Spondylolisthesis treatment

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med7343

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Hi Team
Grade 1 or 2 Spondylolisthesis - What treatment has got best benefited to your patients?
someone mentioned transforaminal is better over interlaminar - whats the rationale for it?
Thanks
 
med7343 said:
Hi Team
Grade 1 or 2 Spondylolisthesis - What treatment has got best benefited to your patients?
someone mentioned transforaminal is better over interlaminar - whats the rationale for it?
Thanks
Click to expand...
What symptoms are you treating is the first question to be answered
 
I'm not PMR trained. Does anybody have a strong opinion one way or the other for PT in setting of dynamic instability (or pars defects)?
Thanks.
 
Lol who has had spondy for years get mbb then rf. Younger pt with pars defect gets flex/ext and PT and possibly a fusion.

If there is corresponding NF stenosis and leg pain then tfesi.

The way you frame the question: TFESI for sponsylolisthesis--is an oversimplification and troubling
 
BobBarker said:
Minuteman
Click to expand...

You been talking to my wife bro? That only happens occasionally...

I see a lot of spondy. I don't treat it any different than any other spine pt to be honest.

Most of my pts don't want surgery once they learn what a pedicle screw looks like...So we manage it no different than anything else.
 
It has little windows that are under the wings for the bone graft to sit in. You decorticating with the sizing tool and then screw it in across from a lateral approach. After you deploy the wings the bone graft is adjacent to the decorticated spinous processes. The device is HA coated as well.

So, yes it is surgical. But I would classify it as MIS.
 
buddababa said:
The designer of this device has a pretty bad reputation as a surgeon. Many of his colleagues who watched him create/use this device have stayed away. Just some food for thought...
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That doesn’t matter to me. I can see it now... “Jim can’t place a pedicle screw for s*its sake so he came up with this crutch for him to use.” The fact is it is easy for the right type of pain doc to place and is better suited for some cases and has more durablilty than vertiflex can offer. It is just an improved toggle screw with graft windows and HA coating. Doesn’t take a rocket genius to come up with that idea.
 
I have a 28 mm L5 on S1 slip that I treat with S1 TFESI or caudals for 2 yrs. Does great, but for this pt the caudal is dramatically superior bc I use Depo 80mg.
 
I'll do it, but I ain't doing it in 28mm. That's either wet tap or posterior, neither of which get us anywhere.

Caudal with 80mg Depo, 4cc saline and 3cc bupi does great and takes me like 10 sec of fluoro time.
 
SommeRiver said:
I'll do it, but I ain't doing it in 28mm. That's either wet tap or posterior, neither of which get us anywhere.

Caudal with 80mg Depo, 4cc saline and 3cc bupi does great and takes me like 10 sec of fluoro time.
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Thats a lot of flouro.

Pulsed 4, low dose
Palpate the landmarks prior. Ive done them in 1-2 seconds fluoro time. Its not like u need a very high quality view for a caudal
 
Ligament said:
MB RADIOFREQUENCY ABLATION if lumbago and grade II or less spondy on flx/ext films. TF ESI if radicular pain.
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Not a good idea to ablate MB => weakened multifidi. I'd rec facet steroid injection, not ablation.
 
kamilo6 said:
I'm not PMR trained. Does anybody have a strong opinion one way or the other for PT in setting of dynamic instability (or pars defects)?
Thanks.
Click to expand...
PT is a must.
Two ways to stabilize the spondy:
1) fusion
2) stabilize with strengthening multifidi and paraspinals
 
swamprat said:
Thats a lot of flouro.

Pulsed 4, low dose
Palpate the landmarks prior. Ive done them in 1-2 seconds fluoro time. Its not like u need a very high quality view for a caudal
Click to expand...

I take like 4 pictures and run fluoro live. I like to watch contrast flow through L5, and I take another to see how far it traveled.

That is very minimal fluoro.
 
Agree with RF for axial pain and particulate steroid injection for radicular pain. You often won't achieve long term relief of radicular pain from spondy doing TFESI, but fine with start with that, and then switch to ILESI/caudal with depo if they only get a few weeks relief of leg pain after TFESI with dex.

Risk of RF to multifidi is overblown compared to the pain relief patients can obtain. Plenty of other core muscles they can work on after you've reduced their back pain to livable levels.

I do ILESI with depo at the level if mild-moderate stenosis/slip, or one level below if one of those is advanced. For grade 2 spondy at L5-S1, I'd support a caudal with depo for bilateral radicular pain. Even some axial pain often responds to a caudal with depo.
If unilateral radicular pain with grade 2+ L5-S1 spondy, I'd vote for an S1 TFESI with depo, (or S2 if you're too concerned to do it at S1)
 
SommeRiver said:
I take like 4 pictures and run fluoro live. I like to watch contrast flow through L5, and I take another to see how far it traveled.

That is very minimal fluoro.
Click to expand...

Gotya. Yeah I’m mixing threads the other one people were arguing how ur fluoro time on MBBs adds up over a career.
 
Do you guys think that facet pain is actually nerve pain? I was speaking to a very intelligent pain physician a while back and his argument was that how else do people get such sustained relief from MBB. In addition you have people with jacked up spines that have no pain when you can tell their facet joint is twisted and degenerated. Lastly, fusions don’t work always and patients still get relief from MBB despite the joint being fused (my other argument was perhaps it wasn’t fully fused and therefore some movement - I generally don’t do MBB on fusion levels just above and below but I may change my practice)
 
swamprat said:
Do you guys think that facet pain is actually nerve pain? I was speaking to a very intelligent pain physician a while back and his argument was that how else do people get such sustained relief from MBB. In addition you have people with jacked up spines that have no pain when you can tell their facet joint is twisted and degenerated. Lastly, fusions don’t work always and patients still get relief from MBB despite the joint being fused (my other argument was perhaps it wasn’t fully fused and therefore some movement - I generally don’t do MBB on fusion levels just above and below but I may change my practice)
Click to expand...


Not sure what that guy meant exactly. MB is the nerve supply to the joint. We know that sometimes when you block any random nerve in the body, that the nerve doesn't always return to full function as quickly as we would expect. Doesn't change the fact that it is a painful facet joint, supplied by a nerve that we choose to eliminate.


If you're not doing MBB just above and/or below a fusion, you are doing a huge disservice to your patients. Why the hell aren't you offering that? It doesn't always help, but a fusion will stress BOTH the disc (and the facet joint) above and below a fusion. Criminal not to check that with a MBB if the patient has pain primarily with standing/walking/ or lumbar extension.
 
bedrock said:
Not sure what that guy meant exactly. MB is the nerve supply to the joint. We know that sometimes when you block any random nerve in the body, that the nerve doesn't always return to full function as quickly as we would expect. Doesn't change the fact that it is a painful facet joint, supplied by a nerve that we choose to eliminate.


If you're not doing MBB just above and/or below a fusion, you are doing a huge disservice to your patients. Why the hell aren't you offering that? It doesn't always help, but a fusion will stress BOTH the disc (and the facet joint) above and below a fusion. Criminal not to check that with a MBB if the patient has pain primarily with standing/walking/ or lumbar extension.
Click to expand...

For ACDF yes I do them bc my theory is there is still movement. What about huge 360 fusions in the lower back - cant even get motor stim when u try to RFA - not really sure where that nerve would be
 
I occasionally RF lumbar hardware levels. It is interesting to see motor stim consistency.
 
swamprat said:
Do you guys think that facet pain is actually nerve pain? I was speaking to a very intelligent pain physician a while back and his argument was that how else do people get such sustained relief from MBB. In addition you have people with jacked up spines that have no pain when you can tell their facet joint is twisted and degenerated. Lastly, fusions don’t work always and patients still get relief from MBB despite the joint being fused (my other argument was perhaps it wasn’t fully fused and therefore some movement - I generally don’t do MBB on fusion levels just above and below but I may change my practice)
Click to expand...
Why wouldn’t there be movement at the joint above and below a fusion?
swamprat said:
For ACDF yes I do them bc my theory is there is still movement. What about huge 360 fusions in the lower back - cant even get motor stim when u try to RFA - not really sure where that nerve would be
Click to expand...

Agree with doing them on ACDF. Agree that you often can't access the MB through a PLIF, but that doesn't stop you from burning the other nerve to the joint. Can still burn bilateral L5 DR if patient has an L4-L5 fusion.
 
bedrock said:
Why wouldn’t there be movement at the joint above and below a fusion?


Agree with doing them on ACDF. Agree that you often can't access the MB through a PLIF, but that doesn't stop you from burning the other nerve to the joint. Can still burn bilateral L5 DR if patient has an L4-L5 fusion.
Click to expand...
I frequently RF next to pedicle screws (usually under an L4-5 fusion). Often requires a little more oblique, and it’s as much by feel as by fluoro, but I’d say at least 2/3 of the time I get a motor response. My partner often just does the L5 DR and I’ve repeated a few of his that failed, but with both nerves and had success with some (maybe half).
 
callmeanesthesia said:
I frequently RF next to pedicle screws (usually under an L4-5 fusion). Often requires a little more oblique, and it’s as much by feel as by fluoro, but I’d say at least 2/3 of the time I get a motor response. My partner often just does the L5 DR and I’ve repeated a few of his that failed, but with both nerves and had success with some (maybe half).
Click to expand...

#metoo
 
Here's the guy I mentioned up above. He's in his 80s and works in a warehouse moving boxes. A neurosurgeon offered surgery he said, "Hell no." Came to me and he's doing fine getting ESI 3x a year. Moral of the story is no correlation between image severity and clinical presentation, and also epidurals placed nicely are effective and should be always be considered before spine surgery unless there are unusual circumstances - Cord injury, etc.

I hate to say it but this guy's outcome from dex to Depo is pretty dramatic. Just an anecdote though...

By the way, I've never MRI'd this guy.
 

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SommeRiver said:
Here's the guy I mentioned up above. He's in his 80s and works in a warehouse moving boxes. A neurosurgeon offered surgery he said, "Hell no." Came to me and he's doing fine getting ESI 3x a year. Moral of the story is no correlation between image severity and clinical presentation, and also epidurals placed nicely are effective and should be always be considered before spine surgery unless there are unusual circumstances - Cord injury, etc.

I hate to say it but this guy's outcome from dex to Depo is pretty dramatic. Just an anecdote though...

By the way, I've never MRI'd this guy.
Click to expand...

Crunchy aorta.
 
SommeRiver said:
Here's the guy I mentioned up above. He's in his 80s and works in a warehouse moving boxes. A neurosurgeon offered surgery he said, "Hell no." Came to me and he's doing fine getting ESI 3x a year. Moral of the story is no correlation between image severity and clinical presentation, and also epidurals placed nicely are effective and should be always be considered before spine surgery unless there are unusual circumstances - Cord injury, etc.

I hate to say it but this guy's outcome from dex to Depo is pretty dramatic. Just an anecdote though...

By the way, I've never MRI'd this guy.
Click to expand...
Wow, huge. Funny, the neurosurgeons at my hospital love flexion extension films, and will almost always offer a fusion for spondy patients if they have axial back pain.
 
one from today. I had a young pain rep visiting as I was reviewing the films.
He couldn’t spot the abnormality.
E0B90EE3-D9FA-4B06-9CC9-B93DC66BFE93.jpeg
 
callmeanesthesia said:
I frequently RF next to pedicle screws (usually under an L4-5 fusion). Often requires a little more oblique, and it’s as much by feel as by fluoro, but I’d say at least 2/3 of the time I get a motor response. My partner often just does the L5 DR and I’ve repeated a few of his that failed, but with both nerves and had success with some (maybe half).
Click to expand...
I agree. this is almost exactly how I do it too. if i dont get good motor stim, i will usually troll the area with sensory stim until I can get even a mild response. it can be hit or miss with these postop patients and I tell them this from the get go. I have seen some on this forum condemn others for RFA in fused patients but they can truly benefit. it can be a much harder and time consuming procedure which is why I would expect some to avoid it. alot of the time these patients come to me with a hx of multiple surgeries, on multiple meds and are miserable. MBB/RFA I think is a good low risk/high reward option.
 
Re rf at a fused level... I generally don’t. ie rf for adjacent to L45 fusion I’d only rf at L3 mb or L5 dr. How do I know that’s all I’d need to do (ie skip the L4mb) ? .... response to the mbb. If I get 100% relief with mbb x 2 at the L5 dr or L3 mb then why would I expect more benefit from RF at the L4 mb where there’s a pedicle screw? Perhaps if suboptimal response to mbb and the target appears intact and has a little space between sap/tp junction and pedicle I’d consider it.
 
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