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Lumbar disc arthroplasty
0%
8/2287
Lumbar microdiskectomy
1%
23/2287
Lumbar decompression and fusion
94%
2157/2287
Lumbar decompression only
2%
55/2287
Lumbar fusion only
33/2287
Select Answer to see Preferred Response
The clinical presentation is consistent with severe symptoms of degenerative spondylolithesis that have failed nonoperative treatment. Lumbar decompression and fusion is the most appropriate treatment. Degenerative spondylolistheis is ~5-10 times more common in women than men, and is caused by degenerative processes that lead to microinstability of the facet joint and ultimately macroinstability of a lumbar segmental level. Both sagittaly-oriented facets and a transitional L5 vertebral body are risk factors. It is most commonly seen at L4/5 which is one factor that differentiates it from adult isthmic spondylolisthesis that most commonly occurs at L5/S1. Weinstein et al. presented 4 year result of the SPORT trial. The "as treated" analysis showed that patients with degenerative spondylolisthesis treated with operative management had a significantly better results with regards to pain relief and improvement in function. Herkowitz et. al. evaluated patients with spinal stenosis associated with degenerative lumbar spondylolisthesis treated with decompression alone versus decompression and fusion. Those patients treated with both decompression and fusion had better outcomes with respect to relief of lower back and lower extremity pain. Kornblum et al. presented 47 patients with single-level degenerative spondylolisthesis treated operatively with posterior decompression and bilateral posterolateral arthrodesis with autogenous bone graft. They found good to excellent clinical outcomes in 86% of patients with a solid arthrodesis, while only 56% of patients with a pseudoarthrosis had good to excellent clinical results. They conclude that a solid arthrodesis is key to maintaining long-term clinical results. Illustration A shows the mechanism of the central and lateral recess stenosis that leads to the classic symptoms of neurogenic claudication characteristic of degenerative spondylolisthesis. Illustration B shows the mechanism of foraminal stenosis, which may explain the presence of radicular pain in patients with degenerative spondylolisthesis. Illustration C shows the steps of performing an adequate lumbar decompression. Incorrect Answers: Answer 1: Lumbar disc arthroplasty is not indicated in patients with degenerative spondylolisthesis because it does not address the pathology (and pain generator) of the facet joint. Answer 2: A lumbar microdiscectomy does not address the pathology of degenerative spondylolisthesis. Answer 4: Studies have shown ~30% of patients with degenerative spondylolisthesis who have a decompression alone without fusion go on to have progressive instability. Answer 5: An adequate decompression must be performed to ensure the lateral recess and the foramen of both the exiting and descending nerve root is decompressed.
4.3
(18)
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