High-grade (Grade III) Degenerative spondylolisthesis at L4/5 Treated Successfully by Transforaminal Interbody Fusion (TLIF): A Case Report

摘要

We report a rare case of High grade degenerative spondylolisthesis. Degenerative spondylolisthesis is not necessarily rare. However the degree of degenerative spondylolisthesis rarely exceeds Meyerding grade II. The patient 66 years old female present exceed Meyerding Grade III degenerative spondylolithesis with back pain and gait disturbance for over 20 years. Conservative treatment had no effect. Functional radiographs CT and MRI of the lumbar spine revealed the high grade slippage of L4/5 hypermobility and cauda equine was severe compressed. There was not spondylolysis at L4 lamina. The Bilateral facetectomy and partial reduction and transforaminal lumbar interbody fusion (TLIF) at L4/5 was performed, the back pain disappeared and her neurological deficit and activity of daily living ameliorated. There has not been any adjacent level degeneration after 4 years after TLIF operation. Introduction Degenerative spondylolisthesis is common in individuals over age of 50. Previous sdudies have indicated that this condition occurs four times more frequently in women than men and is most commonly seen at L4-L5[1]. The degree of degenerative spondylolisthesis rarely exceeds Meyerding[2] grade I or grade II[3]. It remains controversial whether surgical treatment of high-grade spondylolisthesis, irrespective of whethere it is isthmic or dysplastic, should consist of in situ fusion[4] or reduction and fusion[5].Here, we present a very rare case of Myerding Grade III degenerative spondylolisthesi with back pain and gait disturbance treated successfully by partial reduction and transforaminal lumbar iterbody fuion (TLIF) Case Report 66-year-old woman, who had been suffering from back pain for over 20 years, and had received conservative treatment. In 2003, her back pain became more severe and could not remain in a sitting position for more than 20 min. She had intermittent claudication with bilateral thigh pain. Conservative treatment, including epidural injections and nerve root block, did not relieve the pain in this patient, and she was referred to our clinic. On physical examination, there was obvious knocking pain and tenderness at the L4–L5 level, and numbness in both buttocks and posterior-lateral thighs. Lateral plain X-ray films of the spine showed degenerative spondylolisthesis at L4/5 with a slip angle of 20° and 55% slip. (Figure 1) And there was not severe canal stenosis. (Figure 2) At the L4–L5 segment, 10 mm of translation was noted between extension and flexion. The combination of physical and radiographic findings indicated the potential efficacy of surgical fusion of the unstable segment. She had no level of congenital fusion above or below the L4/5 level and had no connective disorder, such as osteogenesis imperfecta, Ehler-Danlos disease, or Marfan’s syndrome.OperationThe patient underwent transforaminal interbody fusion (TLIF) at the L4/5 level in the prone position on a four-pad frame with the hip joints extended to load the lumbar spine. Titanium interbody cages (OIC cage; Stryker Spine, Allendale, NJ, USA) were inserted bilaterally with harvest of the iliac crest bone. The %slip decreased from 55 to 20%, and the slip angle decreased from 25° to 10°. To prevent intraoperative damage to the L4 and L5 nerve roots, bilateral facetectomy was performed and magnetic evoked potentials (MEP) of the bilateral tibialis anterior muscle were monitored intraoperatively. No abnormal findings were noted during spacer insertion. Finally, a pedicle screw system (ST360; Zimmer Spine GmbH, Münsingen, Switzerland) was used for fixation between L4 and L5.After the operation, the patient’s back pain showed significant amelioration, and radicular pain improved gradually. L1 axis S1 distance decreased to 10 mm, indicating acceptable restoration of sagittal balance[6]. She had no peri- or post-operative complications. At 3 years post-operatively, the patient’s back pain and thigh pain have decreased to an almost tolerable level, and she is