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(OBQ10-143) A 69-year-old female presents with worsening bilateral buttock and leg pain that is worse with prolonged standing and improves with sitting. Her symptoms have worsened to the point that it is now difficult for her to walk small distances. Physical exam shows weakness to EHL on the right. A magnetic resonance image is shown in Figure A. Nonsurgical management, including epidural corticosteroid injections, has failed to relieve the patient’s symptoms. What is the most appropriate next step in management? Topic

Review Topic

FIGURES: A

1. Continued nonsurgical management
2. Decompressive laminectomy alone
3. Right side microdiskectomy
4. Decompressive laminectomy with posterior instrumented fusion
5. Anterior lumbar interbody fusion

PREFERRED RESPONSE >

The clinical situation is consistent with neurogenic claudication due to degenerative spondylolithesis at L4/5. Decompression with a laminectomy and instrumented fusion is the most appropriate treatment.

Weinstein et al performed a randomized and observational cohort study comparing standard decompressive laminectomy (with or without fusion) to nonsurgical care for the treatment of degenerative spondylolithesis. They found patients treated surgically maintain substantially greater pain relief and improvement in function for four years.

Herkowitz et al prospectively studied 50 patients with degenerative spondylolithesis to determine if concomitant intertransverse-process arthrodesis provided better results than decompressive laminectomy alone. They found that the arthrodesis group had significantly better results with respect to relief of pain in the back and lower limbs at an average follow-up of 3 years.

Fischgrund et al shows that in patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws leads to a higher fusion rate.

Wrong Answers:
Answer 1: The patient has failed nonoperative management and her symptoms are affecting her quality of life. In addition, she has neurologic deficits, so operative treatment is indicated.
Answer 2: Posterior decompression alone for the treatment of mobile degenerative spondylolisthesis (DS) can lead to iatrogenic instability, and is not appropriate.
Answer 3: The patient's neurogenic claudication is caused by spinal stenosis, and a microdiskectomy would not address this.
Answer 5: An ALIF would not adequately decompress her spinal canal and is not the most appropriate treatment.

References:

1) 2010 Orthopaedic In-Training Examination, Question #143. American Academy of Orthopaedic Surgeons, Rosemont IL.

2) Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PMID:19487505 (Link to Abstract)

3) Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8. PMID:2071615 (Link to Abstract)

4) Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT. Degenerative lumbar spondylolisthesiswith spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (PhilaPa 1976). 1997 Dec 15;22(24):2807-12. PMID:2071615 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, AFSHIN RAZI MD,

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