L5-S1 Spondylolisthesis: Failed Pain Management
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.
5/5 motor strength in bilateral lower extremities. No tenderness to palpation of lumbar spine.
Previously, the patient had undergone organized physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and narcotic pain medication.
Figure 1A: Lateral x-ray of the lumbar spine. Note the grade II spondylolisthesis of L5 on S1 and levoscoliosis.
Figure 1B: AP x-ray of the lumbar spine. Note the grade II spondylolisthesis of L5 on S1 and levoscoliosis.
Figure 2A: Sagittal T2-weighted MRI of the lumbar spine.
Figure 2B: Axial T2-weighted MRI.
Grade II spondylolisthesis of L5-S1
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
The patient had a mini-open anterior lumbar interbody fusion (ALIF) L5/S1 with percutaneous pedicle screw fixation L5-S1.
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.
Figures 4A and 4B: Post-operative x-rays 3 months after surgery detail the surgical result.
After 3-month follow-up, the patient has improvement of back pain and decreased requirement for narcotics.
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.