[PACFGuy]

#9891

Hi Dr Corenman,

I am a 42 YO very athletic male who does CrossFit 4-5 days/week and plays lacrosse once a week. Since last spring, I have been battling radiculopathy in my left buttock, thigh and back of left foot, with occasional LBP though that is generally minor compared to the leg pain, or non-existent. The pain is present on standing and walking, while sitting and lying are much better. I do not have foot drop or noticeable motor weakness on the left side, and am able to do all activities without restriction, but experience significant pain following those activities, especially ones involving significant extension.

I had x-rays and MRI done last July/August and was diagnosed with stable grade I/II spondylolisthesis of L5 on S1 with a severely degenerated L5-S1 disc, resulting in severe foraminal narrowing on the left side, and moderate on the right. I have tried various approaches (PT, core strengthening, pelvic tilt during activities,
chiropractic, etc.) with varying and limited success. I am trying to find a way to decrease the pain while continuing on in my athletic pursuits.

Is continued conservative therapy the way to go? I feel like I achieve some moderate success w/conservative measures for a couple of days and then backslide into pain as soon as I train/exercise. Is fusion the only viable surgical option at this point or are there other approaches to consider?

Thank you.

——————–

Imaging studies:

7/30/13 X-ray:

3 views of the lumbar spine were obtained. There is spina bifida
occulta at L5. There is a grade 2 anterolisthesis of the L5/S1 level with probable bilateral spondylolysis. There are mild degenerative changes with

anterior osteophytes at the L5/S1 level
where there is also disc space narrowing as well as anterior
osteophytes at the L2/3 level.

Impression: Mild degenerative changes of the lumbar spine with grade 2 anterolisthesis at L5/S1 where there appears to be bilateral spondylolysis.

7/30/13 MRI:

CLINICAL INFORMATION: Left lower extremity radicular pain since March 2013, suspect L5-S1 radiculopathy

IMAGING TECHNIQUE: Multiplanar and multisequence MRI of the lumbar
spine was obtained utilizing 1.5 T magnet.

CONTRAST: None.

COMPARISON: Lumbosacral spine radiographs dated 7/30/13.

OBSERVATIONS:

Mild curvature is noted convex to the left.

Retroperitoneal and paravertebral soft tissues are normal.

Individual vertebral height is maintained.

Marrow signal is normal.

Conus is normal in caliber and signal. The conus terminates at T12-L1

At L1-2 sagittal images only, there is normal disc contour. The
spinal canal is patent. The neural foramen is patent bilaterally.
There is no ligamentum flavum thickening. There is no facet
arthropathy.

At L2-3, there is mild diffuse disc bulge with tiny annular fissure. The spinal canal is patent. The neural foramen is patent bilaterally. There is no

ligamentum flavum thickening. There is no facet arthropathy.

At L3-4, there is mild diffuse disc bulge. The spinal canal is
patent. The neural foramen is patent bilaterally. There is no
ligamentum flavum thickening. There is no facet arthropathy.

At L4-5, there is broad-based central protrusion. The spinal canal is patent. The neural foramen is mildly narrowed bilaterally. There is no ligamentum

flavum thickening. There is mild facet arthropathy.

At L5-S1 there is grade 1 anterolisthesis secondary to bilateral
spondylolyses, uncovering of the posterior disc is present in
addition to severe degenerative disc disease. The spinal canal is
patent. The neural foramen is severely narrowed on the left and
moderately narrowed on the right. There is mild ligamentum flavum
thickening. There is mild facet arthropathy.

IMPRESSION:

1. Bilateral spondylolysis at L5-S1 with grade 1 anterolisthesis of L5 on S1 causing severe left and moderate right neural foraminal narrowing.

2. Broad-based central disc protrusion at L4-5 with mild neural
foraminal narrowing bilaterally. Mild diffuse disc bulge is noted at L2-L3 and L3-L4. No central canal stenosis.

8/7/13 X-Ray:

History: Low back pain radiating down left leg.

Findings: Flexion and extension lateral erect views of the lumbar
spine are compared to the prior study dated 7/30/2013. There is grade 1/2 anterolisthesis of L5 on S1 which is stable. There is no abnormal motion to suggest ligamentous instability. There is spondylolysis of L5. There is diffuse disc space narrowing, most severe at L5-S1.

Impression:

Grade 1/2 anterolisthesis of L5 on S1 with bilateral spondylolysis.

Degenerative disc disease.

[Donald Corenman, MD, DC]

#9892

You have a typical isthmic spondylolisthesis (see website) at L5-S1 associated with significant degenerative disc disease and foraminal stenosis, especially on the left. The initial injury (the pars fractures) probably occurred long ago. Without the protection of the facets (the pars fractures disconnects the facets from the vertebral body), the disc then fails due to extreme shear forces.

Once the disc fails, the vertebra shifts forward and the disc narrows considerably (the height of the disc is lost). Bone spurs inevitably follow and the foramen narrows as at least 1/2 of the height of the foramen is due to the disc height and the other half is lost from spur formation.

The nerve in the foramen then is compressed. In normal daily life, the foramen is opened by the action of forward flexion and narrowed further by extension (bending backwards-the same action needed to stand up). The nerve then is relatively uncompressed with flexion but significantly compressed with extension (standing and walking).

You could try doing your exercises with flexion activities and avoid upright actions like cross fit. Cycling and skiing are two activities that are performed in flexion. Weights in the gym can be modified to prevent extension (no lunges) and the treadmill with a high uphill angulation will also generally fit with this activity limitation.

Unfortunately, this is a mechanical disorder and lifestyle modifications can allow you to function but the actual narrowing and limitations cannot be cured without surgery. If you cannot accommodate the changes necessary to function without leg pain, a TLIF fusion is in my opinion the best surgery to cure this disorder.

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.

[PACFGuy]

#9895

Thank you, Dr Corenman, for the quick response. Indeed flexion-based movements do feel better, but we do a lot of hip extension-based movements in the gym and in sports in general, so it is difficult to modify everything to accomodate this.

A few follow-up questions, if you don’t mind:

– what sort of progression would one expect in terms of the narrowing and nerve root compression? i.e. what is a “typical” (if there is one) progression of the foraminal space and damage to the nerve? Is cauda equina syndrome, etc. an inevitable outcome, or is it mainly continued pain/discomfort if not addressed surgically?

– how long should one pursue conservative measures before considering surgery?

– what sort of athletic limitations are there after an L5-S1 fusion?

– are there good long-term outcome data on TLIF at L5-S1, especially among athletes?

– are there any fusion procedures done for spondy w/o instrumentation/hardware?

– lastly, is there any potential down the road for artificial lumbar disc replacement as an alternative to fusion, or is this not indicated for a spondy?

Thanks again.

[Donald Corenman, MD, DC]

#9900

Progression of nerve root pain does not have to be “expected” as this syndrome can stabilize where your are at now but most do progress. The reason is that this foramen will continue to narrow as the spur increases in size or the disc continues to narrow.

The reason for exaserbations and remissions is nerve root swelling. Any particular activity that temporarily “crushes” the root will cause it to swell. A swollen root does not “fit” as well in the narrowed foramen and is more prone to further compression.

Cauda equina syndrome almost never occurs with this disorder as the pars fractures and slip increase opens the canal-not narrows it.

There are generally no athletic limitations to a successful L5-S1 fusion for isthmic spondylolisthesis. You do have significant degeneration at L4-5 above the slip level so that has to be taken under consideration but this has nothing to do with the L5-S1 level.

I just published a paper in Spine regarding longer term outcomes for a one or two level fusion for degnerative changes with good results (90% satisfaction). The isthmic slips tend to do even better than the degenerative discs do for surgery.

You cannot have this surgery without instrumentation. Years ago, this procedure was performed without instrumentation with a 40-60% success rate and that success rate was not on athletes.

I am not a fan of artifical disc replacement (ADR) for the lumbar spine (see website) in almost all cases but in your case, it would be contraindicated as you have no posterior stability which is required for ADRs.

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.

[PACFGuy]

#9902

Thanks again. Very helpful info!

A few more, if you have chance:

– would epidural injections be worth it to bring down the nerve root swelling after exacerbations?

– do you recommend against heavy weight lifting, if one avoids extension? i.e. is the compression in and of itself dangerous?

– do you have any spine or neuro surgeons you like in the Philadelphia area?

[Donald Corenman, MD, DC]

#9903

Epidurals are one of my mainstays to treat exacerbations.

I would not use heavy weights in the gym as loading the disc can lead to an exacerbation. The exception is lat pull-downs as this is a traction, not a compression maneuver.

Sorry but I do not recommend surgeons at this time. I have too little information to make an accurate recommendation.

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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