409 High Grade Spondylolisthesis. To Reduce or Not to Reduce? A Systematic Review and a Meta-Analysis

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INTRODUCTION: Managing high-grade spondylolisthesis (HGS) poses significant challenges and remains a topic of controversy. The range of possible treatments varies from simple in situ fixation (ISF) to partial or complete reduction of the listhesis followed by posterior fusion, with or without interbody fusion. While the main goal of treatment is to alleviate symptoms, there is no consensus on which approach provides the greatest clinical benefit. METHODS: The PRISMA protocol was used. A systematic review was conducted searching on PubMed, Scopus, Embase and Cochrane databases for relevant English studies. Studies reporting any form of surgical treatment for HGS were included while studies reporting treatment of non HGS, traumatic spondylolisthesis or studies not reporting outcomes were excluded. Data was extracted and analyzed using R version 4.3.2. RESULTS: 1176 papers were reviewed with 23 studies involving 654 patients meeting criteria. A random-effects model compared ISF and reduction surgery for sagittal realignment and slippage reduction. For lumbar lordosis (LL), mean differences were -4.14 (95% CI [-8.21; -0.08]) for ISF and -1.61 (95% CI [-5.87; 2.65]) for reduction, showing no statistically significant differences (p=0.40). On the other hand, the mean difference in slippage decrease was significant (p=0.006). Meta-analysis on pseudoarthrosis rates found no significant difference (p=0.07), with proportions of 0.20 (95% CI [0.07; 0.45]) and 0.05 (95% CI [0.02; 0.14]). Pooled proportions analysis indicated significantly shorter surgery duration (p=0.03) in ISF, although not linked to reduced blood loss (p=0.81). CONCLUSIONS: This meta-analysis indicates that the significant decrease in slippage achieved through reduction is not correlated with improved sagittal realignment or a higher long-term fusion rate. In comparison, ISF has a significantly shorter duration, although this does not correspond to a reduction in blood loss.

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