique should be individualized, considering factors like sacropelvic orientation, pelvic balance, slip angle, and dysplastic features.

• Current evidence is limited to small, heterogeneous case series and reports; no prospective studies exist.

• Larger, well-designed prospective studies are strongly recommended before widespread recommendations can be made.