SpineUniverse Case Study Library

Severe Lumbar Spinal Stenosis with Spondylolisthesis

Does fusion result in a better outcome than laminectomy alone for lumbar spinal stenosis with spondylolisthesis?


A 67-year-old female presents with1.5 years of progressive back pain and inability to walk a distance greater than one to two blocks. She is adopting a progressively forward-flexed posture.

Her past medical history includes hypertension and hypothyroidism.


The patient’s physical examination is notable for diminished right ankle reflex and 4+/5 weakness bilaterally in the extensor halluces longus muscles.

Prior Treatment

A program of organized physical therapy was attempted, and a series of three epidural blocks was not effective.

Pretreatment Imaging

A preoperative x-ray (Fig. 1, below) demonstrates a grade 1 spondylolisthesis with degenerative disc disease at L4-L5.

preoperative x-ray shows grade 1 spondylolisthesis with degenerative disc disease at L4-L5Figure 1. Image courtesy of Joshua M. Ammerman, MD, and SpineUniverse.com.

The sagittal MRI (Fig. 2, below) shows severe spinal stenosis at L4-L5 with grade 1 spondylolisthesis.

sagittal MRI shows severe spinal stenosis at L4-L5 with grade 1 spondylolisthesisFigure 2. Image courtesy of Joshua M. Ammerman, MD, and SpineUniverse.com.

In Figure 3 (below), the axial MRI identifies facet arthropathy at L4-L5.

facet arthropathy at L4-L5Figure 3. Image courtesy of Joshua M. Ammerman, MD, and SpineUniverse.com.


Severe spinal stenosis with grade 1 spondylolisthesis at L4-L5

Suggest Treatment

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Selected Treatment

Minimally invasive laminectomy and interbody fusion at L4-L5 with percutaneous pedicle screws.


The patient experienced immediate improvement in back pain and walking distance tolerance. Fusion is radiographically evidenced by CT scan at 4 months postop (Fig. 4, below).

fusion is radiographically evidenced by CT scan at 4 months postopFigure 4. Image courtesy of Joshua M. Ammerman, MD, and SpineUniverse.com.

Authors' Discussion

In discussing fusion versus decompression alone for spondylolisthesis with spinal stenosis, the US data favors fusion, whereas the European data does not favor fusion.

  • Ghogawala et al concluded that among patients with degenerative grade 1 spondylolisthesis, “the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life,” than laminectomy alone.1
  • Försth et al stated that among patients with lumbar spinal stenosis, “with or without degenerative spondylolisthesis, decompression surgery plus fusion did not result in better clinical outcomes at 2 years and 5 years than decompression surgery alone.”2

The ultimate decision is an individual one arrived at jointly by the surgeon and patient after reviewing the patient’s unique clinical scenario, overall health and long-term health goals.


  1. Ghogawala Z, Dziura J, Butler WE, Dai F, et al. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;374:1424-1434.
  2. Försth P, Ólafsson G, Carisson T, Frost A, et al. A randomized controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med. 2016;374:1413-1423.

Peer Case Discussion

The authors describe a problem that commonly presents in every spine surgeon's office—spinal stenosis associated with degenerative spondylolisthesis. They have obtained an excellent clinical and radiological outcome, although four months after surgery may be too early to say that a solid fusion has been obtained.

The dilemmas in decision-making are the key, and by highlighting the most recent studies, the authors of this case have attempted to address the situation. Ghogowala et al as part of the SLIP study (Spinal Laminectomy versus Instrumented Pedicle Screw trial) went on to say, in the absence of significant low back pain, laminectomy alone was reasonable but one-third needed subsequent revision fusion surgery.

Variables that need to be considered in the decision-making process include the absence or presence of foraminal stenosis, dynamic instability, degree of slippage, body habitus, general health, and the absence or presence of severe mechanical back pain. There are various ways to achieve the decompression and fusion.

This case illustrates a common problem with a good result. It's a controversial problem; handled well. Not all will agree with their solution but that only highlights that the management of degenerative spondylolisthesis is a controversial topic.

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