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L5-S1 Spondylolisthesis: Failed Pain Management

History

The patient is a 51-year-old female with a history of chronic back pain. She denies any radicular pain or weakness. The patient has received extensive medical pain management, which failed to satisfactorily control her pain.

Examination

5/5 motor strength in bilateral lower extremities. No tenderness to palpation of lumbar spine.

Prior Treatment

Previously, the patient had undergone organized physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and narcotic pain medication.

Pre-treatment Images


Lateral x-ray of lumbar spineFigure 1A: Lateral x-ray of the lumbar spine. Note the grade II spondylolisthesis of L5 on S1 and levoscoliosis.
 

AP x-ray of the lumbar spineFigure 1B: AP x-ray of the lumbar spine. Note the grade II spondylolisthesis of L5 on S1 and levoscoliosis.


Sagittal T2-weighted MRI of lumbar spineFigure 2A: Sagittal T2-weighted MRI of the lumbar spine.


Axial T2-weighted MRIFigure 2B: Axial T2-weighted MRI.

Diagnosis

Grade II spondylolisthesis of L5-S1

Suggest Treatment

Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.

Selected Treatment

The patient had a mini-open anterior lumbar interbody fusion (ALIF) L5/S1 with percutaneous pedicle screw fixation L5-S1.

Surgical Technique

A standard L5-S1 mini-open anterior lumbar interbody fusion was performed first in the supine position. A PEEK interbody graft filled with allograft was placed. Two bone screws (5.0 x 25mm) were inserted into the S1 vertebral body anteriorly to achieve stability of the interbody graft, but no anterior bone screws were placed into L5 vertebral body to allow for reduction posteriorly.

The patient was then placed into the prone position and percutaneous pedicle screws were placed bilaterally at L5 and S1. The spondylolisthesis was then reduced and the screws secured with rods to achieve rigid fixation and maintain reduction.

Figures 3A-3E show intraoperative radiographs of placement of interbody graft, fixation of graft to S1 with bone screws, reduction of spondylolisthesis with percutaneous pedicle screws, and final construct.
 

3A intraoperative radiographFigure 3A
 

3B intraoperative radiographFigure 3B
 

3C intraoperative radiographFigure 3C
 

3D intraoperative radiographFigure 3D
 

3E intraoperative radiographFigure 3E

Post-treatment Images

Figures 4A and 4B: Post-operative x-rays 3 months after surgery detail the surgical result.

4A post-operative x-rayFigures 4A

 4B post-operative x-rayFigures 4B


Outcome

After 3-month follow-up, the patient has improvement of back pain and decreased requirement for narcotics.

Case Discussion

I would agree that the ALIF with percutaneous screws is an excellent treatment. However, an MIS TLIF with ipsilateral percutaneous screws and an interspinous process spacer allows for a biomechanically similar procedure that can be done through a single incision. The 360º approach offers excellent results but forces a change in position during surgery, extending the case time and complicating the procedure. It also opens up a whole set of risks, abdominal and vascular, that can be avoided by going solely posterior. The fusion rates of TLIF are similar to mini-open ALIF, and as the patient presents with good sagittal balance and pelvic tilt, there is no need of correction. The steep angle of the L5-S1 disc space can make an ALIF problematic at this level. The addition of a compressive interspinous process plate can be easily done at L5-S1 through the incision used to decompress and fuse, allowing for a single incision, one-stage approach.

Community Case Discussion (7 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


It would not be unreasonable to have tried L4 and L5 medial branch blocks following a double diagnostic paradigm before fusion surgery. Given the lack of any exam findings (no weakness, sensory loss, bowel/bladder issues) and the lack of improvement with therapy, the next step could have been interventional in an effort to avoid surgery until she developed radicular pain or neurologic findings on exam. Many patients will grind their listhesis to a halt at Grade II and RF neurotomy is a useful tool in those without root symptoms or damage or those who are not candidates for surgery due to medical comorbidities. That being said- I'd opt for surgery if it were my spine.

I agree with Dr. Taylor that for most patients a posterior-only approach is equally effective and much less invasive/safer that a combined anterior-posterior approach. The combination of unilateral screws and interspinous fixation is biomechanically sound, technically easier, much safer from a neurovascular and visceral standpoint, and much less painful for the patient. These patients have outpatient surgery and return to work within six weeks of their procedure.

I respectfully disagree that a TLIF is a superior approach. An ALIF at L5-S1 can be safely accomplished in less than one hour with limited risk and pain. The combined ALIF/percutaneous screws also avoids neurologic manipulation with subsequent epidural scar tissue formation. Carragee's work has demonstrated superior results of a combined approach without laminectomy for this pathology. Obsiously, there is more than one way to skin a cat, but I applaud the author on his excellent approach and outcome.

An excellent case with an excellent reduction and restoration of sagittal profile. I would agree the Dr. Carragee has shown very well that an anterior approach is quite effective for this pathology. I would also point out that the anterior approach to L5-S1 is mechanically superior to TLIF in it's ability to restore disc height and the mechanical support of the implant. TLIF does put the exiting nerve root at risk and I have not been as impressed by it's ability to reduce stubborn listheses or restore intradiscal lordosis. Personally, I now do only anterior approach for L5-S1 (in appropriate patients) and use a stand-alone zero-profile device. I have not yet needed to place posterior fixation with this. The caveat is that the success of this approach depends heavily on your approach surgeon. I am very lucky in this.

While the excellent radiographical result should be congratulated, I would like to add a few thoughts:

1. Mini-TLIF allows harvesting of local bone graft from the facet joint, making the use of allograft unnecessary.
2. A front-back approach lengthens operative times considerably when compared to posterior-only approaches and harbours a slight risk of large vessel injury.
3. Chronic LBP is still a spinal enigma, even with conclusive evidence of segmental instability, and prolonged conservative management can provide similar long term results.

I agree 100% with the treatment

There is misconception that anterior subdiaphragmatic surgery is a morbid operation : An anterior L5/S1 fusion for a case like this takes 90 / 120 mn and will bleed less than 150 cc. Patient will be out of the hospital just like for a TLIF 2 days later.
I think the concept to fix the anterior cage on only one side was brilliant as it allows further reduction and or increase of lordosis in the posterior fixation.

I agree completely with Dr Harper that now even with spondylolisthesis it is possible to have a standalone device with a stabilized anterior cage ( no profile ) +- an anterior plate.
Percutaneous fixation is always very nice , but in spondylolisthesis I am probably not good enough not to bust the facets L4/L5 with my percutaneous screws, reason why I still do a mini open posterior fixation. ( even with open posterior fixation , I find it very difficult to be totally outside the facet L4/L5

Lastly in this case with a very large pelvic incidence of 80 degrees . the lordosis of the L5/S1 disc was probably when the patient was young around 25- 30 degrees. For such case an anterior surgery first with a very wedge allograft (25 degrees ) and 2 antikick out screws, followed by a posterior fixation , would definitively the best anatomic result

Hello,
I have done many such cases and I per se have never gone for an anterior approach and also never repented not going anterior. For such corrections I always go only posterior and do reduction and TLIF. With one approach you get the same results as a combined approach and with less morbidity and in case of some mishappening you always have one approach virgin.
I always use K-FIXATOR for such cases and I believe it is an excellent system to work with and I am grate ful to have worked with the originator of this fixator Dr Patrick Kluger from Germany.

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