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Lumbar degenerative spondylolisthesis
Introduction
Low back pain is prevalent in the United States and the world, and spondylolisthesis is one of the most common causes of back pain with an estimated prevalence of 11.5%. Spondylolisthesis refers to the anterior, posterior, or rotational translation of a vertebra relative to another that occurs after an acquired (traumatic fracture, iatrogenic, etc.) or congenital bony defect in the pars interarticularis or a facet subluxation (see Chapter 1 , Table 2 ). Degenerative spondylolisthesis (DS) is the most common type and affects the aging population. Patients can develop debilitating instability and neurological deficits from spinal or neuroforaminal stenosis. In this chapter, we utilize an example case to illustrate the clinical presentation and surgical management of lumbar degenerative spondylolisthesis.
Example case
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Chief complaint : back pain
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History of present illness : The patient is a 66-year-old female with a 3-year history of worsening back pain and no radicular symptoms. She underwent imaging for spondylolisthesis ( Figs. 2.1 and 2.2 ).
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Medications : Oxycodone, Aleve
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Allergies : no known drug allergies
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Past medical and surgical history : obesity with a body mass index (BMI) of 38
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Family history : noncontributory
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Social history : no smoking; occasional alcohol
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Physical exam : awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi; and plantar flexion 5/5
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Reflexes : 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle and no clonus or Babinski; sensation is intact to light touch
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| Preoperative | ||||
| Additional tests requested |
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DEXA |
| Surgical approach selected | If physical therapy fails, posterior L4–5 decompression and fusion and TLIF | If conservative measures fail, MIS L4-F TLIF and posterior percutaneous instrumented fusion | L4–5 TLIF with MIS and robotically assisted | L4–5 TLIF |
| Goal of surgery | Decompression of neural elements and stabilization of segment | Indirect decompression of neural elements, reduction, and stabilization of L4–5 | Indirect decompression of neural elements, stabilization | Decompress neural elements, stabilize motion segments, fusion |
| Perioperative | ||||
| Positioning | Prone on Jackson table, no pins | Prone | Prone | Prone on Jackson table, with pins |
| Surgical equipment |
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| Medications | Steroids | Liposomal bupivacaine | None | Liposomal bupivacaine, tranexamic acid |
| Anatomical considerations | Facet joint, pedicle, exiting and traversing nerve roots | Thecal sac, pedicles | Exiting and traversing lumbar nerve roots | Exiting and traversing lumbar nerve roots |
| Complications feared with approach chosen | Weakness namely foot drop, bleeding, wound dehiscence | Wound breakdown, instrument failure, nerve root injury | Nerve root injury | Durotomy, lumbar radiculopathy, wound infection |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | L4–5 | L4–5 | L4–5 | L4–5 |
| Levels decompressed | L4–5 | L4–5 | L4–5 | L4–5 |
| Levels fused | L4–5 | L4–5 | L4–5 | L4–5 |
| Surgical narrative | Position prone on Jackson table, level marking using intraoperative navigation, placement of reference frame on L3 spinous process, acquisition of images and connect to navigation system, insert navigation-guided guidewires into the pedicles of L4 and L5 bilaterally using navigated Jamshidi needles, incision of guidewires approximately 3.5 cm off of midline on both sides, confirmation with fluoroscopy, intermuscular dissection reaching right facet joint, right facetectomy under microscope with preserving bone for graft material, identification of right L5 pedicle, decompress both right L5 and L4 nerve roots, L4–5 discectomy and end plate preparation, bone graft application and cage insertion with fluoroscopy, screws are inserted over guidewires and rods are placed with compression, intraoperative O-arm to confirm accuracy of screw insertion, closure in layers, infiltration of subcutaneous Marcaine | Position prone, place reference array on iliac crest, O-arm spin and navigation acquisition, bilateral paramedian incisions, place percutaneous MIS pedicle screws at L4–5, dock MIS tubular retractor over L4–5 facet joint for TLIF, facetectomy under microscope, TLIF and cage placement, placement of auto and allograft, place rods, standard closure | Position prone, intraoperative O-arm and CT, register with surgical robot, MIS percutaneous screw insertion with robotic-assisted, placement of rod on contralateral side, placement of tubular retractor and serially dilate on ipsilateral side, TLIF with microscopic visualization, placement of bullet cage, layered closure | Position prone, x-ray to localize skin incision, posterior midline incision, x-ray to confirm levels, place pedicle screws at L4–5 bilaterally using anatomical approach, check intraoperative x-ray to confirm safe position of implants, use intraoperative EMG to stimulate implants to confirm no nerve root irritation, left facetectomy or symptomatic side of patient’s leg pain, isolate exiting nerve root, perform subtotal discectomy through an annulotomy, place interbody cage packed in the interbody space with allograft with femoral head or commercially available allograft, perform manual reduction utilizing rods to fix the spine in place, complete remainder of decompression and the contralateral foramen, dilute betadine irrigation/soak, decorticate contralateral facet and bilateral transverse processes, pack remainder of the bone posteriorly and posterolaterally, final tightening of implants, layered closure without a drain, inject liposomal bupivacaine in the skin and subcutaneous tissue |
| Complication avoidance | Surgical navigation, minimally invasive approach, placement of cage under fluoroscopy, intraoperative imaging to confirm screw location | Minimally invasive approach in obese patient, surgical navigation, percutaneous pedicle screws | Minimally invasive approach, surgical navigation, robotically assisted, percutaneous pedicle screws | Anatomical placement of pedicle screws, use intraoperative EMG to stimulate implants to confirm no nerve root irritation, facetectomy on symptomatic side, manual reduction with rods |
| Postoperative | ||||
| Admission | Floor | Floor | Floor | Floor |
| Postoperative complications feared | Weakness namely foot drop from L5 nerve root, infection, medical complications | Instrument failure, nerve root injury | Nerve root injury | Durotomy, lumbar radiculopathy, wound infection |
| Anticipated length of stay | 5–7 days | 2 days | 1–2 days | 3 days |
| Follow-up testing |
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| Bracing | None | None | None | Lumbar corset out of bed for 3 months |
| Follow-up visits | 1 month after surgery | 4 weeks, 3 months, 12 months after surgery | 2 weeks after surgery | 2 weeks, 3 months, 12 months after surgery |
CT , Computed tomography; DEXA , dual-energy x-ray absorptiometry; ERAS, enhanced recovery after surgery; EMG, electromyography; ESI , epidural spinal injections; IOM , intraoperative monitoring; MIS , minimally invasive surgery; TLIF , transforaminal lumbar interbody fusion.
Differential diagnosis and actual diagnosis
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Spondylolysis
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Congenital or dysplastic spondylolisthesis
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Inflammatory arthritis
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Lumbar stenosis
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Spondylolisthesis
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