What is the recommended treatment for a patient with 32° levoscoliosis, multilevel degenerative changes, discogenic and facet disease, and significant neurological symptoms?

Treatment Recommendation for 32° Levoscoliosis with Multilevel Degenerative Disease

Primary Treatment Recommendation

For a patient with 32° levoscoliosis, multilevel discogenic and facet disease, anterolisthesis, and significant neurological symptoms, surgical decompression combined with instrumented fusion is recommended over decompression alone, as fusion provides superior outcomes when instability or spondylolisthesis is present. 1

Conservative Management Prerequisites

Before considering surgical intervention, the following conservative measures must be completed:

• Formal physical therapy for at least 3-6 months focusing on core strengthening and flexibility 1, 2
• Trial of neuroleptic medications (gabapentin or pregabalin) for radicular symptoms 1
• Epidural steroid injections if radicular pain is prominent 1
• Anti-inflammatory therapy and activity modification 1

The presence of 2-3mm anterolisthesis at L3-L4 and 4-5mm lateral protrusion at L4-L5 with canal stenosis indicates instability that will likely require fusion even after conservative management fails 1.

Surgical Indications Met in This Case

This patient meets criteria for surgical intervention based on:

• Documented instability: Anterolisthesis at L3-L4 represents mechanical instability 1
• Multilevel stenosis: Both central canal stenosis at L4-L5 and foraminal stenosis at L3-L4 are present 3
• Degenerative scoliosis: 32° levoscoliosis with multilevel facet disease indicates progressive deformity 4, 5
• Significant neurological symptoms: The combination of stenosis and spondylolisthesis typically produces disabling claudication and radiculopathy 1

Recommended Surgical Approach

Decompression with instrumented fusion is superior to decompression alone for patients with stenosis and spondylolisthesis, with studies showing 96% excellent/good results versus 44% with decompression alone 1.

Specific Technical Considerations:

• Fusion levels: Should address all levels with instability (L3-L4 at minimum) and significant stenosis (L4-L5) 1
• Instrumentation: Pedicle screw fixation provides optimal biomechanical stability with fusion rates up to 95% 1
• Decompression extent: Bilateral decompression at L3-L4 for foraminal stenosis and L4-L5 for canal stenosis 3
• Scoliosis consideration: The 32° curve may require longer fusion construct to prevent adjacent segment degeneration, particularly if coronal imbalance exists 4, 5

Evidence Supporting Fusion Over Decompression Alone

Class II medical evidence demonstrates that patients with spondylolisthesis and stenosis achieve statistically significantly better outcomes with fusion: less back pain (p=0.01) and leg pain (p=0.002) compared to decompression alone 1. The presence of anterolisthesis represents mechanical instability that will not be addressed by decompression alone and may progress postoperatively 3.

Critical Decision Points

When Fusion is Mandatory:

• Preoperative spondylolisthesis (present at L3-L4) 1
• Intraoperative instability discovered during decompression 3
• Extensive decompression that might create iatrogenic instability 1
• Degenerative scoliosis >30° with documented progression 4, 5

Decompression Alone May Be Considered Only If:

• No spondylolisthesis is present on flexion-extension films 3
• Minimal facet resection required (<50% of facet joint) 3
• No coronal or sagittal imbalance exists 4

This patient does NOT meet criteria for decompression alone given the documented anterolisthesis and multilevel facet disease 1.

Expected Outcomes and Complications

Anticipated Results:

• Clinical improvement: 86-92% of patients experience significant functional improvement 1
• Fusion rates: 89-95% with instrumented fusion 1
• Pain reduction: Significant decreases in both back and leg pain compared to preoperative levels 1

Complication Considerations:

• Instrumented fusion complications: 31-40% complication rate versus 6-12% for decompression alone 1
• Adjacent segment degeneration: Risk increases with shorter fusion constructs in degenerative scoliosis 4, 5
• Pseudarthrosis risk: Minimized with rigid instrumentation and appropriate bone graft 1

Common Pitfalls to Avoid

Underestimating the degree of instability: Flexion-extension radiographs are mandatory to assess dynamic instability beyond the static anterolisthesis 1. Failure to recognize instability leads to poor outcomes with decompression alone 3.

Inadequate fusion length: In degenerative scoliosis, fusing only the symptomatic level may lead to adjacent segment failure and curve progression 4, 5. Consider extending fusion to include the entire deformity if coronal imbalance exceeds 4cm 4.

Ignoring sagittal balance: Degenerative scoliosis often includes sagittal plane deformity that must be corrected to achieve optimal outcomes 4, 5.

Proceeding without adequate conservative management: Fusion surgery without documented failure of comprehensive conservative treatment (minimum 3-6 months) does not meet evidence-based criteria 1, 2.

Inpatient Setting Requirement

Multi-level decompression with instrumented fusion requires inpatient admission due to surgical complexity, higher complication rates, and need for close postoperative neurological monitoring 1. The combination of bilateral decompression and instrumented fusion at multiple levels significantly increases surgical risk compared to single-level procedures 1.