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Orthopedics 5th year, 5th lecture (Dr. Hamid)

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The lecture has been given on May 18th, 2011 by Dr. Hamid.

Published in: Health & Medicine

Orthopedics 5th year, 5th lecture (Dr. Hamid)

  1. 1. Spodylolysthes is
  2. 2. Introduction  Spondylolisthesis is a common cause for lower- back pain, radiculopathy, and neurogenic claudication among the adult population.  Definition: ant. slipping of the spine.  Site  Normal locking mechanism
  3. 3. Classification (Wiltse et al 1976)  congenital,dysplastic  isthmic,* 5%,7year,gymnastic,wt,lifters,  degenerative,*L4-L5  pathologic,  iatrogenic,  traumatic.
  4. 4. Epidemiology  level L4-L5.&L5-S1  F:M = 6:1  Black : White = 6:1 pathology
  5. 5. Clinical Presentation  Hx acording to age of presentation  lower-back pain,  neurogenic claudication,  Vesicorectal disorder,  radiculopathy is present, the L5 nerve root most often is affected.L4 second most common 
  6. 6. Physical Examination  loss of lumbar lordosis,flat buttock,sacrum,scoliosis  Transverse loin crese  Hip flexion contractures  Muscle atrophy  Fell- step-off at the listhetic level.  range of motion (ROM) usually is normal and occasionally hypermobility may exist.  Hamstring tightness  Neurological examination
  7. 7. Imaging Studies  lumbar AP, lateral, and oblique views.  lateral flexion and extension,MRI  Meyerding’s system for grading: Grade 1 is 25%, Grade 2 is 50%, Grade 3 is 75%, Grade 4 is 100% displacement , GradeV --spondyloptosis
  8. 8. Risk factors for progression  Clinical ,gender,age,symptome,gaite  Radilogical,angle,typ sarcum,l5
  9. 9. Prognosis Dysplastic Lytic Degenerative
  10. 10. Non-operative treatment  1-day to 2-day period rest-  short course of anti-inflammatory medications  Physiotherapy  Spinal support  Modification of activity  Psychological support  Epidural injection
  11. 11. Surgical treatment ------Surgical goals  pain reduction,  improvement of neurologic symptoms,  improvement in the quality of life. If attainment of these goals is unlikely, conservative treatment should be continued.
  12. 12. Indications  indications : --progressive neurologic deficit --cauda equina syndrome. --slip >50% and progressive - persistent radiculopathy -persistent and unremitting lower-back -pain for more than 6 months, -disabling symptom-affect work,sport
  13. 13. Decompression Alone Laminectomy and Posterior Spinal Fusion (without Interpedicled Instrumentation( Decompression with Anterior and Posterior Spinal Fusion
  14. 14. SPONDYLOLYSTHESIS
  15. 15. Post traumatic spondylolethesis
  16. 16. Spinal stenosis
  17. 17. Lumbar Spinal Stenosis  Normal canal  “Narrowing of osteoligamentous vertebral canal and/or the intervertebral foramina causing compression of the thecal sac and/or the caudal nerve roots”  Classification  ----congenital  -----aquired
  18. 18. Lumbar Spinal Stenosis  Developmental & Congenital ----Idiopathic narrowing -Short pedicles -Reduced interpedicular dist. --Bone dysplasias ---Achondroplasia
  19. 19. Acquired or Degenerative  Spondylosis  Facet lig flavum  Chronic PID  Post-traumatic  Tumor  Infection  Spondylolisthesis  pagets
  20. 20. Pathoanatomy  Adult degenerative lumbar spinal stenosis (ie Acquired stenosis)  Facet hypertrophy  Vertebral osteophytes  thickened ligamentum flavum  Disc protrusions  Overall decreased volume of spinal canal
  21. 21. Stenotic  Vertebrae provide body support  Discs act as “shock absorbers”  Vertebra protects spinal cord and nerves  Nerves have space and are not pinched  As we age, ligaments and bone can thicken  Narrowing is called “stenosis”  Narrowing squeezes nerves in spinal canal and nerve roots exiting spine to legs  Result - pain & numbness in back and legs Nerve Root Spinal Canal Lumbar Vertebra Bone (Facet Joint) Healthy Intervertebral Disc Thickened Ligament Flavum Pinched Nerve Root Narrowed Spinal Canal
  22. 22. Clinical Presentation  Hx-age- ach-heaviness,n,symptoms  neurogenic claudication with intermittent pain radiating to the thighs or legs.
  23. 23. Claudication,ppppsn  Neurogenic  Pain proxdist  Relief w/ flexion sitting,squating  Extension worsens pain  Better w/ stairs  Pulses wnl  Skin wnl  +/- Neuro deficits  Vascular  Pain dist prox  Relief w/ standing  Pain not positional  Pulses diminished  Mottled skin  Neuro exam wnl
  24. 24. EMG-NCS  Differentiation between neuropathy and radiculopathy
  25. 25. Evaluation  AP & Lat radiographs 20-16  Flex/ext films to reval stability  CT 16-11  MRI  Lumbar myelography + CT  Evaluation of extent of neural element compression
  26. 26. Treatment  Non-Operative  NSAIDs  Physical therapy Stretching, strengthening,  heat, electrical stimulation,Activity modification  Bracing- especially w/ spondylolisthesis  Steroid injection-
  27. 27. Non-Operative Treatment  Good for non-progressive minimally debilitating conditions  Pt getting better  non op  Pt getting worse  Surgery
  28. 28. Surgery?  Indications  Worsening neuro sx, bowel bladder dysfunction, cauda equina syn, debilitating pain  Best candidate  Predominantly leg pain  Clinical exam ∝ Imaging studies  Mild to moderate neuro deficit  No back pain (excluding spondylolisthesis)
  29. 29. Operative Treatment  Laminectomy Bilateral laminectomies for all affected levels  If discectomy performed, consider arthrodesis  Hemilaminectomy  Pts w/ unilateral symp  Better preserves post op stability  Difficulty in accessing Contralateral side Neural foramen  Risk for dural tear
  30. 30. Operative Treatment  Laminoplasty  Hinging open the lamina on one side, interpositioning the resected spinous process  Increased size of spinal canal  X-Stop  Device designed to selectively impart relative flexion at one symptomatic motion segment of the spine
  31. 31. The X-STOP® Spacer Supraspinous ligament Spinous process  Spacer only limits extension  Wings prevent side-to-side and upward migration  Preserves your supraspinous ligament, which prevents backward migration  Preserves anatomy  Treats LSS symptoms, not “anatomy”
  32. 32. Compared to traditional LSS surgery, X-STOP benefits include:  Can be done under local anesthesia  Can be done as an outpatient procedure  No removal of the lamina (vertebral bone) or ligaments that protect and stabilize the spine  Potential of a shorter recovery The X-STOP Spacer
  33. 33. STENOSIS
  34. 34. STENOSIS
  35. 35.  Compresses the exiting nerve root FORAMINAL STENOSIS
  36. 36. CANAL SHAPE  Round  Triangular  Trefoiled (15%)  Trefoiled & asymmetric
  37. 37. POSTURE
  38. 38.  Root symptoms  Unilateral  No claudication  Acute or chronic FORAMINAL STENOSIS
  39. 39.  Claudication  Radicular pain  Weakness is rare  Acute or chronic LATERAL RECESS STENOSISLATERAL RECESS STENOSIS
  40. 40. CENTRAL STENOSIS  Varied presentation  Classically with neurogenic claudication  Some may only have back pain  Rarely painless progressive weakness
  41. 41. X-RAY
  42. 42. SPINAL STENOSIS
  43. 43. MRI  Non-invasive  Soft tissue visualization  Gold standard
  44. 44. MRI  Sagittal images  Visualization of foramen
  45. 45.  Excellent for intra-canal pathology  Poor for foraminal pathology  Replaced by MRI MYELOGRAPHYMYELOGRAPHY
  46. 46.  Excellent visualization of spinal canal CT-MYELOGRAPHY
  47. 47. EPIDURAL STEROID  Commonly prescribed  50% short-term efficacy  Not as selective  May not require fluroscope
  48. 48. Facet joint injection or RF Medial branch block or RF Transforaminal epidural injection Intradiscal procedure: Discography Provacation test Ozone discectomy Laser discectomy Percutanous disc Epiduroscopy and adhesolysis Epidural injection
  49. 49. d
  50. 50. TRANSFORAMINAL ROOT BLOCK  Highly selective  Diagnostic as well as therapeutic  Delivers medicine to the floor of spinal canal
  51. 51. FACET INJECTION  Facet for back pain  Not for radicular pain  May act as epidural in 40% of cases
  52. 52. OPERATIVE TREATMENT  Decompression of neural element  Stabilization of unstable segment
  53. 53. FUSION  Sagittal instability  Scoliosis  Iatrogenic pars defect  Greater than 50% facet joint resection
  54. 54. INSTRUMENTATION

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