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1. Thank you for this web site and your videos. They are most informative.
2. I understand that generally Spondys G1-2 are treated conservatively, and generally G3-4 are treated surgically. Are there similar guidelines for instability? Or even guidelines that combine grading and instability with recommendations.
3. My L5-S1 Spondy Grade 0 (cross table lateral) bone slips right back in alignment, Grade 1 (standing lateral), 6 mm (standing extension), 1.2 cm (standing flexion). Complication: Ehlers-Danlos Syndrome (Type 3 Hypermobility). Symptom: Debilitating muscle spasms.
You note a general rule that spondylolisthesis grade I-II are “treated conservatively” and grade III-IV are “treated surgically”.
First- let us define what a “grade” is. The L5 vertebra sits on the sacrum. When a spondylolisthesis occurs, the “doorstops” in the back of the vertebra break off (fracture) and allow the L5 vertebra to slide forward. Since the sacrum is angled like a ski slope and the entire weight of the upper body sits on the L5 vertebra, the vertebra starts to slide down this ski slope.
In order to grade the slip, a physician named Meyerding split the sacrum into four sections- 0-25% is grade I, 25-50% is grade II, 50-75% is grade III and 75-100% is grade IV. The amount of slip of L5 on the sacrum (S1) then can be graded with the larger the number reflecting the amount of slip.
You are partially correct in that grade III-IV slips are generally always corrected surgically (very few exceptions) as these slips have the greatest chance of creating pain and instability. However, the most common slips that I correct surgically are the grade I slips.
This is because these slips are by far the most common that occur and grade I slips do create both instability of the spine and compression of the nerves (in a smaller total percentage than the larger slips). Because there are so many of these grade I slips present in the population (estimated to be one in twenty individuals), a portion of these grade I slips will cause pain and dysfunction.
You have a classically unstable slip which moves a total of 1.2 cm (1/2 an inch). This is very significant and your muscle spasms are a result of the attempt of your body to stabilize this very unstable segment. Ehlers-Danlos syndrome of course means your collagen fibers are very stretchable which allows this slip to move as much as it does. I cannot speak to your condition personally but if I had a patient in my office with this problem, we would be having a surgical discussion.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Thank you for your response.
Follow-up questions…
1. Is aquatic therapy safe while I evaluate my surgical options? It does cause me to spasm significantly, but can it do me harm as long as I stop when the spasms feel as if they are compromising the joints in my left leg, arm, neck? (I am treating with Soma and rest)
2. Up to how many millimeters of movement characterize a stable Spondy and how many indicate an unstable one? And when do you typically recommend surgery over physical therapy for instability?
Aquatic therapy requires a stable spine unless you just use a kick board in the pool. With this slip, you develop significant spasms in the pool. This is the muscle reaction to the instability. You might be better off with a more stable exercise like the use of a stationary bike.
Stable vs unstable slips have to do with both the amount of slip and the reaction to the instability. In general, 3mm of motion from flexion to extension is worrisome. I have a patient in my office now with 5mm of slip and no significant symptoms. She will be watched very carefully but I assume she will eventually need surgery.
Your total motion of 12mm is significant. I think a surgical option is on the table now.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.I tried aquatic therapy again on Monday, but the result was significant spasms. Bike, the same.
My original diagnosis was this level of instability. Realizing now, conservative treatment was just delaying the inevitable. Wish I had had surgery 3 mths ago. Moving forward…
Thanks for the confirmation.
I think you will be happy to have this level surgically stabilized.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books. -
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