Round Table Discussion of a MIS Spine Surgery Case
The patient is a 23-year-old woman, who was doing well until she was thrown from her horse. Since then she has had excruciating low back pain, radiating into her buttocks, the lateral aspect of her thighs, and into her lateral calves bilaterally. Neurologic examination is normal. She has no other medical comorbidities. This pain has been going on for 1 year and has not responded to pain medication, physical therapy, bracing, epidural steroids, and chiropractic manipulations with anything other than partial, temporary relief. She wishes to proceed with some type of surgery.
Richard Fessler: What is your thought process in evaluating her? What would you recommend?
Mick Perez-Cruet: This is a classic case of Grade I spondylolisthesis. Certainly this condition may have and probably was preexisting before the accident, the accident just brought on the symptoms that she is currently experiencing. I usually try a course of rehabilitation and targeted L4,5 epidural steroids. However, if significant instability exists, which I suspect is the case, these treatments are usually only temporary at best. Therefore, I think this patient would benefit from surgical intervention. I would offer her a minimally invasive fusion and instrumentation and reduction.
The current instrumentation available has really facilitated this procedure. I would preform a transforaminal lumbar interbody fusion (TLIF), using a peak TLIF shaped cage device, followed by percutaneous instrumentation and reduction using the Pathfinder system (I am very familiar with the nuances of this system). Alternatively, the Sextant would work as they also have a new reduction device, although I have not used it yet.