L5-S1 Spondylolisthesis in a Young Female, Previous Gymnast
A 33-year-old female presented with bilateral leg pain and low back pain. The patient had no prior medical history. She reported having been an active gymnast.
The patient reported being unable to sit for more than 10 minutes. Upon examination, her pain was noted to be in the bilateral L5 and S1 distributions.
MRI imaging showed a Grade 1 spondylolisthesis at L5 with disc bulge (Figure 1), bilateral up-down stenosis of the L5 foramen (Figures 2, 3A, 3B), with pars fracture and mobile listhesis at L5-S1 (Figures 4A, 4B). CT imaging confirmed the L5 pars fractures (Figures 5, 6A, 6B).
Figure 1: T2 sagittal MRI; showing Grade 1 spondylolisthesis with disc bulge
Figure 2: T2 parasagittal MRI; showing up-down stenosis of the L5 foramen
Figure 3A: T2 axial MRI; showing bilateral foraminal stenosis
Figure 3B: T2 axial MRI, bilateral foraminal stenosis
Figure 4A: Dynamic x-ray; revealing pars fracture and mobile listhesis at L5-S1
Figure 4B: Dynamic x-ray; revealing pars fracture and mobile listhesis at L5-S1
Figure 5: Sagittal CT scan; confirming pars fracture
Figure 6A: Axial CT scan; L5 pars fracture
Figure 6B: Axial CT scan; L5 pars fracture
The patient had undergone 6 months of physical therapy and steroid treatments. These treatments were unsuccessful, and at the time of presentation the patient was taking a prescribed opioid for long-term pain management.
Grade 1 L5 spondylolisthesis (isthmic) with disc bulge, bilateral foraminal stenosis, and bilateral L5 pars fracture.
When discussing surgical options with the patient, she noted that she wears swimsuits and dislikes scars. The surgeon needs to consider several options when planning for this type of case, including:
- Open versus minimally invasive
- Approach: Anterior versus posterior
- Spacer: Allograft versus composite cage, versus metallic cage
- Graft and biologics: Local autograft versus iliac autograft, versus allograft, versus off-label biologics
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Keeping in mind that the patient wanted to avoid an abdominal scar, and based on the merits of the technique, a TLIF was selected, and it was performed minimally invasively. Bilateral tubular retractors were used for direct visualization and to decompress the exiting L5 nerves and to place the cage and screws. A composite cage was selected, based upon its ease of use through the tubular retractor.
The graft was a combination of iliac crest and local autograft. This was chosen for several reasons, including: the iliac crest could be harvested through the same posterolateral incision, autograft represented a relative cost saving over alternatives, and it enabled the procedure to avoid using an off-label biologic.
Post-operatively, the patient reported some radiculitis. However, this resolved by the 3-month follow-up appointment. The patient is currently one year post-op and reports that her pain is reduced by 80%, and she has discontinued all prescribed opioids and OTC pain medications. Radiographs show a solid fusion. The patient has returned to an active lifestyle, and although she has discontinued running, she has maintained her exercise through swimming and cycling.
This is excellent management of a common place diagnosis, which is seen in nearly every spine surgeons' office. Indeed, we would likely all agree that surgical intervention would be the mainstay of treatment after non-operative measures have failed—and the surgical intervention necessary would include fusion with or without direct decompression.
As Dr. Mummaneni stated, his options are anterior, posterior or both approaches. If the patient is not consenting to anterior surgery, then the only options are posterior surgery. My thought too would be to consider posterior surgery with direct decompression. The use of an interbody cage is a good one as well. Interbody devices improve stability and fusion rate because they provide anterior column support. This turns an all-posterior construct into a load-sharing versus a load-bearing construct. It also provides direct decompression of nerve roots by increasing disc height, thereby improving foraminal dimensions in both cephalo-caudal and dorso-ventral directions.
Performing this operation using minimally invasive surgical (MIS) techniques I believe will be more broadly accepted over the coming years. Dr. Mummaneni was able to accomplish the critical surgical goals with MIS TLIF, and is to be commended for his expert care and restoring her quality of life.