[Music] the next type of spine pathology is what we call a spondy and i want to just clarify the name because there's a lot of different words that are used um to describe this but it's basically spondylolisthesis and that is a slip of one of the vertebral bodies out over another and there's three different grades based on how far forward you're slipped that's not something you necessarily need to know now at your level but as long as you understand what a spondy is you're already a little bit ahead of the game these patients will have a mix of nerve root pain and back pain the slip itself causes tightness and it also puts tension on the joints in the lumbar spine which causes back pain so these patients are going to have a mix but you always want to ask them what percent back pain are we talking what percent leg pain are we talking because that impacts your plan for how to best treat their pain on exam it's really just like a herniated disc where you might have focal motor weakness or generalized pain limited weakness the paresthesias or sensation issues can be variable and to figure out what's going on with the nerves it's the same thing you want an mri or a myelogram the x-ray is helpful for operative planning and that's where we like to get dynamic x-rays a dynamic x-ray is also called a flexion extension x-ray where the patient leans all the way forward and then they lean all the way back and you shouldn't see this fondy getting bigger or smaller but if you see it moving or shifting that means they need a fusion not just a discectomy not just a decompression and as far as the term so your spondylolisthesis spondy a slip pars defect you may have heard of that in your anatomy classes a pars defect promotes that slip in the spondy and that creates the canal compromise or effacement or stenosis where the nerves then become tight and compressed as they transit through the canal so how do we manage a spondy how is it different from just a micro discectomy the first thing that i tell patients i need to get their expectations in line with reality and i tell them your back pain will never disappear if someone has knee pain and bad osteoarthritis in their knee you can get a knee replacement you can't get a spine replacement we don't have the technology yet so i'm sure someday we will but because of that because arthritis is usually diffuse you can't just eliminate back pain if you have one particular joint in the back that is really bad you can fuse across it and that will often help with the back pain but i will tell my patients you're going to have back pain for life this is a palliative situation where we're just trying to make it better just because you see this does not mean the patient needs a surgery so they deserve conservative management physical therapy injections these patients are more typically given opioids because this is a chronic problem and sometimes they will be on chronic opioids for this but that comes with the whole debate over opioid abuse and how best to use them but what i will tell patients even though the back pain is never going to be gone there are options to palliate it and to manage it a little better and some of them are surgical so the surgical management of a spondy it often depends if it's fixed or mobile those x-rays can help us to figure that out and first you need to accomplish a decompression so you drill off the bones that are posterior to the canal and that helps give the nerves room to breathe then a fusion stabilizes this mobile and potentially unstable slip that fusion is what accomplishes a relief of back pain the decompression is what gives you the relief of leg pain that's the nerve pain or the radiculopathy effusion's a bigger operation it means more blood loss more post-op pain more recovery time that's a bigger physiologic stress on the body so generally speaking this isn't something that would be well advised in a 98 year old patient additionally a fusion changes the biomechanics of the spine so it puts it creates a bigger lever arm to the next joint so if you do a fusion the chances of following joint the adjacent joint deteriorating and degenerating at some point over the next 10 years or two years were pretty high so just as you wouldn't want to do a big fusion operation in a 98 year old it's also something you don't really want to do in an 18 year old because if you fuse a joint in an 18 year old spine they will have adjacent level disease at some point in their life hey everyone ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world