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Grade 1/2 Degenerative Spondylolisthesis Unstable - Update


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Old 05-17-2017, 12:25 PM   #1
gabrielalo
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Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

hello
this is an update to my old thread
http://www.healthboards.com/boards/back-problems/1018278-grade-1-spondylolisthesis-l4-l5-doctor-suggests-2-level-fusion.html

I have new XRays done on 12/27/16 and here are the reports:

XR Lumber Spine flexion/extension 2/3 views:
FINDINGS:
The vertebral body heights are maintained. Anterolisthesis of L4
on L5 approximately 10 mm in flexion and 8 mm in extension. Grade
1 anterolisthesis of L3 on L4 approximately 1.5 mm in flexion,
reducing on extension. Disc space narrowing at L4-L5 and L5-S1.
Minor marginal osteophytosis. Facet arthropathy lower lumbar
spine.

IMPRESSION:
- Anterolisthesis of L4 on L5 approximately 10 mm in flexion and 8
mm in extension.
- Grade 1 anterolisthesis of L3 on L4 of approximately 1.5 mm in
flexion, reducing completely on extension.

XR Spine Scoliosis standing 1 view:
FINDINGS: 11 paired rib bearing thoracic vertebra. While there
are 6 nonrib-bearing lumbar type vertebra, to maintain
consistency the last lumbar type vertebra, a transitional
vertebra, will be labeled L5. Partial pseudoarticulation of the
expanded right transverse process of L5 with the sacrum. No
significant scoliosis. The right iliac crest is approximately 6
mm higher than the left. No appreciable congenital vertebral
anomaly.

IMPRESSION:
Transitional lumbosacral vertebra. Nomenclature as mentioned
above. No scoliosis. The right iliac crest is approximately 6 mm than the left.

My current status:
- pain level increased, sciatica mainly on left leg
- pin/needles on legs and feet
- bladder acting up - have issue emptying it, not all the time though

concerns:
- new DS Spondy on L3/4, do I need to fuse that level too since it's unstable too?


surgical options:
- Dr. has 20+ years of spine surgeries
- minimum invasive approach-less blood loss and smaller incision
- single level TLIF on L4/L5
- very high score on spine surgery
Cons:
- long wait for follow up appt-7/25/17
- long wait for surgery date - mostly likely october
- not my provider so need to get preauthorization on everything

Pros:
- surgery available in mid June
- single level PLF on L4/L5
Cons:
- very young and new, his fellow-trained in Harvard was completed in 2013
- open approach
- hospital has very low score on spine surgery

Since my last thread in March 2016, I am trying to avoid surgery but I come to the decision that I need fusion to stabilize my spine or it will get worse.

I would greatly appreciate any feedback/advices.
thansk,
gabriela

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Old 05-18-2017, 07:31 AM   #2
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable

From rereading your previous posts, it doesn't appear that your issues would require a particularly complex surgery.

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Old 05-18-2017, 08:07 AM   #3
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable

Every patient looks for different things in a medical practice...so some of the things I find appealing and important might not be important to you. It isn't necessary to go to a top surgical center to have a good outcome. Some surgeons have different priorities and having their name in the "spotlight" is not at the top of the list. The surgeon I eventually selected was like that. I "interviewed" surgeons in three states before deciding on a local one. I went to several surgeons with the big reputations, but what I found was very impersonal care...a waiting room full of many people, a very long wait, a very short time spent with the doctor after being examined and giving my story to several different people, etc. I felt like I was in a factory, and I didn't like the feeling.

I could go on and on but am not sure what things would help you to decide. Do you have specific concerns?

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Old 05-18-2017, 10:30 AM   #4
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable

Hello Teteri66,
thank you so much for your insights and fast response.
I like to be operated by a top notch surgeon knowing I will be in good hand but it's a long wait.

The doctor ordered more tests which none of the local surgeons I saw had ordered: CT scan, DEXA test, scoliosis/full spine xray(36"). So I know he is technically/medically superior than those I saw: DEXA shows I have severe osteropenia, full spine Xray shows pelvic parameters(Pelvic tilt, SVA, cobb angle, Pelvic incidence). I think the pelvic parameters are critical as I read a lot about people with success fusions still with huge pain due to the fact that their pelvic parameters were not corrected(lordosis) during fusion surgery. He also prescribed ESI before prescribing surgery. He recommends TLIF minimized invasive.

what is your opinion/experiences on MIS TLIF?
- I know the surgeon has to be very experienced.
- the advantages are less blood loss and less OR time?
- will the long term outcome same or better than open PLF?

What is your opinion/experiences on Caudal ESI?
- I am scared of its side effect(dura puncture and arachnoid infection)
- not sure if it will help to heal/correct my slipping spondies

Hospital rating: - 2 for infection
- is that very critical for fusion surgery?
- overall very low ratings across the board(27 out of 100)

- We've planned to go with USCF until a month ago when I have more symptoms
- new symptoms probed me to seek surgery earlier than later:
-pin/needles and ants crawling on my legs/feet(come and go but more if I walk or swim)
-more frequent/longer leg pain especially sitting/walking/standing
-intermittent trouble to empty bladder(but it seems to get better now)

I know you've waited a long time before committing to fusion surgery.
Based on my recent xrays from December, can I wait much longer?

thanks so much for your invaluable advices.
You are a guidance angel on this board!
gabriela

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Old 05-18-2017, 11:38 AM   #5
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable

In hindsight, I probably waited longer than I should have, but you never know for sure. I know one person who had surgery very quickly after first signs of nerve compression and she ended up with permanent nerve damage...so it isn't always a matter of timing! Whether I would have had less nerve damage had I acted more quickly, no one can really say.

You can afford to wait a few more months. Your spondylolisthesis is pretty minimal and your symptoms aren't all that debilitating. The exception would be if you would suddenly develop bladder or bowel issues like incontinence or sudden muscle weakness like drop foot. Then you would probably need emergency surgery to get the pressure off the nerve.

As to MIS vs. open surgery, it is hard to evaluate. If all things were equal, MIS would be easier...but, in my experience, many people experience difficulties with MIS too. Other than the way the area is entered, there aren't that many differences. All my surgeries were open and I had no blood loss due to my surgeon's skills! But after three surgeries, using the same incision, certain back muscles are "mush" according to my PT! I don't notice it, but people who work on me do!

In terms of recovery, it doesn't make a huge difference. The time consuming part is the time it takes to grow new bone, and that's the same regardless of how the body was entered. In terms of recovery from the surgery itself, MIS is faster because the muscles aren't cut. However, with TLIF, they go in from the side and sometimes people end up with thigh pain or femoral nerve damage. I think long term the results are similar.

The caudal steroid injection is very similar to the ESI...don't know if you've had one of those yet. It is not more dangerous...but again, you want to go to a place that knows what they are doing! Frankly, I doubt it will help much but sometimes you have to do it before insurance will cover the surgery.

Infection is one of the major risks of spine surgery -- particularly with an open surgery...but anytime they are putting a foreign object into your body, the risk for infection is higher than for other surgeries.
In a case of spondylolisthesis where there isn't disc disease there is no reason to remove the disc. I have had it done both ways. My first fusion which was a PLIF at L4-5, the disc was removed and a cage packed with BMP (a synthetic bone product) was inserted to hold the disc space and to aid fusion. When my fusion was revised and he added on at L3-4 and L5-S1, he did a posterolateral "gutter" fusion. I fused faster with the PLIF, but both were ultimately successful.

Sometimes it is just a matter of personal preference -- the surgeon's, not yours!!

Last edited by Administrator; 07-06-2017 at 10:14 PM.

 
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Old 05-18-2017, 12:35 PM   #6
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable

Hello Teteri66,
thanks for your advices.
questions on the Dec 2016 flexion/extension XRays:
1) Anterolisthesis of L4 on L5 approximately 10 mm in flexion and 8 mm in extension
- I think my previous xray was 7mm in flexion. Your comment of "Your spondylolisthesis is pretty minimal and your symptoms aren't all that debilitating." So 10mm in flexion/8mm in extension are considered minimal? I read other sources saying 10mm is a big slip that requires immediate fusion surgery.

2)Grade 1 anterolisthesis of L3 on L4 approximately 1.5 mm in flexion, reducing on extension.
- would this eventually be like L4/5?

3)Disc space narrowing at L4-L5 and L5-S1
- so should I replace the disc at L4/5 as in TLIF?
please advise.

I am not in constant debilitating pain, they come and go. Certain activities(walking/sitting/standing) will aggravate the pains and numbness. Certain movements also cause shooting pain from back to foot(sitting up from bed, getting up from chair, and changing positions). But once I rest in bed for a few hours, the pain subside and I feel better.

But knowing I need fusion sooner or later, I am more incline to go with Dr. Ravi on an open Posterolateral lumbar fusion on L4/5 and decompression. My son's graduation is a month away and I hope I can attend the ceremony before the surgery.

thanks again for all your advices.
gabriela

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Old 05-18-2017, 06:59 PM   #7
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable

It isn't so much the amount it is shown to be slipping as it is the symptoms it is causing. Some people live a lifetime with a Grade 2 spondylolisthesis and never require treatment. My surgeon basically told me I needed a fusion. When I had it done was up to me. However, before I had my revision surgery, my family flew across the country for my mother-in-law's 90th birthday. This surgeon didn't tell me I couldn't go, but he did ask me to consider whether I would want to have emergency back surgery in that location in the event something happened. The family went. I stayed home with the dogs! Most likely, I would have been fine, but I didn't want to risk it! I wanted the surgeon I had selected...not anyone else.

I can't really answer your question about the spondy at L3-4, but I think it unlikely that it will advance too much. However, having one fused segment puts additional stress on the adjacent discs.

Regarding what type of surgery to have...I believe it is best to pick the surgeon and then follow along with what he/she thinks is the best way to proceed. Every case is different and at some point you just have to trust the training and experience of the doctor you select.

You do have a couple "oddities" that you might want to discuss prior to surgery....the transitional vertebra and the discrepancy in height of the left and right iliac crest. I imagine he will say it won't make any difference, but I would ask anyway.

You could arrange to have a wheelchair at your son's graduation if walking long distances is involved. My daughter graduated 6 months prior to my first fusion. My surgeon gave me prednisone to get through the week of festivities, and it helped quite a bit.

Last edited by teteri66; 05-18-2017 at 07:08 PM.

 
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Old 11-10-2017, 07:45 PM   #8
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Hello Everyone,

I would like to share update to my spondy condition and surgery!
I have a MIS TLIF on L4-L5 this Monday, 11/6/17 at UCSF.

I have some complications per the neurosurgeon as follow:
- extra bone on L4-L5 that they have to spend an hour to remove
- vertebra at L4 on left side(side that I have the most pain and sciatica) was soft and have difficult to secure the screw. They said they finally fixed it but not sure what they did to fix it.... cement injection??
I had -.0.9 T-Score on my spine and was on Forteo 1 month prior to surgery and continue Forteo for 6 months post-op.

The surgery was supposed to be 3 hrs but took 7 hrs and I took 4 hrs to recover!
Since I woke up, my left leg from thigh down to toes were numb!!
I did not have any numbness on the left, just sciatica!
after 4 days in hospital, I regained the partial feeling on left thigh and back but still totally numb from knee down to toes. My knee like to bugle and cannot support my body weight! I came home yesterday, 11/9/17
My knee is hyper sensitive and feel like burning without even touching it.
I can barely move with a walker as my left knee bugles and locked up!
I can barely dosi-flex or curve my toes!

Questions:
Are all these numbness and burning sensation common after a TLIF?
would it go away? if so, how long will it take?
I hope it's not permanent as I DON"T have numbness and locked knee before surgery.

Any advices and post-op tips would be greatly appreciated.

Thanks
glo

 
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Old 11-10-2017, 10:14 PM   #9
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Wow. That sounds like quite a surgery. I can't imagine how it took seven hours. Did he end up doing the whole procedure MIS? Happy it is over and you can get on with recovery.

Your new symptoms are a result of the surgery. The doctor probably had to tug on the nerve to free it up. Chances are good that it will eventually go away, but it may take some time. I had surgery on Sept. 22nd at L2-3 and awakened with nerve pain in both thighs on the front side. They felt freezing cold and were numb. Eventually that mostly went away and was replaced with burning. It is mostly gone now, but not completely.

You are very early in recovery...and it will take the nerves a while to recover. You need to develop patience as recovery usually takes long than you think it should. The most important tip I can give you is to take frequent short walks. At this point walking is the best exercise to keep scar tissue from attaching to a nerve as it forms and fills in during the first twelve weeks post surgery. It is important to walk around your house, or, up and down a hall, or similar, every couple hours. If you wake up during the night to take medication, get up and walk for several minutes. If you need to use the bathroom, take the opportunity to walk a bit more. Do not shirk on this as scar tissue can ruin a surgery and you want to do what you can to try to keep this from happening!

Be sure to get lots of rest and drink lots of fluids. It takes energy to grow new bone cells.

 
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Old 11-10-2017, 10:51 PM   #10
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Thanks for your quick response.
I have 2 2" incisions on each side and one on my butt about 1/2". Would that be full MIS?
I forgot about the dura issue they said the dura was very thin so they glued it up?? Not sure what it mean but I was ordered to lay flat for at least 24 hrs
Thanks for the advice
I will walk as much as I can
When can you wean off norco and neurotin?
Any advice on constipation remedy?
My biggest hope is to regain sensation of my left leg and foot soon!
Thanks
Glo

 
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Old 11-11-2017, 09:06 AM   #11
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

The pain medications are very constipating so things like stool softeners, gentle laxatives, etc. can be helpful. Drink lots of fluids and eat high fiber fruits and vegetables. Blueberries and prunes are especially helpful.

You should keep taking gabapentin (neurontin) for the nerve pain. Unless your surgeon says otherwise, I would think you could wean off pain medication if you don't think you need it. With my L3-S1 fusion I was off pain medication by the 12th day. I just didn't need it. But if you are in pain, then you should keep taking it as the body will heal better.

Yes, you were not cut open...so the surgery would be considered MIS.

I have found the best way to approach this is to take it one day at a time. All you have to do is get through today the best way you can. Don't look ahead, wondering how long something will take. Just do the best you can for today. Stay optimistic and learn to listen to your body! Don't overdo the walking! Remember you don't need to go far...you just need to move around for a few minutes, frequently! After twelve weeks you can worry about walking for other reasons!

You will be feeling better before you know it.

 
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Old 12-05-2017, 07:32 PM   #12
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Teteri66, thanks for your valuable responses.

Like to provide an update to my 4 weeks post-op since my fusion.
Numbness from knee to toes still no improvement. Pain has improved somewhat but my groin to quad and outside leg are still very sore and hurting.

I tried to do little walk as suggested. However, I found out my left foot turned out and slapped the ground with my knee hyper-extended and locked up, and my hip popped and hurt. I can manage to walk with a cane for about 10 minutes and then my knee and hip hurt so bad that I have to stop.

Is this some form of foot drop? I cannot do heel walk nor dosiflex on my left foot. Since I have a dura tear and soft/eroded L4 vertebra during screw instrumentation, would the tear and/or screw at L4 damaged the L4 exiting nerve and caused all my issues on left leg?

I had xray prior to my discharge and the report said the spondy is about the same as prior to surgeryÖ.so I compared the reports and the difference is 1mm which is nothing! I thought the fusion supposed to correct my slippage and stabilize the vertebrae. The surgeon told my husband the surgery was successful even it took 8+hrs instead of 3!

My first post-op appointment with the surgeon is at 9 weeks post-op, which is another 5 more weeks away! I plan to ask about the xray report and also PT to help with my left leg and foot. I was on Forteo 1 month before surgery and continue for another 4 more months to help bone growth. I also started 2 hrs/day on the bone growth stimulator.

Anyone has similar issues post fusion with leg pain/numbness and foot drop? Can they be resolved? If so, how long and what treatments? Any inputs would be greatly appreciated.

Thanks,
glo

 
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Old 12-06-2017, 08:54 AM   #13
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Is the surgeon aware of the foot drop? Seems like 9weeks is a long time to wait for your first post op appointment.

 
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Old 12-06-2017, 09:09 AM   #14
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Regarding the spondylolisthesis, the vertebrae will not be pulled back into position so the edges of the vertebrae line up perfectly, but the segment will be stabilized. This is typical and should not cause any issues.

You might want to contact the hospital, the records dept., and request copies of all operating room notes. This may provide some indication of why the surgery took so long, etc.

 
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Old 12-07-2017, 12:17 AM   #15
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Re: Grade 1/2 Degenerative Spondylolisthesis Unstable - Update

Thanks for your advice
I am confused about foot drop. Is this a medical emergency?
I'd dura tear so was in strict bed rest 48 hrs so I didn't know I'd foot drop, just numbness from knee to toes and can't dosiflex.
They told me it will go away in couple weeks and discharged me home. Then I started walking and found my foot slapped. Should I go to the ER, but it has been 5 weeks so am I domed with permanent disability? Or I can afford the wait of 1-2 months?
Normally what are the best diagnostics on foot drop after fusion: Emg or MRI?
Is that true that MRI with contrast or Ct with contrast will not work to detect nerve compression? Only myelogram with dye works?
Thanks
Glo

 
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