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Background: High-grade L5-S1 spondylolisthesis is challenging to treat, and there is no standard recommended operative technique. The authors performed a systematic review of the literature evaluating the efficacy and safety of modern transsacral instrumentation techniques for high-grade L5-S1 spondylolisthesis., Methods: A systematic PubMed search adherent to PRISMA guidelines included relevant clinical studies reporting transsacral instrumentation for high-grade L5-S1 spondylolisthesis in adult humans from 1980 onward. Available data regarding clinical and radiographic outcomes for individual patients were abstracted., Results: Nine of 311 studies were eligible for detailed review. They reported on 38 patients (mean 33.1 years; range 18-66 years) treated with transsacral instrumentation. Transsacral cages (6 articles, n = 23), screws (2 articles, n = 12) and rods (1 article, n = 3) were used. Posterior (86.8%) and combined anteroposterior approaches were used, both with (55.2%) and without decompression, partial reduction (23.7%), posterior pedicle screw fixation (94.7%), and adjacent level inter-body fusion (42.1%). Four patients had 6 perioperative complications (15.8%). Mean follow-up time was 30.1 months (range 2-58 months; n = 37). All patients had adequate fusion on follow-up imaging (n = 34) and no progression of slip (n = 32). All patients had improvement in pain (n = 32) and at least average function postoperatively (94.7%; n = 33/35)., Conclusion: Operative techniques for managing high-grade L5-S1 spondylolisthesis are evolving. In our systematic review, modern transsacral instrumentation resulted in good clinical outcome and fusion rates, and acceptable complication rates. Risks and benefits should be individualized for each patient. Transsacral instrumentation is a viable and effective treatment option for this pathology., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background Context: Bowel perforation is an uncommon complication of posterior spinal surgery. The AxiaLIF transsacral instrumentation system has been used for the treatment of L5-S1 spondylolisthesis and degenerative disc disease since its introduction in 2005 as a potentially less invasive alternative to traditional anterior or posterior interbody fusion., Purpose: In this article, we report a case of a rectal perforation as a complication of placement of the AxiaLIF instrumentation system that was successfully treated without the removal of the device., Study Design: Case report., Methods: The patient presented with progressive back pain and sepsis 3 weeks after an L5-S1 fusion done with the AxiaLIF technique at an outside facility. The patient was managed with antibiotic therapy and a diverting ileostomy, without the removal of the AxiaLIF device., Results: Over the next year, she had symptoms indicative of nonunion of the operated level and breakdown at the adjacent level, which were confirmed with imaging. She underwent revision posterior spinal fusion without the removal of the AxiaLIF device. Eighteen months after the AxiaLIF device was placed, the patient continued to demonstrate no signs of infection recurrence., Conclusions: Delayed presentation of rectal perforation with a subsequent anaerobic sepsis is a potential complication of the presacral approach to the L5-S1 disc space. Recognition and treatment with fecal diversion and long-term intravenous antibiotics is an alternative to device removal and sacral reconstruction., (Copyright © 2013 Elsevier Inc. All rights reserved.)