TITLE:
Surgical Management of Grade IV L5-S1 Spondylolisthesis Using Posterior Instrumented Fusion with Sacral Dome Osteotomy: A Case Report
AUTHORS:
Charles Taylor, Ebrahim Izadi, Pierre Kostanteen, Suzan Kayitesi, Henry Bowyer, Jasem Merza, Pavlos Panteliadis, Panagiotis Liantis
KEYWORDS:
Spondylolisthesis, Sacral Dome Osteotomy, Spinal Fusion, Posterior Instrumentation
JOURNAL NAME:
Open Journal of Modern Neurosurgery,
Vol.16 No.3,
July
22,
2026
ABSTRACT: Background: High-grade spondylolisthesis (HGSL) remains a complex surgical condition with no clear consensus on optimal management. Current controversy lies between in situ fusion vs reduction with fusion as in-situ fusion reduces neurological risk but may inadequately correct deformity and pelvic parameters. Recently, a posterior-only approach incorporating sacral dome osteotomy has been proposed to allow controlled shortening, facilitating deformity correction while minimising neural tension; however, supporting evidence remains limited. Case Presentation: A 27-year-old female presented with an 11-year history of chronic low back pain without neurological deficit. Imaging demonstrated grade IV L5-S1 spondylolisthesis with severe foraminal stenosis. Following multidisciplinary discussion, she underwent single-stage posterior instrumented fusion from L4 to S2, with decompression, sacral dome osteotomy, and partial reduction. Intraoperatively, complete neural decompression and controlled sacral dome resection enabled safe reduction of the slip from grade IV to grade II. The L5 nerve roots were protected throughout and stable fixation was achieved. At 3 month follow up she was mobilising independently with minimal pain and had returned to work with high satisfaction. Radiographs confirmed maintained alignment and stable instrumentation. Conclusion: This case demonstrates that posterior-only fusion with sacral dome osteotomy is an effective strategy for managing HGSL. Partial reduction combined with controlled shortening can achieve satisfactory clinical and radiographic outcomes while preserving neurological safety. These findings support the role of posterior shortening techniques as a viable operative approach. Further prospective studies are required to define their role in the surgical management of HGSL.