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

L5-S1 Pseudoarthrosis with Adjacent Level Spondylolisthesis in 44F

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PRESENTATION
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POLLS
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OUTCOMES
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VIDEOS
6
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EVIDENCE
17
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Comments
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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.
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?
Other
2) Would you use the Meyerding Classification, and if so what Grade would you assign?
Other
3) Would you use a Pelvic Incidence (PI) measurement to guide your management, and if so how would you measure it?
Other
4) How would you manage this patient at this time?
Other
5) If you choose Operative Management, what levels would you include in the surgery?
Other
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?
Other
7) If you choose a Posterior Only Treatment Approach to include L3-S1, what would you do at the L5/S1 pseudoarthrosis?
Other
8) If you choose a Posterior Only Treatment Approach to include L3-S1, what would you do at the L4/L5 spondylolithesis?
Other
9) If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), what level(s) would you do an ALIF on?
Other
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?
Other
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?
Other
12) If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), would you use BMP in your ALIF?
Other
13) If you choose Anterior-Posterior Operative Management of L3-S1 (3 levels), would you perform osteotomies during the posterior procedure?
Other
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?
Other
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?
Other
CASE OUTCOMES
PROCEDURE 1: ALIF L3-4, L4-5, L5-S1; L5-S1 ALIF utilized fibula allograft strut approached through L4-5 disc space (reverse Bohlman technique).
DOP: 5/18/2021
Intra-procedure P1
https://upload.orthobullets.com/cases/101971/8d0fd630-1380-4462-b739-1a5a77be7338_5a06cca8-a54a-4967-98aa-f14190da4901..jpg https://upload.orthobullets.com/cases/101971/7160d8f7-6631-4750-9903-9e77a4ca867c_70068d8d-fdf7-4498-8eb5-b5db6b31bc05..jpg
Post-procedure P1
https://upload.orthobullets.com/cases/101971/f2a2b038-4f50-49e5-9ce1-d55669710972_691f2c0f-e176-4363-a569-2d7c75991224..jpg
VIDEOS & PODCASTS (6)
EVIDENCE (17)
EXPERT COMMENTS