Spondylolisthesis Diagnosis and Treatment Guide

www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com
Spondylolisthesis
Visit us at:
www.drsandeepagrawal.com
www,agrasenortho.com
Dr.Sandeep Agrawal

Consultant Orthopedic Surgeon

MS,DNB

Agrasen Hospital

Gondia

Maharashtra

India

www.agrasenortho.com


drsandeep123@gmail.com

09960122234

- OVERVIEW!!
- PATHOPHYSIOLOGY & TYPES!
- CLINICAL PRESENTATION!
- PHYSICAL EXAMINATION!
- DIAGNOSIS!
- DIAGNOSTIC TESTS!
- DIFFERENTIAL DIAGNOSIS!
- TREATMENT!!
- SUMMARY

Spondylolisthesis
•Displacement of a
cephalad vertebra
on the adjacent
caudal vertebra
•Slipage : anterior,
posterior and lateral 3
Spondylolisthesis is derived from the
Greek words spondylo , meaning spine,
and listhesis , meaning to slip or slide.
OVERVIEW (definition)
• Lead to a deformity of the spine as well as a
narrowing of the spinal canal (central spinal
stenosis) or compression of the exiting nerve
roots (foraminal stenosis).

4
OVERVIEW ( Anatomy )
Pars
interarticulars
Spinous
process
Articular process
(inferior)
OVERVIEW ( Anatomy)

OVERVIEW (Dermatomes)

6
OVERVIEW (Dermatomes)

Classification
•Wiltse classification system –
anatomy
•Meyerding system- by degree of
anterior translation

8
It can be classified into 6 distinct
categories as the following
( developed by Wiltse, Macnab, and Newman ):
TYPES ( according to etiology )
❑ Type I: Congenital spondylolisthesis
!
❑ Type II: Isthmic spondylolisthesis
!
❑ Type III: Degenerative spondylolisthesis
!
❑ Type IV: Traumatic spondylolisthesis
!
❑ Type V: Pathologic spondylolisthesis
!
❑ Type VI : Postsurgical

• characterized by presence of dysplastic
sacral facet joints allowing forward
translation of one vertebra relative to
another.
Type I: Congenital spondylolisthesis
!
• Caused by the development of a stress
fracture of the pars interarticularis.
• It is also further divided into 3 subtypes :
Type IIA , type IIB and type IIC .
!
Type III: Degenerative spondylolisthesis
It is commonly caused by intersegmental
instability produced by facet arthropathy.
Type II: Isthmic spondylolisthesis

Type IV: Traumatic spondylolisthesis
Caused by fracture or dislocation of the
lumbar spine, not involving the pars
!
Type VI : Postsurgical (iatrogenic)
Type V: Pathologic spondylolisthesis.
Caused by malignancy, infection, or other
types of abnormal bone

• Heavy Athletic activities requiring
predispose some athletes to developing pars
defects.
!
• Approximately 82% of cases of isthmic
spondylolisthesis occur at L5-S1.
Another 11.3% occur at L4-L5.
!
• Degenerative spondylolisthesis occurs more
frequently with increasing age.
!
• L4-L5 interspace is affected 6-10 more times than
any other level.
!
• Sacralization of L5 is frequently seen with L4-5
degenerative spondylolisthesis .

!
!
• Acute isthmic spondylolysis often
occurs during the first and second
decades of life. Most cases occur before
the patient reaches age 15 years.
!
• Younger patients are at higher risk
than older patients for developing
progressive spondylolisthesis.
!
• But the risk for progression in adults is
rare when the lesion is at L5..
Age

Type I ( Dysplastic / congenital )
• Failure of formation of the anatomic
elements of the lumbosacral facet
joint
• Axially oriented facet with dyplasia of
the superior end plate of the sacrum
• Intact pars interarticularis limited
splippage < 30% -35 %

Type II ( Isthmic )
• Presence of a defect in the pars
interarticularis ( isthmus )
• Scotty dog sign
• Secondary to repetitive
microtrauma or a single trauma
episode
• Subtype A : defect in pars
• Subtype B : defect in
elongated pars
• Subtype C : acute fracture of
the pars

• Spondylolisthesis occurs when there’s
bilateral defects in the vertebral pars
intrarticulariss which permit the
vertebral body to slip anteriorly. Usually
occurs at level (L5,S1)
!
• Spondylolysis is the most common
cause for spondylolisthesis. It’s a
unilateral or bilateral defect in the
vertebral pars interarticularis result from
stress fracture.
PATHOPHYSIOLOGY

Type II ( Isthmic )
• Alaskan Eskimos : 26 %
• Hyperextension forces

Type III ( Degenerative )
•Facet joint OA and
Hypertrophic lig.
flavum

18
!
• spondylolysis typically is acquired as the
bone "fatigues" from recurrent
microtrauma during excessive lumbar
hyperextension or repeated lumbar
flexion and extension.
• rebeated Hyperflextion and extension of
the joints are more common in athletes.
• (diving, weight lifting, wrestling and
football)

• Spondylolysis progresses to
spondylolisthesis in approximately
15% of cases. Progression to
spondylolisthesis is correlated with
persistent pain and lack of healing.

6- Patients with degenerative spondylolisthesis
(DSPL) are characterized by an increased
pelvic tilt (PT) and decreased sacral slope
(SS) than the control population, suggesting the
presence of a pelvic compensation

Type IV ( Posttraumatic )
•Trauma induce
disrupt the posterior
arch and its
articulations other
than pars
interarticularis

Type V ( Pathologic )
•Systemic disease associated :
osteogenesis imperfecta,
osteopetrosis, arthrogryposis,
syphilis
•Localized process : infection,
neoplasm

Type VI ( Postsurgical )
• Laminectomy induced
instability
• Direct disruption of the
facet joint complex
• Direct disruption of pars
interarticularis
• > 50 % posterior facet
joint complex removal

Meyerding classification
• Anterior translation as a
percentage of vertebral
body on lateral view
•Grade I : < 25 %
•Grade II : 26-50%
•Grade III : 51-75 %
•Grade IV : 76 – 100 %
•Grade V : > 100 %
( spondyloptosis )
Grade 1
Grade 1
Grade 2 Grade 3
Grade 4 Grade 5
Normal

25
Grades ( Myerding Classification)

Presentation and evaluation
• Pain at the lumbosacrum junction
may radiate to the buttock and
posterior thigh but rare below the
knee
• Restricted motion of lumbar spine
• Palpable step-off at L-S junction
• Focal kyphosis at L-S junction

1-Phalen-Dickson sign:
!
bent-knee, hip-flexed posture with high-grade
spondylolisthesis
2-One-legged hyperextension test (stork test):
!
Use To differenation between
spondylolysis (+) and spondylolisthesis(-)
PHYSICAL EXAMINATION

With increasing slippage, the sacrum
becomes relatively more vertical, impairing
hip extension and compelling the patient to
walk with a knee-flexed, hip-flexed gait
1-Phalen-Dickson sign:

A positive one-legged hyperextension test
while standing on one leg and bending
backward, pain is experienced in the
ipsilateral back.
2-One-legged hyperextension test (stork test):

!
!
!
1- Radiography:
lateral view of lumbar spine is especially useful
in detection Spondylolisthesis.
!
2- Computed Tomography:
CT SCANNING axial or sagittal image of the
lumbar spine can be performed with or without
contrast enhancment.
!
3- Magnetic Resonance Imaging(MRI):
has the distinct advantage of imaging of the
spine in any plane. Typically, the axial and
sagittal planes are used.
!
!
DIAGNOSTEC TESTS

Spondylolisthesis. Oblique projection radiograph shows the presence of
bilateral pars defects (arrows), with an appearance resembling a Scottie
dog with a collar. (The collar is the pars defect.)

A) -Lateral lumbar spine. Note the pars defects (arrow)
and anterior displacement of the L5 vertebra.
B) -Oblique lumbar spine. Observe the clearly visible
lucent collar (arrow).

Sagittal CT reconstruction
image shows the pars
defect along with grade 1
spondylolisthesis.
Spondylolisthesis. Axial CT image
shows bilateral spondylolysis
(arrows). Note elongation of the
spinal canal at this level

Image Diagnosis
• AP + Lateral L-S views
• Stress dynamic view
(flexion and extension)
- 4 mm Ant. Translation
100 Angulation
• Both oblique view
for R/O pars fracture

DIFFERENTIAL DIAGNOSIS
!
!• Lumber facet-arthropathy .
• Coccyx pain.
• Mechanical low back pain .
• Overuse Injury.
• Lumber compression Fracture.
• Lumber canal stenosis .
• Lumbar disk herniation .
!
!
!

• degenerative arthritis affecting the facet
joints in the spine
• Low back pain can radiate to gluteal, back
of the thigh and rarely below the knee.
• was no numbness, no muscle weakness
and the reflexes were normal.
• Stiffness
• Poor posture
• Radiography: CT and X-ray
Lumber facet-arthropathy

Axial CT
✓ marked osteophytosis and joint space narrowing
✓ severe osteoarthritis

• Coccydynia is inflammation localized
to the tailbone pain and tenderness
at coccyx.
!
• The pain is often worsened by sitting.
• Patient leaning against the buttocks
!
Coccyx pain

Lateral radiograph (a) and sagittal CT reconstruction (b)
demonstrating a fractured coccyx in a patient who was
diagnosed with coccydynia following a ground-level fall
6 months earlier

• fracture of lumber spine due to
trauma or pathological fracture in
osteomyelitis.
• Common in woman who is near
or over age 50 .
• Sudden back pain radiate to
lower limb. numbness and motor
weakness in lower limb if nerve
roots is affected
Lumber compression Fracture

42
• congenital narrowing of the lumbar spinal
canal.
• low back pain,
• weakness, numbness, pain, and loss of
sensation in the legs.
• worse pain in standing or walking and
backward. It is relieved by sitting and forward.
• sphincteric function impairment.
• Negative straight leg raising test
• Radiography: X-ray, CT and MRI
Lumbar canal stenosis

Natural history
• Multifactorial etiology
• 91 % without treatment had lower back pain
• 55 % had sciatica
• 18 % had neurologic defect
• 5 % progression and most in adolescent
• Risk factor : slippage > 25% , early disc
degeneration

TREATMENT!
1. Conservative .
2. Surgery and Complications
3. Complications
!

➢Treatment for spondylolisthesis depends
on several factors, including the age and
overall health of the person, the extent
of the slip, and the severity of the
symptoms.
!
!
➢Treatment most often is conservative and
more severe spondylolisthesis might
require surgery.

Nonsurgical Rx
•Mainstay of treatment at < 50 %
slippage
•Brace : goal to reduce hyperlodosis
and stabilize motion
•Physiotherapy
• Specific training of muscle surrounding the spine

47
➢Surgery might be necessary if the vertebra
continues to slip or if the pain is not relieved
by conservative treatment and begins to
interfere with daily activities.
!
➢The main goals of surgery for
spondylolisthesis are:
1) to relieve the pain associated with an irritated nerve,
2) to stabilize the spine where the vertebra has
slipped out of place,
3) and to increase the person’s ability to function.
Surgical treatment

Surgical Rx
•Persistent symptoms (pain and
neurologic deficits) affecting quality of
life and progression of slip are
indicated for surgical Rx.
•MRI for further survey (pain source
and stenosis )

Surgical Rx
!
!
• Instrumentation with fusion => better for
immediate stability and fusion rate
• Low-grade slip with lysis => arthrodesis
alone better than decompression + fusion
• High-grade slip => fusion in situ with good
long term results.
• Circumferential fusion (A+P) for good fusion
if anterior defect or local kyphosis

2. Fusion
➢ A spinal fusion is normally done immediately
after laminectomy for spondylolisthesis.
➢ It is designed to fuse the two vertebrae into one
bone and stop the slippage from worsening.
!
➢ The fusion is used to lock the vertebrae in
place and stop movement between the
vertebrae.
!
• Types :
A. Traditional Fusion
B. Minimally invasive surgical spine fusion

51
A. Traditional Fusion
!
✓ The vertebrae are affixed to one another
using surgical instrumentation.
✓ Bone graft is then placed between the
vertebrae allowing them to "fuse" together
over time.
✓ This stabilizes the painful joint segment and
relieves pressure from the painful spinal
nerves
Examples :
1. Postero-lateral fusion (PLF)
2. Posterior Lumbar Interbody Fusion(PLIF)

1. posterolateral fusion (PLF)
➢ posterolateral fusion is the grandfather of fusion technique as
it was developed just over 100 years ago.
➢ In a posterior approach to lumbar fusion, the surgeon makes
an incision down the middle of the lower back.
➢ One of the criticisms of PLF is that it involves an extensive
dissection (the stripping of muscle and fascia off of bone) of
the adjacent transverse processes, facet(s) and sometimes
lamina.
➢ After the decompression, the surgeon will place graft material
along the sides of the vertebrae to stimulate bone growth.
➢ Titanium screws and rods are often used to provide
immediate stability to the spine until a solid fusion has been
achieved.

2. Posterior Lumbar Interbody
Fusion(PLIF):
➢ In this procedure, the problem vertebrae are
fused from the anterior (front) and posterior
(back).
➢ The surgeon works from the back of the spine
and removes the disc between the problem
vertebrae.
➢ Bone graft material is inserted from the back of
the spine into the space between the two
vertebrae where the disc was removed (the
interbody space)
➢ Transpedicular instrumentation is attached to
stabilize the motion segment while fusion
occurs.

Spondylolytic spondylolisthesis L4,5
L4 Pars fracture

Degenerative Spondylolisthsis L4,5
with Spinal Stenosis

Degenerative Spondylolisthsis L4,5
with Spinal Stenosis S/P OP

o Implant failure.
o Pseudoarthrosis.
o Nonunion.
o Foot drop.
o Spinal compression.
o Acute bowel ischaemia
Complications of surgical repair

- Spondylolisthesis is a forward or backward
slippage of one vertebra on an adjacent vertebra.
!
- Causes of spondylolisthesis include trauma,
degenerative, tumor, and birth defects.
!
- Symptoms of spondylolisthesis include lower back
or leg pain, hamstring tightness, and numbness and
tingling in the legs.
!
- diagnosis is mainly based on imaging .
!
- Most people with spondylolisthesis can be treated
conservatively, without the need for surgery.
!
- Patients who fail to improve with conservative
treatment may be a candidate for surgery.
SUMMARY

Visit us at:

This presentation is for doctors in general.!
. Some graphics and jpeg files are taken from Google Image to heighten
the specific points in this presentation. !
• If there is any objection/or copyright violation, please inform
drsandeep123@gmail.com for prompt deletion. !
• It is intended for use only by the doctors of orthopaedic surgery.!
. Views expressed in this presentation are personal. • .For any confusion
please contact the sole author for clarification. !
• Every body is allowed to copy or download and use the material best
suited to him. !
Visit us at:!
www.drsandeepagrawal.com!

Visit us at:!
www.drsandeepagrawal.com!

Spondylolisthesis Diagnosis and Treatment Guide

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (20)

Similar to Spondylolisthesis Diagnosis and Treatment Guide

Similar to Spondylolisthesis Diagnosis and Treatment Guide (20)

More from AGRASEN Fracture Arthritis Hospital, Ganesh Nagar,Gondia,Maharashtra,INDIA

More from AGRASEN Fracture Arthritis Hospital, Ganesh Nagar,Gondia,Maharashtra,INDIA (11)

Recently uploaded

Recently uploaded (20)

Spondylolisthesis Diagnosis and Treatment Guide