SallyMemberJune 6, 2011 at 10:30 pmPost count: 1
Hello Dr. Corenman,
I am a 55 year old female, very athletic. I have been diagnosed with a Grade 1 L5-S1 anterior spondylolisthesis with bilateral chronic pars interarticularis defects at L5. My symptoms are essentially all on my left side with pain in my lower left back and down to my left buttocks. I have no pain in the leg, but then extreme pain and discomfort (tingling/burning) along the outside of my left foot. My MRI shows that I have a stable grade 1 L5-S1 spondylolisthesis of approximately 3mm with evidence of bilateral pars inter articularis defects at L5 (L5 spondylolysis). There is no central or formainal stenosis from L1 through L5. There is a diffuse pseudo disc bulge but no central canal stenosis. There is a mild left side foraminal stenosis with contact with the exiting left nerve root.
I have received differing opinions as to surgical options. I have seen several surgeons who believe I should have a fusion with hardware. I am very concerned about this extensive surgery which could be more problematic because I have severe osteoporosis. I have also received the opinion that I could be helped by a foraminotomy of the left side without hardware. This would obviously be less invasive. I am wondering whether I truly need the more extensive surgery with hardware. I have seen several articles in the literature recently where patients with seemingly similar symptoms and defects to mine have been helped without hardware. Since my symptoms seem consistent with the left side foraminal stenosis, could the foraminotomy be sufficient for relieving the pressure on the nerve? Afterall, I likely lived pain free for years with the small instability and only likely developed the pain from the left side stenosis that developed. I realize you can not make a determination without an exam, but I would value your opinion and thoughts on my surgical options. I have had several series of steroid injections and they did not really help.
Thank you for your time.Donald Corenman, MD, DCModeratorJune 7, 2011 at 7:30 amPost count: 8436
By your complaints, you have evidence of radiculopathy from foraminal stenosis which is a common sequela of an isthmic spondylolysthesis (see web site). However, you also complain of lower back pain which may be a sign of instability from the pars fractures. The fact that the lower back pain is only one sided may possibly be an indication of nerve irritability and not instability. The pain in the outside of the foot normally belongs to the S1 nerve root but would be unusual with an L5 isthmic spondylolysthesis, as this normally affects the L5 root. None-the-less, I have seen the L5 root occasionally cause this symptom.
The foraminotomy on the left at L5-S1 in the face of an isthmic spondylolysthesis can be problematic. The cause of the collapse and bone spur formation that leads to the nerve compression stems from the pars fractures and instability/ degenerative changes. Performing a foraminotomy can create further destabilization of the level.
In addition, if some of the pain is originating from your spondylolysthesis, foraminotomy surgery will not eliminate that pain. You can get an idea if most of the pain is originating only from the nerve by using a selective nerve root block (SNRB- see website). With great temporary relief- there is a reasonable chance that the pain is nerve only.
So to get to the point- foraminotomy can work to relieve leg pain but the chance of developing instability after the surgery is high and therefore, I personally don’t recommend it except in very special cases. The TLIF procedure for decompression of the root and permanent stabilization of the isthmic segment is most likely the procedure that has the best results for nerve pain from an isthmic spondylolysthesis. This procedure reconstructs the missing disc height and makes more room for the nerve. Yes- it is a fusion but this segment most likely has a degenerative disc along with root compression and pars fractures with possible instability.
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