Degenerative Spondylolisthesis Case Presentations

Speaker 1All right. So, here's a 71-year-old male. He's a Business owner. He's got 30% low back Pain, 70% bilateral leg Pain, left more than right. Uh, the leg Pain is claudatory. It's been getting progressively worse. Uh, it's standing and walking, better with sitting. He's curtailed activities. He stopped exercising, stopped playing tennis. Um, he, he's got very good core strength. He participates in the core strengthening program. He's doing an appropriate level.

Speaker 1It gets temporary relief with injections. This is something I found to be very helpful in my practice is uh transamin injections at the level of the Pathology for both diagnostic purposes as well as therapeutic and seems to be a good predictor of surgical outcomes in my hands. Uh, you know, he's got some typical stuff, a high blood pressure, occasional glass of wine. He's got numbness and tingling in both lower extremities with some, uh, EHL and dorsiflexion weakness, uh, on both sides.

Speaker 2So the one glass of wine was before we all got sequestered in our homes, probably measured in bottles, although I'm out of bottles I'm onto boxes.

Speaker 1So, here he says uh pre-op films. You can see he's got a, a decent sacral slope. Um, his L4 is not parallel to the ground, um, but his pelvic incidence lumbar loosis is well within 10 degrees, it's within 5 degrees. So, nothing, nothing startling here on just the isolated lumbar film. Now, I don't have standing X-rays on this guy, but at the same time, you know, with these parameters, I don't think you necessarily need them.

Speaker 1Uh,

Speaker 3one

Speaker 1of the things you

Speaker 3wrote about in the history there, you, you said that it was, uh, uh, leg Pain more than back Pain, and, and how do you use that ratio, uh, when you're thinking about, uh, decompression versus the, the role for fusion? How, how do you quantify that?

Speaker 1So anytime I see a patient, there's 3 questions I want to answer. There's, it's what root, what level, what Pathology. So, if you can answer those 3 questions, you can say this person has L5 radiculopathy on the left, secondary to lateral recess stenosis without instability.

Speaker 1Um, at the, so at the L4-5 level, so you got the root, the L5 root, the level 45, and the Pathology, a lateral recess stenosis. Usually you can address that with a minimally invasive Approach. So,

Speaker 1That's sort of my go to, and that's, that's the first way I'll Approach a patient. And I'll try to pinpoint that as much as possible. You know, it's harder to do with back Pain. We, we're not very good with back Pain, and we also don't necessarily know where back Pain comes from. So, now, if, if back Pain is more, um, if it's more claudicatory, like today, I saw a patient that had distinctly claudicatory back Pain. You know, I think that's the posterior Primary ramus sometimes, that's causing paraspinal spasm. And so, it's still radicular Pain.

Speaker 1It's just not going down the leg. It's the posterior ramus versus the anterior ramus. So, you know, the mechanical component of it is important, whether it's claudatory leg Pain, claudatory back Pain, mechanical back Pain. So, in patients with degenerative Spondylolisthesis, bending, twisting, that kind of stuff, playing tennis, aggravating the back, um, tells me that there's instability, there's symptomatic instability.

Speaker 1So, you know, really, that's the definition of stability, right? It's abnormal motion that's symptomatic. If you have abnormal motion, it doesn't hurt, who cares? Uh, I've, I've, I've had a few patients that have had, had some motion reflection extension. I probably would have preferred just intellectually to infuse them, but they didn't want to go through the recovery process. I had a, I had a

Speaker 1An accountant who was getting ready for tax season, and she's like, no, I cannot be out while I'm during the middle of tax season, and opted for an endoscopic decompression. And actually did very well. And a lot of times in those patients, I'm surprised at how much the back Pain improves, despite doing a procedure that theoretically could aggravate the back Pain. But when it's got that proper mechanical nature and it's associated with appropriate radicular Pain, uh, I think, I, I think you can address that reasonably well.

Speaker 1So

Speaker 2I think that's a great, I think that's a great point, Ray, about, you know, you see an image like this, and you know you would expect a tremendous amount of back Pain here, uh, by looking at the facet joints and, and my question always comes up is when you see such disease facets like this, does that automatically obligate them to have a fusion?

Speaker 1So, I don't think there's any one parameter that is pathic mnemonic and completely forces you one way or the Other. You know, it's a constellation of symptoms. It's a plus and minus checklist, just like if you're trying to decide if you're gonna pick a job or move or you get the, you get the good column, the bad column, you make your marks in each one, and the, and the overwhelming one.

Speaker 1One is the way to go. So, you know, if I see gap facets like that, yeah, I'm thinking, all right, this person probably has instability, is more likely to need uh a stabilization procedure. But, you know, if I get flexion extension X-rays, and they don't move at all, I've seen people with gap facets like that that have huge anterior osteophytes that are basically auto-fused. And

Speaker 1Uh, occasionally, I'll decompress that. So, um, I, I'd love to give absolutes. I just don't think they apply to Spine Surgery well. I think you gotta take the whole picture into account. That's why

Speaker 1You know, trying to parse out what are the couple of parameters and measurements in the preoperative phase when you're looking at these patients. Is it a, is it a physical exam finding? Is it an X-ray finding? I, I think it's a combination of these things. You know, like Sig said, if you, if you grab their pelvis, and they're retroverted, and, and they're standing with a slightly flexed Knee, I don't really care what the X-ray says. They're, they're got sagul imbalanced. Um, so,

Speaker 1Again, you gotta pile all these things together and, and, and take the cumulative data and, and make, you gotta make a decision based on incomplete information. That's the hardest part about Spine Surgery.

Speaker 2So, moving on.

Speaker 1So you can see he's got some gap facets. You can see, um, you know, one's very coronal, one's very sagittal. So it's almost like he's got a little subluxation. That's another thing I've noticed looking more at these, uh, MRIs, especially on the axial views, is you'll see sometimes a single facet subluxus, you know, you see these patients with degenerative Spondylolisthesis and they've got just left leg Pain. You're like, I don't understand why the hell your right leg doesn't hurt because

Speaker 1Both lateral recesses look terrible. And if you, if you look at it, you'll see a, a, a subluxation where it's pivoting on one facet joint versus the Other. Now, that's a patient that I think I can do very well with a unilateral facetectomy and, and careful innerbody work and be able to correct their position and reduce their Spondylolisthesis and decompress them and make them happy with a very small procedure.

Speaker 1So, that's what I did with this guy, um.

Speaker 1You can see you had an innerbody placement. I kind of do a Tcliff, I guess it really, if you, if you, if you get down to it. I don't go lateral to the pedicle and retract on the exiting root. If anything, I'm gonna retract the traversing root, so I'm less likely to get that radicular Pain and

Speaker 1And, and DRG irritation. And that also allows me to decompress the canal easier and we get cross if I need to do a bilateral decompression like I did with this guy. He had bilateral leg Pain. So, bilateral over the top decompression through a 16 millimeter tube as an Outpatient. He came in, had Surgery, uh, went home the same day. He, uh, I do a thocal lumbar interfascial plane block, which does a very good job of controlling the localized back Pain and spasm immediately after Surgery.

Speaker 1This gentleman came back and sees me 22 weeks after Surgery. He's off Pain Medicine after 1 week and a half, and the leg pain's better. Uh, back pains basically nothing to speak of.

Speaker 3Ray, you talked earlier about uh really relying on that innerbody, uh, fusion and, uh, tell me, um, first of all, when do you actually, uh, are, are there circumstances where you don't use posterolateral instrumentation at all? And, and secondly, um, what do you do to really optimize that innerbody fusion? What, what, what, what are your, uh

Speaker 3Techniques to um uh because you're not putting bone posterilaterally, you're perking it at most posterilaterally. What, what do you do to really optimize that antibody space?

Speaker 1So I

Speaker 1use biologics. I use bone morphogenic protein, and I think that's one of the, one of the uh components of minimally invasive Approach is you have to do everything you can to achieve the fusion, um.

Speaker 1You know, when you do a T lift, whether you do it open, minimally invasive, however you do it, really, the limitation on how you clean out the disc is your angulotomy. So, no matter what, uh, many open, open, minimally invasive.

Speaker 1The annulotomy is what restricts your access to the disc space and what limits your ability to, to clear out that posterolateral corner. So, you know, if you look at the overall time I take on the T lift, the majority of it is just cleaning out the disc and trying not to violate the endplate. Um, so, I, I take the local autographed, I take the BMP, I take some, some adjuvants, and, and I basically throw the kitchen sink in there. I wanna get everything I can that's gonna ensure fusion. If I could use, um,

Speaker 1You know, um, Forteo, that would be fantastic. Uh, because there's some really good data on that, uh, after, uh, lumbar fusions and fractures and such, so, um, but, you know, this is his post-op Pain sheet, uh, you know, he's off Pain medication. Um, I think we had it, we had the measurements. I don't, I guess they're not up on this slide, but, um the next one, next one.

Speaker 1So, you know, pelvic innocence, uh, 62, lumbar loosis is 60, so that actually improved by, by 3 degrees. segmental loosis improved 7 degrees here. Uh, L4 to S1 improved 6.8 degrees. So, we got some segmental correction. And, you know, the, the problem is, is not everybody that has a, a, an innerbody fusion from a posterior Approach maintains that. So, you know, one and two years out.

Speaker 1These, these numbers may not be as good for everybody. And we know they're not as good for everybody. The reality is, is that even if you look at laterals, they're not as good for, for those either if you look at them at 1 and 2 years out. A lot of people like to throw up an X-ray that's, uh, you know, 3 weeks post-op and go, look at the correction I got. Well, you know, I did a study as a resident, we looked at scoliosis correction in adolescents, and we're looking at the 2-year films, and they drifted 50% back to their, their baseline in those, and, and I, I have a, you know,

Speaker 1I have a bias. I think, I think the Spine tends to go where it wants to go, and it tends to drift back a lot to where, where it was. Um,

Speaker 2so it's really interesting we're getting a few, uh, questions about is there a role just for decompression alone. I just want to let you know that that's, that's coming up, um.

Speaker 2Uh, we, uh, one question I had about the, the cage here, uh, Ray, so one of the things that we've talked about, um, uh, about subsidence, the issue of subsidence, and what role does the size of the cage and the forces that are, uh, imparted on the end plates, what role does that play, uh, in developing, um, subsidence, and how do we deal with that or what, how are we're gonna deal with that in the future?

Speaker 1Well, so I, I think the biggest component for the biggest reason you get subsidence with the posterior innerbody, whether T-lift lift or a single cage type procedure from a posterior Approach is the size of the cage. You just got a smaller footprint and you get higher edge loading and you're more likely to get into the end plate. You know, I don't think you're any

Speaker 1I think you can do just as good a job cleaning out the disc if you're careful with the inplates and not violating it. You know, in some ways, even direct laterals, when you get really aggressive, you violate the in plate on that just as easily with those, with those paddle shavers when you're trying to uh open up the contralateral annulus. So, um, you know, you gotta not violate the end plate.

Speaker 1You gotta have reasonable enough bone quality. because an osteoporotic patient, it probably doesn't really matter how big the, the cage is, it's gonna, it's gonna collapse. If you do those things, my, the preference would be to have the biggest footprint you can have. So, you know, if you can achieve this Approach, which I like because it's not very invasive, it's not very painful, you have quick recovery. You can do it as an Outpatient without risks of things like retroperitoneal hematomas.

Speaker 1Um, if, if you had the ability to do that and then deploy an innerbody device that has an ALLftty footprint, I think that's like the best of all worlds and would probably be the market leading implant because again, the majority of surgeons still do posterior approaches.