Competitive Equestrienne: Incapacitating Low Back Pain

Patient History

The patient is 32-year-old healthy female who is a competitive equestrienne. She presented with a 2-year history of incapacitating low back pain, inhibiting many of her daily activities, and preventing her from riding. The pain does not radiate to her legs.

Examination

Physical and neurological examinations were normal.

Prior Treatment

The patient tried several conservative treatments, including physical therapy, chiropractic care, analgesics (narcotics and muscle relaxants), and epidural steroid injections. In addition, she tried bracing and traction. None of the conservative treatments were effective.

Images

The patient's sagittal x-ray (Figure 1) shows a grade 1 spondylolisthesis at L4-L5 and spondylolysis at L4. Her flexion x-ray (Figure 2) shows a slight worsening of the spondylolisthesis at L4-L5. The extension x-ray (Figure 3) demonstrates the same issues as presented in Figure 1. Figure 4 is the patient's oblique x-ray with right L4 spondylolysis. The axial CT (Figure 5) shows L4 bilateral spondylolysis.

Figure 1. Grade 1 Spondylolisthesis at L4-L5

Figure 2. Flexion, slight worsening of the spondylolisthesis

Figure 3. Extension, same issues as Figure 1

Figure 4. Right L4 spondylolysis

Figure 5. L4 bilateral spondyloysis

Diagnosis

Grade 1 spondylolisthesis at L4-L5 with L4 spondylolysis.

Selected Treatment

The patient underwent a minimally invasive TLIF at L4-L5. The surgery was completed with minimal blood loss. Post-operative images below (Figures 6, 7).

Figure 6

Figure 7

Outcome

A solid fusion was attained and the patient reported complete relief of back pain. She has returned to all pre-operative activities, including horseback riding.

Case Discussion

Jeffrey C. Wang, MD

Professor of Orthopaedic Surgery and Neurosurgery

Keck School of Medicine, University of Southern California

This is a 32-year-old active female with incapacitating back pain. The radiographs demonstrate a grade one L4-L5 spondylolisthesis with motion and increasing subluxation in flexion radiographs of the instability. In this situation, conservative treatment with physical therapy, chiropractic care, medications, bracing, traction, and epidural injections are all acceptable initial treatments, and it is absolutely appropriate for these to be completed in order to alleviate symptoms.

However, the conservative treatments will not alter the structural problems in the spinal anatomy and, it appears the patient continued to experience symptoms despite conservative treatments. In this situation, it is reasonable to discuss surgical options with the patient. The treatment options posted in the case are all appropriate surgical options, each with some advantages and some disadvantages when directly compared. These options all include a spinal fusion, which would stabilize the instability from the malalignment of the L4-L5 segment. The choice of a posterior approach to the spine also allows for a direct decompression of the nerve roots, which is an added advantage over the anterior approaches.

I favor posterior decompression and fusion and agree with the treatment that was performed. Another option would be the use of an interspinous spacer. However, this is newer technology and it is unclear if the results of an interspinous spacer in this patient would be of equal results.