What is the best course of treatment for an 89-year-old female patient with vertebral body plana, spinal canal stenosis, spondylolisthesis, and nerve root compression?

Management of Spinal Stenosis and Spondylolisthesis in an 89-Year-Old Female

For this 89-year-old female with vertebral body plana at L1, spinal canal stenosis, spondylolisthesis, and nerve root compression, decompression with fusion is strongly recommended as the optimal surgical intervention due to the presence of both stenosis and spondylolisthesis. 1, 2

Initial Assessment and Conservative Management

• Conservative management should be the first-line approach for 3-6 months unless there are progressive neurological deficits or cauda equina syndrome 2, 3
• Conservative treatment should include:
  • Supervised exercise programs focusing on strengthening paraspinal and abdominal muscles 4
  • Pain management with NSAIDs if not contraindicated 5
  • Physical therapy with emphasis on lumbar flexion exercises 5

Surgical Decision-Making

• Surgery is indicated in this case due to:

  • Multiple level involvement (L1, L4-5, L5-S1) 6
  • Presence of both spondylolisthesis and spinal stenosis 1
  • Nerve root compression at multiple levels (L3, L5, S1) 2

• The American Academy of Neurological Surgeons strongly recommends decompression with fusion for patients with lumbar stenosis and spondylolisthesis 2, 7

Recommended Surgical Approach

• Decompression with posterolateral fusion (PLF) is the recommended procedure for this patient 1, 7
• Multiple studies demonstrate superior outcomes with decompression plus fusion compared to decompression alone for patients with spondylolisthesis 7
• Clinical evidence shows 96% of patients treated with fusion/decompression reported excellent or good outcomes compared with only 44% of those treated with decompression alone 1

Instrumentation Considerations

• Pedicle screw fixation should be added to the fusion procedure due to:

  • Presence of multiple level involvement 6
  • Marked facet arthropathy noted in the CT report 1
  • Potential for iatrogenic instability during decompression 1, 3

• While pedicle screw fixation significantly improves fusion success rates (83% vs 45% without instrumentation), the decision should consider the patient's age and bone quality 1, 7

Special Considerations for Elderly Patients

• At 89 years of age, careful preoperative medical evaluation is mandatory due to frequent comorbidities 3
• The risks of surgery, including potential complications, should be thoroughly discussed with the patient 7
• If the patient is deemed too high risk for a major fusion procedure, a more limited decompression focusing on the most symptomatic levels may be considered 3

Expected Outcomes

• With appropriate patient selection, decompression and fusion procedures for spondylolisthesis have demonstrated significant improvements in both back and leg pain 7
• Patient satisfaction rates of 93% have been reported following decompression with fusion for stenosis and spondylolisthesis 7
• Failure to address the spondylolisthesis with fusion is associated with progression of spinal deformity and poorer outcomes 1

Pitfalls to Avoid

• Performing decompression alone in the setting of spondylolisthesis and facet arthropathy risks creating iatrogenic instability 1, 3
• Too little decompression is a more frequent mistake than too much decompression 3
• Failure to recognize the need for fusion in patients with both stenosis and spondylolisthesis leads to inferior outcomes 1