Reduction of adolescent grade IV L5-S1 spondylolisthesis with anterior joystick manipulation during a combined anterior and posterior surgical approach: A case report.

Background: High-grade isthmic spondylolisthesis poses a clinical challenge in the pediatric and adolescent population. Current surgical management using posterior-based approaches may lead to incomplete reduction and restoration of listhesis, disc height, and lordosis. Combined anterior and posterior approach addresses these issues but has been infrequently reported, mainly in the treatment of low-grade isthmic spondylolisthesis. Neither offers good disc space visualization and control of spinal alignment during reduction. Case Description: A healthy 17-year-old female presented with 9 months of progressively worsening lower back pain radiating down the left lower extremity and 3 inches of height loss. Diagnosis of grade IV L5-S1 spondylolisthesis was made using plain radiographs, CT, and MRI. Management with combined anterior and posterior fusion, involving the manual manipulation of segments using an anterior pedicle screw joystick, was pursued. Outcome: Satisfactory alignment, solid arthrodesis, no complications, and improved patient reported outcomes. Conclusions: Combined anterior and posterior fusion with anterior joystick manipulation allowed for full reduction of grade IV spondylolisthesis and restoration of disc/foraminal height and L5-S1 segmental lordosis without neurological complication. Although less commonly performed in children and adolescents, this surgical approach can assist in restoring optimal alignment in isthmic spondylolisthesis.