A 42 year old very athletic woman presented with Grade 3 Isthmic Spondylolisthesis. She had a long history of back pain. Dr. Pashman performed an anterior and posterior spinal fusion.

1. Case Review:
42 year old female
with Grade 3 Isthmic
Spondylolisthesis
Robert S Pashman, MD
Scoliosis and Spinal Deformity Surgery
www.eSpine.com

2. Patient History
42-year-old female who is quite athletic.
The patient was a competitive swimmer whose primary events
were breaststroke and butterfly, both hyperextension events.
The patient had some low back pain when she was a child, and
she had this investigated, but in the intervening time she really
had no problem until recently.
Low back pain
On physical examination, she has significant sacral promontory.
The patient has significant rotation of the pelvis consistent with
grade 3 Isthmic Spondylolisthesis. She has hamstring tightening
and definite weakness of the dorsiflexors and extensor hallucis
longus of left leg, paresthesias and numbness in the L5
distribution of the legs bilaterally.

3. Pre-op X-rays
Grade 3 Isthmic
Spondylolisthesis with
significant slip angle
degeneration, retrolisthesis
of L4 on L5, bilateral pars
fractures, compression of
the L5 nerve root, lateral
recess stenosis at L4-5, and
significant slip angle and
junctional lumbar kyphosis.

4. Flexion and Extension X-rays

5. Indications for Surgery
1. Grade 3 Isthmic Spondylolisthesis, L5-S1.
2. Degenerative disk disease, L4-5.
3. Evolving motor sensory deficit with weakness of extensor
hallucis longus, tibialis anterior bilaterally indicating L5 nerve
root crush.
4. Increasing low back pain due to significant progressive isthmic
spondylolisthesis and hyperlordosis, lumbar spine.
5. Bilateral pars fractures pars interarticularis, L5.

6. Surgical Strategy
Abdominal retroperitoneal approach to the lumbosacral spine.
Subtotal vertebrectomy, L5, with removal of L5 overhang
constituting greater than 1/3 of vertebra for entrance and
reduction of spondylolisthesis, L5-S1.
Radical diskectomy, L5-S1, including epidural decompression.
Interbody fusion with 8 x small millimeter grafts with
autogenous vertebrectomy bone centrally.
Anterior screw fixation of fully threaded screw over a washer,
L5- S1.
Spondylolisthesis reduction.
Intraoperative fluoroscopic interpretation.

7. Surgical Strategy – Part two
Segmental spinal instrumentation L4 to S1 using the Allez
Laguna titanium pedicle screw/rod construct, 5.5 titanium.
Complete laminectomy Gill fragment of L5 lamina under loupe
magnification and microscope.
Neuroforaminotomy with removal of bilateral pars
interarticularis callus, L5-S1, under the microscope.
Posterolateral and posterior fusion, L4 to S1, using locally
harvested autogenous bone, including laminectomy and anterior
vertebrectomy bone.
Intraoperative fluoroscopy management.
Spondylolisthesis reduction at L-S1.
Intraoperative O-arm neuronavigation and interpretation.

8. Post-Op Films

9. Pre-Op/Post-op Comparison
The slip angle was
reduced from a
Grade 3 to a Grade 1

10. Pre-Op/Post-op Comparison