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Case Study: Reversing L5 – S1 Lumbar Spondylolisthesis

April 19, 2018 7 min read
woman examines model of lumbar spine with doctor

Meet the Patient

The patient was a 47-year-old woman who presented with symptoms of lower back pain. Upon physical examination, the patient reported stiffness, throbbing, and spasms in her lumbar spine (or lower back). When Dr. Frazier examined the patient’s legs, he discovered tightness in her hamstrings and weakness in her right and left legs.

In addition, the patient had a number of characteristics that increased her risk of developing lumbar spondylolisthesis, or a slipped vertebra. These “risky” traits included:

  • Her Gender: Women are 3x more likely than men to suffer from a slipped vertebra in the lumbar spine. This gender-based difference has much to do with estrogen. During pregnancy, estrogen serves to loosen up the pelvic ligaments in preparation for childbirth. However, outside of pregnancy, a woman’s estrogen levels will ebb and flow throughout the course of her lifetime. When the ligaments that support the back side of the spine become loose–regardless of the reason–injuries become more common.
  • Her Weight: Obesity places added stress on the weight-bearing supports of the body. This can lead to unnecessary wear and tear on the spine and an enhanced risk of developing back problems.
  • Her Diagnosis of Diabetes: Perhaps because carrying excess weight is linked to Type II Diabetes, diabetic patients are more likely to sustain a slipped vertebra.
  • Her Smoking Status: Not only is smoking bad for your heart and your lungs, but it also affects the health of your spine. Studies show that individuals who smoke are 2x more likely to experience joint inflammation than non-smokers. In addition, researchers believe that smoking may damage the system of blood vessels that delivers nutrients to your spine. Aside from increasing your risk of spondylolisthesis, researchers have also linked smoking to arthritis, degenerative disc disease, and SI joint pain… Among many other issues.

Putting the Pieces Together: The Diagnostic Phase

Suspecting spondylolisthesis, Dr. Frazier ordered x-rays of the patient’s lumbar spine and sacrum. These films revealed the following issues:

  • Lumbar Spondylolisthesis at L5 – S1:  The patient had a slipped vertebra (also known as spondylolisthesis) at L5. Because the L5 vertebra had slipped forward between 26 – 50% over the S1 vertebra beneath it, Dr. Frazier classified the patient’s condition as a Grade 2 on the Wiltse Scale. (For example, a score of Grade 5 would indicate that the vertebral body had fallen completely off of the spinal column.)
  • Fractures of the Pars Interarticularis: In addition, the woman had sustained dual fractures to her right and left pars. The pars interarticularis is a tiny strip of bone on the backside of the spine that holds the facet joints together. Your facet joints articulate, or come together to create the movement of your spine. (Hence, the interarticularis part of the name.) Fractures of the pars are common in childhood, affecting nearly 5% of 5 to 7-year-olds. However, complications–like spondylolisthesis–don’t often arise until adulthood.
  • L5 – S1 Collapsed Disc: Where the L5 vertebra had slipped over the sacrum, the L5 – S1 disc had collapsed from the shifted weight of the spine. Because a collapsed disc often causes pinching of the spinal cord, nerve symptoms such as the patient’s leg weakness can occur.
  • Lordosis: 90% of all slipped vertebrae occur at L5 – S1. When this occurs, it changes the curvature of the patient’s lower back, leading to hyper-lordosis or swayback.
  • Sclerosis: Dr. Frazier also found evidence of sclerosis, or hardening of the tissues that support the patient’s lumbar spine. Like bone spurs, sclerosis can occur in response to inflammation or trauma.

More Background Details: Understanding Lumbar Spondylolisthesis

In Greek, the root word spondylo- means “bone”; and -lolisthesis translates to “displacement.”

Most patients with spondylolisthesis, including our patient, have anterolisthesis. This means that the “displaced” vertebra slipped forward, in the anterior direction, and over the vertebra that lies beneath it.

Although there are 5 major types of spondylolisthesis, the 2 most common types include:

  • Isthmic Spondylolisthesis: The most common type of slipped vertebra, this form of spondylolisthesis occurs when a congenital defect or stress fracture compromises the pars interarticularis. This tiny, but crucial, piece of bone forms the narrowest part of the vertebral arch. For this reason, the pars is prone to fracture, especially when we are young (between the ages of 5-7). However, a slipped vertebra usually occurs as a result of the pars fracture many years later (when we are between the ages of 30-50). This was likely the case for our patient, who had fractures on the right and left sides of her vertebral arch.
  • Degenerative Spondylolisthesis: The degenerative version of this condition mainly affects seniors, and senior women in particular. This disorder occurs when the joints, ligaments, and tendons that support your spine become weak with age. When this occurs, your backbone becomes less able to maintain vertebral alignment and slippage can transpire.

Worried that you might have a lumbar slipped disc or isthmic spondylolisthesis? If you are experiencing symptoms such as lower back pain, tight hamstrings, or leg weakness, then see a board-certified spine surgeon today. Untreated spondylolisthesis can lead to spinal stenosis, or narrowing of the spinal canal that houses your spinal cord. When this occurs, serious nerve symptoms like incontinence or partial paralysis can emerge.

For spondylolisthesis treatments that you can trust, contact Dr. Daveed Frazier, your Harvard-trained spine expert.

Reversing a Slipped Vertebra with Spinal Fusion

To reverse the patient’s slipped vertebra and restore the strength of the spine, Dr. Frazier performed a minimally invasive spinal fusion.

The procedure–known as a TLIF, or transforaminal lumbar interbody fusion–involved accessing the spine from the side. During the procedure, Dr. Frazier used 3-D imaging to visualize the damaged tissues of the spine. With the spine in proper view, Dr. Frazier used a series of tubular retractors to:

  • Gently move any delicate tissues, like muscles, away from the spine
  • Create a guided channel through which to execute the procedure

Furthermore, performing the entire operation through a metallic tube and using only tiny instruments allowed Dr. Frazier to minimize any trauma to the patient’s spine.

Next, Dr. Frazier used surgical tools to widen the foramina. Your foramina are small passageways, through which spinal nerves exit from the spinal cord. When these nerves become compressed by a slipped vertebra, symptoms such as the patient’s leg pain can emerge. Widening the foramina decompresses these pinched nerves, restoring neurological function.

After completing the foraminotomy (i.e. broadening of the foramina), Dr. Frazier removed the patient’s collapsed disc. To replace this disc, Dr. Frazier inserted an implant containing bone graft material into the vacant space.

Pedicle screws were added to the back side of the spine to reinforce the L5 – S1 vertebrae as the bone graft healed. Dr. Frazier then connected rods to these screws to hold each vertebra securely into place and to prevent further injury. As the bone graft healed during the days following the surgery, the L5 and S1 vertebrae fused permanently together. This allowed the patient to enjoy life once more with a healthier, sturdier, and pain-free spine.

Minimally Invasive Spine Surgery (MISS) In Action

Minimally Invasive Spine Surgery (MISS) refers to any form of surgical treatment that involves smaller incisions, and hence, less trauma. For example, our patient who underwent a TLIF enjoyed the following benefits of MISS:

Less Blood Loss, Scarring, & Trauma:

  • The patient lost only 10 cc (or two teaspoons) of blood throughout the entire procedure.
  • The procedure required the patient to receive two incisions that were 2-cm in length. In contrast, open back surgical procedures usually require 6-inch incision sizes or greater.
  • Because Dr. Frazier used tiny tools and a tubular retractor to perform the procedure, he could minimize trauma that was enacted to the patient’s back. Specifically, Dr. Frazier was able to avoid cutting through delicate tissues of the back, like muscles and ligaments.

Shorter Operative Time & Less Postoperative Pain:

  • Dr. Frazier was able to perform the entire procedure in only 1.5 hours. In contrast, open back surgical methods often require up to 8 hours of operative time.
  • The patient reported feeling immediately better after her surgery. All of her symptoms, including leg pain, had significantly improved.

Faster Recovery Times & Better Results:

  • The patient was discharged from the hospital on the same day as surgery.
  • Because the patient had a history of diabetes, smoking, and obesity, she was more likely to experience complications, like infections, after surgery. By undergoing MISS, the patient was able to avoid much of this risk.

To discover how minimally invasive spine surgery can change the course of your life, contact NYC Spine today. A board-certified, Harvard-trained spine surgeon, Dr. Frazier is a master of minimally invasive techniques. For spondylolisthesis relief, like the TLIF, contact an award-winning spine surgeon in your area, like Dr. Daveed Frazier, MD!