Circumferential fusion for degenerative lumbar spondylolisthesis complicated by distal junctional grade 4 spondylolisthesis in the sub-acute post-operative setting

Introduction: Surgical management for lumbar stenosis is generally safe and provides significant improvements in pain, disability, and function. Successful lumbar decompression hinges on removing an appropriate amount of lamina and other compressive pathology in the lateral recess. Too little bony decompression can result in persistent pain and disability, while over resection of the pars and/or facets may jeopardize spinal stability. Case report: In this unique report, we present for the first time an acute iatrogenic grade 4 L5–S1 spondylolisthesis distal to a L3–5 laminectomy and circumferential instrumented fusion due to bilateral iatrogenic L5 pars fractures and its management and clinical outcomes after revision operation. The patient presented with worsening pain, neurologic compromise, and severe sagittal imbalance. The iatrogenic, high-grade spondylolisthesis was urgently addressed with a L5–S1 anterior lumbar interbody fusion and extension of posterior instrumentation to the pelvis, which resulted in considerable pain relief, resolution of neurologic deficits, and reconstitution of acceptable sagittal imbalance. Conclusion: All attempts during a lumbar decompression should be made to prevent iatrogenic pars fractures, as they may result in severe sagittal imbalance, neurologic compromise, and persistent disability. Iatrogenic, high-grade L5–S1 spondylolisthesis can be successfully treated with reduction using circumferential fusion of the lumbosacral junction.