When Should Some Form of Surgical Intervention be Considered with Spondylolisthesis? Top Four Factors

• When should some form of surgical intervention be considered with Spondylolisthesis? - Top Four Reasons

  
  

  While it's important that any kind of surgical intervention be a last resort, there are many factors to consider when it comes to the decision of, if & when, to have spinal surgery for one's Spondylolisthesis slip. If you wait until you literally can't walk, or your ability to use your extremities (upper and/or lower, dependent upon where the slip resides in the spinal column) is lessening to some palpable degree, the nerve damage is more likely to be severe enough that a surgery may not save your full ability to move and feel your lower extremities (or upper extremities) and eliminate any & all nerve-involvement on a permanent basis. The longer the damage exists and settles into your nerves and spinal cord, the less likely there may be a full & complete recovery on the horizon (not that it's impossible). 

  *Please keep in mind that every person and every case is different - No one fits perfectly into a box. 

  
  

  So, the big questions remain: Should I have surgery? And if so, when should I have some form of surgical intervention? 

  
  

  These questions are a frequent topic on the group page, so I thought it might be helpful to provide what I consider the top four reasons or factors to consider when making this big decision. 

  In addition, I also address the matter of finding the best surgeon (or surgeons) for you & your particular case, located at the bottom of the document. 

  
  

  Some of the bigger factors (top four reasons) which play into having surgery are the following: 

  
  

  1) The GRADE of a Slip: 

  
  

  What grade is your slip?

  
  

  Higher grades (usually considered grades 3-5), or complete slips (beyond 100% & called Spondyloptosis), are typically the more severe cases, especially when it comes to the spinal cord itself & the many nerves which branch out from the spinal cord. As a slip moves, it often places an increasing amount of stress and general impingement upon both the nerves - which branch out from the given vertebrae - and of course, the spinal cord. The further out of alignment the vertebrae become, the more likelihood that the spinal cord & vital nerves may be directly affected by the slip - which is an issue that is obviously best to be avoided if at all possible. 

  
  

  When a slip progresses to a higher grade, it often becomes a greater challenge (and literally technically more complicated) to reduce the slip, as well as to stabilize & fuse. Complexities include avoiding nerve damage (whether it be in the upper or low extremities), in addition to other issues of this nature, which may affect the bladder and/or bowels (this is witnessed in cases involving the lower region of the spine). Reduction of a slip does carry additional concerns and possible complications, although for some with high grades or complete slips, reducing the slip to some degree becomes a necessary piece of surgical intervention. Avoiding the need to reduce a slip at all is one of the reasons it is important to consider some form of surgery prior to the condition increasing so dramatically in severity. Often times, the greater a slip progresses, the higher the likelihood for some degree of nerve impingement to present, as well as the possibility of nerve damage, which sometimes may be permanent. In VERY rare and worst case scenarios, an extreme slip with these factors can, and may result in permanent paralysis, as well as loss of bowel and bladder function/control. 

  
  

  2) The STABILITY/INSTABILITY of a slip:

  
  

  Is your slip considered stable or unstable?

  
  

  A slip which is considered "stable" is one which does not show much, if any, movement. This factor of a Spondylolisthesis slip is important to know and understand because of it's usefulness in analyzing one's degree of overall pain and severity of the slip, but most importantly, it helps to determine the possibility of future progression of the slip to a higher grade. The stability, or rather instability, also provides some idea of how vulnerable the region of the Spondyo may be. When a slip is considered "unstable," this ultimately means that it's rather mobile - which it shouldn't be. This type of movement (instability) may be viewed through a series of x-rays. A slip which lacks stability, is one that should be carefully considered for some form of surgical intervention. Even when it comes to lower grades, surgery may still be considered due to the likelihood of any progression of the slip. Stabilizing the slip through fusion may be one's best bet to avoid future complications - both with the condition itself, as well as with surgical intervention. 

  
  

  Your doctor must determine your degree of stability or instability through x-ray imaging. If you do not know your stability factor, please request that your doctor order a series of standing x-rays. In order to most correctly estimate one's degree of stability, it's important for at least three films to be taken and reviewed. These x-rays include the following: Standing x-ray (shot to your side), while you're standing straight, standing x-ray in full flexion position, and standing x-ray in full extension position. You may also read more about diagnosing Spondylolisthesis (how to determine grade and stability), in another document under the files section. Please note that It's much harder to determine stability, and even sometimes the correct grade, through x-rays laying down, or via MRI films. 

  
  

  What is considered a "stable slip" typically should not be touched surgically unless there are other concerns involved. If one has a stable slip, it becomes very important that the patient stays on top of alternative therapies and other forms of treatments - in order to both lower pain levels, and ensure continued functioning and stability of the condition. Even with a stable slip, it may be vital to alter one's physical activities to some degree in order to avoid any further damage or future vulnerability. If your slip is considered stable, the last thing desired is for it to become unstable. It's vital with both cases (stable and unstable) to create a "support system" for the back; specifically through strengthening of the core muscles. The main muscles upon which to focus in order to create more support for the spine include the abdominal, the lower back muscles and the Psoas (*The Psoas are the muscles located under the abs and in front of the spine). Because the entire body is literally connected, it's also important that other areas of the body are strengthened as well, specifically the legs, hips and buttocks, as these muscle groups do play a part in supporting the spine as well. It's important to be cautious while exercising, while you want to do your best to avoid any further injury in your attempts to improve your overall muscle support system. Pilates (performed utilizing some of the alternative moves offered, if things are uncomfortable or are too challenging), and various forms of exercise in the pool (including swimming itself), are two of the best workouts available to strengthen one's core, yet avoid any physical damage. You may find additional exercise ideas and suggestions in another document under files, as well as listed on the group page (To easily and quickly located some posts related to this subject, use the "search" box, which is labeled by a symbol of a magnify glass, and is located on the upper far right-hand side of the group page). 

  
  

  3) The Degree of NERVE INVOLVEMENT:

  
  

  Do you experience any form of nerve involvement as a result of the condition? 

  
  

  The amount of nerve impingement, and therefore nerve-related symptoms, play a part in determining when surgical intervention may be one's best option. If one's Spondylolisthesis is a low grade, and is considered stable, nerve pain and other symptoms caused by nerve impingement may be able to be treated by medication and various forms of alternative therapies and western medical treatments. Often - in such a case as mentioned above - it could be that another condition is also partly to blame, for example; Spinal Stenosis. This condition, and several others, are fairly common in combination with Spondylolisthesis. If this type of pain, and other nerve symptoms remain an issue, and are not controlled or decreased through non-surgical means, it may be important to consider the option of surgery. This would be especially true if there's a constant or dramatic increase in the degree of nerve pain (burning pain, shooting pain, electric pain, pins and needles, etc) and symptoms one is experiencing daily. Some nerve-related symptoms, aside from pain itself, include weakness in the extremities, numbness, loss of mobility and so forth. 

  
  

  Typically, when it comes to a Spondylolisthesis slip itself (not taking into account other conditions like Spinal Stenosis), there are two main sources for this kind of pain and other nerve complications - Specifically the little nerves which come out of each vertebrae, and then the spinal cord itself. When it comes to higher grade cases with nerve involvement, the spinal cord is, in many ways, being severely or completely impinged. Actual spinal cord impingement is dependent upon where the slip is located. Those with slips in the most common area at the L5/S1 will not experience actual spinal cord impingement, as the spinal cord itself does not extend past the L2. In this region, the multitude of nerves which branch down from the spinal cord may be affected in the same manner as explained with the spinal cord. *Please take a look at the "photos section" to view high grade and complete slip (Spondyloptosis) cases. You will be able to see just how one's spinal cord & nerves would be significantly affected by a severe slip of alignment - Imagining how the spinal cord & nerves run through all of the vertebrae, and with a dramatic misalignment, may very well end up coming out of the vertebrae which has slipped, squeezes in-between the two vertebra involved, then twists back into the remaining vertebra below. Unfortunately, the longer a slip remains this way (untreated and un-stabilized), the harder it is to retain normal functioning of the nerves involved, as they literally become accustomed to this "new" arrangement, if you will. 

  
  

  The process of reducing a slip which is severe in grade is much more complicated when it comes to the nerve involvement, as it likely took a number of years to reach the high grade or complete slip, allowing some time for the nerves to 'adjust' to this particular positioning. Therefore, reducing a slip in one relatively short surgery, in comparison to those years, can and may be highly traumatic and literally shocking to both the nerves themselves, as well as to the spinal cord. It may be helpful to think of any nerve involvement (any of the symptoms discussed above), as a "warning sign" of sorts. If these issue continue to increase, whether in number or severity, it's important to immediately speak with your doctor, determine the exact & direct cause, and consider your surgical options. 

  
  

  Nerve involvement resulting from a Spondylolisthesis slip does not mean just pain & issues with your extremities. Our spinal cord, encased and protected by our vertebrae, may be considered one of the more important foundations of our body's. Our nerves - which branch out from the spinal cord and then each vertebrae - all have a very specific "job," and when those areas are damaged or affected by a slip, the result may be impeding upon the given job they are meant to perform. For example; for those with slips in the low back region (mainly at the L4, L5 & S1 vertebra), as a slip progresses in grade there's an increasing chance for areas like the bowel and/or bladder to be directly affected to some degree. In worst case scenarios, some lose full control and function over both regions. This is why it's vital to report and address any concerns you may have involving your slip and symptoms which may indicate some problems connected to the bowel and bladder. 

  
  

  Nerves are a part of our bodies which are hard to fully understand and address. When it comes down to nerve damage resulting from a slip, there's opportunity and possibility for complete recovery, as well as the unfortunate outcome of little to no nerve repair, following the onset of obvious involvement and damage. Again, this is why nerve involvement itself is something with this condition which is not to be taken lightly or ignored. Sometimes one of the best options is to take preventative measures prior to nerve impingement presenting as too severe, therefore again, it's important to consider surgery as one of your options when your nerves are at risk ... especially when symptoms are increasing in number, frequency and severity. 

  
  

  Bottom line: Please do not wait to have surgery until you are unable to walk! 

  
  

  4) The QUALITY OF LIFE:

  
  

  What would you consider your overall quality of life to be as a result of this condition? 

  
  

  Quality of life is a big factor that plays into the decision of when to take that next big step (& leap of faith), and move forward with having surgery (or surgeries) to stabilize a slip, release nerve impingement(s), as well as possibly reducing the grade of a slip. 

  
  

  In a nutshell, what 'quality of life' comes down to, is how this condition (and any additional related conditions), interfere with, and seriously affect your day-to-day functioning; your basic survival (everything from taking basic care of yourself, relationships, work, school, daily basic tasks, etc), in addition to your ability and 'willingness' to endure any amount of chronic pain you may be experiencing (both nerve-related & otherwise). If you are spending the majority - or all of your day - in a good amount of pain, you find yourself unable to function on a decent level, have trouble doing day-to-day activities, have trouble sleeping due to pain & general discomfort, have no energy & are constantly fatigued, experience changes in appetite, as well as new or worsening conditions like anxiety and depression, etc., please note that these are all problematic in nature, and are all clear 'warning signs' that your quality of life has decreased a large degree. This is no way to live! ... You are purely 'existing.' And, in my opinion, this factor, in and of itself, plays a big role in making the decision to move forward with surgical intervention. 

  
  

  Of course, the three reasons listed above should be considered along with this final reason. For example, if you know that your slip is stable and not likely to progress (being sure to avoid certain high-risk activities which may result in sudden & unexpected progression), you do not experience any nerve-involvment (nerve pain in the extremities, nerve-related symptoms, issues & other concerns involving matters like your bowels & bladder, etc), and your slip is considered a lower grade, it's important that you make an effort to seek out as many forms of therapies & treatments (both alternative & western medicine based), as you feel comfortable pursuing. In doing so, you may find that with the 'right combination,' you are able to improve your overall quality of life, and therefore, live and function with this condition without requiring any surgical intervention at this point in time (and perhaps ever). I do want to note that if this is the route you take, and you find the right balance to improve your quality of life - including pain concerns - that you continue to keep a watch on your Spondylolisthesis slip over time. Being sure to monitor it's status once every few years (at minimum), via some kind of diagnostic films. And, should you begin to experience new symptoms and/or an increase of pain, that you immediately visit your spine specialist to ensure all is well. 

  
  

  
  

  SUMMARY & MY PERSONAL EXPERIENCE COMPARED TO THESE FOUR FACTORS: 

  
  

  Each of the factors listed above are all issues in their own right. And, obviously a combination of these enhance the problematic nature of the condition as a whole, which ultimately may need to be addressed (sometimes sooner rather than later). While I have accumulated knowledge of various individual's stories and experiences with their respective condition and surgeries, I can only speak from what I know on a personal level with Spondylolisthesis. In order to better explain the greater need for surgical intervention as a slip progresses, I will do my best by way of comparing this to my own case below. But, before I continue, I would like to say that I do not share my story & experience in order to increase your anxiety or fears around this condition and having surgery ... Rather, I share a part of my story below in order to state the importance of carefully considering all of the previously stated factors, as well as making a clear case for keeping one's eye on the condition and truly listening to the body and any warning signs it may be presenting - All as ways to best avoid the more severe case scenarios on the continuum of this condition. 

  
  

  
  

  
  

  My first case of Spondylolisthesis started around the young age of 9, and wasn't diagnosed until I was 14 years old. This particular slip, when finally recognized, was considered a complete slip called Spondyloptosis, and was located at the most common location of the L5/S1. It had a tremendous impact on my lower extremities as a direct result of severe & extensive nerve impingement. While I could still walk prior to my surgeries, I was experiencing a lot of sudden and scary nerve-related issues. These included, but were not limited to: Several types of nerve pain sensations, weakness in my lower extremities, random and sudden loss of sensation, numbness, and occasional inability to move my legs & feet. Prior to my surgeries, these symptoms (aside from the actual nerve pain itself - which remained a constant), would come and go without rhyme or reason. Between the age of 9 when I first recall having pain severe enough to cause worry and halt my sports activities from time to time, and the age of 15 when I finally had my surgeries, my quality of life decreased dramatically. Initially it was gradual, one thing here and one thing there ... It wasn't until the last two years prior to my surgical intervention when I experienced a rapid decline in a number of my physical abilities and a dramatic increase in overall pain symptoms. 

  
  

  Once I was finally diagnosed, I was told that I needed some form of surgical intervention within a maximum time period of 9 months, otherwise they would not touch me/attempt any form of surgery due to severity of my condition, various additional risk factors and other likely permanent complications. It was estimated that I could wake up one morning without feeling or use of my legs (as well as sudden and permanent loss of bladder and bowel functioning). They estimated - with an almost 100% certainty - that within 12 months I would be paralyzed. Surgeons also informed my parents and I at the time, that without intervention, and given the continued progression of my slip, that my internal organs would become so compacted (literally crushed), that the final prognosis was fatal in the sense that the heart & lungs would be affected. It was estimated that I would live for approximately a decade more before the condition killed me from secondary factors involved with this key piece. This case was very rare & severe in nature, but it does provide some idea of how dramatically this condition can affect one's spine and body if left untreated when all of the factors for surgical intervention are present for a long period of time & remain unaddressed. When considering the degree of the slip, and given the opportunity for the L5 to fall even further, the window of opportunity for fusion was rapidly closing. Even at this point in time, my case required a reduction of some degree prior to fusion. My outcome was a reduction to a grade 5, where I am fused now. This was their minimum requirement for reduction of the slip prior to attempting any type of fusion. 

  
  

  The further a slip progresses, as I shared before, the more complications are likely to be involved. This is simply in regard to the basics of the respective operation(s) themselves - not taking into account any possible negative complications. Unfortunately, performing surgical interventions on higher grades, or complete slips, carry more risk factors, even when all goes as planned. One factor that plays into the equation when attempting to fuse a higher grade or complete slip, is causing nerve damage which was not previously present pre op; as a general rule, there's literally less room/space to place the various chosen hardware & create a fusion, therefore, avoiding the many nerves and the spinal cord itself becomes more of a challenge. 

  
  

  When it comes to trying to reduce a slip (to some degree or another) prior to the actual fusion, there may be other nerve-related complications involved - Specifically that, it likely took several years (or longer) for the slip to progress to that point, which, while unpleasant and problematic in it's own right, this slower progression is less damaging to the spinal cord & multitude of nerves. Reducing the slip - whether performed during a surgery or through slower traction over days and/or weeks - is rather shocking & truly overwhelming to the spinal cord & nerves. By all intents & purposes, the spine is literally being "stretched." This stretching process is where there's a higher likelihood of permanent nerve damage post op, especially when faced with a higher grade slip.  While I did not experience nerve deficits from the actual surgeries themselves, I did witness permanent nerve damage resulting directly from the reduction of my slip. Even though we chose to proceed with the less aggressive option of full body traction (in order to best avoid additional 'shock' and permanent damage to the nerves and spinal cord), the reduction process was simply too much for my many nerves, and unfortunately, caused permanent foot drop and other nerve-related complications. Although, I must admit that I am still very thankful for this outcome, as I whole-heartedly believe (and feel), that had we gone with the more rapid reduction, the resulting damage would have been much more dramatic in nature, most likely paralysis. 

  
  

  
  

  *If anyone has any questions about what I've shared above, or if I've made a mistake, please let me know. And, just to cover my bases again, I am not a doctor nor a specialist of the spine. But, most importantly, I am also human and I make just as many mistakes as the doctors (lol - yes, docs make MANY mistakes - they just have difficulty admitting to them it seems!). 

  What I've shared above is based on my personal understanding, knowledge, experience, research and education about this subject. 

  
  

  I hope this document may be helpful to anyone who may be contemplating surgery for this condition - Those whom have questions about when to proceed and when to wait on surgical intervention. 

  
  

  
  

  SUGGESTIONS FOR FINDING THE BEST SURGEON FOR YOU & YOUR CASE:

  
  

  Surgery - no matter what kind - is a big deal! Spinal surgery, like that of open heart surgery and brain surgery, are operations which reside on another level, as they are very much the 'foundations' of our bodies! So, when dealing with, and facing an operation of this nature, it becomes incredibly vital that we seek out as many surgeons as needed & possible. I would encourage anyone in this position to consult with at least 3 different surgeons - and at the very least, please do get a second opinion, even if you feel fully confident with the first physician you located. With this thought in mind, it is also important to seriously consider seeing several types of surgeons; most importantly with this condition, the specialities of Orthopedic Spine & Neurology. 

  
  

  
  

  Finding a surgeon to follow you through treatment - whatever that treatment may entail - can be a challenging task in and of itself. I recommend the following factors to best determine if a particular physician may be a good fit for you & your case. While some feel strongly that Orthopedic Spine Surgeons are the best for Spondylolisthesis cases, others feel equally as confident in Neuro Surgeons. Just as there are several factors for deciding upon surgery itself, the same goes for the matter of Ortho verses Neuro. A deciding factor may very well come down to your specific case, situation, and any complications you have pre op. Some physicians will work on cases together, combining their respective expertise during surgical interventions, which if possible, is an awesome route to take in my opinion. In some cases, patients have the fortune of additional surgeons expertise on their case and in the operating room. 

  
  

  Here are a few questions to consider & ask yourself when choosing a Specialist and/or Surgeon:

  
  

  - Do you trust & respect this Doc? 

  - Feel confident & safe with this Doc? 

  - Is this Doc compassionate & caring?

  - Does this Doc truly listen to you, hear all of your concerns, and address them appropriately/to your liking?

  - Does this Doc have a good record/history with patients & throughout his/her medical practice? (i.e., any malpractice lawsuits, negative surgical outcomes with serious permanent complications, if so, how many & why? etc) 

  - Do they have a good amount of knowledge & general understanding of the condition itself, as well as any other related conditions which may need to be addressed during treatment? 

  - Have they dealt with similar cases to your own?

  - How much experience & expertise do they have in relation to the condition itself, the type of surgery you would undergo, and what have the outcomes looked like in past cases?

  - How many operations have they performed specific to this condition and your particular situation? 

  - Do you feel 'bullied' or 'cornered' by this doc (in any way) in regards to your treatment/surgery? (i.e., They state there's only one option for surgery, that other surgeons would do the exact same, or that you must do the given operation right now & have you move forward out of fear, etc)

  - Is the surgeon advising the best surgical intervention for your particular case, or, on the other side of the spectrum, are they 'pigeon-holing' your case because they are only capable of performing a specific kind of surgery? 

  - Do they give you positive or negative 'vibes?' (i.e., does something feel 'off' or 'wrong' about them or what they propose to do? Does your gut instinct tell you not to proceed forward with this Doc's plans?)

  
  

  When it comes to finding a good fit for any doctor, remember to do a "gut check" with yourself. Please, never ever discount your intuitions when it comes to this stuff - They are your "internal red flag" and will rarely, if ever, fail you! Same goes for your body and how you feel. You know your body the best - you're the one living in it afterall! Always do your best to advocate for yourself, your body, and your needs. And, if you're unable to, ask someone you trust to do so for you. 

  There are many surgeons out there, just as there are many surgical options available - There's no 'one surgery fits all' operation for Spondylolisthesis!