Unstable, painful spinal shippage with fusion and instrumentation

History:The patient was a 27 year old woman that presented with a chief complaint of low back pain and left leg pains aggravated by activity. Her symptoms first developed several years earlier and over time progressive increase in pain and disability was noted despite treatment with physical therapy, bracing, activity modification and medication. None of this offered relief of symptoms and a progressive increase in pain was noted. The patient had noted a steady decline in her overall function to the point of not being able to walk more than five blocks and having difficulty with sitting and other activities of daily living.

Physical Examination:The patient was a well developed young woman walking with a normal gait. Examination of the back revealed tenderness over the lumbosacral area. Motion of the lumbar spine provoked pain shooting into the left leg with side bending and extension. Hip motion was painless bilaterally, left leg raise precipitated pain at 75 degrees. Weakness in the left lower extremity was evident in the great toe extensor and ankle dorsiflexion. Diminished sensation was noted over the left foot and lateral ankle area.

Radiographic Evaluation:On standing radiographs of the lumbar spine a grade I (grading system I to IV by increasing slippage) spondylolisthesis at L5-S1 was evident. (figure 1) Dysplasia with abnormal formation and thinning of the posterior arches was noted. Dynamic x-rays revealed significant abnormal motion between flexion and extension (figure 2). An MRI was obtained which revealed severe spinal stenosis at the level of slippage (figure 3).

Treatment Options:In general terms, spondylolisthesis ( the slippage of one vertebra over another) is first treated with non-operative means (unless neurologic symptoms are present). In most cases a combination of activity restriction, bracing and physical therapy are effective. When this fails and slippage of the vertebrae continues or is unstable and persistently painful (or leads to nerve dysfunction) then surgery is sometimes considered. Surgical treatment options include posterior surgery alone, anterior surgery, a combination of anterior and posterior surgery. In some cases instrumentation (rods and screws) are used in addition to bone graft to ensure immediate stability and increase the chance of a successful spinal fusion. Each case is approached in a very individual manner and the optimal treatment approach is dependant upon a number of different factors including patient age, degree of slippage, degree of nerve compression or dysfunction, and the degree of spinal instability.

Discussion:In this particular case, the spondylolisthesis was mild in degree yet quite unstable, showing significant motion on xrays taken in different positions (flexion vs. extension). Furthermore, nerve dysfunction had developed with leg pain and weakness. Non-operative treatment had failed and thus after thorough discussion of options the patient decided to proceed with surgical treatment. The goals of surgery were: to stabilize the spine and stop painful motion, to obtain a solid bone fusion across the unstable level, and to free the compressed nerves at the level of spine slippage. Given the degree of instability present, and the dysplasia at the level of spondylolisthesis itwas felt that a solid fusion would best be obtained with a circumferential fusion (posterior and anterior spinal fusion). Although this is often done through two incisions, techniques such as the lumbar interbody fusion (commonly called TLIF or PLIF) can permit disc removal and fusion in the front of the spine through one incision in the back. Due to the instability present spinal instrumentation may be necessary to ensure a stable and solid fusion.

Treatment and Results:As planned, the patient had a posterior spinal decompression (to free the nerve roots), a posterior fusion and an interbody fusion (complete circumferential spinal fusion) through a posterior incision alone (figure 4). To optimize the chance of fusion, instrumentation was placed. The L5-S1 level was fused in lordotic alignment. The patient recovered rapidly and was discharged within 4 days from the hospital. A solid fusion developed over the subsequent months and the patient had complete relief from her symptoms

See a presentation on the TLIF Procedure

Adult Spondylolisthesis Medical Condition

Child Spondylolisthesis Medical Condition