CHAPTER
67
High Dysplastic Spondylolisthesis:
Anatomic Reduction. The Harms/
Shufflebarger Technique
INTRODUCTION
The surgical treatment of high-grade dysplastic spondylolisthe-
sis has been the subject of multiple methods and descriptions
over the past century.2,3,5,9,10,13,14 This report concerns a tech-
nique of reduction and stabilization of high dysplastic spon-
dylolisthesis developed by Professor Juergen Harms3 (personal
communication, July 1993), which was adopted by the author
some 15 years ago. The procedure requires an understanding
of the pathomechanics of high-grade spondylolisthesis, effect-
ing a near anatomic reduction of the deformity, and establish-
ing structural anterior column support and the posterior
tension band.
This section is concerned only with dysplastic spondylolis-
thesis grades III and IV, with associated lumbosacral kyphosis.
The described procedure is applicable to lesser degrees of dis-
placement and kyphosis. In the Marchetti and Bartolozzi clas-
sification scheme,7 this deformity is a developmental, high dys-
plastic spondylolisthesis. The measurements of pelvic incidence,
sacral slope, and pelvic tilt are key to understanding the patho-
logic anatomy. The reader is referred to the work of Mac-
Thiong and Labelle for a complete discussion of these mea-
surements and a classification of the spondylolisthetic
deformity.6 In this classification scheme, this deformity is a
high-grade spondylolisthesis. The pelvis is either balanced or
retroverted, depending upon the pelvic incidence, sacral slope,
and pelvic tilt.
PATHOMECHANICS OF HIGH-GRADE
DYSPLASTIC SPONDYLOLISTHESIS
The primary anatomic changes are dysplasia of the posterior
elements at the lumbosacral junction. These changes include
facet dysplasia, lamina dysplasia, and spina bifida occulta (usu-
ally of the sacrum). Deficiency of the posterior bony hook, the
pars interarticularis, is the primary event leading to develop-
ment of spondylolisthesis. The deficiency is manifest either as
fatigue failure or elongation of the pars. Instability at the lum-
bosacral junction results, leading to disc degeneration and loss
660
LWBK836_Ch67_p660-667.indd 660
Harry L. Shufflebarger
of anterior column load sharing. Segmental instability results,
permitting anterior displacement of lumbar five relative to the
sacrum. Secondary changes develop over time. These include a
monosegmental kyphosis, wedging of lumbar five, and doming
of the sacrum.
Changes in the sagittal spinopelvic alignment may result,
dependent upon the sagittal orientation of the sacrum and pel-
vis. Figure 67.1A depicts an example of high pelvic incidence
and high sacral slope with large shear forces across the lum-
bosacral junction. Figure 67.1B depicts an example with low
pelvic incidence and sacral slope, with much less shear force at
the lumbosacral junction (adapted from Mac-Thiong and
Labelle).6
Shear forces at the lumbosacral junction are normally
resisted by an intact posterior bony hook (tension band) and a
competent intervertebral disc (anterior column support).
Figure 67.2 demonstrates lumbosacral forces with an axial load.
It can be appreciated that the resultant shear force increases as
the verticality of the disc space increases. Failure of these struc-
tures results in inability to resist the lumbosacral shear forces.
Figure 67.3 demonstrates the increasing shear forces associated
with the segmental instability and the anterior displacement of
lumbar five.
The restoration of the ability to resist shear forces at the
lumbosacral junction in high-grade spondylolisthesis requires
establishment of the posterior tension band and provision for
anterior column support to execute a successful surgical proce-
dure. This requires reduction and restoration of the sagittal
spinopelvic alignment and balance. Figure 67.4 demonstrates
the anterior column deficiency produced by reduction of spon-
dylolisthesis. This space must be filled to provide anterior load
sharing.8 In addition, Figure 67.5 demonstrates the ability to
increase lumbosacral lordosis with posterior compression (the
tension band) with a structural interbody member. This is lik-
ened to using a hand truck. Figures 67.6A to C graphically dem-
onstrates reduction with establishment of the posterior tension
band and structural anterior column support.
The mechanics at the lumbosacral junction of high dysplas-
tic spondylolisthesis consist of segmental instability with a
deficient posterior tension band and lack of anterior column
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 Chapter 67 High Dysplastic Spondylolisthesis: Anatomic Reduction. The Harms/Shufflebarger Technique 661

A B

Figure 67.1. (A) High sacral slope is present with a balanced pel-
vis in this representation of a high dysplastic spondylolisthesis. High
shear forces are present at the lumbosacral junction. (B) Sacral slope Figure 67.3. A high dysplastic spondylolisthesis is depicted. Note
is low with a retroverted pelvis in the high dysplastic spondylolisthesis. the increased shear forces at the lumbosacral junction.
Shear forces would be less at the lumbosacral junction.

support. Axial load forces are generally converted to shear

forces, resulting in increasing displacement of lumbar five and
increasing shear forces. Correction of the deformity requires
reduction with provision of the posterior tension band and
anterior column support (see Table 67.1).

RATIONALE FOR REDUCTION OF HIGH

DYSPLASTIC SPONDYLOLISTHESIS
Reduction of high dysplastic spondylolisthesis has a deserved
bad reputation. Schoenecker et al describe the procedure as
extremely demanding and potentially dangerous.12 Multiple
other authors report catastrophic neurological injury, nerve
root deficits, nonunions, progressive slippage, and the need for
revision surgery.9,10,12
Fusion in situ is not without complications and problems.
The deformity remains with in situ fusion, as well as the sagittal

Biomechanical Keys for

TABLE 67.1 Reduction of High
Dysplastic Spondylolisthesis
Restoration of sagittal spinopelvic alignment
Requires reduction of spondylolisthesis
Restoration of posterior tension band
Figure 67.2. The forces acting at a normal lumbosacral junction Requires posterior instrumentation
are depicted. The resultant shear force is relatively small and is Provision of anterior column support
resisted by the intact posterior bony hook and the intact lumbosacral Requires interbody structural graft
disc.

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 662 Section VI Spondylolisthesis

Figure 67.4. Reduction of the

high-grade spondylolisthesis is
depicted. Note the anterior column
deficit produced with reduction. It is
necessary to place a structural member
in the anterior deficit, or the reduction
will most likely fail.

spinopelvic malalignment. This can only result in adjacent seg-
ment deformity and early degeneration. In addition, a 6% inci-
dence of cauda equina syndrome has been reported with only
fusion in situ.12 Additional problems with in situ fusion include
progression of the deformity, pseudarthrosis, and failure to
relieve symptoms.2,9,10
Spondylolisthesis reduction and fusion, correcting the sagit-
tal spinopelvic imbalance, are desirable for multiple reasons.
The deformity is corrected. Arthrodesis should and usually
does occur in excess of 95% of cases. Reduction of the defor-
mity reestablishes the normal biomechanics of the lumbosacral
junction. Shear forces are neutralized. Anterior load sharing is
restored, as is the posterior tension band. Posterior bone grafts
are not under tension forces. All of these mechanical factors
favor union. Monosegmental fixation and fusion may be accom-
plished. With restoration of sagittal spinopelvic alignment and
monosegmental fusion, adjacent segment deformity and degen-
eration should be minimal. Restoration of normal lumbosacral
lordosis decreases the compensatory increases in lordosis prox-
imal to L5-S1. This mechanical fact theoretically decreases the
potential for proximal junctional degenerative disease.
Reduction, primarily sagittal plane rotation or lumbosacral
kyphosis correction, can be accomplished with neurological
safety, particularly regarding the lumbar five roots. Translational
correction, secondary to kyphosis correction, occurs as a by-
product (see Table 67.2).

A B

Figure 67.5. (A and B) Here is depicted the ability to increase lumbosacral lordosis by posterior compres-
sion with a structural interbody graft in place. This is similar to tilting of the hand truck to carry a load.

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 Chapter 67 High Dysplastic Spondylolisthesis: Anatomic Reduction. The Harms/Shufflebarger Technique 663

A B

Figure 67.6. (A) A high dysplastic spondylolisthesis is depicted. The dotted line depicts the area of sacral
dome resection. This acts similar to a pedicle subtraction osteotomy more proximal. This posterior shorten-
ing procedure is a powerful tool for correcting the deformity. (B and C) One year after reduction, the coro-
nal and sagittal alignment and balance are excellent.

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 664 Section VI Spondylolisthesis
Steps in Reduction of High-
TABLE 67.2
Grade Spondylolisthesis
Exposure L4 through sacrum
Complete laminectomy L5
Remove fibrocartilaginous material in defect
Complete exposure of L5 root to sacral ala
Expose lumbosacral disc bilaterally
Place screws L4,5, S1, and ilium
Distract between screws
Excise lumbosacral disc
Excise sacral dome
Remove distraction rod
Reduce with lordotic bent rods
Apply distraction
Bone graft anterior interspace
Place cage(s)
Compression
Posterolateral L5-S1 fusion
/ Remove L4 screws at 3 mo
SURGICAL TECHNIQUE OF
SPONDYLOLISTHESIS REDUCTION
This surgical technique of reduction and internal fixation of
high dysplastic spondylolisthesis was developed by Professor
Juergen Harms and has been reported by this author13 and by
Professor Harms.3 Multiple steps are necessary to successfully
perform the procedure. Monitoring of the lumbar five nerve
root is recommended.
Monitoring of the lumbar five nerve root is easily performed
throughout the procedure. The pedicle screw stimulation tech-
nique reported by Calancie et al1 has been routinely employed
by many surgeons. The same technique can be applied to the
lumbar five roots during the various stages of spondylolisthesis
reduction. The root should be first stimulated with its identifi-
cation medial to the lumbar five pedicle. The normal nerve
root stimulation threshold is usually less than 2 mA. In this con-
dition, the stimulation threshold is typically elevated, frequently
in excess of 10 mA. With further exposure and decompression
of the root, the stimulation threshold usually decreases.
Repeated root stimulation throughout the procedure provides
the surgeon with evidence of conduction of the root and hence
function. Assurance of postsurgical function is present with
peripheral response to intraoperative stimulation. Should there
be increase in stimulation threshold during the procedure, the
surgeon should alter the procedure and seek the cause of
change.
The procedure is performed using the Jackson surgical table
(OSI, Union City, CA). A lower lumbosacral skin incision is
made, and exposure of lumbar four to the caudal sacrum is
accomplished. This is carried to the tips of the transverse pro-
cesses of lumbar four and five as well as the alae of the sacrum.
Care should be exercised during exposure, as the sacrum is fre-
quently dysplastic, and incidental durotomy may be avoided.
With exposure complete, the loose posterior element of lum-
bar five is excised, either in one piece or piecemeal. The lum-
bar five lamina is usually removed through the spondylolytic
defect or through the elongated pars interarticularis.
Next, the lumbar five and sacral one nerve roots should be
identified bilaterally. Sacral one root is usually easily identified.
LWBK836_Ch67_p660-667.indd 664
The lumbar five roots may be quite difficult to identify. Removal
of fibrocartilaginous debris from the area of the defect should
facilitate identification. Usually, the lumbar five roots can be
identified ventral to the spondylolytic defect, medial to the
lumbar five pedicle. Direct stimulation by the stimulus-evoked
electromyography (EMG) method may assist in identification
of this root. Failure to identify the lumbar five roots may predis-
pose these to injury during the procedure.
Medial retraction of sacral one root exposes the lumbosacral
disc space. Abundant epidural veins are usual around the sacral
pedicle. Bipolar cauterization of these is advised. The lumbar
five roots should then be exposed lateral to the L5-S1 foramen
to the tips of the lumbar five transverse processes. Complete
exposure of the lumbar five roots is mandatory to successful
performance of the procedure. The ala-transverse ligament,
inserting on the lumbar five transverse process, should be
divided dorsal to the lumbar five roots.
Having completely exposed the lumbar five roots, the articu-
lar process of the sacrum should be excised if not already
accomplished. This results in wide exposure of the L5-S1 fora-
men, from lumbar five pedicle to sacral pedicle. The sacral ala
should be well exposed and are seen to be continuous with the
sacral pedicle.
Next, screws are placed. Currently, reduction screws in lum-
bar four and five are preferred. The extended tabs on the
reduction screws permit a gradual reduction of the deformity
and are subsequently removed. The lumbar five pedicles have
been reputed to be dysplastic on occasion. Using fluoroguided
pedicle navigation and a hand drill for navigation, these pedi-
cles should always accept pedicle screws. The lumbar four
reduction screws are useful to obtain the reduction and may be
removed either after the reduction or at a later date. S1 screws
are also placed, directing these to the tricortical zone at the
junction of the anterior cortex of the sacrum and the end plate
of the sacrum. Lastly, bilateral iliac screws are placed. The
medial portal to the inner table of the ilium is preferred.
Bilateral iliac screws provide a powerful backup to the sacral
screws and serve to prevent any pull out of sacral screws during
the reduction maneuver.
At this point, application of distraction is quite helpful. This
may be accomplished via the lumbar screws and the S1 screw
on one side. Or, if the midline of the sacrum is intact, a lamina
spreader may be used. An alternative method of distraction
could be via a sacral ala hook and lumbar 2 or 3 hook.
Distraction at this stage partially reduces the translation and
the kyphosis at the lumbosacral junction, facilitating discec-
tomy and sacral dome excision. The lumbar five roots should
be stimulated with distraction to ensure function. Should EMG
responses deteriorate, further exploration of the lumbar five
roots must be done. These should be followed laterally to the
point the root moves anterior to the sacral ala. Should responses
not be restored, a difficult clinical decision presents. If the sur-
geon is convinced that there is no compression, the reduction
should be sequentially lessened. Confident that no tension is
present, consideration for fixation at that point should be
given. Further shortening of the sacrum should also be consid-
ered. Staging the shortening and reduction is also a consider-
ation.
The lumbosacral disc should be well exposed from foramen
to foramen and ventral to the dural sac. The cortical bone of
the posterior cephalad portion of the sacrum should likewise
be well exposed from foramen to foramen, and ventral to the
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 Chapter 67 High Dysplastic Spondylolisthesis: Anatomic Reduction. The Harms/Shufflebarger Technique
dural sac. Next, the posterior longitudinal ligament is incised
and excised from the attachments to the sacrum and to the
lumbar five vertebral body. This accomplished, the disc mate-
rial is removed with pituitary rongeurs and curettes. Exposure
of the sacral dome is also accomplished.
Sacral dome excision is the next step in the instrumented
reduction of high dysplastic spondylolisthesis. This step is the
key to a successful and uncomplicated procedure. Figure 67.6A
illustrates the area to be excised. Dome excision is equivalent to
a pedicle subtraction osteotomy more proximal in the spine.
Dome excision is a posterior shortening procedure, effective in
correcting the lumbosacral kyphosis and preventing excessive
stretch of the lumbar five roots.
Sacral dome excision is done with fluoroscopic control. The
lateral projection is employed to guide the excision. An osteot-
ome is employed in the excision. The cut is initiated a few mil-
limeters caudal to the disc space, on the dorsal surface of the
sacrum. The amount of dome resection required is dictated by
the severity of the deformity, the greater the deformity, the
more needs to be removed. In spondyloptosis reduction from
the posterior approach, the pedicles of lumbar five may need
excision to protect the lumbar five nerve roots. The cut is
directed to the anterior cortex of the sacral dome, taking care
to end cephalad to the sacral screws. The osteotomy is carried
under the dural sack from either side. The bone is removed
piecemeal. Extending the osteotomy lateral into the ala of the
sacrum may be accomplished, also facilitating reduction. With
dome excision accomplished, further removal of disc material
is accomplished.
At this point, reduction of the deformity may be accom-
plished. Simultaneous rod placement is desired. Rods of appro-
priate length are bent to approximate lumbosacral lordosis,
and placed in the iliac and sacral screws. The distraction will
have been released, and the lumbar five roots stimulated. The
rods are then introduced into the reduction screws of lumbar
four and five, and then advanced to the body of the screws by
advancing the setscrew in the tabs to the bodies of the screws.
Reduction is accomplished over several minutes, with frequent
monitoring of the lumbar five roots. After entrance of the rod
into the lumbar screws, the reduction is checked on the C-arm.
If not satisfactory, the rods can be removed and bent to achieve
more lordosis and thus more correction.
With the reduction maneuver completed, slight distraction
via the screws is again applied. Autogenous bone graft is then
placed in the anterior portion of the interspace. The structural
interbody cage of the surgeons choice is the placed in the lum-
bosacral interspace. In general, the least tall cage is preferred,
preventing additional tensioning of the lumbar five roots. This
is usually 7 to 9 mm. After cage placement, posterior compres-
sion shortens the lumbosacral junction, further decreasing root
tension. With the cage in place, compression is then applied via
the screws. Cage position and reduction is again monitored
fluoroscopically. The lumbar four screws with a portion of the
rods may now be removed, or this may be accomplished several
months later. Posterior lateral fusion is then accomplished,
preferably with autogenous bone graft. Closure is then accom-
plished, usually over a subcutaneous drain (see Table 67.3).
After-surgical management is relatively routine. An elastic
lumbosacral corset is employed, usually during waking hours
for approximately 6 weeks. A TLSO is also an option. However,
the elastic corset is a sufficient reminder to limit activity.
Ambulation is begun on the first day after surgery and progressed
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665
Technical Tips during
TABLE 67.3 Reduction of
Spondylolisthesis
Beware of dysplastic changes
Spina bifida occulta of sacrum or L5
Avoid incidental durotomy
Control epidural veins at sacral ala before torn
Identify L5 root at the L5 pedicle
Verify L5 root by direct nerve root stimulation
Repeat multiple times during reduction
TcMEPs can be recorded from tibialis anterior
Repeat multiple times during procedure
Control bleeding with bipolar electrocautery, FlosealTM
Use reduction screws at L4 and L5
Distraction will greatly aid sacral dome excision
Perform reduction maneuver slowly
If inadequate reduction, replace rods with more lordotic bend
Distraction will aid in interbody graft placement
Final compression increases lordosis
to independence. Activities are significantly restricted for the
first 3 months after surgery.
COMPLICATIONS
Intraoperative bleeding has the potential to be a significant
problem and can be termed a complication. Management of
this potential complication has several facets. Control of epidu-
ral veins around the sacral pedicle and lumbar five pedicles is
managed with bipolar electrocautery. Coagulation of these
before tearing is desirable. A number of commercial products
are available to assist in the control of bleeding. These are a
combination of gelfoam and thrombin, in a relatively liquid
state. These are quite useful while working in the disc space
and with the sacral dome excision.
The pseudarthrosis rate in the literature for a variety of pro-
cedures for high-grade spondylolisthesis varies between 5% and
50%, but usually less than 15%.2,5,9,10 Harms reports a high rate
of union.3 In the authors report of 18 patients, there were no
pseudarthroses.13 In an additional 50 unreported cases, no
pseudarthroses have been observed. One patient had signifi-
cant loss of correction, which stabilized and achieved arthrod-
esis. As nearly anatomic reduction is usually obtained and the
mechanical objectives achieved, failure of fusion is not to be
expected. In addition, the interbody graft favors rapid fusion.
Increasing displacement after in situ surgery is common.2,9,10
Because of the factors stated above, this was not observed after
reduction. One patient developed bending of the sacrum
through an articulated S1-S2 space. Addition of iliac fixation
and extension of bone graft to the S2 segment should obviate
this development in the patient with S1-S2 segmentation.
Radiculopathy, particularly of the lumbar five roots, is the
most common neurologic complication after spondylolisthesis
reduction. Harms reports three instances, none permanent, in
approximately 100 cases.3 This author reports no neurologic
injuries in 18 patients.13 In an additional 50 unreported cases,
there was one permanent unilateral lumbar five roots lesion.
The etiology of lumbar five roots injury includes stretch,
compression, and possible devascularization. More proximal
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 666 Section VI Spondylolisthesis

radiculopathy (L3 and L4) has also been described, with no
clear mechanism of production. Intermittent stimulation of the
lumbar five roots at various stages of the reduction should alert
the surgeon to impending root injury. Cauda equina injury
during or after surgery was not observed.
In the presence of a new neurologic deficit after the
described surgery, investigation by computed tomography
(CT)/myelography may elucidate a site of compression or
hematoma. Surgical exploration of the injured structure is usu-
ally indicated in this situation.
RESULTS AND OUTCOMES
The authors reported results are similar to those reported by
Harms. Fusion rate is clinically 100%. No radiographic studies
(CT scans) were employed to document arthrodesis. The per-
centage slip was improved from a mean 75% to 15%, and the
slip angle from 35 to 5. The complications are noted above.
No patient in the authors group has required a second opera-
tive procedure, except the one patient with the unilateral lum-
bar five nerve root injury.3,13
Helenius et al4 report long-term follow-up (17 years) of
nearly equal groups of patients with high dysplastic spondylolis-
thesis treated with either posterolateral, anterior, or circumfer-
ential in situ fusion. Combining the radiographic, functional,
and patient-based outcomes, there was little difference among
the three methods. However, only 83% of the consecutive series
of 83 patients was available at final follow-up. The same authors
(plus others), in a separate publication, compare outcomes of
22 adolescents with high dysplastic spondylolisthesis.11 Eleven
had a posterior instrumented reduction followed by an ante-
rior interbody fusion. The other group had in situ anterior and
posterior fusion. They report better functional results at 15-year
follow-up for the in situ group. However, the reduced group
only improved to a 57% slip, compared with 78% in the in situ
group. The small numbers of the latter publication make this
report difficult to interpret.
The author and Professor Harms remain convinced that a
near complete reduction with posterior instrumentation and
structural interbody graft from the posterior approach remains
the procedure of choice for high dysplastic spondylolisthesis.
This is particularly true given the reported potential for cata-
strophic neurologic injury associated with an in situ fusion.

CASE 67.1

Figure 67.7 depicts a typical patient with high dysplastic spon- screws at lumbar four and five to achieve the reduction.
dylolisthesis treated by the described surgical procedure. An Three months after surgery, the lumbar four screws were
approximate 75% spondylolisthesis is present initially, associ- removed. At 1 year after surgery, excellent sagittal alignment
ated with lumbosacral kyphosis. The procedure employed is present.

A B C

Figure 67.7 (A and B) Erect anteroposterior and lateral views of a 16-year-old girl with a high dysplastic
spondylolisthesis are depicted. There is approximately 60% anterior displacement with a high slip angle.
Note the modeling changes of the sacrum. (C) An erect lateral radiograph 1 month after surgical reduction
shows near complete reduction and correction of the lumbosacral kyphosis. Screws are in lumbar 4 and 5, as
well as the sacrum and ilium. (continued)

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 Chapter 67 High Dysplastic Spondylolisthesis: Anatomic Reduction. The Harms/Shufflebarger Technique 667

D E

Figure 67.7 (Continued) (D and E) The lumbar four screws were removed at 3 months after surgery. At
1 year following surgery, coronal and sagittal alignment is excellent.

8. Molinari R, Bridwell K, Lenke L, et al. Anterior column support in surgery for high grade
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Spine 1999;24:17011711.
2. Grzegorzewski A, Kumar S. In situ posterolateral spine arthrodesis for grades III, IV, and V
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5. Hu S, Bradford D, Transfeldt E, et al. Reduction of high grade spondylolisthesis using
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6. Mac-Thiong JM, Labelle H. A proposal for a surgical classification of pediatric lumbosacral
14. Smith M, Bohlman H. Spondylolisthesis treated by a single stage operation combining
spondylolisthesis based on current literature. Eur Spine J 2006;15:14251435.
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