[Renee123]

#22041

For a cervical isthmic spondylolisthesis when you do a cervical fusion you approach the neck from the front and use a plate to hold the cage in place, correct ? There is not posterior fusion.

I was just curious why the same procedure is not used at L5,S1 ? Isn’t it the same problem just at a different level ?

[Donald Corenman, MD, DC]

#22042

There is no cervical isthmic spondylolisthesis as the anatomy here prevents a fracture of the pars. Now there is a degenerative spondylolisthesis (slip due to wear of the facets) and yes, you approach the neck from the front to do an ACDF. I can see how you could equate these together and then draw a conclusion that the surgeries must be similar. There are however great differences between the ALIF and ACDF.

First, the ACDF is the easiest approach in all of spine surgery. There is a natural plane between the esophagus/trachea and the carotid sheath. This means that all you have to do is incise the skin and a very thin layer of muscle (the platysma) and there is no other real dissection you have to do to get to the front of the spine in the neck. The dissection for the front of the lumbar spine is complex and requires much dissection (including cutting the anterior abdominal wall and moving the vena cava and iliac vessels).

The difference in size of the discal space between the cervical and lumbar is at least 6-8 times (the cervical being so much smaller than the lumbar space). Grafts have to heal a much longer distance (which is why it takes at least 6 months to heal a lumbar disc space while the cervical disc takes 6-8 weeks generally).

Also, the compression of the nerve roots in an isthmic spondylolisthesis normally comes from the pedicle spurs which are not reachable from the front of the disc.

Now you will find that many surgeons who do an ALIF will use posterior pedicle screws. If the surgeon is going to make a posterior incision anyway, why not do the entire surgery from the back of the spine and eliminate the anterior approach with all the potential complications?

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.

[Renee123]

#22051

Sorry to ask again but if a ALIF is done what is the risk of not removing the pars fracture? Is there anyway to determine from a CAT scan or an MRI if there are bone Spurs ? Also once the segment is stabilized will the pain fibers in the pars fracture create a problem ?

Also how painful is the TLIF the first week? Is pain well-controlled with iv pain meds ?

My issue is that I do not believe most surgeons are as skilled as yourself with TLIF for isthmic spondy!

[Renee123]

#22052

Also wanted to ask would injections of HGH hormone assistant in rehabilitating low back pain

[Donald Corenman, MD, DC]

#22053

The theory of an ALIF “curing” the foraminal stenosis is that if you distract the disc space when you place your graft, you indirectly decompress the nerve roots by this distraction. It does work for a percentage of cases but there are many cases that patients continue with reduced but not eliminated leg pain.

The TLIF is painful for the first 24 hours but if Duramorph (a morphine based compound that is injected directed into the spinal sac) is used, the first 24 hours are generally painless. I like to talk about the “newspaper test” (although not too many newspapers are left in Vail). I walk in on a patient in the morning and they are reading the newspaper like they never had surgery as they were pain free the entire night.

I am sure there are plenty of surgeons who are skilled at the TLIF.

HGH is an interesting hormone. It does help to heal the body but too much will cause a condition called Acromegaly. It is dangerous enough that I have never considered using it for healing.

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.

[Renee123]

#22061

1.) Thank you for your explanation regarding the indirect decompression. If I currently have no leg pain or leg symptoms is there any risk to have having the ALIF 360 and not removing the pars fracture ? Once the segment is fused, would the pars fibers still be source of back pain !?

2.) My confusion is if my surgeon sent me for pars injections to diagnose pain generator and I get pain relief, wouldn’t that then mean that the pars fracture is a source of pain and would need to come out with a TLIF ?

3.) I would not be getting a posterolateral fusion with ALIF 360 so I am trying to figure out when it would even be recommended for isthmic spondy before a TLIF ? Surgeon says he only uses BMP with TLIF with revision cases not with first time….because of complications and cost to the hospital!

[Author]

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