A Case Series of Three Patients with Single-Level Spondylolisthesis: Clinical and Functional Results Following Transforaminal Lumbar Interbody Fusion.

Savuthri D et al | DOI: 10.65188/nurexus.1071

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

A Case Series of Three Patients with Single-Level Spondylolisthesis:

Clinical and Functional Results Following Transforaminal Lumbar

Interbody Fusion.

Dr. D Savuthri

1

, Dr. M Ahmed

2

Assistant Professor, Professor

Department of Orthopedics, JIPMER, Puducherry.

Email ID: savuthridms@gmail.com

Submission Date: 09.02.2026

Accepted Date:16.03.2026

Published Date: 31.03.2026

DOI: 10.65188/nurexus.1071

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Lumbar spondylolisthesis, characterized by lumbar instability and forward slippage in relation to the underlying

vertebrae, is a common condition often accompanied with chronic low back pain, radiculopathy and interfering

functionality factors that may necessitate surgical treatment when conservative approaches have been tried. TLIF had

emerged as a leading surgical method to achieve both decompression and stabilization through the single posterior

approach. In this case series, 3 cases of single level lumbar spondylolisthesis in which TLIF surgery was performed

were presented and their clinical evaluation with VAS (Visual Analogue Scale) score, ODI (Oswestry Disability

Index) score and radiologically assessed. All patients showed impressive improvement following surgery, as the

mean VAS score decreased from 8.0 preoperatively to a corresponding measurement of 1.6 at 6 months post-surgery;

similarly, ODI scores improved significantly by reporting a percentage of disability reduction from original states

(58%) to stable remote state (18%). Fusion was achieved on radiographs in every case, and there were no major

complications. TLIF is a safe and effective surgical modality, with excellent pain relieve, functional improvement

and high fusion success in single-level spondylolisthesis as evidenced by these findings.

Keywords: TLIF; Spondylolisthesis; Case series; Lumbar fusion; Functional outcome

Introduction

Spondylolisthesis is defined as forward displacement of one vertebral body over another, with the lumbar

spine being the most common location. It is a major source of chronic low back pain and disability,

commonly with radiculopathy and neurogenic claudication involvement. The disease mainly affects the

lumbosacral junction, and the most commonly affected segments are L4–L5 and L5–S1 levels (1).

Meyerding categorized spondylolisthesis into 5 grades, from I (0–25%) to V (>100%), otherwise known as

spondyloptosis, based on the amount of vertebral migration (2).

There are various types of spondylolisthesis based on etiology [dysplastic, isthmic, degenerative, traumatic,

pathological and iatrogenic] (3). Degenerative and isthmic types are the most frequently seen types

clinically, among these. Degenerative spondylolisthesis is most commonly arises in the older adult

population, resulting from progressive degeneration of the intervertebral disc, facet joint arthropathy and

ligamentous laxity leading to segmental instability (4). On the other hand, isthmic spondylolisthesis

typically occurs in a younger population and involves defects of pars interarticularis (5).

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The clinical presentation of spondylolisthesis consists of different levels of back pain, radicular signs and

functional limitation. In more severe cases, patients may have neurological deficits and gait disturbances.

Various factors such as the extent of slip, spinal instability, and concomitant degenerative changes affect

how natural history turns out (6). Epidural steroid injections are usually considered as a part of the initial

management along with physiotherapy, analgesics and lifestyle modification. However, surgical

intervention is required in patients with symptomatic persistence, progressive neurologic deficits, or

imaging evidence showing instability (7).

Different surgical techniques are confirmed in lumbar fusion, such as posterolateral fusion (PLF), anterior

lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and transforaminal lumber

interbody fusion/TLIF. Of these techniques, the TLIF has become most widely used because of its unique

advantages. The two-segment long fixation of the rig was sufficient in minimizing the excessive retraction

of neural tissues while maintaining spinal stability in a single posterior approach, which could significantly

reduce iatrogenic injury, as suggested by previous studies (8).

The TLIF technique entails unilateral facetectomy, discectomy, interbody cage insertion with bone graft

placement and posterior stabilization via pedicle screw instrumentation. The circumferential fusion method

provides better biomechanical stability and greater rates of fusion. Studies have shown that TLIF achieves

fusion scores >90%, with significant pain and functional improvement (9). TLIF also has been linked to

reduced operative morbidity relative to other fusion methods and especially PLIF due to less manipulation

of the dural and nerve roots (10).

While TLIF has its benefits, it is also not free of complications. Intraoperative and postoperative

complications can be dural tears, nerve root injury, surgical site infection, implant failure and

pseudoarthrosis (11). Surgical outcomes and the rate of complications can also be influenced by patient-

related factors like age, comorbid disease, underlying bone quality and degree of spondylolisthesis. As a

result, precise selection of patients and exacting surgical technique are prerequisites for optimal outcomes.

Many articles have studied the results of TLIF on a population basis requiring large numbers and statistical

evaluations; however, series of case provide better understanding regarding the individual patient outcomes,

clinical diversity as well as actual surgical experience. They enable granular assessment of symptom

trajectory, surgical response and recovery dynamic that may not always be detectable in larger cohort

studies.

Thus, the current case series aims to report the clinical picture, surgical treatment and functional results of

three patients with single-level lumbar spondylolisthesis who underwent TLIF. This study aims to solidify

TLIF as a highly effective, safe and clinically applicable option for the treatment of symptomatic

spondylolisthesis based upon case-specific characteristics and outcomes.

Case Presentation

Case 1

A 47-year-old female visited the outpatient department with complaints framing chronic low back pain

since about two years which has worsened during the last six months. The pain appeared to be a steady,

aching sensation limited to the lower lumbar area, with subacute radiation to the left lower extremity

covering the L5 dermatome. The symptoms were aggravated on standing for long periods, walking and

forward bending while there was partial relief with rest and analgesics. However, conservative management

with physiotherapy, non-steroidal anti-inflammatory drugs and activity modification did not provide

sustained relief over time.

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Clinical examination revealed bilateral lumbar paraspinal muscle spasm and restricted range of motion Left

lower limb showed positive straight leg raising test at 50 degrees suggesting nerve root irritation.

Neurological examination showed a mild sensory deficit over the dorsum of foot (L5 nerve root distribution

involvement) but preserved motor function. Reflexes were normal.

Figure 1: Preoperative X-ray - AP & Lateral view

Plain radiographs (anteroposterior and lateral view) radiological evaluation shows Grade I anterolisthesis

at L4–L5 level. MRI of the thoracic spine revealed degenerative changes consistent with disc desiccation,

facet joint hypertrophy and bilateral foraminal narrowing with nerve root compression.

Keeping in mind the persistent symptoms and radiological correlation patient was planned for surgical

intervention. She was taken for Transforaminal Lumbar Interbody Fusion (TLIF) under GA. A standard

posterior midline approach was utilized, with unilateral facetectomy and decompression. L4 and L5 pedicle

screws were placed, followed by discectomy. Interbody cage with autologous bone graft was placed,

followed by rod fixation and final tightening.

Postoperatively, the patient was mobilized in under 48 hours with adequate pain control. Wound healing

was uneventful. At 6-month follow-up, the patient showed considerable clinical improvement—Visual

Analogue Scale (VAS) score decreased from 8 preoperatively to 2, and Oswestry Disability Index (ODI)

improved from a value of 60% to a value of 20%. Postoperative radiographs confirmed satisfactory

interbody implant positioning and suggested interbody fusion. No complications were encountered.

Case 2

A 55-year-old man came with complaints of one year history of radicular low back pain, bilateral lower

limb irradiation and neurogenic claudication. The patient complained of difficulty in walking beyond 100–

150 meters due to bilateral lower limb pain and heaviness that severely impaired his activities of daily living

(ADL) and quality of life (QOL). The patient had received several conservative treatment modalities such

as physiotherapy and epidural steroid injections without success.

On examination, the patient had an antalgic gait with a forward stooping posture. Motion of the lumbar

spine was painful and limited. Straight leg raising test was bilaterally positive at 40 degrees. Neurological

examination showed decreased sensation in the S1 dermatome on both sides and mild weakness of plantar

flexion. Deep tendon reflexes were diminished at the ankle jerk.

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Figure 2: Pre-operative X-ray Lateral _ Flexion & Extension views

Radiological investigations demonstrated Grade II spondylolisthesis at L5–S1 level with spinal canal

stenosis. Magnetic resonance imaging demonstrated disc degeneration, ligamentum flavum hypertrophy,

and thecal sac compression.

Due to severe symptoms and ineffectiveness of conservative management, surgical intervention was

planned. The patient was treated with TLIF, decompression and stabilization. On intraoperative evaluation,

there was significant canal stenosis, which was sufficiently decompressed. Pedicle screw fixation at L5 and

S1 followed by interbody cage insertion.

Postoperatively, he had an uneventful recovery and was mobilized on the second postoperative day. At

follow-up, there was a significant improvement in symptoms. VAS score improved from 9 pre-operatively

to 2 at 6 months, and ODI improved from 65% to 22%. The patient also noted that walking distance and

daily activities improved significantly. Radiological evaluation confirmed successful fusion. No

intraoperative or postoperative complication was observed.

Case 3

A 40-year-old-female patient presented with intermittent low back pain and right-sided radicular symptoms

for the past eight months. Initially, mild to moderate in intensity but progressively worsening and interfering

with daily activities. The patient also experienced occasional paraesthesia in the right lower limb.

Conservative treatment with medications and physiotherapy gave only transient relief.

On clinical examination there was localized tenderness over the lower lumbar spine and mild restriction of

the movements. Positive straight leg raising test at 60 degrees on the right. Neurological examination was

negative for motor deficit, but mild sensory changes were present.

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.

Figure 3: MRI Image- Sagittal Section

Radiological evaluation demonstrating Grade I spondylolisthesis at L4–L5 level. MRI disc bulge + nerve

root compressiono n early degenerative changes. The patient underwent TLIF after conservative therapy

failed. The surgery was done with general anesthesia using an ordinary posterior approach. A

decompression, discectomy and interbody fusion with cage placement was performed, and pedicle screw

fixation was subsequently performed.

The patient achieved satisfactory pain relief postoperatively and was mobilized early. However, she had an

atypical superficial surgical site infection on the 7th postoperative day, which was effectively treated with

antibiotics and local wound management. Now, no infection — and it can resolve without complications.

At 6-month follow-up, the patient displayed a great functional recovery with improvement of VAS point

(7 to 1) and ODI points (55% to 12%). Radiographs demonstrated solid fusion and stable instrumentation.

Discussion

This case series illustrates the clinical impact and functional improvements attained with Transforaminal

Lumbar Interbody Fusion (TLIF) for single level lumbar spondylolisthesis. All three patients showed

considerable progression in pain, functional capacity and radiological fusion reinforcing the role of TLIF

as a successful surgical mode.

Spondylolisthesis is a common spinal disorder related to mechanical instability, degenerative changes, and

neural compression which are associated with chronic pain and disability. Degenerative spondylolisthesis

primarily involves the L4–L5 level according to prior studies that have observed this finding in two of our

cases (1,2). The pathophysiology includes progressive disc degeneration, facet joint arthropathy and

ligamentous laxity resulting in vertebral slippage or compressription of nerve roots (3,4).

In our case series, all patients had undergone conservative management prior to surgical intervention; this

is concordant with established treatment guidelines that suggest surgery in cases with refractory symptoms

or neurological deficit (5). Among various lumbar fusion methods, TLIF has become one of the most

common because it can achieve circumferential fusion through a single posterior approach with good neural

retraction (6).

A major finding of our study was a substantial reduction in pain scores. Demonstrated that the mean VAS

score decreased from severe postoperative pain levels to an average of mild pain by 6 months. Roh YH et

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al (7) and Wang Y et al (8) have reported relatively similar improvements, with TLIF leading to significant

pain reduction. This is made possible by appropriate neural element decompression and restoring spinal

stabilization.

There was also significant improvement in all cases in the functional outcomes as assessed using the

Oswestry Disability Index(ODI). Lower ODI figures denote better mobility, improved daily activities and

quality of life. Studies to date have consistently reported ODI improvements of over 70% at TLIF, which

is comparable to our results (9,10). Radiologic fusion is an important factor for surgical success. In our case

series, all patients achieved successful fusion at 6 months follow-up. Literature cites in excess of 90%

fusion rates when using TLIF (11,12). Biomechanical stability is improved, and the risk of further slippage

is eliminated by augmenting inter-body cages with pedicle screw fixation promoting fusion.

Among the different methods of fusion namely Posterior Lumbar Interbody Fusion (PLIF), Anterior

Lumbar Interbody Fusion (ALIF) and TLIF, And TLIF offers certain advantages over others. It prevents

neural retraction, spares the dura, and hence provides unilateral approach which leads to reduced surgical

morbidity (13,14). The use of minimally invasive TLIF techniques has subsequently been associated with

less blood loss, reduced operative time, and shorter hospital stays (15).

Our complication rates were minimal in our study, as superficial surgical site infection occurred once and

was treated conservatively. No significant complications like dural tear, nerve root injury or implant failure

occurred. This concurs with previous reports noting low complication rates in TLIF (16,17).

An important observation in the current case series is that early mobilization contributes to recovery. All

patients were mobilized within 48 hours postoperative mobilization, which was associated with improved

functional outcomes and decreased length of stay. Studies demonstrate that early mobilization, including

all its rehabilitation elements, can improve circulation and lower complications while increasing patient

satisfaction (18).

The close correlation between clinical improvement and radiological fusion demonstrated by this study

emphasizes the need to obtain both mechanical stability and neural decompression. However, clinical

outcomes do not always correlate directly with radiological findings and patient-reported outcomes are still

important (19). Despite the encouraging results of this study, there are limitations. However, this was a case

series with small sample size and results cannot be generalized to the larger population. Furthermore, the

follow-up also only extended up to 6 months which fails to identify any potential long term complications

of DSIS such as adjacent segment disease or implant failure (20).

Summary

In this case series, three patients with single-level lumbar spondylolisthesis who underwent TLIF were

evaluated. All patients had chronic low back pain and radiculopathy refractory to conservative treatment.

VAS and ODI were used to test whether clinical evaluation is treated postoperatively and whether

significant improvement has been made. Radiological evaluation revealed successful fusion in all patients.

The procedure had few complications (one case of superficial infection). These results underscore the

efficacy of TLIF for pain relief, functional recovery, and spine stability. It supports TLIF as a safe surgical

procedure with good clinical and radiological outcomes.

Conclusion

The TLIF approach is a safe, effective, and reliable surgical procedure for the treatment of single-level

lumbar spondylolisthesis. This is a procedure that yields a large degree of pain relief, functional

improvement and very high rates of radiological fusion with relatively few complications. Was inspired by

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early mobilization, also in suitable patients of course will imporve postoperative recovery and outcome.

Based upon our findings, we feel that TLIF can be considered a favorable surgical treatment for patients

with symptomatic spondylolisthesis who fail conservative management.

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