Adult Isthmic Spondylolisthesis Pathway Posted: 1/30/2022 ID: (C101971)

L5-S1 Pseudoarthrosis with Adjacent Level Spondylolisthesis in 44F

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EVIDENCE

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CASE DESCRIPTION

AGE	44 / Female
CC	Severe low back pain w/ occasional mild bilateral leg pain
HPI	The patient is a 44-year-old female that previously underwent an L5-S1 instrumented fusion and decompression 12 years ago for L5-S1 isthmic spondylolisthesis with associated L5 radiculopathy. The patient reported excellent relief of symptoms for the last 17 years following her fusion surgery. However, over the last several months she has experienced worsening pain in her back that is worse with standing and activity. The back pain is severe and limits many of her activities. Occasionally she has mild bilateral leg pain that is exacerbated by standing and walking, but that is not her primary complaint. Denies any numbness or tingling in her legs. Denies any bowel or bladder incontinence.
PMH	Healthy, former smoker
PE	The previous incision is well healed. No paraspinal muscle tenderness. Motor graded 5/5 in the iliopsoas, quadriceps, tibialis anterior, extensor hallicus longus, and gastrocsoleus. Her sensation is intact to light touch L2-S1. Brisk capillary refill in all digits. Dorsalis pedis pulse 2+. Negative Babinski's sign.

AGE/GENDER:

44 / Female

CHIEF COMPLAINT:

Severe low back pain w/ occasional mild bilateral leg pain

HISTORY OF PRESENT ILLNESS:

The patient is a 44-year-old female that previously underwent an L5-S1 instrumented fusion and decompression 12 years ago for L5-S1 isthmic spondylolisthesis with associated L5 radiculopathy. The patient reported excellent relief of symptoms for the last 17 years following her fusion surgery. However, over the last several months she has experienced worsening pain in her back that is worse with standing and activity. The back pain is severe and limits many of her activities. Occasionally she has mild bilateral leg pain that is exacerbated by standing and walking, but that is not her primary complaint. Denies any numbness or tingling in her legs. Denies any bowel or bladder incontinence.

PAST MEDICAL HISTORY:	Healthy, former smoker
PHYSICAL EXAM:	The previous incision is well healed. No paraspinal muscle tenderness. Motor graded 5/5 in the iliopsoas, quadriceps, tibialis anterior, extensor hallicus longus, and gastrocsoleus. Her sensation is intact to light touch L2-S1. Brisk capillary refill in all digits. Dorsalis pedis pulse 2+. Negative Babinski's sign.
DIAGNOSIS:	L5-S1 Pseudoarthrosis with Adjacent Level Spondylolisthesis in 44F

Pre-procedure IMAGES:

https://upload.orthobullets.com/cases/101971/5a1005e8-94ff-4dab-8f59-195e5b2af3b3_0ce8e72a-b688-4ba1-8b1e-6674aa030bc1..jpg

https://upload.orthobullets.com/cases/101971/90c250f1-d1f5-48f2-b2e1-2f5d7f5ff762_ap.jpg

https://upload.orthobullets.com/cases/101971/36f1c7e0-9567-4bf2-809b-79b74f45204c_5f79bf1f-cdd3-40ce-9436-b7ecc1a51e87..jpg

https://upload.orthobullets.com/cases/101971/72175f4e-56b7-4a99-81c5-89ee4eff0239_6a7cd5e5-f91c-4abf-b5bb-959aa302ff76..jpg

https://upload.orthobullets.com/cases/101971/ct.jpg

https://upload.orthobullets.com/cases/101971/untitled-23.jpg

https://upload.orthobullets.com/cases/101971/l3-4.jpg

https://upload.orthobullets.com/cases/101971/l4-5.jpg

https://upload.orthobullets.com/cases/101971/479e5afc-1070-4b9d-b316-1aff9301f81d_l5-s1.jpg

POLLS

OB Community

1) In addition to the plain film radiographs, would you obtain any further imaging to guide your treatment?

No - current imaging is sufficient

Yes - additional radiographs (aXR)

Yes - CT scan (CT)

Yes - MRI

Yes - aXR + CT

Yes - aXR + MRI

Yes - CT + MRI

Yes - aXR + CT + MRI

Outside of my area of expertise - best if I don't vote

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2) Would you use the Meyerding Classification, and if so what Grade would you assign?

I would not use the Meyerding Classification system for this patient

Yes - Grade I

Yes - Grade II

Yes - Grade III

Yes - Grade IV

Outside of my area of expertise - best I don't answer

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3) Would you use a Pelvic Incidence (PI) measurement to guide your management, and if so how would you measure it?

No - I would Not use a PI measurement to guide management

Yes - I would use use and measure by hand with a Goniometer

Yes - I would use and measure using imaging Software

Outside my area of expertise - best if I don't vote

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4) How would you manage this patient at this time?

Nonoperative

Operative

Outside of my area of expertise - best if I don't vote

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6) If you choose Operative Management to include L3-S1 (3 levels), would you do the procedure from the front or back, and in what order?

I would not choose Operative Management t to include L3-S1 (3 levels)

Anterior Only (includes direct lateral, oblique lateral))

Posterior Only

Anterior then Posterior (do anterior with old instruments in place)

Posterior then Anterior

Posterior (take down instruments), then anterior, then posterior

Outside my area of expertise - best if I don't vote

Other

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8) If you choose a Posterior Only Treatment Approach to include L3-S1, what would you do at the L4/L5 spondylolithesis?

I would not choose Posterior Only Treatment Approach to include L3-S1

Nothing in Disc Space / No Interbody

Interbody Cage - Static (PEEK or Titanium)

Interbody Cage - Expandable (PEEK or Titanium))

Other

Outside my area of expertise - best if I don't vote

Other

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9) If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), what level(s) would you do an ALIF on?

If would not choose Anterior-Posterior Operative Management of L3-S1 (3 levels)

L5/S1 ALIF Only (1 level)

L4/L5 ALIF Only (1 level)

L3/L4 ALIF Only (1 level)

L4/5 + L5/S1 (2 levels)

L3/4 + L4/L5 (2 levels)

L3/4 + L5/S1 (2 levels)

L3/4 + L4/5 + L5/S1 (3 levels)

Outside my area of expertise - best if I don't vote

Other

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11) If you choose Anterior-Posterior Operative Management of L3-S1 with a Trans L4 Bone Strut Across L5/S1 (Reverse Bohlman Technique), what kind of graft would you use?

I would not choose Trans L4 Bone Strut Across L5/S1 (Reverse Bohlman Technique)