SpineUniverse Case Study Library

L5-S1 Grade II Spondylolisthesis

Patient Presents PMVA


The patient is a 21-year-old female who presents after a motor vehicle accident. She also has a 5-month history of low back pain, along with right leg pain and tingling.


She shows a right L5 sensory deficit, but no motor deficit.

Prior Treatment

Previously, she had physical therapy and facet epidurals to try to address her low back pain and leg pain with no pain relief.


 fig1 Girasole Spondy PMVA Pre-op Lat X-rayFigure 1: Pre-op lateral x-ray showing Grade II spondylolistheis at L5-S1. There is also a Grade I spondylolisthesis at L4-L5. Lumbar kyphosis is 20º. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.

fig2 Girasole Spondy PMVA Pre-op PA X-rayFigure 2: Pre-op PA x-ray. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.

fig3 Girasole Spondy PMVA Pre-op Flex-ExtFigure 3: Pre-op flexion and extension x-rays. There is motion on flexion-extension. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.

fig4 Girasole Spondy PMVA Pre-op Lat MRIFigure 4: Pre-op lateral MRI showing some compression at L5-S1. 24515. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.

fig5 Girasole Spondy PMVA Pre-op Axial MRIFigure 5: Pre-op axial MRIs of L4-L5 (left) and L5- S1 (right) showing hyperactivity around the pars. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.


The patient was diagnosed with Grade II spondylolisthesis at L5-S1 and Grade I spondylolisthesis at L4-L5.

Suggest Treatment

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Selected Treatment

The patient had an L4-S1 anterior-posterior decompression and instrumented spinal fusion.

An anterior-posterior approach was chosen because the patient was a young female, and I felt I could better reconstruct the anterior column, reduce her slip angle, and correct the pelvic incidence from an anterior-posterior approach, as compared to a posterior-only approach.

Post-treatment Images

 fig6 Girasole Spondy PMVA Post-op Lat X-rayFigure 6: 6 weeks post-op lateral x-ray showing improved deformity. Note the reduced spondyloisthesis at L5-S1 especially. There is also a reduced slip angle and improved pelvic incidence. The sagittal imbalance has been corrected. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.

fig7 Girasole Spondy PMVA Post-op PA X-rayFigure 7: 6 weeks post-op PA x-ray. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.

fig8 Girasole Spondy PMVA Pre-op vs Post-op Lat X-rayFigure 8: Pre-op (left) to post-op (right) lateral x-rays showing improved deformity. Image courtesy of Gerard J. Girasole, MD, and SpineUniverse.com.


 The patient is two years post-op and is doing well. She’s back to her normal activities.

Case Discussion

The operative management of spondylolisthesis may include a broad spectrum of approaches. Major areas of controversy in operative management of spondylolisthesis include the role of reduction of deformity, the role of interbody fixation, and the role of iliac fixation. This case exemplifies some important principles of care, and the result is a stable fixation with excellent restoration of lumbopelvic parameters.

The patient is a 21-year-old female with a grade 2 spondylolisthesis at L5-S1 and a grade one spondylolisthesis at L4-5. She became symptomatic after a motor vehicle accident and the pathology may be post-traumatic. The patient presents with significant deformity including a lumbosacral kyphosis of 20º. L4 is kyphotic, and the first horizontal vertebra in the sagittal plane is L1.

The surgeon's first decision in planning operative care is whether to gain reduction of the deformity. The deformity is partially reducible as demonstrated on the MRI scan better than extension views. An in situ fusion would result in significant sagittal plane malalignment, both regionally and globally.

The choice of a combined anterior and posterior approach facilitated an excellent reduction of the lumbosacral kyphosis and restoration of normal lumbopelvic measures. A posterior-only approach with or without interbody fixation would have been unlikely to result in as reliable a restoration of lumbopelvic balance.

Therefore, the surgical strategy of reduction of deformity and circumferential fusion with a combined anterior and posterior approach was well-guided.

The fusion from L4-S1 is a relatively short construct and should have limited stress on the S1 screws. However, in the setting of a significant reduction of deformity, the strain on the S1 screws is significantly increased. One potential mode of failure of this construct may be loosening or migration of the S1 screws. Extension of fixation to the ilium may be a reasonable option in this case to limit the possibility of loss of correction.

Overall, surgical strategies for the management of spondylolisthesis are characterized by significant variability. The goals of care in this case included a reduction of lumbosacral kyphosis and an improvement of regional and global balance. A combined anterior and posterior approach provided the most reliable technique for deformity reduction and maintenance of reduction.

Community Case Discussion (4 comments)

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

Such a dynamic fixation at L4-L5 will prevent upper adjacent segment degeneration.

In this case of 21 years old female with I would say oligolisthesis at L5/S1 and right leg radicular pain with additional back pain first we would first have to address her pain. So radicular pain origin is foraminal stenosis and back pain origin is DDD. Like first treatment, especially that is 21 years old girl, I would recomend MISS discectomy and anuloplasty( endoscopic I would prefer). If that treatment wouldnt work than I would think about some kind of fusion surgery but fusion is not for shure first choice of action in 21 y old female.

I would do an EMG and see if there is any denervation. Flexion/extension views for instability. She is so young I would encourage 3 ESIs before surgery for the leg pain and possible RFA of the facets before resorting to a 2 level fusion.


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