Hey Clinic Spondylolisthesis Day. Physical Examination findings for spinal instability. Using TLIF distractor to jack open foramen for better visualization.

Last week we had an interesting day surgically, and in the clinic.

In the morning, we fixed a woman with C7T1 anterolisthesis below a previous long fusion using an anterior cervical discectomy and fusion with an allograft bone wedge and andterior cervical plate.  This young lady would walk around holding her head up, and tilted to the left side to prevent her nerves at C7T1 from getting pinched.  After surgery, she had excellent relief, and did not have to hold her head bent to side, and with her hand

In between surgeries we saw a woman from Savannah, Georgia who was referred up to us with back and leg pain.  Her –Rays showed a Grade I lumbar spondylolisthesis.  She told us that it is painful for her to sit, stand or walk.  As she sat in her chair, she actually supported a lot of her weight on her arms, pushing her fists into the seat so hard that her knuckles turned white.  This woman was actually making up for her lack of stability in her lumbar spine by supporting the weight of her torso through her arms down to the chair.  For our medical student, PA student, residents, and fellow readers this is a good lesson:  Always observe how your patients sit, stand, walk, and how they change positions.  These subtle observations may reveal signs of spinal instability or pain induced due to instability.

In the afternoon the same day I did a revision instrumentation and fusion for a woman who had an L4-S1 instrumentation and fusion for an L5S1 severe high Grade I anterolisthesis.  This woman developed severe leg swelling and pain and trouble walking a few weeks after surgery, with her leg almost looking like an “RSD” Reflex Sympathetic Dystrophy picture.  She did smoke after her surgery, which put her at risk for pseudarthrosis.  Her CT myelogram looked fairly open at all levels, but EMG suggested L5 radiculopathy.  Sympathatic nerve block did not help.  I performed a revision posterior wide decompression of L4 and L5 and S1 nerve roots, using special magnification and palpation intruments was able to clear out the L5S1 neural-foramen well past the pedicle bilaterally.  There was some scar combined with a far lateral osteophyte/portion of old pars that was touching the L5 nerve root.  I also reinforced the instrumentation and fusion with iliac wing screws.  Postoperatively, this woman had 100% relief of her leg pain, and her swelling went down almost immediately.  Her foot dorsiflexion also improved during her hospital stay, and she was discharged walking great.  Lesson here for Resident/Fellows:  L5 nerve root irritation is common with L5S1 spondylolisthesis and requires meticulous wide decompression.  If symptoms occur/develop postoperatively that even appear to be RSD, the symptoms can be corrected with revision decompression and fusion.  I actually used the TLIF distractor to help jack open the foramen while I used the Ganz 4 and 45 Kerrison and other tools to open up the foramen further, which was a helpful tool.  I did double-check the foramen opening after releasing the distractor, feeling out the holes bilaterally with the Ganz 4 – wide open, all the way.

Lloyd A. Hey, MD MS

http://www.HeyClinic.com

The Hey Clinic for Scoliosis and Spine Surgery