The procedure of choice is an in situ posterolateral spinal fusion (Fig. 38-4). The procedure can be performed through either a midline approach or a paraspinal approach. Spinal implants are not routinely used by all surgeons because of the good potential for healing of posterolateral fusions in pediatric patients with low-grade slips. Many surgeons consider pedicle fixation advantageous if a decompression is performed at the time of fusion. Traditional teaching is to perform posterolateral fusion from L5 to S1 if the slip is less than 50% and to extend fusion to L4 if the slip is greater
than 50%. Use of postoperative immobilization (brace, cast) is also controversial. To decrease motion at the L5-S1 level, an orthosis must incorporate the patient's thigh.
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