Case Review:42 year old female with Grade 3 IsthmicSpondylolisthesis

Robert S Pashman, MDScoliosis and Spinal Deformity Surgerywww.eSpine.com

Patient History

4242--yearyear--old female who is quite athletic. old female who is quite athletic. The patient was a competitive swimmer whose primary events The patient was a competitive swimmer whose primary events were breaststroke and butterfly, both hyperextension events. were breaststroke and butterfly, both hyperextension events. The patient had some low back pain when she was a child, and The patient had some low back pain when she was a child, and she had this investigated, but in the intervening time she reallshe had this investigated, but in the intervening time she really y had no problem until recently. had no problem until recently. Low back pain Low back pain On physical examination, she has significant sacral promontory. On physical examination, she has significant sacral promontory. The patient has significant rotation of the pelvis consistent wiThe patient has significant rotation of the pelvis consistent with th grade 3 grade 3 IsthmicIsthmic SpondylolisthesisSpondylolisthesis. She has hamstring tightening . She has hamstring tightening and definite weakness of the and definite weakness of the dorsiflexorsdorsiflexors and extensor and extensor hallucishallucislonguslongus of left leg, of left leg, paresthesiasparesthesias and numbness in the L5 and numbness in the L5 distribution of the legs bilaterally. distribution of the legs bilaterally.

Pre-op X-rays

Grade 3 Grade 3 IsthmicIsthmicSpondylolisthesisSpondylolisthesis with with significant slip angle significant slip angle degeneration, degeneration, retrolisthesisretrolisthesisof L4 on L5, bilateral pars of L4 on L5, bilateral pars fractures, compression of fractures, compression of the L5 nerve root, lateral the L5 nerve root, lateral recess stenosis at L4recess stenosis at L4--5, and 5, and significant slip angle and significant slip angle and junctionaljunctional lumbar kyphosis.lumbar kyphosis.

Flexion and Extension X-rays

Indications for Surgery1. Grade 3 Isthmic Spondylolisthesis, L5-S1. 2. Degenerative disk disease, L4-5. 3. Evolving motor sensory deficit with weakness of extensor

hallucis longus, tibialis anterior bilaterally indicating L5 nerve root crush.

4. Increasing low back pain due to significant progressive isthmicspondylolisthesis and hyperlordosis, lumbar spine.

5. Bilateral pars fractures pars interarticularis, L5.

Surgical StrategyAbdominal retroperitoneal approach to the Abdominal retroperitoneal approach to the lumbosacrallumbosacral spine. spine. Subtotal Subtotal vertebrectomyvertebrectomy, L5, with removal of L5 overhang , L5, with removal of L5 overhang constituting greater than 1/3 of vertebra for entrance and constituting greater than 1/3 of vertebra for entrance and reduction of reduction of spondylolisthesisspondylolisthesis, L5, L5--S1. S1. Radical Radical diskectomydiskectomy, L5, L5--S1, including epidural decompression. S1, including epidural decompression. InterbodyInterbody fusion with 8 x small millimeter grafts with fusion with 8 x small millimeter grafts with autogenousautogenous vertebrectomyvertebrectomy bone centrally. bone centrally. Anterior screw fixation of fully threaded screw over a washer, Anterior screw fixation of fully threaded screw over a washer, L5L5-- S1. S1. SpondylolisthesisSpondylolisthesis reduction. reduction. IntraoperativeIntraoperative fluoroscopic interpretation. fluoroscopic interpretation.

Surgical Strategy – Part twoSegmental spinal instrumentation L4 to S1 using the AllezLaguna titanium pedicle screw/rod construct, 5.5 titanium. Complete laminectomy Gill fragment of L5 lamina under loupe magnification and microscope. Neuroforaminotomy with removal of bilateral pars interarticularis callus, L5-S1, under the microscope. Posterolateral and posterior fusion, L4 to S1, using locally harvested autogenous bone, including laminectomy and anterior vertebrectomy bone. Intraoperative fluoroscopy management. Spondylolisthesis reduction at L-S1. Intraoperative O-arm neuronavigation and interpretation.

Post-Op Films

The slip angle was The slip angle was reduced from a reduced from a Grade 3 to a Grade 1Grade 3 to a Grade 1

Pre-Op/Post-op Comparison

Pre-Op/Post-op Comparison