Rough personal notes on review of management of degenerative lumbar spondylolisthesis with lumbar spinal stenosis and pseudoclaudiation

Every so often I review a medical topic and stick my notes into Simplenote for later reference. The reviews are quite messy since it’s just for my use. For what it’s worth, some hasty notes on this topic.

IMAGING

Initial Plain film: spondylolysis/listhesis. Standing flexion/extension lateral plain film, oblique (for pars interarticularis), AP for severity. (or just lateral, oblique and AP). See https://emedicine.medscape.com/article/2179163-workup

Considering surgery: MRI (neurosurgeon will have preferences)

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2270383/
Degenerative spondylolisthesis - European perspective - 2008

“Symptoms of neurogenic claudication that cause the patient to stop and sit after less than two blocks of walking usually correspond to the time, when the patient consents to surgery …

…. The plain radiographic features include the essential finding on a lateral view of forward displacement of L4 on L5 or, more rarely, L5 on S1 or L3 on L4 in the presence of an intact neural arch. Defect of pars interarticularis (which has the appearance of a Scottie dog with a collar) that can be seen on lateral or bilateral oblique views helps to distinguish between DS and isthmic spondylolisthesis …

… Only 10–15% of patients seeking treatment eventually will have surgery…

… The intervertebral spaces of the slipped segments were decreased significantly in size during follow-up examination in patients in whom no progression was found. LBP improved following a decrease in the total intervertebral space size. The development of osteoarthritic spurs, hypertrophy and ossification of the intervertebral ligaments, and facet arthrosis may lead to secondary stabilization that prevents slip progression…

Indications for surgery:
1. Persistent or recurrent back and/or leg pain or neurogenic claudication, with significant reduction of quality of life, despite a reasonable trial of non-operative treatment (a minimum of 3 months).
2. Progressive neurological deficit.
3. Bladder or bowel symptoms.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6357993/ (2019 review, neurosurgery)
A systematic review of the literature has shown that delaying surgery for a period of conservative management is not associated with a worse surgical outcome and that surgery is more effective than continued conservative treatment when conservative options have failed for a period of three to six months…
… minimally invasive surgical approaches that preserve stabilizing paraspinal musculature …

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Some other odds and ends:

- We suggest that the angular instability of the intervertebral disc may play a more important role than neurological compression in the pathogenesis of disability in degenerative lumbar spondylolisthesis (this was weird — from MRI study of axial loading)

- Vanderbilt neurosurgery study from 2014 claimed medical management didn’t work but it looked like a horrible study

- BMJ review of 2016 was down on non-surgical treatment but not super keen on surgical. Consistent with trying conservative management for some time before trying surgery.