Unstable, painful slip treated with fusion and instrumentation

History:The patient was a 15-year-old girl that presented with 2 years of low back pain aggravated by activity and involving intermittent pain and tightness in both legs. Spondylolisthesis had been diagnosed initially and treatment approaches included bracing, physical therapy and activity restriction. None of these offered relief of symptoms and a progressive increase in pain was noted by the patient even with limited activity.

Physical Examination:The patient was a cheerful adolescent walking with a normal gait. Tenderness in the paraspinal muscles of the lumbar back region was noted. Some hamstring tightness was present in the legs. Good strength was present in all muscle groups and sensation was fully intact. Reflexes in the legs were brisk but no abnormal reflexes were present.

Radiographic Evaluation:On standing radiographs of the lumbar spine a grade II (grading system I to IV by increasing severity) spondylolisthesis at L4-L5 was evident. Isthmic defects (the spondylolysis) were evident bilaterally (fractures through the posterior part of L4). On flexion-extension X-rays significant motion across the spondylolysis was evident. Of note the patient had a mild scoliosis present in the thoracic spine.

Treatment Options:In general terms, spondylolysis (the fracture of the posterior portion of a vertebra, that can lead to spondylolisthesis - the actual slippage of one vertebra over another) is first treated with non-operative means (unless neurologic symptoms are present). In most cases a combination of activity restriction, bracing and physical therapy are effective. When this fails and slippage of the vertebrae continues or is unstable and persistently painful, then surgery is sometimes considered. Surgical treatment options include posterior surgery alone, anterior surgery, a combination of anterior and posterior surgery. In some cases instrumentation (rods and screws) are used in addition to bone graft. 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 slippage and the degree of stability.

This patient also had a mild scoliosis. This is not unusual in spondylolisthesis and sometimes the scoliotic curvature improves or stops progressing if the spondylolisthesis is surgically stabilized. If the curvature is mild it is usually recommended to first treat the spondylolisthesis and follow the scoliosis. No particular scoliosis treatment may be necessary in the mild curves.

Discussion:In this particular case the spondylolisthesis is moderate in degree yet it is quite unstable, showing significant motion on x-rays taken in different positions (flexion vs. extension). Non-operative treatment had failed and thus after thorough discussion of options the patient and her family decided to proceed with surgical treatment. The goal of surgery was two-fold: to stabilize the spine and stop painful motion, and to obtain a solid bone fusion across the unstable level. Given the young age of the patient it was felt that a solid fusion could be obtained with posterior surgery alone (without an anterior spinal fusion). Due to the instability present it was decided to implant instrumentation to ensure a stable and solid fusion.

Treatment and Results:As planned, the patient had a posterior spinal fusion with instrumentation and bone graft. The L4-5 and L5-S1 levels were fused in lordotic alignment. The patient recovered rapidly and was discharged within 4 days from the hospital. A solid fusion developed and the patient had complete relief from her symptoms.

The scoliosis was followed on a regular basis but no progression has occurred and the patient may not require any intervention to treat this.