So we're going to do three quick cases, and then we'll try to get back a little bit some of the time that we're behind. So for case number one, I need a volunteer. Come on up. You can come, or I can pick. OK, apparently I'm going to pick. I like the back row over there, second to the end. What's your name? Shane. Come on down. All right, so this case is a 59-year-old woman with mechanical low back pain, and she has a lot of left leg pain. Pain is primarily on the L5 distribution, and she has failed multiple measures like epidural steroid injections, placette blocks. Doesn't have any medical history. She shows up in your clinic, Shane. And where are you from, Shane? From UT Houston. From Houston, OK. So she shows up in your clinic in Houston, and she has this kind of complaint. What are you going to do? Just to move this along a little bit, she has some imaging. So if she comes in with these plate films, she has almost no, or a very small level of lumbar malignancy. She's got some collapsed discs, a little degenerative stuff, L5, S1. So this is a dynamic flexion extension x-ray that her physiatrist got. Extension here. So she's got a small spondy as well at L5, S1. It's here present in flexion, but increases slightly. So she's got a 5.1 spondy. Who grades spondys? If you were going to grade this, you would grade it as a? A 5.1. And whose grading system is that, out of curiosity? Myerding. OK, so it's a Myerding grade 1. Spondylolisthesis can have subtypes. The couple most common ones are? Isthmic and degenerative. OK, which one is this? She has an isthmic spondylolisthesis. OK, what does isthmic mean? The isthmus, it's a parsed effect. She's got a parsed fracture. Very good, excellent. All right, so she's got also this MRI that her outside doc gave to her. The mid lumbar discs look OK. That bottom disc is really quite collapsed and slipped, as you said. It's a grade 1 spondylolisthesis there. You can see the axial, a little bit of left-sided disc bulging there, probably responsible for her radiculopathy. So anything else you want to see, besides this? It looks like she may have a little coronal imbalance just from the way the cut is, but it's hard to tell just on this. So you want more imaging? I would get, it didn't look like she had any surgery before. She's never had surgery, no. She's sent for, she's like a routine degenerative patient. They sent to you for. I would just get 36 inch. Oh, you would get 36 inch. So she didn't have those before. She got a CT scan as well from her CT guided injection of her parsed. But as you pointed out, she's got the parsed fracture there. And you wanted 36 inch long cassettes. So here's her 36 inch long cassettes. Is this the same patient? Yeah. OK. It is the same patient. I wouldn't have expected that if we weren't in this course. So she's got, she looks like she's probably pretty decent coronal alignment overall. Yeah, she's a little bit of shoulder asymmetry on the right, just a little bit. And then her sagittal balance is probably a little bit positive here, but probably in the 570 range. Which is reasonable, though, huh? Yeah. So what are we going to do? If she's got pure L5 radiculopathy, that means to me that the bigger issue, I'm sorry, how old is she again? She's 50-ish something, 50 something. Yeah, so if she's asymptomatic from this, she's not having a lot of back pain? She's not, just at the very bottom. Yeah, then I think it might be reasonable to address the one level right now. But this has got to be followed over time. And I think if she progresses, it's hard to tell what her alignment is. But I think it's a few of those measurements. OK. So her lumbar lordosis is within 10 degrees of rheumatopoietic incidence. Her SVA is normal, as you described here. Cronal and sagittal balance are really quite good. OK. So I think if we just do one level on her, she's going to continue out to the rest of her curve. These are choices? These are potential choices, yeah. Where are we going? Which ones would you not do? Let's eliminate what you wouldn't do. So I wouldn't do just a straight posterior fusion for her spondylolisthesis. OK, why not? Because I think you can help increase her foramenal diameter and decompress her with an inner body fusion at 5-1. Something like an A-lift or a plift, whatever you want to do is better. You can help get greater lordosis from A-lift as well. So I think I would start small with you, but I think that there's a pretty good chance that she'll progress over time. OK. I think you had a lot of very good ideas there, and that's excellent. You can have a seat. I'll take that back. So these are the kinds of things where Justin said, what do you think about when the patient comes to your clinic? So these are the kinds of questions that when a patient comes to my clinic, sometimes rarely there's a resident in my clinic, but it does happen once a blue moon. Often there's a fellow in my clinic. I usually say, what is the SVA? I want to know, what is the LLPI mismatch? If they have radiculopathy, I want to know, where is the stenosis? I want to know if there's dynamic instability. If there's a coronal Cobb angle, I want that measured. What are the endpoints? And then I ask myself, do I need to cross the TL or LS junction? I think if I ask myself these questions, these five questions, one, two, three, five, six questions, I can usually get most of the data that I need to make a treatment decision. So let's just think about this on this particular case. Patient's SVA is normal, so I don't really need to make a sagittal parameter correction here. The LLPI mismatch is really quite good. It's less than 10 degrees. So again, I don't need to make a lot of correction there either. What are the levels of stenosis? It's only 5.1. Where is there dynamic instability? Again, it's only 5.1. She's got a balanced double major curve. Now, she does have a bit of a lateral ascesis at L3. It's not today's problem. That could be a problem that will affect her later. It's not today's problem. So the question is, do I need to cross the TL or LS junction, or can I limit myself to L5S1? This is the choice that I gave to the patient. Do we want to do this curve only because there's a little bit of a lateral ascesis here, though she's not symptomatic from it today, or do we want to focus here, which is really her symptom? So I talked to her about that, because we could potentially also fix this, and there is some degenerative arthritis there with lateral ascesis. Lateral ascesis of more than 6 millimeters is an indicator that this is likely to progress some point in the future. So that's something to watch out for. But overall, her parameters are not bad. And so this is one where, even though this godawful thing is there, it's not really the major issue. The major issue is here. So I just did an L5S1 for her. And basically, just like you said, I did an ALIF. This is the ALIF setup. Started small. I wanted to get some indirect foraminal opening, so we got a little bit bigger, put in a graft. And because she has an isthmic spinal asthesis, I also wanted to fixate from the back, too, because I don't trust this construct. Because the dorsal elements are not intact. So I did put in screws from the back, as well. She actually did really well from this. I'm still following her, watching that L3-4 listhesis. That's the lateral asthesis. Hasn't been a problem yet, but it probably is going to be a problem eventually, I'm guessing. But this is the kind of thing that I thought about when I did this case. So this is where she ended up. So I'd need a new volunteer for the next case. And let's see, over here in the green shirt. What's your name? Winston. Winston? Oh, are you from UVA? Yes. Ah. Here you go. All right, so 67-year-old woman with low back pain and bilateral sciatica and anterior thigh pain. And bilateral sciatica and anterior thigh pain. And also failed multiple epidural steroids. This patient is on oral narcotics. And then, just to move this along a little bit, she comes in with these x-rays. So what do you see? So the C-zone, the whole line looks like it's in a pretty good position. This looks like it's a flat back. So we'll look at the pelvic incidence of a lumbar ligosis mismatch. There isn't a big hormonal imbalance. If there is, it looks like a grade 1, 5S1, that must not have ceased this inflection. OK. And this is the MRI. And the axials with the stenosis were 3, 4, and 4, 5. So it looks like there is central zoosis, as well as forming a stenosis at 4, 5, and 4, 7. So what are we going to do with this person? So I can tell you the SVA here is about maybe 6 centimeters-ish. The LLPI mismatch is about 25 degrees. I measured all that. I won't make you measure it all, because Justin wants me to move this along. So you probably want to correct probably 10 more degrees of orgosis to correct the mismatch. Maybe 15. So probably we'll be able to get away with even a two-level tumor, L34, since there's 280-degree stenosis there, as well. Not unreasonable. You would do it open, you would do it MIS. What are we going to do if the 2-3 disc looks pretty collapsed too? That's OK. Are we leaving 2-3 alone? There's no stenosis there. OK. Is it OK to stop a multilevel fusion when the disc immediately adjacent is already degenerated? Is that OK? Not OK? What do you think of that? OK. So basically, this is how I thought about this case. And I think, who gave the chronal talk this morning? Was it Dan? Dan gave the chronal talk this morning. I think he showed something similar. Basically, we want to know, what are the cob and cob vertebrae of this curve? And so for this curve, these are the questions again. And let's see where it takes us. So SVA was under 5. The LPI mismatch is about 25 degrees. The stenotic levels are 3 to 5. There's no real dynamic instability. There is a bit of a 5-1 slip, but it's fixed there. The chronal cob angle is 2 to 5. And all of those levels are degenerated. Actually, 2 to S1 was degenerated. So when I asked myself, do I need to cross the TL junction, I don't think so. Chronal cob doesn't extend up there. L2 is not an unreasonable stopping point. I do think I need to cross the lumbosacral junction, because that disc is already degenerated and slipped a bit. I don't want to park a couple level fusion on top of that. And so I did want to do that. But this is one that you could consider doing MIS. Now, why is that? As we went about earlier today, the SVA is under 6. The pelvic tilt is less than 25. The LPI mismatch is under 30. So you're in a class 2 situation here. So you could do this MIS. Certainly is a feasible way to think about doing this. So I did laterals at L2 to 5. And then I did a TLIF at 5-1 MIS with screws. So that's ended up where we are with the TLIF down at the bottom. The percutaneous screws up at the top. And we slid in the rod. And so she ends up here. So you can see, you can get quite a bit of correction from that lateral. Very good coronal correction for sure. Now, the question is sagittal correction, right? The coronal doesn't really count. Sagittally, she didn't need a lot, though. She did need about 15 degrees. But I got some sagittal correction out of it, too. I put my cages towards the front, and I squeezed down on the back. So sagittally, she ended up OK, too. But this is one where you could consider MIS. That first one, I kind of did a pseudo MIS thing. Open ALIF, and then small thing on the back. That's very good. OK, I think I'll show you this, and then we'll stop. So basically, a partial facet resection. And this is going in the new MOC book that I'm helping Chris Schaffrey with. But partial facet resection will give you 5 degrees. A full facet removal, which you might call Smith-Peterson, but other people might call pontiosteotomy. That'll give you 10 degrees. PSO, which is going to be a grade 3, will give you about 30 degrees. And in a PSO, you want that bone to kiss. Because if that bone doesn't kiss, then you won't get your fusion mass. And then if you want more than 30 degrees, you can do a grade 4, where you do the PSO, but you also take the cranial disc. And then you can put a cage in there and pivot a bit on the cage, and you'll get a lot of correction. Maybe the bone is a little bit too big. Maybe you want to make it a little bit smaller. Maybe 35, 40 degrees. And there's also 5 and 6, which is a VCR, and multiple VCRs. But I'll digress there. So I'll stop there, ask if there's any questions, and we can go on to the next speaker.

low back pain

sciatica

mechanical low back pain

spondylolisthesis

collapsed discs