Grade II Isthmic Spondylolisthesis Revision
This 27-year-old female, with a grade 2 isthmic spondylolisthesis, with low back pain and bilateral lower extremity radicular pain was treated with a L4-S1 instrumented posterior lumbar fusion with iliac crest bone graft.
She did very well for 9 months without almost no low back or leg pain. While lifting a 75-pound box at a Wal-Mart warehouse, she heard a "pop" with marked increase in low back pain and bilateral lower extremity radicular pain.
The patient had a normal neurological examination, but back tenderness was noted.
Posterior / anterior (Figure 1A) and lateral (figure 1B) x-rays demonstrate previous instrumentation and fusion.
The images below (Figures 2A-2C) are axial myelography.
Figure 2A: L4
Figure 2B: L5
Figure 2C: L5-S1 showing broken screw at S1
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Grade II isthmic spondylolisthesis revision
The patient underwent an L4-L5, L5-S1 ALIF followed by posterior instrumentation and fusion. The broken screws were removed with broken screw removal set.
Standing postoperative anterior / posterior and lateral x-rays (Figs. 5A, 5B)
The patient returned to work, where her tasks include lifting packages. She has also returned to a fully active lifestyle. The patient reports a 2/10 low back pain score.
The initial fixation failed because of lack of anterior column support following a wide-Gill laminectomy at L5. Dr. Shaffrey addressed the lack of anterior column support with an ALIF at L4-L5 and L5-S1, which will appropriately load share the posterior construct. I commend him on being able to remove all of the broken screw fragments and performing the required posterior revision. Extra distal fixation could have been achieved with iliac wing fixation that may have required removal at a later date.
My preference for these revisions is to perform an all-posterior procedure, obtaining interbody support through TLIFs or PLIFs at both levels with iliac fixation, especially if there is difficulty in obtaining good S1 fixation.