Downloaded 175 times
Uploaded byCollege of Medicine, Sulaymaniyah
Orthopedics 5th year, 5th lecture (Dr. Hamid)
Spondylolisthesis is the slipping of one vertebra over another. It is commonly caused by dysplastic, isthmic, degenerative or traumatic conditions. It most often occurs at the L4-L5 or L5-S1 levels and presents with lower back pain, neurogenic claudication or radiculopathy. Imaging studies can classify and grade the spondylolisthesis. Conservative treatment includes rest, medications and physical therapy while surgical treatment is considered for progressive neurological deficits or severe, persistent pain.
More Related Content
Similar to Orthopedics 5th year, 5th lecture (Dr. Hamid)
More from College of Medicine, Sulaymaniyah
Orthopedics 5th year, 5th lecture (Dr. Hamid)
- 1.
- 6. Introduction Spondylolisthesis isa common cause for lower- back pain, radiculopathy, and neurogenic claudication among the adult population. Definition: ant. slipping of the spine. Site Normal locking mechanism
- 9. Classification (Wiltse etal 1976) congenital,dysplastic isthmic,* 5%,7year,gymnastic,wt,lifters, degenerative,*L4-L5 pathologic, iatrogenic, traumatic.
- 10. Epidemiology level L4-L5.&L5-S1 F:M = 6:1 Black : White = 6:1 pathology
- 11. Clinical Presentation Hxacording 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
- 12. Physical Examination lossof 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
- 14. Imaging Studies lumbarAP, 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
- 15. Risk factors forprogression Clinical ,gender,age,symptome,gaite Radilogical,angle,typ sarcum,l5
- 17.
- 18. Non-operative treatment 1-dayto 2-day period rest- short course of anti-inflammatory medications Physiotherapy Spinal support Modification of activity Psychological support Epidural injection
- 19. 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.
- 20. Indications indications : --progressiveneurologic 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
- 21. Decompression Alone Laminectomy andPosterior Spinal Fusion (without Interpedicled Instrumentation( Decompression with Anterior and Posterior Spinal Fusion
- 23.
- 26.
- 28.
- 30. 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
- 31. Lumbar Spinal Stenosis Developmental & Congenital ----Idiopathic narrowing -Short pedicles -Reduced interpedicular dist. --Bone dysplasias ---Achondroplasia
- 32. Acquired or Degenerative Spondylosis Facet lig flavum Chronic PID Post-traumatic Tumor Infection Spondylolisthesis pagets
- 33. Pathoanatomy Adult degenerativelumbar spinal stenosis (ie Acquired stenosis) Facet hypertrophy Vertebral osteophytes thickened ligamentum flavum Disc protrusions Overall decreased volume of spinal canal
- 35. Stenotic Vertebrae providebody 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
- 36. Clinical Presentation Hx-age-ach-heaviness,n,symptoms neurogenic claudication with intermittent pain radiating to the thighs or legs.
- 37. Claudication,ppppsn Neurogenic Painproxdist 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
- 38. EMG-NCS Differentiation betweenneuropathy and radiculopathy
- 39. 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
- 40. Treatment Non-Operative NSAIDs Physical therapy Stretching, strengthening, heat, electrical stimulation,Activity modification Bracing- especially w/ spondylolisthesis Steroid injection-
- 41. Non-Operative Treatment Goodfor non-progressive minimally debilitating conditions Pt getting better non op Pt getting worse Surgery
- 42. Surgery? Indications Worseningneuro 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)
- 43. Operative Treatment Laminectomy Bilaterallaminectomies 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
- 44. 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
- 45. The X-STOP® Spacer Supraspinous ligament Spinous process Spaceronly 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”
- 46. Compared to traditionalLSS 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
- 47.
- 48.
- 49. Compresses the exitingnerve root FORAMINAL STENOSIS
- 50. CANAL SHAPE Round Triangular Trefoiled (15%) Trefoiled & asymmetric
- 51.
- 52. Root symptoms Unilateral No claudication Acute or chronic FORAMINAL STENOSIS
- 53. Claudication Radicularpain Weakness is rare Acute or chronic LATERAL RECESS STENOSISLATERAL RECESS STENOSIS
- 54. CENTRAL STENOSIS Variedpresentation Classically with neurogenic claudication Some may only have back pain Rarely painless progressive weakness
- 55.
- 56.
- 57. MRI Non-invasive Softtissue visualization Gold standard
- 58. MRI Sagittal images Visualization of foramen
- 59. Excellent forintra-canal pathology Poor for foraminal pathology Replaced by MRI MYELOGRAPHYMYELOGRAPHY
- 60. Excellent visualization ofspinal canal CT-MYELOGRAPHY
- 61. EPIDURAL STEROID Commonlyprescribed 50% short-term efficacy Not as selective May not require fluroscope
- 62. Facet joint injection orRF Medial branch block or RF Transforaminal epidural injection Intradiscal procedure: Discography Provacation test Ozone discectomy Laser discectomy Percutanous disc Epiduroscopy and adhesolysis Epidural injection
- 63.
- 66. TRANSFORAMINAL ROOT BLOCK Highlyselective Diagnostic as well as therapeutic Delivers medicine to the floor of spinal canal
- 67. FACET INJECTION Facetfor back pain Not for radicular pain May act as epidural in 40% of cases
- 68. OPERATIVE TREATMENT Decompressionof neural element Stabilization of unstable segment
- 69. FUSION Sagittal instability Scoliosis Iatrogenic pars defect Greater than 50% facet joint resection
- 70.
Editor's Notes
- #36 The vertebrae are the building blocks, providing support for your head and body while the discs act as cushions, or “shock absorbers.” In addition to providing support, the spine encloses and protects a column of nerve tissues called the spinal cord. The spinal cord is surrounded by a bony channel called the spinal canal. In the lumbar spine, nerve roots pass out of the spinal canal through the intervertebral foramen, where they extend down into your back and legs. In the healthy spine, there is space between the spinal cord and the borders of the spinal canal so that the nerves are free and are not pinched. However, as we age the ligaments and bone that surround the spinal canal can thicken. This thickening results in narrowing of the spinal canal, which is called “spinal stenosis.” The spinal cord and nerve fibers that exit the spinal canal (nerve roots) become crowded and pinched due to this narrowing, resulting in pain and numbness in the back and legs.
- #46 The X-STOP device relieves the symptoms of lumbar spinal stenosis by limiting extension without any significant restriction of flexion or lateral rotation. Additionally, the X-STOP Spacer addresses many of the traditional concerns about destabilization of the spine associated with invasive decompressive procedures such as laminectomy. The X-STOP procedure does not typically require removal of bony structures or the supraspinous ligament. Preserving the supraspinous ligament has the added benefit of working along with the device’s wings to prevent lateral and posterior migration.