Spondylolisthesis as an entity for back pain agrasen hospital gondia vidarbha dr sandeep c agrawal ...

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Spondylolisthesis

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www,agrasenortho.com

Dr.Sandeep Agrawal Consultant Orthopedic Surgeon

MS,DNB

Agrasen Hospital Gondia

Maharashtra

India

www.agrasenortho.com

www.drsandeepagrawal.com

[email protected]

09960122234

http://www.drsandeepagrawal.com/

http://www.agrasenortho.com

http://www.drsandeepagrawal.com

http://agrasenortho.com


- OVERVIEW !!- PATHOPHYSIOLOGY & TYPES !- CLINICAL PRESENTATION !- PHYSICAL EXAMINATION !- DIAGNOSIS !- DIAGNOSTIC TESTS !- DIFFERENTIAL DIAGNOSIS !- TREATMENT !!- SUMMARY




Spondylolisthesis

• Displacement of a cephalad vertebra on the adjacent caudal vertebra

• Slipage : anterior, posterior and lateral 3

Spondylolisthesis is derived from the Greek words spondylo , meaning spine, and listhesis , meaning to slip or slide.

OVERVIEW (definition)

• Lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal

stenosis) or compression of the exiting nerve roots (foraminal stenosis).




4

OVERVIEW ( Anatomy )

Pars interarticulars

Spinous process

Articular process (inferior)

OVERVIEW ( Anatomy)




OVERVIEW (Dermatomes)




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OVERVIEW (Dermatomes)




Classification

•Wiltse classification system – anatomy

•Meyerding system- by degree of anterior translation




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It can be classified into 6 distinct categories as the following ( developed by Wiltse, Macnab, and Newman ):

TYPES ( according to etiology )

❑ Type I: Congenital spondylolisthesis !❑ Type II: Isthmic spondylolisthesis !❑ Type III: Degenerative spondylolisthesis !❑ Type IV: Traumatic spondylolisthesis !❑ Type V: Pathologic spondylolisthesis !❑ Type VI : Postsurgical




• characterized by presence of dysplastic sacral facet joints allowing forward translation of one vertebra relative to another.

Type I: Congenital spondylolisthesis

!• Caused by the development of a stress

fracture of the pars interarticularis. • It is also further divided into 3 subtypes :

Type IIA , type IIB and type IIC . !

Type III: Degenerative spondylolisthesis It is commonly caused by intersegmental

instability produced by facet arthropathy.

Type II: Isthmic spondylolisthesis




Type IV: Traumatic spondylolisthesis Caused by fracture or dislocation of the

lumbar spine, not involving the pars !

Type VI : Postsurgical (iatrogenic)

Type V: Pathologic spondylolisthesis. Caused by malignancy, infection, or other

types of abnormal bone




• Heavy Athletic activities requiring predispose some athletes to developing pars

defects. !

• Approximately 82% of cases of isthmic spondylolisthesis occur at L5-S1.

Another 11.3% occur at L4-L5.

!• Degenerative spondylolisthesis occurs more

frequently with increasing age. !• L4-L5 interspace is affected 6-10 more times than

any other level. !

• Sacralization of L5 is frequently seen with L4-5 degenerative spondylolisthesis .




!!

• Acute isthmic spondylolysis often occurs during the first and second

decades of life. Most cases occur before the patient reaches age 15 years.

!• Younger patients are at higher risk

than older patients for developing progressive spondylolisthesis.

!• But the risk for progression in adults is

rare when the lesion is at L5..

Age




Type I ( Dysplastic / congenital )

• Failure of formation of the anatomic elements of the lumbosacral facet joint

• Axially oriented facet with dyplasia of the superior end plate of the sacrum

• Intact pars interarticularis limited splippage < 30% -35 %




Type II ( Isthmic )

• Presence of a defect in the pars interarticularis ( isthmus )

• Scotty dog sign • Secondary to repetitive

microtrauma or a single trauma episode • Subtype A : defect in pars • Subtype B : defect in

elongated pars • Subtype C : acute fracture of

the pars




• Spondylolisthesis occurs when there’s bilateral defects in the vertebral pars intrarticulariss which permit the vertebral body to slip anteriorly. Usually occurs at level (L5,S1) !

• Spondylolysis is the most common cause for spondylolisthesis. It’s a unilateral or bilateral defect in the vertebral pars interarticularis result from stress fracture.

PATHOPHYSIOLOGY




Type II ( Isthmic )

• Alaskan Eskimos : 26 % • Hyperextension forces




Type III ( Degenerative )

• Facet joint OA and Hypertrophic lig. flavum




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!• spondylolysis typically is acquired as the

bone "fatigues" from recurrent microtrauma during excessive lumbar hyperextension or repeated lumbar flexion and extension.

• rebeated Hyperflextion and extension of the joints are more common in athletes.

• (diving, weight lifting, wrestling and football)




• Spondylolysis progresses to spondylolisthesis in approximately

15% of cases. Progression to spondylolisthesis is correlated with persistent pain and lack of healing.




6- Patients with degenerative spondylolisthesis (DSPL) are characterized by an increased

pelvic tilt (PT) and decreased sacral slope (SS) than the control population, suggesting the

presence of a pelvic compensation




Type IV ( Posttraumatic )

• Trauma induce disrupt the posterior arch and its articulations other than pars interarticularis




Type V ( Pathologic )

• Systemic disease associated : osteogenesis imperfecta, osteopetrosis, arthrogryposis, syphilis

• Localized process : infection, neoplasm




Type VI ( Postsurgical )

• Laminectomy induced instability

• Direct disruption of the facet joint complex

• Direct disruption of pars interarticularis

• > 50 % posterior facet joint complex removal




Meyerding classification • Anterior translation as a

percentage of vertebral body on lateral view • Grade I : < 25 % • Grade II : 26-50% • Grade III : 51-75 % • Grade IV : 76 – 100 % • Grade V : > 100 %

( spondyloptosis )

Grade 1

Grade 1

Grade 2 Grade 3

Grade 4 Grade 5

Normal




25

Grades ( Myerding Classification)




Presentation and evaluation

• Pain at the lumbosacrum junction may radiate to the buttock and posterior thigh but rare below the knee

• Restricted motion of lumbar spine • Palpable step-off at L-S junction • Focal kyphosis at L-S junction




1-Phalen-Dickson sign: !bent-knee, hip-flexed posture with high-grade

spondylolisthesis

2-One-legged hyperextension test (stork test): !Use To differenation between

spondylolysis (+) and spondylolisthesis(-)

PHYSICAL EXAMINATION




With increasing slippage, the sacrum becomes relatively more vertical, impairing hip extension and compelling the patient to

walk with a knee-flexed, hip-flexed gait

1-Phalen-Dickson sign:




A positive one-legged hyperextension test while standing on one leg and bending backward, pain is experienced in the ipsilateral back.

2-One-legged hyperextension test (stork test):




!!!

1- Radiography: lateral view of lumbar spine is especially useful

in detection Spondylolisthesis. !

2- Computed Tomography: CT SCANNING axial or sagittal image of the lumbar spine can be performed with or without

contrast enhancment. !

3- Magnetic Resonance Imaging(MRI): has the distinct advantage of imaging of the

spine in any plane. Typically, the axial and sagittal planes are used.

!!

DIAGNOSTEC TESTS







Spondylolisthesis. Oblique projection radiograph shows the presence of bilateral pars defects (arrows), with an appearance resembling a Scottie

dog with a collar. (The collar is the pars defect.)




A) -Lateral lumbar spine. Note the pars defects (arrow) and anterior displacement of the L5 vertebra.

B) -Oblique lumbar spine. Observe the clearly visible lucent collar (arrow).




Sagittal CT reconstruction image shows the pars

defect along with grade 1 spondylolisthesis.

Spondylolisthesis. Axial CT image shows bilateral spondylolysis

(arrows). Note elongation of the spinal canal at this level




Image Diagnosis

• AP + Lateral L-S views • Stress dynamic view

(flexion and extension) - 4 mm Ant. Translation 100 Angulation • Both oblique view

for R/O pars fracture




DIFFERENTIAL DIAGNOSIS !

!• Lumber facet-arthropathy . • Coccyx pain. • Mechanical low back pain . • Overuse Injury. • Lumber compression Fracture. • Lumber canal stenosis . • Lumbar disk herniation .

!!!




• degenerative arthritis affecting the facet joints in the spine

• Low back pain can radiate to gluteal, back of the thigh and rarely below the knee.

• was no numbness, no muscle weakness and the reflexes were normal.

• Stiffness • Poor posture • Radiography: CT and X-ray

Lumber facet-arthropathy




Axial CT

✓ marked osteophytosis and joint space narrowing ✓ severe osteoarthritis




• Coccydynia is inflammation localized to the tailbone pain and tenderness at coccyx. !

• The pain is often worsened by sitting. • Patient leaning against the buttocks !• Radiography: CT and X-ray

Coccyx pain




Lateral radiograph (a) and sagittal CT reconstruction (b) demonstrating a fractured coccyx in a patient who was diagnosed with coccydynia following a ground-level fall

6 months earlier




• fracture of lumber spine due to trauma or pathological fracture in osteomyelitis.

• Common in woman who is near or over age 50 .

• Sudden back pain radiate to lower limb. numbness and motor weakness in lower limb if nerve roots is affected

• Radiography: CT and X-ray

Lumber compression Fracture




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• congenital narrowing of the lumbar spinal canal.

• low back pain, • weakness, numbness, pain, and loss of

sensation in the legs. • worse pain in standing or walking and

backward. It is relieved by sitting and forward. • sphincteric function impairment. • Negative straight leg raising test • Radiography: X-ray, CT and MRI

Lumbar canal stenosis




Natural history

• Multifactorial etiology • 91 % without treatment had lower back pain • 55 % had sciatica • 18 % had neurologic defect • 5 % progression and most in adolescent • Risk factor : slippage > 25% , early disc

degeneration




TREATMENT !

1. Conservative . 2. Surgery and Complications

3. Complications !




➢Treatment for spondylolisthesis depends on several factors, including the age and overall health of the person, the extent of the slip, and the severity of the symptoms. !!

➢Treatment most often is conservative and more severe spondylolisthesis might require surgery.




Nonsurgical Rx

• Mainstay of treatment at < 50 % slippage

• Brace : goal to reduce hyperlodosis and stabilize motion

• Physiotherapy • Specific training of muscle surrounding the spine




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➢Surgery might be necessary if the vertebra continues to slip or if the pain is not relieved by conservative treatment and begins to interfere with daily activities. !

➢The main goals of surgery for spondylolisthesis are:

1) to relieve the pain associated with an irritated nerve, 2) to stabilize the spine where the vertebra has

slipped out of place, 3) and to increase the person’s ability to function.

Surgical treatment




Surgical Rx

• Persistent symptoms (pain and neurologic deficits) affecting quality of life and progression of slip are indicated for surgical Rx.

• MRI for further survey (pain source and stenosis )




Surgical Rx!

!

• Instrumentation with fusion => better for immediate stability and fusion rate

• Low-grade slip with lysis => arthrodesis alone better than decompression + fusion

• High-grade slip => fusion in situ with good long term results.

• Circumferential fusion (A+P) for good fusion if anterior defect or local kyphosis




2. Fusion ➢ A spinal fusion is normally done immediately

after laminectomy for spondylolisthesis.

➢ It is designed to fuse the two vertebrae into one bone and stop the slippage from worsening. !

➢ The fusion is used to lock the vertebrae in place and stop movement between the vertebrae. !

• Types :

A. Traditional FusionB. Minimally invasive surgical spine fusion




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A. Traditional Fusion !✓ The vertebrae are affixed to one another

using surgical instrumentation. ✓ Bone graft is then placed between the

vertebrae allowing them to "fuse" together over time.

✓ This stabilizes the painful joint segment and relieves pressure from the painful spinal nerves

Examples :1. Postero-lateral fusion (PLF)2. Posterior Lumbar Interbody Fusion(PLIF)




1. posterolateral fusion (PLF) ➢ posterolateral fusion is the grandfather of fusion technique as

it was developed just over 100 years ago. ➢ In a posterior approach to lumbar fusion, the surgeon makes

an incision down the middle of the lower back. ➢ One of the criticisms of PLF is that it involves an extensive

dissection (the stripping of muscle and fascia off of bone) of the adjacent transverse processes, facet(s) and sometimes lamina.

➢ After the decompression, the surgeon will place graft material along the sides of the vertebrae to stimulate bone growth.

➢ Titanium screws and rods are often used to provide immediate stability to the spine until a solid fusion has been achieved.




2. Posterior Lumbar Interbody Fusion(PLIF):

➢ In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back).

➢ The surgeon works from the back of the spine and removes the disc between the problem vertebrae.

➢ Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space)

➢ Transpedicular instrumentation is attached to stabilize the motion segment while fusion occurs.




Spondylolytic spondylolisthesis L4,5

L4 Pars fracture




Degenerative Spondylolisthsis L4,5

with Spinal Stenosis




Degenerative Spondylolisthsis L4,5

with Spinal Stenosis S/P OP




o Implant failure. o Pseudoarthrosis. o Nonunion. o Foot drop. o Spinal compression. o Acute bowel ischaemia

Complications of surgical repair




- Spondylolisthesis is a forward or backward slippage of one vertebra on an adjacent vertebra.

!- Causes of spondylolisthesis include trauma,

degenerative, tumor, and birth defects. !

- Symptoms of spondylolisthesis include lower back or leg pain, hamstring tightness, and numbness and

tingling in the legs. !

- diagnosis is mainly based on imaging . !

- Most people with spondylolisthesis can be treated conservatively, without the need for surgery.

!- Patients who fail to improve with conservative

treatment may be a candidate for surgery.

SUMMARY




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Spondylolisthesis as an entity for back pain agrasen hospital gondia vidarbha dr sandeep c agrawal ...

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