Severe stenosis with spondylolisthesis, treated with decompression and fusion

History:The patient was a 69-year-old gentleman that presented with a chief complaint of low back pain and leg pains aggravated by activity. His symptoms first developed 5 years earlier and over time progressive increase in pain and difficultly with walking was noted. Even standing for several minutes lead to heaviness and fatigue in the legs requiring rest. Past treatment included physical therapy, activity modification and medication. None of this offered relief of symptoms and a progressive increase in disability was evident.

Physical Examination:The patient was a well-developed man, appearing younger than his age, walking with a normal gait. Examination of the back revealed muscular tenderness over the lumbar area. Hip motion was complete and painless bilaterally, straight leg raise was negative bilaterally. All muscle groups of the lower extremites had full strength (5/5). Sensation was intact to all dermatomes.

Radiographic Evaluation:On standing radiographs of the lumbar spine a grade I (grading system I to IV by increasing slippage) spondylolisthesis at L3-L4 was evident. (figure 1). An MRI was obtained which revealed severe spinal stenosis at the level of slippage (figure 2). This MRI also revealed severe stenosis at the adjacent level of L4-L5. A CT scan more clearly illustrated the narrowing of the spinal canal due to facet joint degeneration. (figure 3).

Treatment Options:In general terms, degenerative spinal stenosis (the narrowing of the spinal canal due to aging with 'wear and tear' of discs and facet joints) is first treated with non-operative means (unless marked neurologic symptoms are present). In most cases a combination of activity restriction, physical therapy and medication offers some relief. When this fails and progressive loss of function with pain and inability to walk is present, then surgery is sometimes considered. Surgical treatment options include: spinal decompression, spinal decompression and fusion with bone only, spinal decompression with fusion using instrumentation and bone, of a combination of anterior and posterior surgery. The use of spinal instrumentation (hooks or rods, and screws) in addition to bone graft can ensure immediate stability of the spine and increase the chance of a successful spinal fusion. Each case is approached in a very individual manner and the optimal treatment approach is dependant upon a number of different factors including patient age, degree of spinal stability, degree of nerve compression or dysfunction.

Discussion:In this particular case the spinal stenosis was severe and associated with spondylolisthesis. Non-operative treatment had failed and thus after thorough discussion of options the patient decided to proceed with surgical treatment. The goals of surgery were: to stabilize the spine and stop painful motion, to obtain a solid bone fusion across the unstable level, and to free the compressed nerves at the levels of severe stenosis.

Treatment and Results:As planned, the patient had a posterior spinal decompression (to free the nerve roots), a posterior fusion and placement of spinal instrumentation. The patient recovered rapidly and was discharged within 4 days from the hospital. A solid fusion developed over the subsequent months and the patient had excellent relief from his symptoms.