A clinical case, 70 year old male presents with L4-5 degenerative spondylolisthesis, severe spinal stenosis L4-5, treated conservatively with multiple epidural injections. Had relief at some point of time, but deteriorates.
So these patient’s natural history is that 33% will get better, 33%, one third will get better, one third will stay the same and one third will deteriorate. This patient had a claudication symptoms on both L5 nerve roots. So these patients can walk for a certain distance, after which they have to stop.
They have to lean forward or sit down leaning forward to relieve their pressure. Once they get better, they can again walk. This distance usually gets less and less over time. That’s sort of a clinical judgment on us that if this distance is getting less, then the severity is increasing on these patients.
These patients usually will not have any neurological deficit in my examination room. They will not have any positive sign that I can elicit. They may not have any back pain also. So the MRI was done, the x-rays were done, which show a grade one spondylolisthesis with stenosis of L4-5. L4-5 is the most common segment for this to be involved because it’s a most mobile segment, next is L5-S1.
After this, x-rays were done, we do dynamic views: flexion extension. I prefer to do standing x-rays for these patients because standing gives the dynamicity to the x-ray rather than lying down.
If I have to compare with a lying down x-ray, actually I can compare with an MRI because MRIs are done lying down, unless we are doing it standup. Postoperatively: so what we did was a procedure, which is again, a common procedure for instability. Now this patient has instability.
So we had to do a fusion. Otherwise, if the patient has only stenosis, we would just do a decompression, which can be done in multiple ways and I’ll show that. But in this patient, we did a L4-5 TLIF. So a cage was put from the back only, and then two screws above, two screws bottom, two rods. Follow-up, it healed well, fused, patient is asymptomatic and doing great.
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