Case Study: Spondylolisthesis with Failed Prior Treatment — Surgical Correction and Recovery – Sardar Spine

The following is a three-part case study illustrating the evaluation, surgical planning, and outcome for a patient with lumbar spondylolisthesis and stenosis who had not improved with prior treatment. All imaging is shared with patient consent for educational purposes.

Part 1: Presentation

A 55-year-old woman presented with progressive back pain and bilateral leg pain that significantly limited her ability to walk. Imaging confirmed lumbar stenosis and spondylolisthesis at L4-5, disc degeneration at L3-4, and severe arthritis at L5-S1. She had already undergone a course of physical therapy and multiple epidural steroid injections with only short-term relief.

On examination, she had significant difficulty with prolonged standing and walking. Her X-rays on presentation are shown below, demonstrating the degree of listhesis and degenerative change at multiple levels.

AP standing X-ray showing lumbar spondylolisthesis at L4-5 — AP standing X-ray demonstrating lumbar spondylolisthesis and multilevel degenerative changes.

Lateral extension X-ray showing lumbar spondylolisthesis — Lateral extension X-ray.

Lateral flexion X-ray showing dynamic instability at L4-5 — Lateral flexion X-ray demonstrating dynamic instability.

Lumbar spine MRI sagittal view showing stenosis and disc degeneration — MRI sagittal view showing multilevel stenosis and disc degeneration.

MRI axial view at L4-5 showing severe stenosis — Axial MRI at L4-5 demonstrating severe central stenosis.

MRI axial view at L3-4 showing disc degeneration and stenosis — Axial MRI at L3-4.

MRI axial view at L5-S1 showing severe arthritis — Axial MRI at L5-S1 showing severe facet arthropathy.

MRI axial overview of lumbar spine — Axial MRI overview of the lumbar spine.

Part 2: Failed Prior Treatment and Worsening

Before presenting to Dr. Sardar, the patient had undergone a Vertiflex interspinous spacer procedure at another institution. Rather than improving her symptoms, the procedure was followed by progressive worsening. By the time of her follow-up evaluation, she was unable to stand upright and required a walker for mobility.

Repeat imaging confirmed that her underlying spondylolisthesis and sagittal malalignment had progressed. The interspinous spacer had not addressed the structural instability at the involved levels, and the added device had not stabilized the segment. Her clinical picture now represented a case of progressive lumbar deformity with neurogenic claudication and functional decline — a pattern that is not amenable to further conservative or minimally invasive intervention.

X-ray showing Vertiflex interspinous spacer in situ with worsened spondylolisthesis — X-ray showing the Vertiflex interspinous spacer in situ with worsened spondylolisthesis and alignment compared to prior imaging.

Post-Vertiflex AP X-ray showing lumbar alignment — AP X-ray at time of re-presentation.

Post-Vertiflex lateral X-ray showing sagittal malalignment — Lateral X-ray demonstrating sagittal malalignment at time of re-presentation.

Part 3: Surgical Treatment and Outcome

After a comprehensive evaluation — including full-length standing X-rays, CT, MRI, and medical optimization — the patient underwent posterior spinal reconstruction from L3 to S1/ilium with transforaminal lumbar interbody fusion (TLIF) at L4-S1. The Vertiflex device was removed as part of the procedure.

The surgical goals were to decompress the neural elements, restore lumbar lordosis, achieve solid segmental fixation, and correct the overall sagittal alignment. Robotic-assisted navigation was used for pedicle screw placement, and intraoperative neuromonitoring was maintained throughout the case.

At follow-up, the patient was able to stand upright without a walker — a functional milestone she had not achieved in years. Her leg pain resolved and her back pain improved significantly. Post-operative X-rays confirmed solid instrumentation, restored lordosis, and well-balanced sagittal alignment.

Post-operative AP X-ray showing L3-S1 posterior spinal fusion with pedicle screw instrumentation — Post-operative AP X-ray: L3-S1/ilium posterior spinal fusion with pedicle screw instrumentation and TLIF at L4-S1.

Post-operative lateral X-ray showing restored lumbar lordosis after L3-S1 fusion — Post-operative lateral X-ray demonstrating restoration of lumbar lordosis and sagittal balance.

Follow-up AP X-ray showing solid fusion and maintained alignment — Follow-up AP X-ray confirming solid instrumentation and maintained alignment.

Follow-up lateral X-ray showing maintained sagittal balance after lumbar reconstruction — Follow-up lateral X-ray showing maintained sagittal balance.

Case presented for educational purposes with patient consent. This post does not constitute individualized medical advice. Treatment decisions should be made in consultation with a qualified spine specialist based on individual clinical findings.

About Dr. Zeeshan Sardar
Dr. Sardar is Co-Chief of Spinal Deformity Surgery at NewYork-Presbyterian / Columbia University and specializes in complex spinal reconstruction, revision surgery, and adult spinal deformity. To schedule a consultation, call 212-932-5187 or visit the contact page.