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Traumatic Spondylolisthesis

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  • Pedical screws used for pat with significant instability

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  • 1. Dr. M. M. Prabhakar Medical Superintendent Director Govt. Spine Institute Prof. & Head Department of Orthopaedics B. J. Medical college Ahmedabad
  • 2. Spondylolisthesis  Definition: Ant. or post. translational displacement of one vertebral body over another.  Due to: 1. Trauma 2. Degenerative changes 3. Defects in the bony architecture congenital or pathological
  • 3. Spondylolisthesis Type I  Dysplastic Spondylolisthesis: secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra
  • 4. Type II Isthmic or spondylolytic: the lesion is in the isthmus or pars interarticularis, If a defect in: the pars interarticularis & no slipping spondylolysis. If one vertebra has slipped forward: Spondylolisthesis. Type II A: Lytic or stress spondylolisthesis and is most likely caused by recurrent micro-fractures caused by hyperextension. It is also called a "stress fracture" of the pars interarticularii and is much more common in males
  • 5. Type II B probably also occurs from micro-fractures in the pars. However, in contrast to Type II A, the pars interarticularii remain intact but stretched out as the fracture fill in with new bone Type II C is very rare in occurrence and is caused by an acute fracture of the pars. Nuclear imaging may be needed to establish diagnosis
  • 6. Type III is a degenerative spondylolisthesis, and occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement. Most often seen in older patients. There is no pars defect and the vertebral slippage is never greater than 30%
  • 7. Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis
  • 8. Type V, pathologic spondylolisthesis, occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases
  • 9. Traumatic Listhesis Traumatic listhesis is rare condition. Results from Acute fracture of the posterior element other then pars… It is fracture dislocation of the spine…involving all three columns… It is the shear forces which cause break in the posterior stabilizers and the force is transmitted at the level of Intervertebral disc resulting in anterior or posterior displacement of the vertebral body.
  • 10. Commonly occurs at cervical spine with axis fractures…resulting in displacement at c2 c3 level (Hangman’s fracture) Rare in lumbar spine usually associated with high velocity trauma. Above L2 level it is fracture dislocation of the spine involving all three columns.
  • 11. Pathophysiology
  • 12. Clinical presentation Severe back pain or neck pain Leg pain or arm pain dermatomal with associated neurological deficit Or combination of both Restriction of the spine movement
  • 13. Physical exam Palpation:  Spasms Paraspinous muscle limiting flex/ext  Step-off Tight Hamstrings Compensatory Hyperlordosis Waddling gait Neurological deficits:  Motor/sensory  Nerve compression in lat. recesses  Cauda equina syndrome (rare)
  • 14. Imaging  X-rays: 1. A/P 2. Lat flex./ext. – 1. Supine and standing Oblique – Integrity of the pars “Scotty Dog”
  • 15. Imaging NORMAL
  • 16. Imaging  Grading: 1. 2. 3. 4. 5. 6. 0 = no slip 1 = 0 – ¼ (25%) 2 = ¼ - ½ (50%) 3 = ½ - ¾ (75%) 4 = ¾ - 1 (100%) 5=dislocation
  • 17. Imaging CT scan: evaluate boney pathology MRI: evaluate soft tissue pathology Nerve compression Spinal compression Disc disruption SPECT: (Single photon emission Computer tomography) Inconclusive x-rays despite high clinical suspicion - Acute vs chronic for differential diagnosis
  • 18. CT Image
  • 19. Conservative Treatment 1. 2. 3. NSAIDS Bed rest Steroid injections Acute phase with neurological involvement.  Not for long term use  1. Bracing
  • 20. Conservative Treatment  Physical therapy: 1. 2. 3. Physiotherapy Tilt table mobilization Muscle strengthening exercise Only after the acute inflammatory pain subside and spasm relives…usually after 6 wks.
  • 21. Conservative treatment
  • 22. CT Image Post treatment
  • 23. Surgical Intervention  GOALS: 1. 2. Stabilization Decompression of neural elements
  • 24. Surgical Intervention  Indications:  High Grade Slip : 1. 2. Cosmetic Gait abnormalities  Failure of conservative management: 1. 2. 3. 4. Severe pain Radiological evidence of instability Documented progression of slip Progression of neurologic signs
  • 25. Surgical Intervention  Contradictions: 1. 2. 3. 4. Smoking Disability/compensation claims, litigation Previous fusions, pseudoarthrosis repairs Predictors Poor Outcome: – – – – – Male Middle age Cigarettes Multiple surgeries Compensation/ litigation
  • 26. Surgical Intervention  Complications: 1. Bone graft, chronic pain 5% pts. 2. Fusion, pseudoarthrosis, bleeding, infection 3. Instrumentation, loss of fixation, loosening and bone screw interface, implant breakage 4. Decompression (neural elements), nerve damage, dural tears, arachnoiditis, surgical scars
  • 27. Surgical Intervention Decompression with Posterior Lateral Fusion:  1. 2. 3. Younger pts (30 y.o.) Intact vertebral disk Fusion: – – 1. In situ Pedicle screws McGuire and Anderson: – – – – – 27 pts, military recruits Stable, low grade slips No difference in fusion rate with in situ vs pedicle screws Smokers less effective outcomes (40% nonunion) Fusion did not determine success 67% went back to military service, decrease leg and back pain
  • 28. Surgical Intervention Ant. Column support and Posterior Stabilization: Interbody Graft techniques: Mini-laportomy retroperitoneal  Requires separate incision  Post. Trans-foraminal approach  Post lateral fusion with pedicle screws Post. Trans-foraminal approach: Decompression and stabilization 1 approach  Decreased risk of neural compromise 
  • 29. Surgical Intervention Ant. Column support and Posterior Stabilization: Spruit et alt. 21% pre-op slips 7 % post op 100% fusion rates 75% returned to pre injury activity
  • 30. Surgical Intervention
  • 31. Surgical Intervention Reduction of High Grade Spondylolisthesis/Spondyloptosis Advocated by some authors Improve cosmesis  Correct slip angle  Improve kyphosis  No need to perform in adults HIGH rate of neural compromise Don’t do it!!!!!
  • 32. Hangman’s Fracture Younger age group (Avg 38 yrs) Usually due to hyperextension-axial compression forces (windshield strike) Neurologic injury seen in only 5-10 % (acutely decompresses canal) Traditional treatment has been Halo-vest Collar adequate if < 6 mm displaced Coric et al JNS 1996
  • 33. Hangman’s Fracture  Traumatic spondylolisthesis of C2.  The fracture line passes through the neural arch.  It may or may not result in ant. displacement of C2 on C3.  Most commonly caused by a Motor Vehicle accident and a fall.  Current classification (Levine & Edwards) is based on radiological findings: 4 types are described and each category has different mechanism of trauma.
  • 34. Type I Mechanism: hyperextension – axial loading Integrity of ALL, PLL, and Disc No angulation. Displacement < 3 mm Stable fracture: Collar.
  • 35. Type II Significant angulation and translation. Extension – axial loading followed by flexion. Most common type Unstable: halo vest.
  • 36. Type IIA Significant angulation No translation Flexion – distraction Unstable: Halo vest
  • 37. Type III Severe angulation and translation + unilateral or bilateral C2-3 facet dislocations. Flexion – compression. Unstable fractures: Surgical reduction and fixation.
  • 38. Treatment Low grades like type I and Type II are treated conservatively Skull traction (contra indicated in IIA causing distraction and further damage) Cervical collar/ SOMI brace Halo traction device High grade type II facture require surgical intervention Open reduction, fixation and fusion Trans pedicular screw fixation for motion preservation in type II fracture
  • 39. Direct pars screw: the C2 pedicle should be palpated using a fine dissector after removal of soft tissues.
  • 40. Key points Conservative treatment is mainstay Progression of slip rarely occurs Decompression and fusion give excellent results for radiculopathy and back pain 4. Fusion 360 degrees increases fusion rates but does not correlate with better outcomes 5. Poor outcomes in high grade of cervical listhesis. 1. 2. 3.
  • 41. THANK YOU