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With a spondylolisthesis, it is never too late if there is no motor weakness. You do not burn any bridges with conservative care. Changing the therapy to avoid extension is the correct pathway and it is possible to rehab using core strengthening and extension avoidance to stabilize the spine. I have some concern that with your profession, when under a stressful situation, you may not be able to avoid extension and aggravate your back. Continue down this course and try to retrain your brain to avoid any backwards bending.

Dr. Corenman

Most likely, you have had this isthmic spondylolisthesis of L3 for some years and the injury aggravated this condition. That is unless you took a significant fall or had a severe impact in which case these fractures could be new (traumatic spondylolisthesis).

You have had 6 months of treatment including, I presume, physical therapy as well as the noted epidurals and facet injections and have failed treatment. After 6 months of failed conservative care, further therapy is much less likely to bring you back to full duties.

The chance of these fractures healing on their own is highly unlikely. More likely is that the fractures have been present since the age of 12.

I will assume that there is a degenerative disc at L3-4 and a small slip noted on the standing flexion/ extension X-ray films. If that is accurate, you are most likely a candidate for a fusion of this level. If the disc is normal at this level without a slip, the pars fractures can be repaired but that scenario is unlikely.

Dr. Corenman

Your MRI report note multiple areas where you have a “pinched nerve” on the left. “L4-5: Thickening of ligamentum flavum and facet capsular tissue with mild left subarticular and left foraminal narrowing” as reported by the radiologist.

Commonly with degenerative scoliosis, there will be foraminal collapse. The foramen is made up by the two adjacent vertebra. If the vertebra are parallel to each other, the foramen is rarely compromised. However, if the adjacent vertebra are angulated greater than 6 degrees to each other (very common in degenerative scoliosis), the foramen will be significantly narrowed (see website for details). When you then stand up, this further narrows the foramen as the diameter of this opening narrows with extension (bending backwards) which is a component of standing up.

This problem is better appreciated on the standing front to back X-ray and not necessarily on the MRI. The question then; is your pain in your leg worse with standing (and walking) but improved with sitting down or crouching/ leaning forward like when you hold onto a shopping cart?

Dr. Corenman

There has never been a study to determine what precautions can be taken other than avoiding impact and accidents. The sternocleidomastoid muscles (SCMs) are the one set of muscles strong enough to possibly prevent extension in an accident. See the website for “neck sit-ups” to understand what is entailed with strengthening. Do not do the “reverse neck sit-ups” as this causes extension of the neck which you need to avoid. Remember that it takes about 3 months to strengthen muscles substantially.

Dr. Corenman

My advice to you is based upon only what you have told me so take everything with a grain of salt. You are in some danger with the symptoms and the cord compression that you have described.

The spinal canal enlarges with neck flexion (bending the head forward) and narrows with extension (bending the head backwards). If you have a fall onto the front of your forehead that causes your head to bend backwards, you could injure your spinal cord. This could even happen if you are rear-ended in a motor vehicle accident so you need to take precautions.

The surgery generally makes your neck stable immediately depending upon the type of surgery and the skill of the surgeon. I personally allow patients to travel within one week of surgery (they fly in, stay a week and then depart) but I cannot tell you what your surgeon would suggest.

Dr. Corenman

Back pain is generally not related to congenital stenosis if the back pain is central (middle of your back). This pain however can be related to a degenerative facet. Standing X-rays including flexion and extension views can be helpful to look for a degenerative spondylolisthesis (see website) which is associated with a degenerative facet.

If your pain is located in the sacroiliac or buttocks region, this could be either from disc and facet or from nerve compression. Impact that aggravates your pain more likely than not is from disc incompetency.

I cannot comment on any activity modification you would need to make without a diagnosis. You are welcome to send your X-rays and MRI to me if you so desire.

Dr. Corenman