This 42-year-old female presents with ten years of progressive low back pain and leg pain. She had mild left dorsiflexion and EHL weakness. She had tried physical therapy, but her symptoms persisted. MRI revealed an L4-5 grade 1 spondylolisthesis with stenosis (Fig 1). We discussed options. We decided to try an epidural injection and continue with physical therapy. She will follow up with me in 6-8 weeks to see how she is doing with her pain and strength.
My thinking is that if she has no significant improvement, I would give her the option of going to a chiropractor or getting acupuncture. Ultimately, if she does not improve over the next couple of months, where her quality of life is affected or she has progressive weakness, surgery will be offered.
An L3-5 laminectomy would be offered with an extensive facetectomy to fully decompress bilaterally her L4 and L5 nerve roots and perform a posterolateral fusion with titanium screws to fixate her level to prevent further instability and to prevent recurrent stenosis. Because of her relative disc height loss and to provide more stability, an interbody spacer would provide the best restoration of her anatomy, disc height, and by distracting the interspace, improve foraminal dimensions.