Degenerative Disc Disease and Spondylolisthesis with Progressive Back and Leg Pain
Unresponsive to conservative treatment
This surgeon is a consultant of Medtronic, but received no compensation for this case discussion.
The patient is a 55-year-old male who works as a heavy equipment operator. He is 5’-11” tall and weighs 250 pounds. His symptoms, listed below, have worsened and continue to worsen in the last 12 months.
- Bilateral lower back pain
- Aching and burning in his buttocks, posterior thighs and calves
- Sensations of pins and needles in the plantar and anterior aspects of both feet
He rates his pain as 5 to 8 on a 10-point scale. Bed rest provides relief. The severity and consistency of his symptoms compromise all of his activities of daily living.
The patient reports smoking six cigars and consuming six beers per day.
The first three epidural steroid injections reduced pain to 2 to 3 on a scale of 10 for a period of six months. The second series of three injections were of no value. Further, a six-week course of organized physical therapy worsened his symptoms.
- Fifty percent (50%) restriction in active range of motion in the lumbosacral spine
- No reflex asymmetry
- Positive straight left leg raise: 30-degrees while seated
- Positive straight right leg raise: 45-degress while seated
- No overt weakness in the quadriceps or calf muscles unless he walks 30 feet or stands longer than 10 minutes. Then, after he walks 30 feet or stands longer than 10 minutes, his objective muscle testing demonstrates a full grade loss of strength in both knees during resisted knee extension testing, and a half grade in ankle dorsiflexion. Sitting for 60 seconds resolves loss of strength.
- There is no vascular insufficiency to his legs.
Figure 1 depicts the patient’s anteroposterior (AP) x-ray. The lateral x-ray (Fig. 2) demonstrates degenerative disc disease and a spondylolisthesis at L4-L5.
Figure 1. AP x-ray, L1-L5
Figure 2. Lateral x-ray, spondylolisthesis at L4-L5
Symptomatic degenerative disc disease and spondylolisthesis at L4-L5
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The patient underwent a MIS TLIF with bilateral decompression and reduction and segmental pedicle instrumentation. The CAPSTONE® Implant, with locally harvested (autogenous) bone, was placed within the disc (intra-discal).
Figure 3. Intra-operative fluoroscopy
The patient was discharged home within 23 hours of admission.
Surgeon's Treatment Rationale
This MIS TLIF technique has been replicated over the last nine years in our clinic more than 700 times with statistically significant and consistent reduction of Oswestry Disability Indices (ODI) and Visual Analogue Scale (VAS) scores from preoperative levels.
One week after surgery, the patient started a structured 12-week rehabilitation program, which he completed in 8 weeks. He was released to return to work without restrictions. At the12 week post-op visit, all of the patient’s pre-operative pain was resolved. The 12-month post-op x-rays were interpreted as being representative of a solid fusion without failure of any implants.
One-month after surgery (Figs. 4, 5)
FIgure 4. AP x-ray
Figure 5. Lateral x-ray
One-year after surgery (Figs. 6, 7)
Figure 6. AP x-ray
Figure 7. Lateral x-ray
Medtronic Technology Featured
CD HORIZON® SEXTANT® Percutaneous Rod System
CAPSTONE® PEEK Spinal System
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Dr. Rouben has presented a spondylolisthesis addressed entirely with posterior decompression and instrumentation. He obtained a complete reduction of the deformity which, while non-essential, is quite impressive.
This pathology could be addressed by an anterior, lateral, posterior or combined approach. Most surgeons would advocate fusion over a purely decompressive procedure. I favor an anterior or lateral approach in smokers like this because of the larger footprint those cages provide. However, body habitus may be a limiting factor to the anterior approach in this case. Furthermore, in the lateral approach, the femoral plexus is difficult to navigate at this level, especially in higher-grade deformities.
The interbody work is done with the screws, but not rods, already in place. While not specified, there are several instruments that can help reduce spondylolisthesis off pedicle screws intra-operatively. A word of caution: The K-wire at L4 almost perforates the anterior cortical margin. While speculative, vessels draped across a slip are likely under greater tension and may be more prone to injury. Regardless, it is a precarious location.
I am curious to know how much of the correction was obtained at each step (decompression, interbody and posterior instrumentation). Certainly, the combination of these is essential to maintain the reduction, and the patient demonstrates a solid bony fusion one year post-op. This case demonstrates an impressive radiographic and clinical outcome, for which the author should be commended.
Dr. Rouben presents a case of a 55-year-old male with a relatively atypical isthmic spondylolisthesis at L4-L5. His patient is an obese male who smokes six cigars per day. The patient failed conservative care, including a 6-week course of physical therapy, which worsened his symptoms. The reader should be cautioned about accepting at face value that physical therapy failed without getting more information about the specifics of therapy. Many patients who claim to have had physical therapy have not done any active exercise or may have a directionality to their pain, and the therapy was done counter to their preferred direction. 1
Dr. Rouben does not mention if he counseled the patient to stop smoking prior to surgery, but this is something that certainly should be considered.
Once the patient has failed therapy, there are multiple surgical options for this condition. In principle, any procedure that stabilizes the level and decompresses the exiting nerve root should have a reasonably good success rate. In this case, Dr. Rouben elected to perform an MIS TLIF. As seen in the post-op and final imaging, the spondylolisthesis was reduced and the foraminal heights significantly increased. In addition, the final follow-up films would indicate a solid arthrodesis.
MIS surgery has the advantage of shorter hospital stays and quicker recovery but has not been shown to improve long-term results [versus open procedures].2,3 Even so, the decreased pain and increased function in the short-term are often a significant benefit to patients and so as long as the long-term results are equivalent MIS techniques may be preferred. Further longer-term studies will clarify the role of these interesting new technologies.
1 Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004 Dec 1;29(23):2593-602.
2 Adogwa O, Parker SL, Bydon A, Cheng J, McGirt MJ. Comparative Effectiveness of Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion: 2-year Assessment of Narcotic Use, Return to Work, Disability, and Quality of Life. J Spinal Disord Tech. 2011 Feb 17. [Epub ahead of print]
3 Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009 Jun 1;34(13):1385-9.
Author's Response to Case Discussions
I am honored by the insightful and knowledgeable responses offered by both Dr. Highsmith and Dr. Orr.
The issue of smoking and poor personal commitment to proper health is a continuing and pervasive problem in our society. Unfortunately, the state, in which I reside, is inundated with obesity and smokers. If local healthcare professionals restricted care to only those that did not smoke, no patients would be treated.
Access to physical therapy is controlled and restricted based on healthcare mandated funds. The number of visits and what is done at these visits is closely controlled and restricted by the insurance carriers.
I have tried to avoid using the pedicle screws to both distract and also to compress the disc spaces so as not to stress the screw bone fixation
Finally, the question of long-term results of MIS TLIF, as well as an explanation of the MIS TLIF technique, has been painstakingly and definitively addressed in the recently published peer reviewed literature.