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« Thread started on: Nov 19th, 2006, 10:49pm »

Degenerative spondylolisthesis

Osteoarthritis of the facet joints can also lead to instability of a vertebral segment. Typically, as continued degeneration weakens the facet joints, the L4 vertebral body slips forward on the L5 vertebral body (see Figure 1). Since the L4-L5 segment has substantial flexion-extension type movement, this area is most likely to slip. The next most likely level is L3-L4, and rarely L5-S1.

As the body tries to capture the unstable segment, the facet joints get bigger and place pressure on the nerve root (lumbar spinal stenosis). Therefore, both the symptoms and conservative treatment are essentially identical as for patients with lumbar spinal stenosis.

In considering surgery for potential treatment, both the lumbar spinal stenosis and the instability need to be addressed. A lumbar laminectomy (open decompression—taking pressure off the nerve root) is done along with a posterolateral gutter fusion (eliminating the motion at a painful motion segment).

There are some surgeons who recommend only doing the laminectomy/decompression, but literature on the subject seems to favor doing both the fusion and laminectomy/decompression at the same time. Ironically, even though this represents more surgery, results for a fusion and decompression for a degenerative spondylolisthesis are better than for a decompression alone for spinal stenosis, with a 90-95% expected success rate.

Additionally, the results of the combined surgery tend to last because the fusion provides the following advantages:

It stops the progression of the stenosis.
It stops motion in the joint and therefore stops the arthritic pain.
However, the combined surgery is more extensive and the healing times are longer. Specifically:

There is more soft tissue (e.g. muscle) dissection that is related to the fusion surgery, which takes longer to heal.

Obtaining the bone graft for the fusion (from the pelvis) can also cause postoperative pain, although modern techniques seem to limit this complication.

In experienced hands, pedicle screws may be safely used to enhance the fusion. They probably do not affect the final success rate, but do allow for earlier rehabilitation, and prevent the need for a back brace after surgery.

By: Peter F. Ullrich, Jr., MD

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