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L5-S1 Pseudoarthrosis with Adjacent Level Spondylolisthesis in 44F
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.
1.
In addition to the plain film radiographs, would you obtain any further imaging to guide your treatment?
No - current imaging is sufficient
15%
47/303
Yes - additional radiographs (aXR)
6%
21/303
Yes - CT scan (CT)
6%
20/303
Yes - MRI
14%
44/303
Yes - aXR + CT
1%
5/303
Yes - aXR + MRI
2%
9/303
Yes - CT + MRI
33%
102/303
Yes - aXR + CT + MRI
14%
44/303
Outside of my area of expertise - best if I don't vote
3%
11/303
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
9%
25/277
Yes - Grade I
33%
92/277
Yes - Grade II
38%
106/277
Yes - Grade III
9%
27/277
Yes - Grade IV
1%
3/277
Outside of my area of expertise - best I don't answer
8%
24/277
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
19%
53/268
Yes - I would use use and measure by hand with a Goniometer
10%
29/268
Yes - I would use and measure using imaging Software
53%
144/268
Outside my area of expertise - best if I don't vote
15%
42/268
4.
How would you manage this patient at this time?
Nonoperative
15%
40/266
Operative
77%
206/266
Outside of my area of expertise - best if I don't vote
7%
20/266
5.
If you choose Operative Management, what levels would you include in the surgery?
I would not choose Operative Management
1%
5/261
L5/S1 Only (1 level)
1%
5/261
L4-L5 Only (1 level)
6%
16/261
L4-S1 (2 levels)
37%
99/261
L3-S1 (3 levels)
19%
50/261
L5-Pelvis (2 levels)
1%
3/261
L4-Pelvis (3 levels)
14%
39/261
L3-Pelvis (4 levels)
8%
21/261
L3-L5 (2 levels)
1%
3/261
Outside of my area of expertise - best if I don't vote
7%
20/261
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)
14%
35/246
Anterior Only (includes direct lateral, oblique lateral))
2%
5/246
Posterior Only
34%
85/246
Anterior then Posterior (do anterior with old instruments in place)
17%
44/246
Posterior then Anterior
5%
14/246
Posterior (take down instruments), then anterior, then posterior
13%
34/246
Outside my area of expertise - best if I don't vote
11%
29/246
7.
If you choose a Posterior Only Treatment Approach to include L3-S1, what would you do at the L5/S1 pseudoarthrosis?
I would not choose a Posterior Only approach to include L3-S1
15%
34/225
Nothing in Disc Space / Interbody
4%
10/225
Interbody Cage - Static (PEEK or Titanium)
15%
34/225
Interbody Cage - Expandable (PEEK or Titanium)
7%
17/225
Trans S1 Strut Across L5/S1 (modified Bohlman technique)
3%
7/225
S1-L5 Bilateral Screws (across L5/S1 disc space)
4%
9/225
Modified Bohlman technique + S1-L5 Bilateral Screws
3%
8/225
Interbody Cage - Static + S1-L5 Bilateral Screws
18%
41/225
Interbody Cage - Expandable + S1-L5 Bilateral Screws
10%
24/225
Other
0%
1/225
Outside of my area of expertise - best if I don't vote
17%
40/225
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
14%
32/214
Nothing in Disc Space / No Interbody
10%
22/214
Interbody Cage - Static (PEEK or Titanium)
45%
97/214
Interbody Cage - Expandable (PEEK or Titanium))
13%
29/214
Other
0%
0/214
Outside my area of expertise - best if I don't vote
15%
34/214
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)
22%
45/199
L5/S1 ALIF Only (1 level)
11%
22/199
L4/L5 ALIF Only (1 level)
5%
10/199
L3/L4 ALIF Only (1 level)
1%
3/199
L4/5 + L5/S1 (2 levels)
30%
60/199
L3/4 + L4/L5 (2 levels)
4%
9/199
L3/4 + L5/S1 (2 levels)
1%
2/199
L3/4 + L4/5 + L5/S1 (3 levels)
11%
23/199
Outside my area of expertise - best if I don't vote
12%
25/199
10.
If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), and did an ALIF at L5/S1, how would you do it?
If would not choose Anterior-Posterior Operative
19%
35/176
Trans L4 Bone Strut Across L5/S1 (Reverse Bohlman Technique) Management of L3-S1 (3 levels)
1%
2/176
Allograft Bone without Screws and no Plate
0%
1/176
Allograft Bone without Screws + Plate
1%
3/176
Allograft Bone with screws/washer (stand alone)
3%
7/176
PEEK Cage without Screws and no Plate
2%
5/176
PEEK Cage without Screws + Plate
6%
12/176
PEEK Cage with screws (stand alone)
16%
29/176
Titanium Cage without Screws and no Plate
5%
9/176
Titanium Cage without Screws + Plate
5%
10/176
Titanium Cage with screws (stand alone)
17%
31/176
Outside of my area of expertise - best if I don't vote
18%
32/176
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)
32%
52/160
Allograft fibula strut
15%
25/160
Autograft fibula strut
11%
18/160
Cage/Metal strut with bone graft
19%
31/160
Other
0%
1/160
Outside my area of expertise - best if I don't vote
20%
33/160
12.
If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), would you use BMP in your ALIF?
I would not choose Anterior-Posterior Operative Management of L3-S1 (3 levels)
17%
27/157
No - I would not use BMP
20%
32/157
Yes - I would use BMP on L5/S1 Only (1 level)
7%
12/157
Yes - I would use BMP on L4/5 + L5/S1 (2 levels)
22%
36/157
Yes - I would use BMP on L3/4 + L4/5 + L5/S1 (3 levels)
14%
22/157
Outside my area of expertise - best if I don't vote
17%
28/157
13.
If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), would you perform osteotomies during the posterior procedure?
I would not choose L3-S1 posterior instrumentation
10%
17/157
No - I would not perform osteotomies
32%
51/157
Yes - facetectomies alone
29%
47/157
Yes - Ponte osteotomies
12%
19/157
Outside of my area of expertise - best if I don't vote
14%
23/157
14.
If you choose to perform a Posterior fusion, would you instrument, and if so what technique would you use to you place your pedicle screws?
I would not choose to perform a Posterior fusion
3%
5/157
No – I would not instrument (decorticate and graft only)
0%
0/157
Yes – Anatomic technique (X-rays or fluoro After screws placed)
23%
37/157
Yes – Fluoro-assisted technique (fluoro During screw placement)
36%
58/157
Yes – Navigation without robot (intra or preoperative CT)
15%
24/157
Yes – Robot + Navigation (intra or preoperative CT)
9%
15/157
Other
0%
0/157
Outside my area of expertise - best if I don't vote
11%
18/157
15.
If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels) and obtained the construct below, would you use a post-operative brace?
I would not choose Anterior-Posterior Operative Management of L3-S1 (3 levels)
9%
15/157
No - I would not brace post-operatively
35%
55/157
Yes - lumbar corset
20%
32/157
Yes - TLSO (off the shelf)
14%
23/157
Yes - TLSO (custom clamshell)
8%
13/157
Outside my area of expertise - best if I dont vote
12%
19/157
PROCEDURE #1
DOP: 5/18/2021
ALIF L3-4, L4-5, L5-S1; L5-S1 ALIF utilized fibula allograft strut approached through L4-5 disc space (reverse Bohlman technique).
Intra-procedure P1
OUTCOMES
Post-procedure P1