Spondylolisthesis: Is Surgery Required

 

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This is a high level discussion of the need for spondylolisthesis surgery.

Dr. McLaughlin, Orthopedic surgeon John D. Tydings MD, and Med Student Maggie Fitzpatrick MS, led a discussion of Spondylolisthesis for med students, practicing physicians, and healthcare pros.

NeuroRounds is the LIVE online resource for Med Students, Pre-Med, and medical professionals. You''ll see Real Cases and Real Patients, and interact with leading experts from practice, medical academia, and med schools.

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Transcript

Dr. McLaughlin: They have—this person has essentially no leg pain, maybe a little bit of buttock pain at times, but is active, fit, not overweight, and has a normal neurological examination. They come for advice, take non-steroidal medications occasionally, but overall are functioning well, have not missed a day of work from this, and are just concerned because they were told they needed spine surgery.

So, this is their X-ray, and I do have an MRI scan. Anyone want to take a crack at this? Anybody? This is a complex one—we can jump up to the professor, but I wanted to see if anybody wanted to describe it.

Alright, John, it’s all yours.

Dr. Tydings: Well, the obvious finding there is a Grade 2 spondylolisthesis, as per your chart below. It also looks like there’s a pars defect. I can’t tell from just this one view if it’s unilateral or bilateral. With this degree of slippage, I would suspect it’s bilateral, but it looks like it’s been there for a long time because the edges are well-formed and rounded, which wouldn’t be consistent with an acute fracture.

What I would do at this point is obviously a history and physical examination to check for neurological issues, and you already told me that was essentially normal. So, the next step is figuring out if this is unstable or acute—whether it needs to be done or can wait. The first thing I would get is flexion-extension views to check for any instability, and I absolutely agree with an MRI to check out the neurological structures. I’d also get a CT with reformatted images—it’s quite possible this is already fused in that position, and a CT would give much better information on that than an MRI. Those are my preliminary thoughts.

Dr. McLaughlin: Excellent, yeah. The only thing I’d add is that this almost looks like a calcification across this bridge here—that’s what I initially thought.

Dr. Tydings: Hence the CT requirement.

Dr. McLaughlin: Alright, so she came to me with an MRI scan, and she is getting further workup. Here’s the MRI scan, so I’ll play the sagittal first. I’ll leave the midline just for a second for your viewing pleasure, and then we’ll go off to the sides. A number of juicy findings here—anybody want to take a crack? This is a sagittal view, and I think there’s a really good view of a foraminal compression. Anybody? Everybody’s quiet today.

Hi, Chris, how you doing?

Chris: Good, how are you?

Dr. McLaughlin: Good, good. What do you think?

Chris: Um, would that be like an S2?

Dr. McLaughlin: No, this is—whenever you have spondylolisthesis, remember it’s the higher root. So, if you have a disc herniation at L4-5, almost always the nerve root that’s compressed is the L5 root. But if you have an L4 spondylolisthesis, most likely the L4 root is going to get compressed due to foraminal compression.

Chris: Oh, okay.

Dr. McLaughlin: And/or stretching. Right. So, here’s a beautiful sagittal image—look at every one of these foramina. You see the nerve root, you see a little cuff of fat around the nerve root. Nerve root, cuff of fat. Nerve root, cuff of fat. There’s the pedicle above. The neural foramen is bounded by the pedicle below, the pedicle above, the disc in front, and the facet joint in back. This is a perfect neural foramen, but where’s the L5 neural foramen? It’s gone—completely obliterated, right?

Dr. Tydings: Sometimes you have to go a little more lateral for L5-S1 because it is a little more lateral, but you can see it a little bit.

Your point is well taken—all the other ones are pristine.

Dr. McLaughlin: And then we’ll go to the other side. Chris, I’ll go midline, and you can describe what you see in the midline. So, we’re going to the other side now.

Maggie Fitzpatrick: How often are these completely asymptomatic, with this degree of slippage?

Dr. McLaughlin: In my experience, they’re rarely totally asymptomatic, but some people come in with mild or moderate back pain or a long history of back pain, often dating back to childhood, but they never got anything checked out, and they’re functional. What about you, John?

Dr. Tydings: Well, they’ve done studies on army recruits and other groups where they mandate X-rays, and even in completely asymptomatic people, you’ll find somewhere between a 10-20% incidence of L5-S1 spondylolisthesis in their 20s. So, just because you see it doesn’t mean you have to operate on it. A lot of times, these are stable, longstanding, and very common. That’s why you don’t operate based on X-rays alone—you have to get the full history and examination.

Dr. McLaughlin: Chris, tell me what you see on this scan. Oh, hold on, we have a question from Neelay. Go ahead.

Neelay: Yeah, I was just going to ask, like you said, just because it shows up doesn’t necessarily mean it needs to be operated on. But how much risk does this patient have of developing cauda equina syndrome, or even conus medullaris syndrome, where it could become a neurosurgical emergency?

Dr. McLaughlin: That’s a great question, especially considering the sagittal image here. Chris, tell me what you see.

Chris: Well, I’m not exactly sure what the intense region within the L5 and S1 vertebrae is.

Dr. McLaughlin: Okay, you’re talking about these signal changes within the vertebral body?

Chris: Yes.

Dr. McLaughlin: Okay, and then more posterior to that, there’s a hyperintense region right past the vertebra.

Chris: Yes.

Dr. McLaughlin: So, what would you say about the spinal canal?

Chris: Is it stenotic?

Dr. McLaughlin: I wouldn’t classify that as stenotic, would you?

Maggie Fitzpatrick: No, I agree—it looks open.

Dr. Tydings: I’d say it’s widely patent, especially above L4-5. There’s no evidence of stenosis, cauda equina, or conus medullaris issues whatsoever. The only question to ask is whether this is stable or unstable spondylolisthesis.

Dr. McLaughlin: Neelay, to your point, this patient has been blessed with a very large spinal canal, which some people naturally have. There are standard deviations in spinal canal size, but this one is very open.

Chris, you pointed out some changes here—this hyperintense area. I’m not really sure what this is. If you look at the other discs, they’re completely normal. Then we come down here, and these changes have an eponym—they’re called Modic changes, named after Michael Modic from the Cleveland Clinic. These indicate endplate sclerosis, which happens due to continued microtrauma to the area.

Again, on the X-ray, we saw this looks very dark. On an MRI, especially a T2-weighted image, something dark has no water in it, and this looks like an osteophyte that’s formed here. So, I think this patient’s body has probably done the fusion already.

I’ll show you the axial images. Couple of little things—spinal canal here. Daniel, what’s this structure right here? You’ve got to know the structures around too, right? You’ve got one on each side.

Daniel: Dorsal root ganglion?

Dr. McLaughlin: Good job! Here’s our cauda equina. Widely open spinal canal here. Nate, I’d say the chances of cauda equina syndrome are very low, unless as Dr. Tidings mentioned, there’s some kind of instability. The canal is open everywhere. So, as you pointed out, John, I sent the patient for a CAT scan and some flexion-extension X-rays, but based on their complaints, I have a low threshold. I spoke with the patient about the fact that this would be a big operation to decompress those two foramina and put screws in at the L5-S1 level. I wasn’t optimistic we could eliminate back pain with that procedure due to the chronicity and level of pain, so we’re probably going to leave this alone.

Do we have any other pictures, Maggie?

No? Okay, any other questions on this Grade 2 bordering on Grade 3 spondylolisthesis

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