Is fusion necessary for the treatment of spondylolisthesis with stenosis? | Best Practice LIVE
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- Опубликовано: 1 июл 2024
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0:00 Comment question from a viewer: is spinal fusion surgery needed for spondylolisthesis with stenosis?
0:45 This is an area in which orthopedic spine surgeons and neuorsurgeon's practice is changing.
1:04 Spinal stenosis means narrowing of the spinal canal or an adjacent structure (the foramen).
1:20 Why spinal stenosis happens in people with spondylolisthesis.
2:15 Spondylolisthesis is the shift in of the vertebral bones of the spine.
2:50 Laminectomy vs (laminectomy + fusion) are the surgical options for treatment.
3:15 Disadvantages of spinal fusion
3:40 Changes in the standard of care for spondylolisthesis with stenosis and spine surgery
4:05 Studies showed that fusion did not produce greater benefits than laminectomy alone.
4:45 laminectomy alone is a reasonable approach for grade 1 or 2 spondylolisthesis.
5:05 Why there are times when fusion is still the right answer.
Addendum - just a few days after this was recorded, I came across a meta-analysis of randomized controlled trials asking this very question: is fusion needed for stable spondylolisthesis in addition to laminectomy. The analysis found no benefit to fusion:
jnnp.bmj.com/content/early/20...
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Thanks for this video.
Speaking as a surgeon who does biportal endoscopic spine surgery, I'd like to add that fusion really is an option that's reserved for patients whose main problem is mechanical spine instability pain. Patients with JUST radiculopathy from nerve compression - even those who have compression from clinically stable spondylolisthesis (i.e., no complaint of significant instability pain) - improve with decompression treatment ALONE, for as long as the decompression was adequate AND the decompression technique did not introduce added instability to the spine. Even in cases of degenerative spondylolisthesis with stenosis, it's been shown that the spinal mechanical construct does not progress to clinically significant instability if the surgical approach did not sacrifice critical support structures (i.e., facet joints, midline osseous-ligamentous complex, multifidus muscles).
So if there's no PRE-operative clinically significant instability, why do a fusion, right?
And if the surgical technique can achieve adequate decompression WITHOUT creating any instability that will require fusion, then why do fusion?
Great points! Thank you so much for the comment.
Have you heard of the Tops Device procedure from premia spine? This fusion alternative looks very interesting and I hope more surgeons consider this option. Can be a game changer! 🙏
Cheers from Brazil! Thank you for the great content and to all the commenters, I've learned a lot. I have L4/L5 anterolysthesis with stenosis and trying to skip the recommended surgery (the dr appointment was yesterday)... Doing physiotherapy 4x/week and weekly acupuncture for 4 months now. Mostly out of pain meds, after initial awful sciatica down my right leg. Numbness on both feet, not getting better but walking has improved a lot. I'm a 60y old female with many other spine problems (almost everything, lol), top to bottom. Going back to work next Monday 😊
I had my spinal fusion last year!! Best decision in my life
spinal fusion has kind of a bad wrap, but in my experience, for the people who need it, it’s a really life-changing godsend. Thank you for your comment. Unfortunately, a lot of spinal fusions are done for the wrong reasons, and they don’t work. Make sure you’re keeping your core strength up! exercise, yoga, Pilates, tai chi, or some other organized form of course strengthening is really helpful and preventing you from having problems and an adjacent level.
I have L5 S1 grade 1 spondylolisthesis. Your video gave me lot of clarity.
Did your doctor recommend surgery or no and what grade level is yours on?
@@YEAHBIGGIECHEESE not right now. Doctor recommended physio therapy and steroid injection. L5 slipped forward by 3mm in supine position 7mm in flexion and extension.
Thanks!
This is great info! Thank you! I recently had an MRI for a herniated disc and was shocked to see I had this issue (mild) in 2 of my vertebrae. I had no noticeable symptoms! But my current sciatica from my L5-S1 herniated disc is no joke. I'm 9 weeks in, one week post first ESI, so I hope I can avoid surgery for any of this. 🤞
You are so welcome. I'm glad you like the video. It sounds like you have a herniated disc with sciatica. Here are some videos for that: ruclips.net/p/PLsYo8ENYsvpz8bmjf5QkF5IdaX6UPZrPk
Best video,thank you
Excellent video, I have stenosis both in C5,6,7. Then L4/5 S1 I have a leminectomy some 50 years ago at now need fussion at L4/5 S1 due to bad fall 6 months ago now trouble walking
Great explanation ❤. It is good for there too be more options available vs just one way. I’m not there yet but I have recently had my right knee acl operation 😮
Glad to hear that! The rehab after ACL reconstruction is so long and hard. Hang in there. It's worth it. (And it's now or never, so this is a good time to bear down.) Hang in there! You've got this.
Thank you
Thank you! Although I cannot afford any surgery, I’m glad to find videos on this topic. Perhaps eventually I will have the funds and the options to choose. It’s been almost three years now with this exact, very painful and disabling condition. Wish you all a good 2024!
you too, my very patient one. Hang in there. I hope you get the car. You deserve soon! It’s heartbreaking to see people separated from the care they need by money. All my best! And have the best year you can!
@@BestPracticeHealth So kind! Thank you. 💓
Dear Dr. Lieberman... My heartfull (this word ought to exist!) appreciation for your very clear explanations , understanding AND empathy... You are a great teacher and your respect for your patients is so welcome... I too have spondy at L4/5 since about 2005) and in May 2023 the MRI indicates severe lumbar stenosis.. at L4/5 -SIGH :( ....with all the classic symptoms
like peropheral neuropathy, deep pain, incontinence... I am exploring my options... ,so, your videos have and continue to be VERY helpful...If possible, would you be able to take time to explain the Ultra-Sonic Scalpel.... this new technique seems very promising!!
Again, a SINCERE THANK YOU !
Thank you for your kind words; I genuinely appreciate your feedback. It's clear you're dealing with a challenging situation given your diagnosis of spondylolisthesis and severe lumbar stenosis at L4/5, leading to significant pain and even incontinence. Your interest in the Ultra-Sonic Scalpel is understandable, but let me provide some guidance.
In cases of severe stenosis with spondylolisthesis, a Laminectomy is typically necessary. There's some debate about whether a fusion should be combined with a Laminectomy for grade one and grade two cases. The decision often depends on the patient's preference. If you're open to multiple surgeries in the future, having a Laminectomy first and considering fusion later if needed is a valid approach. However, if you prefer a single surgery and want to be done with it, a Laminectomy with fusion might be the right choice. It's crucial to understand that several studies have shown no significant benefit to fusion along with Laminectomy in grade one and two spondylolisthesis cases, despite it being the standard of care.
Regarding the Ultra-Sonic Scalpel, I advise against getting overly concerned about the specific tools a surgeon uses. Whether it's a diamond-tipped burr on a drill, an ultrasonic scalpel, or another tool, the surgeon's expertise and experience matter most. As a patient, focus on finding a surgeon who is minimally invasive, board certified, well-trained, and experienced in minimally invasive spine surgery. Let the surgeon choose the tools they are most comfortable with and have expertise in. Ultimately, the surgeon's skills and knowledge are what will ensure a successful outcome for your procedure.
@@BestPracticeHealth❤
What is your thoughts on the TOPS system? This seems to be an opportunity to maintain range of motion and treat Spondylosis.
What options do you know of if the patient has tested positive for a titanium hypersensitivity? I’ve been diagnosed with bilateral pars defect, spondylolisthesis grade 2, stenosis, herniated disk, all at L4-L5
I have multiple spondylolisthesis...L1-L2 Gr 1 retrolisthesis, L3-L4 Gr 1 anterolisthesis, L4-5 Gr 1 anterolisthesis and L5-6(?) Gr 2 anterolisthesis (three chiropractors have confirmed I have L1 through 6 but not quite sure how that works... My surgeons thought is that I do not need surgery. I recently found out I have hyper mobility syndrome. I also have 2 retrolisthesis in the neck but only 2mm for each so not considered grade 1 at this time. My surgeon is focusing on weight loss and exercise to strengthen core and therapeutic steroid injections....
I'll try to brief. I have arthritis in my hips and predominately in my left side and a replaced knee on that same side. Diagnosed with spinal stenosis in 2018 or so and started evaluating everything from there now most recent X-rays and MRI shows severe spinal stenosis throughout the spine, scoliosis at the l2 l3 level, spondylolisthesis at levels four and five. The first recommendation a few years ago was just a fusion of The l4 l5. I saw the second opinion that had more focus in the cervical area that they wanted to attend to. I took those same set of X-rays and MRIs to a third doctor sports Doctor and he recommended a laminotomy and maybe a fusion if he saw significant movement or shifts. He recommended surgery within a couple of months of seeing him due to the crowding of the cauda equina. Four months later dealing with the VA system I was referred out to a specialist at the Scripps clinic which is pretty respected. After seeing this doctor it has been recommended to me that I have a three-level fusion with a Laminectomy. But then he added and recommended that I see an orthopedic doctor into the arthritis in my hip which is severe and he said I should take care of that before tending to this major surgery that they would have to do. The sports Doctor who had treated some pretty famous athletes and got them back on the field was going to do something less invasive and thought that I should do something soon. And now it's four months later and this just the latest evaluation and I should get my hip replaced before dealing with my back is what they're basically telling me. Does that make any sense and what do you think about that?
Zonkers! You have really had the run around. I'm glad you're still hanging in there! I did part of my training in the San Francisco VA, so I know how great and terrible that system can be at the same time.
From a surgical point of view, I'd recommend getting the back fixed first. Failure to correct severe stenosis have a fatality rate I don't associate with arthritis of the hip. However, three level fusion is not a good answer. You need a less invasive spine surgeon at scripts and get a laminectomy ASAP. Then get your hip done.
I had a decompression surgery lumbar laminectomy typical l4 l5 s1 did not have the fusion The doctor wanted to put colflex steel. With my mechanical engineering background I said that will not correct my scoliosis another surgeon said colflex has no business in a scoliosis procedure traditional rods and screws would be best PS I just had the lumbar laminectomy now looking at possible fusion with a lot of hardware I would love to show my MRI films on the show and my reports if you like thank you have a great day
Dear Doctor, I've been iagnosed 2 months ago, only 2 episodes of sciatic pain 2019, 2023.
End of December 2023 suddenly pain, the same pain that occurred two more times (ambulance involved at 2nd time).
Diagnosis: L5-S1 spondylotic spondylolisthesis, bilateral pars defect with foraminal stenosis left worse than right, severe
stenosis foraminal with sever nerve compression, coccyx subluxation likely old, has no new injury or fall.
Three epidural injections 4 weeks ago, solved sciatic pain but after bending for a longer time - enough a2 days with extensive bending at times, severe pain in the centre of my lower back (felt like "slipped disk, needed ambulance with happy gas to let me sit back, pain excruciating even with minimal head lifting. I was able to move my feet only without getting that breathtaking, making me feel like fainting, pain).I sometimes hear a sound in my lower back, like when a knee joins move - not crack, just dull joins sound).
Is there any hope for me.
Lost my job recently re couldn't be reliable any more.
I'm in my middle 40's
Is there any hope for me?
Thank you, Doctor.
Wow sir u explain so well I m also suffering from spondylolisthesis 😮
Thanks! Hang in there. Most cases of spondylolisthesis without stenosis do not require any intervention. Yoga helps.
I have L5-S1
17 mm moderate degenerative disease with disc uncovering, Grade 2 spondylolisthesis L5 on S1 with multilevel lumbar spondylosis, central annular tear, and severe bilateral formation stenosis! Surgery is the only option since two steroid shots haven’t worked, 12 sessions of physical therapy hasn’t helped me one bit, and I’m in constant agony with numbness and tingling in my butt thigh calf and foot
I have all of that, plus facet joint disease and scoliosis. Have had this for several years. Gone through various conservative treatments, epidural injections, RFA several times, and physical therapy. Nothing has helped. I’m seeing a spine specialist band next visit I’m sure he will recommend surgery. I am going to totally refuse any kind of fusion. I’ve never met anyone who had successful fusions. I’ve never met or worked with anyone who had spine surgery that alleviated the pain. I’ve been studying and researching the spinal procedures available and don’t see any of them that I could trust to alleviate my situation. I don’t want screws/ rods/ hardware shoved into my vertebrae.
Wow. It sounds like you have a very complicated back. Great idea being so informed. Let me know what the specialist says, please. I'd love to hear how it sorts out.
@@BestPracticeHealth thank you. I was a firefighter/EMT for 48 years, retiring 6 years ago at age 67. I had multiple shoulder and knee surgeries from the damage incurred while working. My back bothered me but I didn’t do anything about it until 2019, when I discussed it with my primary care doc. He started me with an MRI and X-rays, then sent me to pain management. I also had done physical therapy, which wasn’t much help. So I went through two years of epidurals, RFA several times. After the last round of those treatments, my doctor sent me a to a spine specialist. Of course you don’t see the doctor until,the 2nd or 3rd visit. I’m very leery of spine surgery as I don’t know anyone of my peers or friends who had a spine procedure that was successful. Every firefighter who had spine surgery suffered horribly and were forced into retirement.
Look into the TOPS procedure. Dr. Ament....West Hills California....just outside LA.
@@BestPracticeHealth Had the spine specialist visit today. After reviewing the MRIs, X-Rays and bone scans, he advised that the only possible treatment is to fuse most of the vertebrae in my spine. I have a distinct scoliosis, plus facet joint disease, multiple stenosis, multiple bulging discs and a lot of pinched nerves. He said that I’ll just need to live with it, get epidural injections when needed, and there’s not much else that can be done, that I’ll just have to live with it until it’s so serious that a multiple fusion be accomplished. I refused any fusion work and I explained why. That was it. A 5 minute consult with him and came away the same as I went in.
Your condition, other than the scoliosis sounds similar to my wife. She has grade 2 spondylolisthesis, herniated disk, stenosis, facet joint diease, arthitis and also refuses fusion. Her father had one of the first fusions for his spondylolisthesis at Duke in NC in 1948 and he was in pain no matter what they tried. What they did to him back then after the fusion was they made him lie on a board for 30 days to "make sure the fusion took!" They did a few revisions after that and he'd be better but only for a while. I have heard her chances of feeling better after a fusion are about: 1/3 are worse 1/3 are the same and 1/3 are better. It seems like they could offer something now that incontinence is coming into play and we had to buy a bidet due to her lack of twisting capability. I will show her this video and at least have a discussion about it. We now live in SW Florida so if anyone has recommendations for doctors, we appreciate the info!
Gee thanks Doc! haha just kidding! yes, this is quite a predicament! My neurosurgeon here in the Ft. Worth area is quite conservative, and I will see him tomorrow and see what he has to say. Thank you.
Best of luck!
Such great info! Ive been diagnosed with stenosis in L3 through S1, spondylolisthesis at L4 and L5. 3 local spine surgeons have recommended traditional fusion. Ive heard about a relatively new TOPS implant by Premia Spine, that addresses the movement issue with a rotating joint. Was approved recently by the FDA. It seems like it would be a much better route to go. Can you speak to whether or not it would be worth looking into? Thank you!
Spondylolisthesis has grades from 1 -4. Do you know your grade? That would help in making the recommendation.
Grade 4. Now constant leg nerve pain.
It usually goes,but been 2 months.
It has impacted me.
They used to say wait then it went to get it done .
I did not want.rods etc cause I did not.want constant surgeries
lumbar fusion is a really effective treatment for high-grade spondylolisthesis with stenosis. It’s really the only effective treatment in the long run. I would strongly consider if I were you. I think you’ll be glad you did.
Looking for 1 and done, does a TLIF mean hardware on only 1 side, as you note is a decent option?
One and done it is! Most surgeons do hardware on both sides.
I want to have the most minimally invasive surgery. Maybe just laminectomy. I have spondylolisthesis at L4/L5 with stenosis at the level above and herniated discs at both levels. Does the herniated discs force me into having the fusion instead of just laminectomy. Since they would get rid of the discs and put in cages???? Or will the herniated discs heal on their own?
Herniated discs generally heal on their own and are not typically a reason to have fusion.
Got those and scoliosis.
Not looking forward to the future surgeries.😔
I know, right! I"m sorry you have to deal with all that. However, a couple ideas for you now. Get into traction. Either inversion table or hanging. It can't hurt. Also, do your research now and find out who will be your doctor when you are ready. Look for an orthopedic surgeon who specializes in scoliosis and does a high volume (more than 100 cases a year) or deformity.
Never got a notification for this.
Thank you so much.
I was wondering about an inversion table.
Finally see spine surgeon tomorrow.
Been so many delays.
You make no mention of the TOPS procedure which is a viable option to the very traditional methods you talk about.
Can u tell me why neurosurgeon wants to do acdf cervical fusion at c4_c5 first before he redoes my fusion at c5_6 is there a reason I'm worried.i already have permanent nerve damage c5c6 I found out I have ataxia now.my legs have been going numb.and tingling arms and hands to and heavy feeling upper arms sometimes.
If you need a revision at C5/6 and a new ACDF at C4/5 those two could be combined into a single surgery.
I have had severe numbness and now frequent cramping in clay and feet the pain and numbness wak manageable but the cramping is new and hard to live with I had fusion in 1981 and lament to my 1982 grade 2 + Are these symptoms due to the grade progression?
I would need to see some films to address this question. Sorry. I hope you feel better soon.
I use magnesium lotion or and magnesium oil spray for cramping. Have had spinal fusion L5-L3
I have a spondylolisthesis L5 S1 with the moderate lateral stenosis. I don’t have pain while siting and laying down. I have pain once I stand and walk. Can i get better without the surgery?
The question of whether spondylolisthesis with moderate lateral stenosis can improve without surgery is a great one. It's noteworthy that about 80% of people with spondylolisthesis do not require surgical intervention. Therefore, the key concern here really is the stenosis.
Symptoms of stenosis, which typically include pain that is triggered by walking and relieved by bending forward or resting, tend to fluctuate over time. This implies that it's entirely possible to experience periods of improvement without resorting to surgery. However, a more pertinent question might be whether you will ultimately need surgery. Stenosis is a progressive condition, which means it tends to worsen over time. If your stenosis advances to a severe level and non-surgical remedies like rest and light exercise no longer provide relief, surgery becomes necessary.
Hi Doctor, I had an extrusion on l5-s1 2 years and a half ago and had a microdiscectomy then. I didn't have any pain after the surgery until 2 weeks ago when I felt my disc exploding again. I had severe back pain for 2 days and then the pain was gone. Now I have mild sciatica. I'm waiting for a MRI, but I'm sure my disc collapsed. I'm following the same procedures that I had to after surgery (no weight lifting, no bending, no twisting). I'm trying to be extra careful. My question is: can a re-herniated disc heal without surgery?
Oh, no! I'm so sorry to hear your pain has come back. At least this time you have some experience dealing with this kind of thing. The answer requires a little background on what causes recurrent disc herniation, and then we can get into your options.
What causes recurrent disc herniation?
Recurrent disc herniation is caused by the same thing as initial disc herniation: a tear in the annulus of the disc which allows the soft inners parts to herniate out.
Treatment options for recurrent disc herniation
Recurrent disc herniations trigger an inflammatory reaction so that your body can attack and remove the herniated components of the disc that are exposed to the space around the nerve roots. I have seen many people get better on their own. You are fine to treat at home with NSAIDs, moist heat, and rest if you have NONE OF THESE 3 THINGS:
Red flags
Functional numbness or weakness, OR
Unbearable pain.
If home treatment fails or conditions worsen, then more invasive options may be considered.
Redo microdiscectomy by a minimally invasive spine surgeon is necessary if you have functionally limiting numbness or weakness. If it's not bad enough for surgery then epidural steroid injections, done by a certified pain management specialist, may provide temporary pain relief.
Once this episode resolves you need to think about your core strength. Normally weightlifting is one of the best things you can do for your core; however, your body is telling you that your core needs to do more to offload your discs. Either look at doing more compound lifts, or even adding yoga or Tai Chi to your weekly regimen.
@@BestPracticeHealth hi Doctor, thank you for all the explanation. I was going to the gym everyday before I felt my disc exploding again. I'm really afraid of weightlifting. Would swimming be indicated to core strenghening?
I'm 60 years young now I have all these problems in my back plus a lot more my core strength could not get any stronger I used to be a professional dancer! But my neurosurgeon is wanting to do a multi-level disk lumpectomy I have spinal stenosis spondylolisthesis herniated disc scoliosis on top of that I have had cervical two disk replaced already. Now from my thoracic down to my ass bone is gone
And I refused having any and I do mean any injections put into my spine.. it plainly states not intended to be injected into the spine very dangerous some people says it helps them and I'm so happy it does but for me when a doctor tells me it can either paralyzed me or kill me I chose to pass
I have a degenerative disc along with spondylolisthesis I did some research and I found out there is something called non-fusion spinal surgery for this condition is this true?
B
Yes I do have stenosis
As one who has a seriously trash bag, spondylolisthesis, L5 S1 with herniation scoliosis, severe stenosis, L234 with bulging disc and 24 seven persistent pain. If you have a greed to spondee or better, there’s nothing it’s going to treat it except stabilizing the two vertebrae that’s all grade one you can go with for years and years I did I’m now in my 60s. it was grADE one of my 20s 30s 40s and early 50s and all of a sudden became grade 2 and completely impossible to function. Getting ready for an MIS TLIF
I used to love doing Transforaminal Lumbar Interbody Fusion (TLIF) for grade 2 spondylolisthesis with stenosis because the results are so predictably good.
For grade 2 spondylolisthesis, where one vertebra slips over another by about 25% to 50%, and stenosis, which involves narrowing of the spinal canal, TLIF can be particularly effective. It's encouraging that the surgeon performing the procedure is skilled in minimally invasive techniques, which can often result in quicker recovery times, less postoperative pain, and reduced risk of complications compared to traditional open surgery.
Good luck with the surgery, and here's hoping for a smooth and speedy recovery. Please do keep updated on the progress post-surgery-it would be great to hear how everything goes!
I have grade 2 scoliosis. You mean doctors that surgery is recommended for a case like me?
Help me understand. Scoliosis is typically measured in the degree of the curve. Spondylolisthesis is graded 1-4. Do you have scoliosis, spondylolisthesis, or both? It makes a difference as to the recommended treatment. If it's scoliosis, how old are you? If it's spondylolisthesis, do you have stenosis as well?
I have Grade 2 Spondylolisthesis L4 over L5. I also have lumbar spondylosis narrowing of L4, L5 and L5, S1. I am not aware if I have stenosis. Suffering numbness of my feet always. I am 71 years old Asian. May I know what kind of treatment form these? Thank you.
I have spondylolisthesis, bilateral pars defect, moderate degenerative disc disease and stenosis and it’s the worse ever
Oh ya and severe foraminal stenosis
I’m so sorry to hear that. I’m very familiar with this condition, and have seen firsthand how severe a pain it can cause. If disabling. The standard treatment for Spond thesis with stenosis that has failed conservative care is lumbar fusion. During the fusion surgery, laminectomy can be done to relieve this stenosis. Medical screws are placed to stabilize the bones and re-create the tension disconnected by the defects. The surgeon can also remove the degenerative disc, and place spacer to allow bone to heal over your introvert Interpace. This operation is highly effective for your problem. And there really is very little other choice.
So if you don't have the fusion you will require another surgery in the future?
What I’m trying to convey more that 17% of all people who have a fusion this year will have another one within five years. That’s just a fact by history.
@@BestPracticeHealthI have bi lateral pars defect at L5S1 and I am not sure what to do. It doesn't cause too much pain maybe some nerve pain in glutes and legs. I have associated ED and genital numbness and little sensation to touch. Seeing a neuro soon. Is fusion always the way to go? If its a fracture is surgery the best option to try and repair it? It is grade 1 spondy at the minute..just worried. i did think surgery was quite successful from what I've read. Thanks for the reply