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helminj1 06-20-2011 02:18 PM

Bilateral L5 pars defects with grade 2 spondylolisthesis. Severe bilateral foraminal
1st post :) :)

Need some advise on my worsening lower back. I had a MRI also in 2007 was the same but without the severe bilateral foraminal stenosis. The pain has been about 6-8 (scale of 1-10) constantly. The sciatica never pain in my buutocks and running down my back is constantly there. I can't take ibprofine becuase i'm on warfin.

My doc is refering me to a othorpedic surgeon . I'm looking for any type of information from someone that has had similar issues for conservative therapy. I'm at the pint where it takes me 1/2 in morning to get going, I can survive with pain but my physical fitness is limited. I run 3-4 days a week slowly. walk maybe twice a week on the golf course. Oddly i feel the best when i'm running or golfing. Not sure why but I do stiffen up after a long run after a few hours even though I stretch out 4-6 times a day. I know some people recommend surgery and others would rather deal with the pain. My profession is not physical but I drive and travel extensively 60%. I can't sleep through the night cause i can only bear to stay on on sides and I have numbness that creeps in everywhere legs manly and my buddocks but also the shifting from side to side in the night is painful. It took me an hour to loosen up after laying on the MRI table for less than 1/2 hour. Felt like I was 100 and I'm only 50 male... Help me if you can. Many thanks in advance for your feedback.


My MRI results:


HISTORY: Low back pain radiating to the left.

COMPARISON: MRI from 7/16/2007.

TECHNIQUE: Routine multiplanar, multisequence imaging was performed.

FINDINGS: Sagittal images demonstrate grade 2 spondylolisthesis of L5
on S1. The spondylolisthesis measures approximately 1.9 cm compared to
1.7 cm on the prior study. Tip of the conus medullaris is at the L1
level. Axial scans were performed from L2 to sacrum. Disc levels above
this are normal in sagittal imaging.

L2-L3: Normal.

L3-L4: Normal.

L4-L5: Degenerative disc disease with mild disc bulge. No central or
foraminal stenosis.

L5-S1: Bilateral L5 pars defects with grade 2 spondylolisthesis. No
significant central stenosis. Severe bilateral foraminal stenosis.

1. Grade 2 spondylolisthesis of L5 on S1 with bilateral L5 pars
defects. Severe bilateral foraminal stenosis.
2. Mild degenerative disc disease at L4-L5 without stenosis.

teteri66 06-21-2011 07:19 AM

Re: Bilateral L5 pars defects with grade 2 spondylolisthesis. Severe bilateral forami
Welcome to the board. I can give you some general impressions about your radiology report based on my experiences as a fellow back pain sufferer, but remember, we are not physicians and most of us have no professional medical training!

Be sure that you are seeing a fellowship-trained spine specialist. This can be either an orthopedic spine specialist or a neurosurgeon who devote their practice to patients with back or neck problems. (Some orthos treat the spine, but also work on joints, set bones, etc. You want one who specializes in the spine, only).

From the description of your symptoms and what is noted in the MRI report, your "issues" seem fairly straight forward. Unfortunately, unlike many problems with the spine, yours are not going to be resolved with exercise and most conservative treatments.

The two things that are causing you problems are the stenosis and the spondylolisthesis. When a patient with these issues can no longer deal with the pain, it is usually time for surgery. The spondylolisthesis you have at L5-S1 has increased since your previous MRI. This is a slippage where one vertebra slides over the top of the adjacent vertebra. When you look at your MRI, you will be able to see that the edges of the vertebra do not line up at this segment.

Spondylolisthesis results in lower back pain. Sometimes a spondylolisthesis puts additional pressure on the surrounding nerves resulting in radicular pain that you feel in the buttocks and/or running down the leg. It also causes that segment of the spine to become unstable. Usually bending backwards will cause pain, while bending forward feels somewhat better.

This condition is graded from I to IV. Grade 2 spondy means that the slippage is from 25% to 50%. Usually grade I and 2 spondy do not necessarily require surgery, unless the pain is such that it is no longer tolerable. As you have found out, it can continue to worsen. Sometimes this happens quickly and sometimes people have a grade 1 or 2 for the rest of their lives.

The other condition, stenosis, is a narrowing. It can occur in the central canal or in the openings that are a part of each vertebral segment that are used by the spinal nerves to exit the spine. This "opening" is called a foramen (foramina is the plural). When this opening is blocked, there is less or little room for the nerve and the result is that the nerve ends up getting "pinched" or compressed. At L5-S1, these nerves supply movement to the ankle reflex and sensation to the foot and the outside of the leg. Pain can also radiate into the groin, buttock and hip. The nerve pain can take on all sorts of characteristics: sharp, stabbing, electrical, numbing, feeling of water running down the leg, etc.

Surgery is often performed for stenosis...kind of a "roto-rooter" thing, where they go in and clean out these openings, which are often clogged with little osteophytes, which are a type of bony overgrowth. It is often done in conjunction with another spinal procedure. I am not aware of another way to open up these spaces.

I'm not sure why you feel best when running or golfing. The twisting and impact when you strike the ball are hard on the spine. Running puts additional stress on the discs, and the impact of each footfall is jarring. Your spine surgeon can advise you on this. Also having to spend so much time in the car is not good...but I know, you do what you have to do!

I had moderate symptoms when I first went to a doctor. I wasted a year with my internist who kept telling me my MRI was normal "for someone my age." I was about 52 at the time, as I recall. Finally I think he got tired of my complaints so he sent me to a spine surgeon who he described as very conservative (meaning: he will only recommend surgery if absolutely necessary). I went in believing he would tell me that there was nothing going on, so I was shocked when the first words out of his mouth were "fusion." But he also explained that very few spine surgeries are ever considered a medical emergency, and that I could wait. He said there would probably come a day when the pain was taking away too much of my normal activity and I would decide it was time to have the surgery. And that is what happened.

I waited for several years before having my first surgery. But in that time, my pain increased to the point that I could not stand for more than a couple minutes at a time, and I couldn't walk more than a very short block. I was lucky in that the pain was relieved as soon as I sat or lay down. Otherwise, it would have been intolerable.

I would guess that you will be able to put off surgery as well, perhaps for a long time. But I'm afraid there are not too many conservative measures that are going to help a lot. Keeping your core and back muscles strong is important. Corticosteroid injections may ease the pain for a short while. However, nothing is going to open up those foramina and allow for more space for the nerves, and nothing will stabilize the L5-S1 segment other than surgery.

If you can put off surgery, there is always the hope that new, less invasive technology will evolve and you can avoid a fusion.

Please let us know what the surgeon says and how he plans to treat you. Feel free to post with any comments or questions.

helminj1 06-21-2011 08:16 AM

Re: Bilateral L5 pars defects with grade 2 spondylolisthesis. Severe bilateral forami
tetonteri66 Many thanks for your thorough and enlightening information. I have been researching and talking with family and friends but it seems like every back issue is slightly different. I was trying to understand the stenosis better and treatment of that without a fusion at this time.

one option maybe:
minimally invasive, laser-assisted procedures . or possibly Microendoscopic Decompression.

My consult appointment is July 1st, so for the time being, I will grin and bearit as I have in the past few years. I welcome peoples comments and I again thank you for your enlightening words and encouragement.

will update as I progress through my options and dealing with pain. Core streghtening is my goal for now and continue to strech and stay loose.


teteri66 06-21-2011 10:57 AM

Re: Bilateral L5 pars defects with grade 2 spondylolisthesis. Severe bilateral forami
They can do a procedure called a foraminotomy which is as it sounds. The surgeon goes in and cleans out the foramen that are clogged and causing nerve compression. The foramen are easily seen on MRI. On one of mine, there was just a pin-***** of an opening, and the technician and doctor were surprised I could even walk at all, as the nerve was so compressed.

My first fusion was successful in terms of the doctor accomplishing what he had planned. I healed well, but the pain never resolved. After that another surgeon performed a foraminotomy to open up the L5 foramen, but ultimately, it only provided relief for a short while. It was an easy surgery. I did stay in hospital overnight, but came home the next morning and baked brownies....

It ultimately turned out that I still had some instability in my lower lumbar spine that was not visible on any imaging that I'd had. So I had more surgery and am now fine.

One thing to consider is that if you are ultimately going to end up with a fusion, it may be wiser to do everything at once. Every time a patient has spine surgery, the risk of infection increases. But that is a minor problem compared to the issue of scar tissue. Every surgery produces scar tissue, and some people's bodies manufacture more than others. When you are going in to operate on the same location several times, this can become an issue. This would be something to discuss with your surgeon.

Also when there is a spondylolisthesis, not every surgeon will consider doing it with a minimally invasive technique. I don't know if it depends on the patient's "issues," the surgeon's preferences, or what...but I do know of surgeons who will usually handle this situation with an open surgery. I know in my situation, I think I went to 8 different orthos or neurosurgeons for consultations before my first surgery. (I kept thinking there must be someone who would do something other than a fusion!!) Everyone recommended fusion, and no one said they would do it minimally I was disappointed.

I found it is best to pick the surgeon and trust his advice rather than picking a procedure and then finding a surgeon who will perform it!! Don't let the promises of newer technologies woo you. Be sure to thoroughly investigate your particular issues and the surgeons you consult with. You don't want to end up being a guinea pig.

You will probably find from talking with family and friends that everyone knows someone who had back surgery and they are only too eager to tell you all about it. Usually what you will learn is a bit removed from the factual reality! So take it into consideration, considering the source, and do your own research as much as possible. Word of mouth can be good for finding a spine specialist and choosing a hospital, but again, do your own investigating, too.

With the internet, it is now fairly easy to learn about a surgeon's background, whether there are lawsuits filed against him, whether he gets a check from a medical device manufacturer, etc.

SpineAZ 06-21-2011 02:52 PM

Re: Bilateral L5 pars defects with grade 2 spondylolisthesis. Severe bilateral forami
For spondylolisthesis the only way to get the displaced vertebrae back in place is to do a fusion. It's not the disc in this case causing the issue, but the vertebrae moves forward and is slightly displaced (Grade 1 is lowest level of displacement and Grade 5 is the worst). Running seems like it would cause more pain. Maybe not in the moment, but afterwords.

Anna SpinalCase 08-09-2011 02:33 PM

Re: Bilateral L5 pars defects with grade 2 spondylolisthesis. Severe bilateral forami
@ helminj1
I am so happy to find all of this information on the web. I have only known about this condition for 10 years. I started complaining about the pain at age 12 and was told numerous times it was due to weight. Well in adulthood the pain condition continued even when I had a healthy weight. Now I am 29 years old and have seen more than a handful of surgeons (ortho and neuro). Only two of them were educated in my spinal dept. One deformity specialist was from Delaware. He was the first consult where he actually agreed that he could preform a surgery. The other was from Univ of Michigan.

I just seen Dr. Park at UofM and the appointment was enlightening. My primary dr encouraged surgery; however Dr. Park told me the %'s and I was not too thrilled to entertain surgery. he stated the surgery would be EXTENSIVE and 40% chance of no relief but a very high chance of it causing more trouble. I have used numerous medications over the years, but now days I find it difficult to find a provider who is not treating you as a drugseeker.

After reviewing your information on your spondyo it sounds erily familiar. As though you were reading my MRI report.

I have a bilateral pars defect L5/S1 with severe foraminal stenosis and its at Grade II spondyololethesis.

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