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Grade 2 anterolisthesis w/ severe neural foraminal narrowing

I am new to the forum and have been dealing with lumbar pain for 15+ years, some of which is probably due to my lifelong struggles with my weight. In 2004/2005 two MRI's confirmed that I had a grade I anterolisthesis at L5-S1 with moderate right neural foraminal narrowing. Several subsequent courses of PT together with hot, moist heat and cold compresses helped me deal with the lumbar pain and occasional sciatica that I was experiencing and I have been relatively comfortable for the last 8 - 9 years. I have occasional bouts of lumbar pain or fleeting sciatica but nothing that has required meds.

About 4-5 weeks ago I noticed a fleeting "twinge" in my right buttock which usually indicated that sciatica would follow soon thereafter. This time however, the pain was much more intense, a burning sensation in my upper right thigh together with a cramp or vise-like sensation down my right calf and across my right foot. The pain was worst when I first got up in the AM or during the night, particularly as soon as I sat up on the side of the bed or sat down in the bathroom. It took several hours before I could move around with any degree of comfort.

Sitting was not comfortable unless I sat “ramrod straight”, but walking wasn’t really a problem with no noticeable discomfort going up or down stairs. Bending forward relieved the lumbar pain and reduced the sciatica. Arching my back didn’t seem to affect either pain. The pain was more tolerable when I was lying down and I could sleep for a few hours by keeping my right leg as straight as possible.

After several days I saw my PCP who ordered an MRI and gave me a prescription for vicodin (5 – 500), 1 every 4-6hrs as needed to help with the pain. The vicodin does not seem to be of much help nor is tramadol. I have peripheral neuropathy from Type II diabetes so it can be difficult to distinguish the nerve related pain.

A summary of the MRI results from 4/29/13 follows.
• The lumbar vertebral bodies maintain normal height, there are no acute fractures.
• Multilevel DDD throughout the lumbar spine.
• For T10-T11, T11-T12, T12-L1, L1-L2, L2-L3, L3-L4 there are either no or small disc protrusions, no central canal stenosis or neural foraminal narrowing.
• Interval increase in Grade II anterolisthesis of L5-S1 2nd ary to severe facet joint arthrosis.
• Interval increase in severe right neural foraminal narrowing of L5-S1 with mass effect on the exiting right L5 nerve root.
• Interval progression of mild central canal stenosis at L4-L5 and L5-S1.
• Interval progression in mild to moderate right neural foraminal narrowing at L4-5.

I have an appointment with an orthopod spine surgeon tomorrow (Friday) AM to review my symptoms and MRI and to recommend a course of treatment. I confess that I’m really apprehensive about this since my symptoms seems to have deteriorated markedly since my last MRI but I’m not ready to commit to a spine fusion yet. Does anyone on the forum have experience with more conservative treatment measures being beneficial in a situation like mine?
Thank you for your advice and help – it is appreciated


  • LizLiz Posts: 7,832
    I am sure that you will find your time on Spine-Health very rewarding. This site is a powerful and integrated system that is dynamic and continues to grow.
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    Liz, Spine-health Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery
  • Liz,
    Thank you for the information. I'm hoping to learn a great deal from the members and the resources.
  • Hello, dcpalmer. I just wanted to welcome you and ask how your appointment went today?
  • So was your doctor able to give you a treatment plan? If so, what is it? Welcome! Lots of people with tons of experience on this forum, I'm sure no matter what the treatment plan you can find support here.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • Evening to you PaininOhio and AllMetal,
    First off thank you both for asking after how I made out Friday. I'm posting a somewhat lenghy answer which follows

    My appointment with the orthopedist Friday AM was much different from any of my previous appointments with orthopedists since this doctor specializes in spine surgery. First off, he was friendly and not condescending, and after he introduced himself to my wife and me he asked me to describe my situation. I gave him a detailed sheet that I had prepared which he read, asked me some further details and then told me that he did not believe that I had progressed to a Grade II anterolisthesis.

    He said that he didn’t pay a lot of attention to others interpretation of MRI results via reports and that he preferred to view the films/CD and then draw his own conclusions. Based on the CD from my 4/29 MRI he interpreted my situation as Grade I. For comparison I had the films from my prior MRI’s 8 and 9 years earlier and he sat with us and showed us how he would interpret those results. He explained the sagittal and transverse views to us and then drew lightly on the film to show us the actual slippage at that time. He measured the slippage of L5 vertebrae on S1 it was < 25% at that time and the latest MRI was essentially the same in his opinion.

    He explained the significance of the neural foramen and showed us on my old MRI film the difference between nerves exiting the left (relatively normal) vs. the right (moderate narrowing). He said that the latest MRI shows some additional narrowing on the right which certainly could give rise to my pain.

    He ordered AP and lateral plain films which he had printed out and then brought them to us. He showed us that there was no significant movement in my L5/S1 joint between the 2 views which meant that my anterolisthesis was stable. Further, he outlined on the x-ray the antherolisthesis and again the slippage was <25%.

    The plan then is for an extended course of PT with a woman who specializes in PT of the spine. I dealt with her 8-9 years ago and she helped me a great deal at that time. He wants her to focus too on my hamstrings which he described as tight as piano wire and which only aggravate my situation. Too, he said that some belly weight loss on my part could reduce the constant distortion on my spine but he acknowledged that this is always easier said than done even with this type of motivation. This won’t correct the damage done but could only improve my situation.

    If I still need some relief in the future we will consider injections but neither he nor I are pushing for them. We left it that there was no need for a formal follow-up appointment unless I was not improving or there was a significant change for the worse in which case I should follow-up for an appointment. He allowed that there was no need to consider surgery at this time so it was never discussed at this visit. He also said that he would pursue a slow and very conservative treatment plan to postpone surgery permanently or for as long as absolutely possible.

    All in all, this was better than I was expecting from all aspects. I’ll post back after I’ve had my PT evaluation and some time to apply the exercise program.
  • I'm happy you have found a spine doctor that is so detailed and attentive. I'm glad you don't need to worry about surgery, at least for now. I will say I have to constantly work on stretching my hamstrings as well. I do stretches at least three times a day specific to hamstrings. If I don't, I pay for it that night. So I know for certain that is sound advice. Loosing some weight is also great advice, but you already knew that, and I've always struggled with that as well, so no judgment here. Who knows though, this might give you the motivation to loose a few pounds, even if it doesn't "show" it will help. Hope your PT goes well. It truly makes a difference when the physical therapist knows and understands spines. Best of luck!
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • Just a fast note to update my last post re: physical therapy. As I noted before I've gone back to the same physical therapist I saw some years back that specializes in and is certified for spine/back problems. Her initial evaluation was detailed and thorough after which she determined that my pain does NOT originate from the foraminal narrowing given that extension relieves it and flexion aggravates it. Thus far we've taken a very conservative approach using moist heat, some simple extension exercises that I do many times/day and some pretty firm back manipulations, not chiropractic.

    All in all this seems to be helping since the sciatica pain has been reduced substantially although I have found that my inane and foolish attempts to do yard work, gardening, garage clean-ups and the like can and will bring on a bout very quickly so I'm by no means "cured" but certainly going in the right direction.

    That said she just instituted hamstring stretches this week and found 1 - that my hamstrings are tight enough to endanger her with snapback and 2 - the order in which I do the exercises matters greatly, i.e. if the hamstring stretches are the last thing she does before I leave, driving home is more unpleasant than if she does them immediately after the moist heat. So I'm sure this PT plan/program will have its blind alleys and corners while we figure out what to do and when. I can say that my flexion has improved just in the 3 weeks that I've been doing PT both in terms of the amount of pain and how far I can bend even with the tight hamstrings.

    That's it for now, I've got to interrupt the program for a necessary trip to see the wizard for thyroid surgery Monday AM. I'll post back once I've started up PT again.
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