[dfreier]

#28350

I have had 2 microdiscectomies (Sept 2016 and January 2015). I also have spondylolisthesis. I do not have any leg pain but my activities are getting progressively more limited. I can ski and walk but pretty much everything else will cause issues the following day. When I first herniated my L4/L5 two out of the three surgeons also recommend a fusion. I went with the 3rd surgeon who had a more conservative approach. I would like to avoid a fusion but I am wondering if it is inevitable (I am 49).

Here is my recent MRI report. What do you think?

History: Lumbar low back pain for 1.5 years, moderate in degree.
History of reported multiple L4-L5 microdiscectomy 7 as well as left
L5-S1 laminoforaminotomy. Known spondylolisthesis at L5-S1.

Technique: Multiplanar multisequence MRI was performed with standard
departmental protocol without IV contrast.

Findings: Grade 1 anterolisthesis at the apparent lumbar sacral
junction with bilateral posterior element apparent defects.

Very slight retrolisthesis several millimeters L4 upon L5.
Postoperative changes at L5-S1 including large left laminectomy.

Moderate Modic I endplate changes at L4-5 moderate Modic II endplate
changes at the lumbar sacral junction. Otherwise, the vertebral bodies
are normal in height and marrow signal. Noted moderate to severe disc
space narrowing at L4-L5, and severe narrowing at L5-S1.

No significant paraspinous abnormality is seen. No abnormality of the
conus medullaris is identified.

It is assumed that there are five lumbarized vertebrae. If surgery is
contemplated, confirmation of lumbar anatomy and level by plain film
AP and lateral imaging and MRI comparison is suggested.

At T12 L1 through L3-L4 there is no degenerative change or significant
central canal or foraminal stenosis identified.

At L4-L5 there is a minimal circumferential spondylotic ridge with
slight retrolisthesis and with moderate broad-based posterior disc
protrusion and spur complex. This extends into the left greater than
right foramina. There is mild facet degenerative hypertrophy.
Resulting moderate left and mild to moderate right foraminal narrowing
with borderline left foraminal narrowing, but widely patent central
canal. Noted small nerve root sleeve cyst involving the right L5 nerve
at the subarticular level.

At L5-S1 there is grade 1 anterolisthesis with prominent
circumferential spondylotic ridge with broad-based posterior minimal
to moderate disc bulge/protrusion. Extensive postoperative changes
upon the posterior elements. Suspected nerve root thickening of the
right greater than left L5 nerve suggesting possible radiculitis.
Evidence of severe left and moderate right foraminal narrowing with
overall patent appearing central canal.

Conclusion:

1. Lumbar spondylosis and facet DJD. Postoperative changes. Grade 1
anterolisthesis at L5-S1. Slight retrolisthesis at L4-L5.
2. No evidence of significant central canal stenosis is identified.
3. L4-L5 and L5-S1 foraminal narrowing as discussed. This is likely
most significant on the left at L5-S1.
4. Suspected bilateral right greater than left L5 nerve thickening
which could indicate radiculitis.

[Donald Corenman, MD, DC]

#28351

Im my opinion, you most likely do need a fusion of L4-S1. The L4-5 level has already had 2 operations and looks very problematic (“Modic I endplate changes at L4-5 moderate Modic II endplate, changes at the lumbar sacral junction”). This means the discs are not doing their job and the endplates are suffering fractures which can be quite painful. The L5-S1 level has an isthmic spondylolisthesis and this cannot be loaded with an L4-5 fusion.

It looks like to make you comfortable, you would need an L4-S1 decompression and fusion.

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.

[dfreier]

#28362

Would you be proactive about the fusion or wait until the symptoms become more significant?

[Donald Corenman, MD, DC]

#28365

Since you have described no dangerous symptoms (weakness), this is a matter of pain toleration. The symptoms, if tolerable can be lived with. It really depends upon how impaired you are and if you can live with your pain level. See https://neckandback.com/treatments/when-to-have-surgery/

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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