Spondylolisthesis

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Spondylolisthesis

  1. 1. Cardiff School of Engineering Coursework Cover SheetPersonal DetailsStudent No: 1056984Family Name: Divecha First Name: HirenPersonal Tutor: Prof Sam Evans Discipline: MMMModule DetailsModule Name: Surgical Practice Module No: ENT547Coursework Title: Weekend 3 Assignment - Define and classify spondylolisthesis and discuss the management of high grade slipsLecturer: Mr S AhujaSubmission Deadline: 3/3/2012DeclarationI hereby declare that, except where I have made clear and full reference to the work ofothers, this submission, and all the material (e.g. text, pictures, diagrams) contained in it, ismy own work, has not previously been submitted for assessment, and I have not knowinglyallowed it to be copied by another student. In the case of group projects, the contribution ofgroup members has been appropriately quantified.I understand that deceiving, or attempting to deceive, examiners by passing off the work ofanother as my own is plagiarism. I also understand that plagiarising anothers work, orknowingly allowing another student to plagiarise from my work, is against UniversityRegulations and that doing so will result in loss of marks and disciplinary proceedings. Iunderstand and agree that the University’s plagiarism software ‘Turnitin’ may be used tocheck the originality of the submitted coursework.Signed: …..…………………………………….………... Date: ……………………
  2. 2. Define and classify spondylolisthesisand discuss the management of highgrade slipsHiren Maganlal DivechaCandidate Number: 1056984ENT547 – Surgical PracticeWord count – 2193
  3. 3. ContentsDefinition of Spondylolisthesis ............................................................................................................1Classification.......................................................................................................................................2 1. Wiltse-Newman Classification .................................................................................................2 I. Dysplastic.............................................................................................................................2 II. Isthmic .................................................................................................................................3 III. Degenerative .......................................................................................................................4 IV. Traumatic.............................................................................................................................4 V. Pathologic ............................................................................................................................4 VI. Iatrogenic.............................................................................................................................4 2. Meyerding Classification..........................................................................................................5Management of high grade slips .........................................................................................................6 1. Child/ Adolescent ....................................................................................................................6 2. Adult .......................................................................................................................................7References........................................................................................................................................ 10
  4. 4. Definition of SpondylolisthesisSpondylolisthesis is the anterior (or posterior) displacement of a vertebra (with the vertebral columnabove) relative to the vertebra below. The origin of this word is from Greek, spondylos – vertebra andolisthos – slipperiness [1]. Spondylolisthesis was first described in 1782, by the Belgian obstetricianHerbiniaux, as an osseous narrowing of the birth canal. Kilian was the first to use the termspondylolisthesis in 1854. 1
  5. 5. Classification1. Wiltse-Newman ClassificationThe Wiltse-Newman classification [2] is the most commonly used clinical classification system ofspondylolisthesis (see Table 1) according to aetiology. Type Description I Dysplastic II Isthmic A – Spondylolysis B – Pars elongation C – Acute fracture III Degenerative IV Traumatic V Pathologic VI IatrogenicTable 1: Wiltse-Newman classification of spondylolisthesis I. Dysplastic This is a rare form of spondylolisthesis (14-21% [3]) and results from congenital malformation of the neural arch or inferior facets of the L5 vertebra and/ or the upper part of the sacrum. This can be associated with spina bifida. Typical structural abnormalities that predispose to anterolisthesis of L5-S1 include a rounded sacrum, trapezoidal L5 vertebral body, hypoplastic inferior L5 facets that subluxate anteriorly. The pars interarticularis and pedicles may appear attenuated/ elongated but will only have a defect in severe slips. 2
  6. 6. II. Isthmic The lesion in this type of spondylolisthesis occurs in the pars interarticularis. A. Spondylolysis – refers to a fatigue fracture of the pars interarticularis with histological features of fibrocartilaginous pseudoarthrosis. Wiltse et al. [4] proposed that this defect arose from chronic loading of a genetically predisposed pars interarticularis. It is never seen in newborns or non-ambulant individuals. Activities resulting in repeated hyperextension of the lumbar spine have been associated with higher incidences (diving, gymnastics, fast-bowlers, weight lifters, javelin throwers, ballet dancers). This is the most common type of spondylolysis in the under 50yr age group. It is more common in males, but severe slips are more common in females. Based on a North American Caucasian population study, Fredrickson et al. [5] reported an incidence of spondylolysis of 4.4% at 6yrs rising to 6% by early adulthood. They also noted that only 25% of these developed spondylolisthesis. Other ethnic groups are reported to have higher prevalence of spondylolysis (Alaskan Inuit >30%; Japanese >40%). The L5 vertebra is most commonly affected (90%) followed by L4 (5%) and L3 (3%). The higher lumbar levels tend to be more symptomatic. B. Pars elongation – a stress fracture of the pars interarticularis may go on to heal, resulting in pars elongation that will allow some anterior slip. C. Acute fracture – an acute hyperextension type injury can result in a pars interarticularis fracture with a resulting spondylolisthesis. The “Hangman’s fracture” of C2 is an example in the cervical spine. 3
  7. 7. III. Degenerative This is the most common form of spondylolisthesis in patients over 50yrs [6]. The neural arch and pars interarticularis remain intact. With degenerative disc disease, facet joint arthropathy develops. Remodelling of the facet joints allows forward slip to occur. L4/5 is more commonly affected (facets are more sagittally orientated).IV. Traumatic This results from an acute fracture to the neural arch not involving the pars interarticularis. These are very rare and involve the pedicles/ posterior elements [7]. V. Pathologic Bony metastases, osteoporosis, Paget’s disease, tuberculosis and giant cell tumours can lead to lytic pars interarticularis defects.VI. Iatrogenic Wide laminectomy or facetectomy procedures can destabilise that vertebra and result in spondylolisthesis. 4
  8. 8. 2. Meyerding ClassificationSpondylolistheses can be classified according to the amount of anterior translation/ slip. Meyerding[8] classified this into Grades I – V (see Figure 1). The superior endplate of the vertebra below isdivided into quarters and the position of the posterior edge of the vertebral body above isdetermined. A slip of more than 50% is considered high grade.Figure 1: Meyerding Classification of Spondylolisthesis - (x/y = % slip). Grade I - 0-24%; Grade II - 25-49%; GradeIII - 50-74%; Grade IV 75-99%; Grade V - >100% (spondyloptosis). ( [9]) 5
  9. 9. Management of high grade slips1. Child/ AdolescentA high-grade slip results in decreased lumbosacral lordosis and a progressive kyphotic deformity. Ithas been suggested that these patients are best treated with fusion [10]. An in situ postero-lateralfusion from L4 to S1 can be performed with placement of graft between the sacral alae and thetransverse processes. This forms a large fusion mass that prevents further slippage (after a period ofbrace immobilisation). Long-term results with in situ postero-lateral fusion suggest maintenance ofsymptom control and no obvious accelerated degenerative changes at the levels above [11]. Forolder adolescents/ adults (especially with neurological symptoms/ cauda equina), it has beensuggested that wide decompression from L4 to S2 can be performed followed by insertion of a fibulastrut graft as a dowel between the S1 and L5 vertebral bodies. A postero-lateral fusion is thenperformed to give a circumferential fusion. In a long-term follow up, Smith & Bohlman [12] reportedgood results in a small cohort treated in this manner.An argument for reduction and fusion can be made based on the following advantages – restorationof sagittal balance/ biomechanics, better cosmesis, improvement of spinal stenosis symptoms andreduced shear forces across fusion mass (theoretically reduces chances of pseudoarthrosis).Furthermore, instrumented fusion allows for earlier mobilisation/ rehabilitation whilst maintainingreduction. Patients with high-grade dysplastic spondylolistheses in particular may be at higher risk ofnon-union and therefore benefit from reduction and instrumented fusion. Interestingly, Poussa et al[13] found similarly good outcomes when comparing reduction with in situ fusion, but highercomplications with reduction (neurological and increased blood loss). The majority of nerve rootstrain occurs at the end of reduction. Therefore, a partial controlled reduction with posterior 6
  10. 10. instrumentation (neurophysiological monitoring throughout) and postero-lateral fusion has beensuggested to be a safer alternative [14].Management of spondyloptosis in children/ adolescents can be done with an in situ circumferentialfusion [12] and has the lowest chance of neurological injury. Alternative, a Gaines procedure can beperformed. The first stage involves an anterior L5 vertebrectomy. The second stage involves excisionof the L5 laminae/ pedicles and posterior instrumented reduction of L4 to S1. Neurological injury canoccur in 1/3rd of patients with this procedure [15].2. AdultSome adults may present with little or no pain despite having a high-grade spondylolisthesis. Theymay describe more mechanical low back pain. A trial of physiotherapy and nerve root injections ifrequired may be attempted. Failing this, operative intervention may be considered.Reduction remains controversial, as there is an increased risk of neurological injury (usually L5 nerveroot, occasionally cauda equina). Some studies have demonstrated improved fusion rates comparedto non-instrumented in situ fusion, though there have been no reports of improved clinical outcomewith reduction as compared to fusion in situ.There are a number of surgical fusion options described, which can be instrumented or not:  posterolateral in situ fusion  posterior interbody lumbar fusion (PLIF) – laminectomy, discectomy and interbody fusion (cage, fibula allograft)  anterior lumbar interbody fusion (ALIF) – trans-l/ retro-peritoneal approach, discectomy, interbody fusion (cage/ structural graft) 7
  11. 11.  transforaminal lumbar interbody fusion (TLIF) – posterior approach through foramen, therefore avoids handling of cauda  circumferential fusion – combined ALIF + posterolateral fusion  posterior trans-sacral interbody fusion (fibula strut or screw)  Gaines procedure – for spondyloptosisPostero-lateral in situ fusion has been the preferred treatment until recently. Whilst this can beperformed without instrumentation, there is a risk of pseudoarthrosis (up to 40%) or of the fusionmass bending, resulting in further slippage (26%) [10] (note – these were reported in an adolescentgroup). Posterior instrumentation is therefore recommended from L4 to S1 with/ without L5 pediclescrews.A study by Helenius et al [16] compared the outcomes for posterolateral fusion, ALIF andcircumferential fusions, all performed in situ without instrumentation. The circumferential fusiongroup had the best functional outcome (pain VAS, Oswestry Disability Index, SRS-22) with the leastprogression of deformity over the follow-up period. Interestingly, complications were lower in thecircumferential fusion group.In a retrospective study of posterior trans-sacral interbody fusion using Hollow Modular Anchorage(HMA) screws filled with cancellous graft, supplemented with postero-lateral fusion and posteriorinstrumentation, Lakshmanan et al [17] found circumferential fusion was achieved in all 12 patientswith 11 experiencing resolution of leg pain. Pain and SF-36 scores improved and there were noneurological complications. The authors concluded that a stable circumferential fusion was achievedwith this technique and the potential complications of using a fibula strut graft (donor site morbidity,fracture) are avoided. 8
  12. 12. It seems that large, randomised, controlled, comparative studies with long-term follow-up are lackingin the area of surgical management of high-grade spondylolisthesis. There are numerousretrospective studies reported, but the lack of large comparative studies makes interpretation andapplication to every-day clinical management difficult. It would seem that the recent literaturefavours partial reduction of high-grade spondylolistheses and circumferential fusion techniquessupplemented with instrumentation to protect the fusion site and allow early mobilisation. 9
  13. 13. References[1] “Spondylolisthesis,” Random House, Inc, [Online]. Available: http://dictionary.reference.com/browse/spondylolisthesis. [Accessed 29 January 2012].[2] L. L. Wiltse, P. H. Newman and I. Macnab, “Classification of spondylolysis and spondylolisthesis,” Clin Orthop Relat Res, vol. 117, pp. 23-9, 1976.[3] P. H. Newman, “The etiology of spondylolisthesis,” J Bone Joint Surg Br, vol. 45, pp. 39-59, 1963.[4] L. L. Wiltse, E. H. Widell and D. W. Jackson, “Fatigue fracture: The basic lesion in isthmic spondylolisthesis,” J Bone Joint Surg Am, vol. 57, pp. 17-22, 1975.[5] B. E. Fredrickson, D. Baker, W. J. McHolick, H. A. Yuan and J. P. Lubicky, “The natural history of spondylolysis and spondylolisthesis,” J Bone Joint Surg Am, vol. 66, pp. 699-707, 1984.[6] K. Majid and J. S. Fischgrund, “Degenerative lumbar spondylolisthesis: Trends in management,” J Am Acad Orthop Surg, vol. 16, pp. 208-15, 2008.[7] H. Miyamoto, M. Sumi, O. Kataoka, M. Doita, M. Kurosaka and S. Yoshiya, “Traumatic spondylolisthesis of the lumbosacral spine with multiple fractures of the posterior elements,” J Bone Joint Surg Br, vol. 86, no. 1, pp. 115-8, 2004.[8] H. W. Meyerding, “Spondylolisthesis,” Surg Gynecol Obstet, vol. 54, pp. 371-7, 1932.[9] “Spondylolisthesis - Degenerative,” Alphatec Spine, Inc, [Online]. Available: http://www.agingspinecenter.com/content/spondylolisthesis-degnerative. [Accessed 29 January 2012].[10] D. Boxall, D. S. Bradford, R. B. Winter and J. H. Moe, “Management of severe spondylolisthesis in children and adolescents,” J Bone Joint Surg Am, vol. 61, pp. 479-95, 1979.[11] A. Grzegorzewski and S. J. Kumar, “In situ posterolateral spine arthrodesis for grades III, IV and V 10
  14. 14. spondylolisthesis in children and adolescents,” J Paediatr Orthop, vol. 20, pp. 506-11, 2000.[12] M. D. Smith and H. H. Bohlman, “Spondylolisthesis treated by a single stage operation combining decompression with insitu posterolateral and anterior fusion: An analysis of eleven patients who had long-term follow-up,” J Bone Joint Surg Am, vol. 72, pp. 415-21, 1990.[13] M. Poussa, D. Schlenzka, S. Seitsalo, M. Ylikoski, H. Hurri and K. Osterman, “Surgical treatment of severe isthmic spondylolisthesis in adolescents: Reduction or fusion in situ,” Spine, vol. 18, pp. 894-901, 1993.[14] L. G. Lenke and K. H. Bridwell, “Evaluation and surgical treatment of high grade isthmic dysplastic spondylolisthesis,” Instr course lect, vol. 52, pp. 525-32, 2003.[15] S. M. Lehmer, A. D. Steffee and R. W. Gaines, “Treatment of L5-S1 spondyloptosis by staged L5 resection with reduction and fusion of L4 onto S1 (Gaines procedure),” Spine, vol. 19, pp. 1916- 25, 1994.[16] I. Helenius, T. Lamberg, K. Osterman, D. Schlenzka, P. Tervahartiala, S. Seitsalo, M. Poussa and V. Remes, “Posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation using the Scoliosis Research Society questionnaire.,” Spine, vol. 31, no. 2, pp. 190-6, 2006.[17] P. Lakshmanan, S. Ahuja, M. Lewis, J. Howes and P. R. Davies, “Transsacral screw fixation for high-grade spondylolisthesis,” Spine, vol. 9, pp. 1024-9, 2009. 11

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