Review Question - QID 4365

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Degenerative Spondylolisthesis Treatment Operative QID: 4365 (OBQ12.5)

QID 4365 (Type "4365" in App Search)

A 57-year-old woman with a past medical history of diabetes mellitus and arrythmias, requiring prior insertion of a pacemaker, presents with severe bilateral leg pain for 12 months. She reports the symptoms are worse with prolonged walking and improved with sitting. The severity of her symptoms has led her to exercise primary on a stationary bicycle, which she reports does not cause her symptoms. On physical exam she is neurologically intact in her lower extremities. She has an ABI of 0.95. A flexion and extension radiograph is performed and shown in Figure A. An axial CT myelogram at the L4/5 level is shown in Figure B. Extensive nonoperative treatment with therapy and epidural steroid injections have failed to provide any relief of her symptoms. What would be the most appropriate next step in treatment?

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Obtain magnetic resonance imaging

14%

736/5248

Refer the patient to a vascular surgeon for treatment of peripheral vascular disease

212/5248

Proceed with a lumbar decompression

16%

814/5248

Proceed with a lumbar decompression and instrumented fusion

63%

3316/5248

Proceed with a lumbar decompression and uninstrumented fusion

107/5248

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The patient's presentation is consistent with neurogenic claudication due to grade I degenerative spondylolisthesis at L4/5. Decompression and instrumented fusion is the most appropriate treatment.

Degenerative spondylolisthesis is a form of intersegmental instability caused by intervertebral disc degeneration, facet joint degeneration and sagittal orientation ligamentous laxity. In adults it usually occurs at L4/5. It is more common in African Americans, diabetics, and women over 40 years of age. The first line of treatment should be nonoperative. If this fails decompression and instrumented fusion is indicated.

Weinstein et al, as part of the SPORT trial, showed that patients with degenerative spondylolithesis who underwent surgical treatment had improved outcomes with respect to bodily pain, physical function, and for the Oswestry Disability Index. They concluded that, compared with patients who are treated nonoperatively, patients with degenerative spondylolisthesis and associated spinal stenosis who are treated surgically maintain substantially greater pain relief and improvement in function.

Fischgrund et al. prospectively analyzed the influence of transpedicular instrumented on the operative treatment of patients with degenerative spondylolisthesis and spinal stenosis. They found successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P = 0.0015). They concluded that in patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate.

Figures A and B show a flexion-extension radiograph demonstrating a Grade I degenerative spondylolisthesis at L4/5. Figure B shows a CT myelogram at the L4/5 level which shows spinal stenosis.

Incorrect Answers:
Answer 1: An MRI can not be performed due to the patients pacemaker.
Answer 2: The patients symptoms are consistent with neurogenic claudication as opposed to vascular claudication. Vascular claudication is characterized by pain with prolonged walking that improves when the patient continues to stand upright. Patients with vascular claudication usually have pain with stationary bicycle exercise. Those with neurogenic claudication often do not because they are in a sitting position. In addition the patient has an ABI of > 0.9, which is normal.
Answer 3: In patients with degenerative spondylolithesis, a decompression alone is not beneficial as the patient will have postoperative segmental instability.
Answer 5: Instrumented lumbar fusions have improved fusion rates relative to uninstrumented fusions.