SPONDYLOLISTHESIS

Presented by :Dr. Mohit Sharma

RELEVANT ANATOMY:

Definition:

• The term "Spondylolisthesis" refers to a condition where one of the vertebrae (usually L5) becomes misaligned anteriorly (slips forward) in relation to the vertebra below. This forward slippage is caused by a problem or defect within the pars interarticularis.

• Greek word spondylos- Spine and olisthanein- to slip.

SPONDYLOLISTHESIS

HISTORY:

• Herbiniaux:- first described spondylolisthesis.• Term coined by:- Killian.• FIRST DESCRIBED AS

PSUEDOSPONDYLOLISTHESIS BY JUNGHANNS.

• Newman in 1963:- coined the phrase Degenerative spondylolisthesis.

INCIDENCE:

• PATIENTS OLDER THAN 40 YEARS.• L4-L5 MORE THAN OTHER LUMBAR LEVELS• L3-L4 MORE AFFECTED THAN L5-S1.• WOMEN> MEN.• SAGGITAL FACET ANGLES OF MORE THAN 45

DEGRESS.• DIABETES – ROLE UNCLEAR.• ESTROGEN – ROLE UNCLEAR.

THEORIES: The first theory proposed a failure of ossification during

embryonic development, leading to a pars interarticularis defect at birth

The second theory demonstrated that the pars defect began to appear around age six and became progressively more common till age 16. After age 16, the incidence fell and rarely developed after adolescence

Saggital Facet theory predilection of slippage because of facet orientation that does not resist anterior translation.

Disc degeneration theory disc narrows-> overloading of facets -> secondary remodelling -> anterolisthesis.

It is currently thought that the defect develops from small stress fractures that fail to heal and form a chronic nonunion.

NEWMAN AND STONE CLASSIFICATION:

• CONGENITAL,• SPONDYLOTIC,• TRAUMATIC,• DEGENERATIVE,• PATHOLOGICAL.

Type Name DescriptionI Congenital Dysplastic abnormalities

II Isthmic

A Lytic (stress fracture)B Healed fracture (elongated, intact)

C Acute high energy fracture

III Degenerative Segmental instability

IV Traumatic Fracture of hook other than pars

V Pathologic Underlying pathology

VI Iatrogenic Surgical excision of posterior elements

WILTSE,NEWMAN AND MC NAB CLASSIFICATION:-

Marchetti And Bartolozzi Classification:

TYPES Sub Types: Causes/Etiology

Developmental Lysis.

Elongation

Acquired Traumatic Stress fractures

Acute fractures

Iatrogenic

Pathologic

Degenerative

Pathophysiology

• Dysplastic pathway

• Traumatic pathway

Dysplastic pathway Traumatic pathway

Weakness in the hook & catch mechanism

Body weight transmitted through

weak zone

Soft tissue restraints: plastic deformation

Growth plate overloaded

Repetitive cyclic loads (sports)

Stress fracture of a Normal pars

Hard cortical pars pre-disposes to fatigue

fracture and non-union

Predisposes to a vertical subluxation

Dysplastic changes• Proximal sacral rounding

• Trapezoidal L5

• Vertical sacrum

• Junctional kyphosis

• Compensatory hyper-lordosis

Contributes to the mechanics of progression, but not causation

Proximal sacral rounding

CLINICAL EVALUATION:

• Mostly asymptomatic ,• LEG PAIN,• Tiredness and • NEUROGENIC CLAUDICATION.• Unilateral sciatica,• Sense of instability.

CLINICAL SIGNS:• Gait:- pelvic waddle gait.• Above slip level- Lordotic posture,• Below slip-Kyphosis of lumbosacral junction,• Heart shaped buttocks,• Shortening of trunk with complete absence of waist line,• Z deformity,• Step sign,• Hamstring tightness,• Objective signs of motor weakness, reflex change and

sensory deficit only seen with Severe slips.

DIAGNOSTIC IMAGING:

• XRAYS- FERGUSON AP VIEW(By angling the x-ray beam parallel to the L5-S1 disc. With this view, the profile of the L5 pedicles, transverse processes, and sacral ala is more easily seen. )• LATERAL VIEW.• OBLIQUE VIEWS.• FLEXION AND EXTENSION VIEWS IN LATERAL

VIEWS.

MEYERDING GRADING SYSTEM:

GRADING

GRADE 1 displacement of 25% or less;

GRADE 2 between 25% and 50%

GRADE 3 between 50% and 75%;

GRADE 4 more than 75%

GRADE 5 the position of L5 completely below the top of the sacrum -SPONDYLOPTOSIS.

ULLMANS SIGN A LINE DRAWN UPWARD FROM THE ANTERIOR SURFACE OF SACRUM NORMALLY IS PROJECTED AT OR IN FRONT OF THE ANTEROINFERIOR ANGLE OF BODY OF LAST LUMBAR VERTEBRA.

WHEN ITS INTERSETED IT SHOWS FORWARD DISPLACEMENT.

PERCENTAGE SLIP:DISTANCE FROM LINE DRAWN PARALLEL TO POSTERIOR PORTION OF FIRST SACRAL VERTEBRAE TO LINE PARALEL TO POSTERIOR PORTION OF BODY OF L5.

SLIP ANGLE:BY INTERSECTION OF A LINE DRAWN PARALLEL TO INFERIOR ASPECT OF L5 BODY AND LINE DRAWN PERPENDICULAR TO POSTERIOR ASPECT OF BODY OF S1.

BOXALL ET AL

Are the best predictors of instability or progression of the spondylolisthesis deformity.

OTHER DIAGNOSTIC INVESTIGATIONS:

• CT, Myelography and MRI,• Discography,• Bone scan,

TREATMENT OPTIONS:-

NON OPERATIVE

Epidural steroid

Neurogenic claudication

NSAIDS, antidepressants, muscle relaxants

Manipulation , traction and

braces

Rehabilitation

RISK FACTORS FOR PROGRESSION OF SPONDYLOLISTHESIS:

RISK FACTORS RISK FACTORS

Clinical Roentgenographic Risk factors

9 to 15 years Dysplastic

Girls > Boys Dome shaped, vertical sacrum

Episodes of back pain Trapezoid shaped L5

Postural deformity or gait deformity due to hamstring spasms

more than 50% slip(grade3 and 4)

Increasing slip angle

Instability

SURGICAL TREATMENT :

• Guidelines:• For most patients with back pain and leg pain

with spondylolisthesis.• For patients with failure of previous posterior

fusion.• For patients over age 60 years with good

stability of the L5 vertebrae body but with signs and symptoms of nerve root compression.

Operative treatment for DEG. Spondylolisthesis:

• For unremitting back and leg pain after adequate Non operative treatment.

*(only 10-15% require surgery).• Decompression,• Decompression With Fusion,• PLIF and TLIF,• Anterior spinal fusion,• Decompression and combined fusion.

DECOMPRESSION:

• In patients with significant disc collapse and no pathological motion dynamic X -rays.

DECOMPRESSION WITH FUSION:

• CLAUDICTORY PAIN AND LEG PAIN,• PRESERVED DISC HEIGHT,• OSTEOPOROSIS(PARS FRACTURE),• ABSENCE OF OSTEOPHYTE AND DYNAMIC

MOTION PRESENT.*(Fusion status and presence or absence of comorbid disease.)

PLIF AND TLIF:

• Discographically concordant single level axial back pain with radiculopathy,

• Minimal disc degenerative changes,• Preserved disc height,• For revison surgeries with inadequate posterior

fusion,• For patients with hypermobile levels,• For small or absent transverse process at the levels

to be fused.

ANTERIOR SPINAL FUSION:

• Only if some indirect spinal decompression is provided by eradication of disc , restoration of disc height and ligamentotaxis by placement of structural bone grafts or cage after distraction of disc space and tensioning of posterior ligamentous structures.

DECOMPRESSION AND COMBINED FUSION:

• For Anterior interbody fusion:• Kyphosis and • Posterior saggital vertical axis,• For posterior interbosy fusion:• For saggitally neutral or lordotic spines with

intac disc

DevelopmentalLess than 50% slip

PL fusion

Spondylotic defect VAN DAM Technique

More than 50% slip • Bilateral PL fusion• Reduction with anterior spinal

fusion• Reduction with posterior spinal

instrumentation

In children Cast reduction and fusion by Scagleitti technique

Neurological less than 50% slip L5-S1 PL fusion

Neurological with more than 50% slip L4-S1 PL fusion

For spondyloptosis or grade 5 Vertebrectomy with posterior spinal instrumentaion with L4-S1 fusion.

• Broadly divided into two categories: – Direct repair of the pars defects – Arthrodesis of the involved segments

OPERATIVE TREATMENT OF PARS INTARARTICULARIS

Pseudarthrosis Repair /Direct Repair

Area of soft-tissueremoval withoutdecortication

Area ofdecortication

Locationof pedicle

Spondylolyticdefect

Recipient bed prepared for autogenous cancellous bone graft

Pseudarthrosis Repair /Direct Repair

Area of excision ofPosterior elements

Ligamentumflavum not tobe excised

Nerve root beforedecompression

Posterior elements overlying affected nerve root are excised.

Pseudarthrosis Repair /Direct Repair

Head of variableanglescrew

Area ofbone graft

Starting point ofscrew insertion

Variable-angle pedicle screw and bone graft inserted

Pseudarthrosis Repair /Direct Repair

Rod

Laminarhook

Rod attached to head of screw with variable angle eyebolt. Laminar hook attached to rod.

L 5 VERTEBRECTOMY:

Resection of the L5 vertebra with reduction of L4 onto S1 described by Gaines and Nichols in 1985