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TS Fong
12.3.2012
SPONDYLOLISTHESIS
 Forward translation of one
vertebra on another in the
sagittal plane of the spine
 Spondylolysis
 de...
ANATOMY
 Pars
 region between the superior and inferior articulating
facet of the vertebra
 weakest area in the neural ...
 Pars defects
 not observed in newborns or nonambulatory
patients
 lysis or elongation does not occur in primates
that ...
EMBRYOLOGY AND OSSIFICATION CENTRES
SAGI ET AL SPINE 1998
 pars ossify at 12-13 weeks gestation
via endochondral ossifica...
CLASSIFICATION
CLASSIFICATION
WILTSE, NEWMAN AND MACNAB 1976
 Type I: Dysplastic (child)
 Type II: Isthmic (5-50 yrs)
 Type III: Degen...
DYSPLASTIC SPONDYLOLISTHESIS
 dysplasia/aplasia of posterior facet joints of
the L5/S1 levels
 constant spina bifida occ...
Lateral radiograph
• rounding of the top of the sacrum as
L5 has rolled round anteriorly due to
poorly formed posterior fa...
ISTHMIC SPONDYLOLISTHESIS
 repetitive cyclical extension/torsion of the spine
 repetitive infraction fatigue failure of ...
Lateral radiograph of a lytic
spondylolisthesis
Oblique radiograph of a lytic
spondylolisthesis
DEGENERATIVE SPONDYLOLISTHESIS
 incompetence of the posterior facet joints
 10x more common at the L4/5 than the L5/S1
...
CT scan
• level of a degenerative
spondylolisthesis
• facets have come forward to
contact the back of the
vertebral body a...
Traumatic spondylolisthesis
 acute vertebral fractures do not occur through the
pars, but through pedicles, bodies, discs...
CLASSIFICATION
MARCHETTI AND BARTOLOZZI 1997
 etiology-based system
 importance of high and low grade developmental spon...
LOW GRADE SPONDYLOLISTHESIS
 low grade variety present in young adults
 frequently associated with spina bifida
 slip i...
HIGH GRADE SPONDYLOLISTHESIS
 Usually at L5-S1 and become symptomatic in adolescents
 wedge shaped L5 and a domed vertic...
CLASSIFICATION BY MARCHETTI AND
BARTOLOZZI
SPINE/SRS SPONDYLOLISTHESIS SUMMARY STATEMENT 2005
 based on etiology
 clearl...
NATURAL HISTORY
 wide spectrum of clinical presentation
 dysplastic and isthmic spondylolisthesis present during
childho...
NATURAL HISTORY
 hamstring tightness, spinal deformity, gait
abnormality
 frank neurology
 severe degrees of spondyloli...
PHALEN-DIXON SIGN
 sciatic crisis typically seen in high
grade adolescent
spondylolisthesis
 sign includes
 sciatic pai...
BACK PAIN AND SPONDYLOLISTHESIS
 The cause of back pain is unclear and is
multifactorial
 The pain may be due to
 disc ...
RADIOGRAPHY
Defect in the pars interarticularis –
‘collar’ around the ‘neck’ of an illusory
‘dog’- oblique xray
THE BENDING FILMS
 demonstrate persistent
motion and instability
 especially in the presence of
degenerated disc disease...
RADIOLOGICAL EXAMINATION
 large number of suggested and preferred radiological parameters to
assess spondylolisthesis
 O...
RADIOGRAPHIC INDEX
Slip angle of Boxall
superior border is chosen
 more constant
 not affected by adaptive changes
comm...
RADIOGRAPHIC INDEX
 the degree of slips or transitional displacement (Meyerding)
RADIOLOGICAL EXAMINATION
CT scan
 helpful in preoperative planning especially in cases with
severe dysplasia
MRI
 assess...
MANAGEMENT
PREDICTORS OF SLIP PROGRESSION
 female gender
 prepubescence
 trapezoidal L5
 domed and vertical sacrum and
sagital ro...
INDICATIONS FOR SURGERY
AGABEGI ET AL (THE SPINE JOURNAL 2010)
 Slip progression
 more common in skeletally immature pat...
INDICATIONS FOR SURGERY
AGABEGI ET AL (THE SPINE JOURNAL 2010)
 Neurological deficit
 In most cases, the L5 nerve root i...
CONSERVATIVE TREATMENT
 Directed at symptomatic relief
 Rest
 anti-inflammatory agents
 lumbar corset
 Physical thera...
SURGICAL TREATMENT
 directed towards symptoms and etiology
 radiculopathy
 neurologic deficit from spinal stenosis
 in...
ISTHMIC SPONDYLOLISTHESIS
TREATMENT
VACCARO ET AL
Findings Treatmennt
Grade I observation
Grade II Asymptomatic: Observe
S...
ISTHMIC SPONDYLOLISTHESIS
OPERATIVE TREATMENT
procedure advantage/disadvantage results
Defect repairs Preserve motion
Tech...
ROLE OF REDUCTION
( AGABEGI ET AL, 2010 )
 high-grade spondylolisthesis causes lumbosacral
kyphosis --- sagittal imbalanc...
DEGENERATIVE SPONDYLOLISTHESIS
OPERATIVE TREATMENT OPTIONS
 Decompressive laminectomy
 Decompression with posterolateral...
THE FUSION OPTIONS
achieve posterior column stability
 posterolateral intertransverse fusion (PLF)
achieve anterior col...
POSTERIOR INTERTRANSVERSE FUSION
 historically most popular
way of performing fusion
 direct decompression of the
neural...
ANTERIOR LUMBAR INTERBODY FUSION
 allows for complete discectomy
 permits placement of a large
interbody graft
 facilit...
ANTERIOR LUMBAR INTERBODY FUSION
 The disadvantages
 related to the approach
 risk of injury to major vessels,
retroper...
CIRCUMFERENTIAL FUSION
 the benefits of anterior and posterior
surgery ( TLIF/PLIF)
 circumferential stability obviously...
SPONDYLOPTOSIS
 severe symptoms of low back pain,
deformity, and neurologic symptoms or
deficits
 Surgical options
 in ...
Gaines Procedure
• resection of L5 and
reduction of L4
onto the sacrum
• combined anterior
and posterior
approach
THANK YOU
Operative Vs Non-operative
 multicenter, prospective study
 highest level of evidence
 guide decision-making on operative vs nonoperative
care for...
Conclusion
 patients with degenerative spondylolisthesis and
spinal stenosis treated surgically showed
substantially grea...
DEGENERATIVE SPONDYLOLISTHESIS
OPERATIVE TREATMENT OPTIONS
Decompression alone or decompression with
segmental arthrodesis...
DEGENERATIVE SPONDYLOLISTHESIS
OPERATIVE TREATMENT OPTIONS
Instrumentation or non-instrumented fusion in
degenerative spon...
Spondylolisthesis
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Spondylolisthesis

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Spondylolisthesis

  1. 1. TS Fong 12.3.2012
  2. 2. SPONDYLOLISTHESIS  Forward translation of one vertebra on another in the sagittal plane of the spine  Spondylolysis  defect in the pars interarticularis of lumbar vertebra  most commonly due to repeated and increased stress on the pars interarticularis
  3. 3. ANATOMY  Pars  region between the superior and inferior articulating facet of the vertebra  weakest area in the neural arch  susceptible to stress fracture
  4. 4.  Pars defects  not observed in newborns or nonambulatory patients  lysis or elongation does not occur in primates that do not have an upright bipedal gait  presence of lumbar lordosis (unique in humans) is necessary for spondylolisthesis to occur
  5. 5. EMBRYOLOGY AND OSSIFICATION CENTRES SAGI ET AL SPINE 1998  pars ossify at 12-13 weeks gestation via endochondral ossification Lumbar Vertebrae  ossification centre in the region of the pars  uneven trabeculation and cortication  ossification centre that arises at the upper end of pedicle  uniform trabeculation throughout the pars  potential stress riser which could be susceptible to fatigue fracture
  6. 6. CLASSIFICATION
  7. 7. CLASSIFICATION WILTSE, NEWMAN AND MACNAB 1976  Type I: Dysplastic (child)  Type II: Isthmic (5-50 yrs)  Type III: Degenerative (older)  Type IV: Traumatic  Type V: Pathologic
  8. 8. DYSPLASTIC SPONDYLOLISTHESIS  dysplasia/aplasia of posterior facet joints of the L5/S1 levels  constant spina bifida occulta at the L5 level – congenital nature  concomitant elongation of the pars interarticularis --- frank lysis  condition is strongly familial, with as many as a third of first-degree relatives affected with the dysplastic form (Wynne-Davis et al)
  9. 9. Lateral radiograph • rounding of the top of the sacrum as L5 has rolled round anteriorly due to poorly formed posterior facet joints AP view • 'Napoleon's hat' appearance of L5 superimposed through the sacrum
  10. 10. ISTHMIC SPONDYLOLISTHESIS  repetitive cyclical extension/torsion of the spine  repetitive infraction fatigue failure of the pars  high prevalence rate  highest biomechanical forces on the pars at L5/S1 level  commonest site of a lytic spondylolysis
  11. 11. Lateral radiograph of a lytic spondylolisthesis Oblique radiograph of a lytic spondylolisthesis
  12. 12. DEGENERATIVE SPONDYLOLISTHESIS  incompetence of the posterior facet joints  10x more common at the L4/5 than the L5/S1  not encountered in the under 50-year-old  the degree of slippage in the sagittal plane is no good guide to the amount of neural compression  fourth dimension, time, is important  degenerative process going on for years and years  patients are much more readily able to adapt to neural compression than for example with a rapidly growing tumour
  13. 13. CT scan • level of a degenerative spondylolisthesis • facets have come forward to contact the back of the vertebral body and completely close off the epidural space DEGENERATIVE SPONDYLOLISTHESIS
  14. 14. Traumatic spondylolisthesis  acute vertebral fractures do not occur through the pars, but through pedicles, bodies, discs  so-called 'traumatic spondylolistheses' are not discrete entities  should not be part of the generic spondylolisthesis classification Pathological spondylolisthesis  metastasis and rheumatoid disease are the more common causes  disease of the whole motion segment rather than the pars in particular
  15. 15. CLASSIFICATION MARCHETTI AND BARTOLOZZI 1997  etiology-based system  importance of high and low grade developmental spondylolisthesis  permitting early recognition and treatment
  16. 16. LOW GRADE SPONDYLOLISTHESIS  low grade variety present in young adults  frequently associated with spina bifida  slip is characterized by translation without any angulatory or kyphotic component
  17. 17. HIGH GRADE SPONDYLOLISTHESIS  Usually at L5-S1 and become symptomatic in adolescents  wedge shaped L5 and a domed vertical sacrum  anterior translation of L5 associated with angulation --true lumbosacral kyphosis  potential to develop into spondyloptosis if untreated or mismanaged
  18. 18. CLASSIFICATION BY MARCHETTI AND BARTOLOZZI SPINE/SRS SPONDYLOLISTHESIS SUMMARY STATEMENT 2005  based on etiology  clearly distinguishes between developmental and acquired forms of this deformity  highlights the pathogenesis of the different types of spondylolisthesis  potentially has the most relevance to natural history, risk of progression, and implications for treatment
  19. 19. NATURAL HISTORY  wide spectrum of clinical presentation  dysplastic and isthmic spondylolisthesis present during childhood and adolescence  dysplastic variety usually at a younger age than isthmic  early stages - low back pain is the only consistent clinical feature  immature patient - high index of suspicion should be raised about the possibility of an underlying spondylolisthesis
  20. 20. NATURAL HISTORY  hamstring tightness, spinal deformity, gait abnormality  frank neurology  severe degrees of spondylolisthesis  usually dysplastic variety - lower lumbosacral nerve roots can be compressed behind the upper back of the sacrum  isthmic spondylolisthesis  some degree of L5 radicular pain is not uncommon  hypertrophic callus around the lysis  degenerative spondylolisthesis  spinal claudication in association with low back pain
  21. 21. PHALEN-DIXON SIGN  sciatic crisis typically seen in high grade adolescent spondylolisthesis  sign includes  sciatic pain  vertical sacrum and pelvis  lumbosacral kyphosis  tight hamstrings  hyperlordotic lumbar spine  waddling gait
  22. 22. BACK PAIN AND SPONDYLOLISTHESIS  The cause of back pain is unclear and is multifactorial  The pain may be due to  disc degeneration  facet degeneration  chronic nerve root irritation from compression or traction  patient may have accompanying spinal stenosis
  23. 23. RADIOGRAPHY
  24. 24. Defect in the pars interarticularis – ‘collar’ around the ‘neck’ of an illusory ‘dog’- oblique xray
  25. 25. THE BENDING FILMS  demonstrate persistent motion and instability  especially in the presence of degenerated disc disease at the level of spondylisthesis  disc degeneration and collapse of the disc space is an attempt to stabilize the motion segment
  26. 26. RADIOLOGICAL EXAMINATION  large number of suggested and preferred radiological parameters to assess spondylolisthesis  Only 2 are of any great importance (Wiltse LL et al ) 1. The amount of displacement 2. The slip angle (the angular relationship between L5 and S1 in the dysplastic form of spondylolisthesis) Percentage slip (x/y(x 100) slip angle or angle of sagittal rotation
  27. 27. RADIOGRAPHIC INDEX Slip angle of Boxall superior border is chosen  more constant  not affected by adaptive changes commonly occur in the inferior end plate represent local kyphosis across the L5-S1 motion segment
  28. 28. RADIOGRAPHIC INDEX  the degree of slips or transitional displacement (Meyerding)
  29. 29. RADIOLOGICAL EXAMINATION CT scan  helpful in preoperative planning especially in cases with severe dysplasia MRI  assess neural foramen on the sagittal views  determine extent of associated disc disease  disc herniation is common  25% cases occur at the level above the slip  15% occur at the level of the slip itself  rule out tumor or infection
  30. 30. MANAGEMENT
  31. 31. PREDICTORS OF SLIP PROGRESSION  female gender  prepubescence  trapezoidal L5  domed and vertical sacrum and sagital rotation  slip angle > -10o  high grade slip (>50% slip progression)  inclined sacrum (>30o beyond vertical)
  32. 32. INDICATIONS FOR SURGERY AGABEGI ET AL (THE SPINE JOURNAL 2010)  Slip progression  more common in skeletally immature patients who have not reached the adolescent growth spurt  the higher the grade of slip, the more likely it is to progress  slip progression rarely occurs in adults  High-grade slip with significant lumbosacral kyphotic deformity causing sagittal imbalance
  33. 33. INDICATIONS FOR SURGERY AGABEGI ET AL (THE SPINE JOURNAL 2010)  Neurological deficit  In most cases, the L5 nerve root is involved  Low back pain unresponsive to a prolonged course of conservative treatment  Radicular pain with associated nerve root compression on imaging studies that is not responsive to conservative treatment
  34. 34. CONSERVATIVE TREATMENT  Directed at symptomatic relief  Rest  anti-inflammatory agents  lumbar corset  Physical therapy  abdominal strengthening exercises  hamstring stretching  avoidance of extension exercises which will exacerbate the symptoms  Sinaki et al showed 3-year outcomes were significantly better in patients who followed the flexion exercise program compared to extension exercise
  35. 35. SURGICAL TREATMENT  directed towards symptoms and etiology  radiculopathy  neurologic deficit from spinal stenosis  instability pain  discogenic pain  the mainstay of treatment is  Decompression  Fusion  Instrumented  Non instrumented
  36. 36. ISTHMIC SPONDYLOLISTHESIS TREATMENT VACCARO ET AL Findings Treatmennt Grade I observation Grade II Asymptomatic: Observe Symptomatic: Activity modification Failed: Surgery Grade III-IV Surgery
  37. 37. ISTHMIC SPONDYLOLISTHESIS OPERATIVE TREATMENT procedure advantage/disadvantage results Defect repairs Preserve motion Technically difficult Variable 60-90% Laminectomy (Gills) Increase instability Poor long term outcome abandoned Posterolateral fusion (in situ) Improved symptoms Children Adult: variable Reduction and fusion Allow correction Add stability Slippage >60% Slip angle >50 degree Age 12 to 30 (Bradford 1988) Anterior and posterior fusion Additional stability 360 degree fusion Difficult surgery
  38. 38. ROLE OF REDUCTION ( AGABEGI ET AL, 2010 )  high-grade spondylolisthesis causes lumbosacral kyphosis --- sagittal imbalance  reduction procedure controversial  literature support both sides of the argument  high rate of neurologic complications  reserved for patients with loss of global sagittal balance because of significant lumbosacral kyphosis  circumferential fusion and stable fixation with iliac screws are strongly recommended to prevent slip progression and pseudarthrosis
  39. 39. DEGENERATIVE SPONDYLOLISTHESIS OPERATIVE TREATMENT OPTIONS  Decompressive laminectomy  Decompression with posterolateral fusion  Decompression with instrumented fusion  Long-term follow-up in patients with degenerative spondylolisthesis reveals a positive correlation between fusion and improved clinical outcome
  40. 40. THE FUSION OPTIONS achieve posterior column stability  posterolateral intertransverse fusion (PLF) achieve anterior column stability  anterior lumbar interbody fusion (ALIF) achieving a circumferential fusion  posterior lumbar interbody fusion (PLIF)  transforaminal interbody fusion (TLIF) no consensus of what constitutes optimal surgical treatment surgical option must be individualized
  41. 41. POSTERIOR INTERTRANSVERSE FUSION  historically most popular way of performing fusion  direct decompression of the neural elements  deformity correction  stability with pedicle screw instrumentation  the disadvantages are  less optimal fusion rate: graft under tension  as it does not address the anterior column: persistent discogenic low back pain is common
  42. 42. ANTERIOR LUMBAR INTERBODY FUSION  allows for complete discectomy  permits placement of a large interbody graft  facilitate slip angle correction  reconstructs the disc space height  anterior graft  biomechanically compressive environment  allowing optimal fusion
  43. 43. ANTERIOR LUMBAR INTERBODY FUSION  The disadvantages  related to the approach  risk of injury to major vessels, retroperitoneal and intraperitoneal structures  in males, the sympathetic plexus can be damaged and cause retrograde ejaculation  does not allow direct nerve roots decompression  Suk et al. anterior support would be helpful for preventing reduction loss in cases of spondylolytic spondy- lolisthesis of the lumbar spine
  44. 44. CIRCUMFERENTIAL FUSION  the benefits of anterior and posterior surgery ( TLIF/PLIF)  circumferential stability obviously promotes high fusion rate  Open or MIS
  45. 45. SPONDYLOPTOSIS  severe symptoms of low back pain, deformity, and neurologic symptoms or deficits  Surgical options  in situ circumferential fusion technique described by Smith and Bohlman  Gaines procedure (resection of L5 and reduction of L4 onto the sacrum through a combined anterior and posterior approach)  Gaines technique is associated with a high rate of postoperative neurologic deficits and is generally reserved for the most severe deformities
  46. 46. Gaines Procedure • resection of L5 and reduction of L4 onto the sacrum • combined anterior and posterior approach
  47. 47. THANK YOU
  48. 48. Operative Vs Non-operative
  49. 49.  multicenter, prospective study  highest level of evidence  guide decision-making on operative vs nonoperative care for the specific disorder of degenerative spondylolisthesis  treatments compared were lumbar laminectomy with a single level fusion vs nonoperative treatment  treating surgeon determined type of fusion (uninstrumented posterolateral fusion, instrumented posterolateral fusion, circumferential fusion)
  50. 50. Conclusion  patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically
  51. 51. DEGENERATIVE SPONDYLOLISTHESIS OPERATIVE TREATMENT OPTIONS Decompression alone or decompression with segmental arthrodesis ?  higher proportion of patients with good or excellent outcomes among patients who underwent decompression and arthrodesis compared with those underwent decompression alone (Herkowitz et al)
  52. 52. DEGENERATIVE SPONDYLOLISTHESIS OPERATIVE TREATMENT OPTIONS Instrumentation or non-instrumented fusion in degenerative spondylolisthesis  Martin et al ( systematic review ) significantly higher rate of achieving a solid fusion in patients treated with instrumentation compared with those treated without instrumentation  Kornblum et al solid arthrodesis is associated with less segmental instability and better outcomes than pseudarthrosis supports the use of instrumentation for fusion rates

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