is a degenerative spondylolisthesis, and occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement. This type of spondylolisthesis is most often seen in older patients. In Type III, degenerative spondylolisthesis there is no pars defect and the vertebral slippage is never greater than 30%.
Spine surgery ought to be considered as a last resort when addressing pathology localized to the spine. All attempts at application of conservative measures, including rest, physical therapy, simple anti-inflammatory medications, various injection techniques, and even simply the passage of time, should be allowed before pursuing a surgical discussion. If neck or back pain is associated with significant new neurologic deterioration, including radiating numbness, tingling, or weakness in either or both legs, medical attention ought to be sought, and the work up ought to be pursued. Even when these symptoms are present, conservative care is usually the mainstay of treatment.
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A fusion is a procedure that results in the connection of one bony vertebra to the next. Typically, the fusion of one vertebra to the next will result in approximately five to ten percent reduction in the lumbar spine's ability to flex and extend. Patients should keep in mind, however, that the majority of forward flexion at the waist as one attempts to reach the floor occurs as a result of flexion occurring at the hips. Certainly, the more levels of lumbar vertebrae that are fused, the more restriction in low back range of motion may occur. Experience in adolescent individuals who have undergone lengthy spinal fusions for scoliosis have shown that even with an extensive fusion of multiple lumbar vertebrae, the majority of individuals can flex forward at the waist due to the preservation of hip flexion, with the added flexion provided at the level of the knees, the individual can reach the floor in a fluid and spontaneous manner.
Many patients with spondylolisthesis will have vague symptoms and very little visible deformity. Often, the first physical sign of spondylolisthesis is tightness of the hamstring muscles in the legs. Only when the slip reaches more than 50 percent of the width of the vertebral body will there begin to be a visible deformity of the spine.
This review concluded that non-operative treatment for spondylolysis and low grade spondylolisthesis in children and young adults showed a high rate of success when measured by functional outcome. Although generally a well conducted review, presence of publication bias, significant variation across studies and lack of a study validity assessment indicate that the findings should be interpreted with caution.
Usually the pain is relieved by extension of the spine and made worse when flexed. The degree of vertebral slippage does not directly correlate with the amount of pain a patient will experience. Fifty percent of patients with spondylolisthesis associate an injury with the onset of their symptoms.
Eligible studies included at least 10 children or young adults with spondylolysis (including those with up to 25% spondylolisthesis) who underwent non-operative treatment. To be included, studies with clinical outcomes had to have a minimum follow-up of one year. In the included studies treatment interventions were non-operative and included forms of bracing, activity restriction and therapeutic exercises. Clinical outcomes were measured as success rates (good or excellent based on a published scale or comparable measure) and radiographic outcomes as evidence of a union of the pars defects; defects were characterised as acute, progressive or terminal. For radiographic outcomes, studies were included where plain radiographs or computed tomography (CT) or both were used for diagnostic purposes. In the clinical pool, 88% of patients had defect(s) at the level of L5 and 70% of patients were male. In the radiographic pool, 82% of defects occurred at L5 and 82% of patients were male. Mean patient age across all studies ranged from 11.4 years to 21 years. Length of follow-up for clinical outcomes ranged from one year to 15.3 years. Studies were undertaken in England, Finland, Sweden, Germany, Belgium, Spain, Japan, Australia and USA.
The need for post-operative bracing depends on many factors. Standard lumbar spine fusions making use of bone grafting without the use of instrumentation typically require post-operative brace immobilization to provide a semi-rigid environment to encourage the bone fusion to occur. With the advent of pedicle screw instrumentation, that rigid environment may be provided internally, foregoing the need for brace instrumentation. The quality of the patient's bone and the length of the spinal fusion may also be factors that contribute to a surgeon's recommendation for post-operative bracing. For example, osteoporosis is a condition in which the pedicle screw instrumentation may have less purchase in the bone and, accordingly, supplemental support by virtue of a rigid post-operative brace may be advantageous until the body can initiate the healing process.
A laminectomy is a surgical procedure that involves the removal of the bony arch in the back of the spine. By removing the bony arch, the compressed spinal cord and nerve roots can expand and float more freely within the spinal canal. This is a common procedure performed for patients with narrowing of the diameter of the spinal canal related to degenerative changes resulting in lumbar spinal stenosis.
Spine surgery is often invasive and requires the dissection through the muscles of the low back. Additionally, the manipulation of nerves and the mechanical changes in the lumbar spine associated with a spinal fusion can result in post-operative pain. Typically, oral narcotic medications are prescribed in the post-operative period. Long-term usage of oral narcotics can result in physiologic addiction. All attempts ought to be made to wean from the post-operative narcotic medication within the first two to four weeks if at all possible.
Most often, spinal fusion surgery is done through a posterior approach, meaning that the surgery is done through incisions in the back of the spine. This type of posterior spinal fusion surgery does not pose any additional risks for men as compared to women. When anterior spine surgery is performed, that is, surgery performed through an abdominal incision resulting in exposure of the front, or anterior, part of the lumbar spine, there are some additional risks that are more relevant to men. Specifically, the dissection of the fine latticework of the parasympathetic nerves spanning the anterior disc spaces at L4-L5 and L5-S1 can result in retrograde ejaculation and impotency.