Alar transverse process impingement of the L5 spinal nerve: the far-out syndrome

This syndrome occurs in two types of patients: (1) the elderly person with degenerative scoliosis and (2) a somewhat younger adult population with isthmic spondylolisthesis and at least 20% slip. On plain radiograph, the Ferguson view (25 degrees caudocephalic) is best for visualizing the condition, however, CT is by far the best diagnostic tool. To show this far laterally, the "window" on the CT scanner must be opened wider than usual. Both coronal and parasagittal views will demonstrate the condition, but the coronal is the most valuable. Symptoms are classical spinal nerve compression. Usually it is the L5/S1 level that is involved, but other levels can be. At surgery, it is most important that nerve decompression be carried far enough laterally. This can mean sacrificing the lower half of the pedicle and the entire transverse process. Part of the body of S1 and of the sacral ala can be removed if the surgeon prefers. Because so much bone is removed, instability is a factor to be seriously considered. How to decompress adequately and still maintain stability often poses a most difficult problem.