Spondylolisthesis

SPONDYLOLISTHESIS
By Dr Gajendra Mani Shah
Orthopedics Department
NAMS, Bir Hospital

Introduction
Herbiniaux, a Belgian obstetrician, noted a bone prominence in
front of the sacrum that caused problems in delivery. Credited
with having first described spondylolisthesis.
The term spondylolisthesis was used by Kilian in 1854 and is
derived from the Greek spondylos, meaning “vertebra,” and
olisthenein, meaning “to slip.”
Spondylolisthesis is defined as anterior or posterior slipping
of one segment of the spine on the next lower segment.

SPONDYLOLYSIS
SPODYLOLISTHESIS
SPONDYLOPTOSIS

Classification
Wiltse, Newman, and Macnab's classification
Marchetti and Bartolozzi

Based on a mixture of etiological and topographical
criteria.

Type I, Dysplastic (20%)
Congenital abnormalities of the
upper sacral facets or inferior
facets of the fifth lumbar vertebra
that allow slipping of L5 on S1.
No pars interarticularis defect

Type II: Isthmic(50%)
Defect in pars interarticularis that
allows forward slippage of L5 over S1
Three Types:
1. Lytic:- stress # of pars
interarticularis
2. Healed version of Lytic- pars
interarticularis intact but
elongated
3. Acute # of pars interarticularis due
high energy injury.

Type III:
Degenerative(25%):-
Due to intersegmental instability
of long duration and subsequent
remodelling of the articilar
process.

Type IV :- Traumatic
# in the area of the bony
hook other than pars, ie
pedicle, laminas or facets.

Type V :-
Pathological :-
D/t generalized or localized
bone disease, osteogenic
imperfecta, multiple myeloma,
TB.

Type VI Post surgical :- Due to loss of
posterior elements secondary to surgery.

Two drawbacks of Wiltse et al classification:
Difficult to predict the progression or response to surgery.
Difficult to identify the type precisely.

Marchetti – Bartolozzi classification
Developmental Acquired
High dysplastic Traumatic
With lysis Acute fracture
With elongation Stress fracture
Low dysplastic Postsurgery
With lysis Direct surgery
With elongation Indirect surgery
Pathological
Local pathology
Systemic pathology
Degenerative
Primary /Secondary

ETIOLOGY
Prevalance: -5%, M= F; However-in Eskimos- 50%; White
males- 6-7%; Black females 1.1% ; indicates definite genetic
predisposition.
Spondylolysis:- in 15-70% of the 1st degree relatives. - 2-3
times more common in boys than girls but Slippage 2-3 times
more common in girls.

ETIOLOGY CONTD…
DEVELOPMENTAL SPONDYLOLISTHESIS
with lysis:- due to stress # in children with genetic predisposition
for the defect.
Wiltse et al:- normal flexon contracture of the hip in childhoods-
increased lumbar lordosis:– increased force at Pars interarticularis.
Lett et al:- shear stress greater at pars when lumbar spine is
extended.
Cryon and Hutton:- Pars is thinner and vertebral disc is less
resistant to shear in children and adolescents than in adults.

ISTHMIC SPONDYLOLISTHESIS:
Due to upright walking and wt . bearing.
M=F: 2:1
Risk factors: Gymnastics / Football/wt. lifting, dancing and others
with excessive lordosis or hyperflexion of the lumbar spine.
ETIOLOGY CONTD…

DEGENARATIVE SPONDYLOLISTHESIS:
TWO THEORIES
a)Sagital facet theory: Facet oriented in such a way that it
doesn’t resist Intratranslation forces over time
LEADING TO degenaration and Spondylolisthesis
b) Disc degeneration theory: Disc narrows first-
overloading of facets
.Accelerated arthritic changes
.Secondary remodelling
.Anterolisthesis
ETIOLOGY CONTD…

TRAUMATIC: Acute fracture other than Pars
POST SURGICAL : Laminectomy, Intervertebral
fusion.
ETIOLOGY CONTD…

PATHOPHYSIOLOGY
TRAUMATIC PATHWAY
DYSPLASTIC PATHWAY
DEGENERATIVE PATHWAY

TRAUMATIC PATHWAY
Erect posture-CG anterior to LS joint
Lumbar spine-forward force and rotate Anteriorly into flexion about
the sacral dome. Initiated by the repetitive cyclic loading
Supr and infr articular process impingement creates a bending
moment that is resisted by the Pars.
Repetitive impingement- fatigue

TRAUMATIC PATHWAY
Stress # of Pars and post. neural arc separates from body
Gap occupied by the fibrous tissue
Non union
Increased shear load to disc though Vertebral
axial load remains unchanged Subluxation
Premature disc degeneration

DYSPLASTIC PATHWAY
Initiated by the cong. defect (dysplasia) in the bony hook
or its catch. -pedicle
-supr articular facet
-infr articular facet
Repeated loading unopposed by bony constraints Plastic
deformation of soft tissue restrains: IV Disc
Antr and postr Long. L
Postr Ligament complex
Subluxation of vertebra

DYSPLASTIC PATHWAY
With continuous growth
Slippage and abnormal growth in the involved vertebral
bodies or sacrum
eg -Trapezoid shape of L5
- Rounding of supero anterior aspect of sacrum
- Vertical orientation of the sacrum
- Junctional kyphosis at involved segments
- Compensatory hyperlordosis at the adjacent levels

DEGENERATIVE SPONDYLOLISTHESIS
Sagital facets Disc degeneration
No resistance for anterior Disc narrows
translation force Subsequent overloading of facets
Predilection for slippage .Accelerated arthritic changes
.Secondary remodelling
.Anterolisthesis
Boden et al - sagital facet angles of > 45 degree at L4-L5 - 25 times
greater likelihood of degenerative spondylolisthesis.

•Whatever the inciting event - Facet arthritis
- Disc degeneration and
- Ligamentous hypertrophy
All contribute to produce the symptoms.
•True deformity of degn spondylolisthesis – Rotatory deformity – not
pure translation
Distort dura and its contents
Exaggerate the appearance of spinal stenosis
DEGENERATIVE SPONDYLOLISTHESIS

PATHOLOGICAL SPONDYLOLISTHESIS
Due to local or systemic pathological process causing a defect in
the neural arch
Vertebral Subluxation

TRAUMATIC SPONDYLOLISTHESIS
High energy trauma
Translational deformity
Fracture of bony hook other than Pars ie: Pedicle,
Superior and Inferior articular facets
Associated multiple bony and STI
Subluxation

POST SURGICAL
Laminectomy : Fusion of segments
Removal of > ½ or entire Resection of capsular, Supraspinous
articular process and Interspinous ligaments
Destabilize the spine
Translational deformity Increasing motion demand
the next
SUBLUXATION
Compression of nerve roots

NATURAL HISTORY
Risk factors for the progression :
1)Young age at presentation
2)Female gender
3)A slip angle of > 10 degree.
4)A high grade slip
5)Dome shaped or significantly inclined sacrum

Natural History is predominantly determined by
• Developmental or acquired spondylolisthesis
• Low or high dysplasia
• Quality of pedical , pars and facets
• Age when diagnosis is made
• Degree of lordosis and position of gravity line
• Degree of secondary or remodeled deformity
• Competency, hydration and height of the disc

NATURAL HISTORY
1)Dysplastic spondylolisthesis : Early age; usually asymptomatic
Severe slip(9-15,seldom after 20)
Risk of neurological complications
Higher risk of slip progression-cauda equina syndrome as the neural
arc is intact.
2)Isthmic spondylolisthesis :
No progression of slip Progression of slip
< 10% displacement
.Asymptomatic >25% slip
.No progression after .Risk of slip progression
adulthood
.No backache later in life .Backache in later life

3)Degenerative Spondylolisthesis :
.Rare before 50.
.Matsunaga et al 10 yrs prospective study-
-34% showed progression of the slippage-though no
significant effect in the clinical outcome
-further disc space narrowing continued in those without slip
However back pain improved
(Autostabilisation)
-83% of the pts with neurological S/S deteriorated
NATURAL HISTORY

CLINICAL EVALUATION
Usually asymptomatic – Incidental finding in X ray.
Symptoms depend on the severity of slip and is caused by :
1)Chronic muscle spasm : Body limits motion around a painful
pseudo-arthrosis of facet and its Pars .
2) Tears in the Annulus Fibrosus of the degenerated discs.
3) Compression of the nerve roots.

When symptomatic :
In Children and Young adults :
• Back fatigue and back pain-on movement (Hyperextension) due to
instability of the affected segment.
• Hamstring fatigue and pain due to irritation of L5 nerve root.
• Sciatica – may occur in one or both legs
CLINICAL EVALUATION

In patients > 50 yrs:
•Backache – episodes of back “giving out”
• Sciatica
•Pseudoclaudication d/t spinal stenosis when subluxation is severe.
•Other signs of nerve root compression- motor weakness, reflex
changes and sensory deficits.
CLINICAL EVALUATION

Compression of central canal :
Features:
1. Bladder and bowel dysfunction
2. Bilateral leg symptoms
3. +ve SLRT B/L
4. +ve crossed SLRT
CLINICAL EVALUATION

ON EXAMINATION:
LOOK:
• Buttocks – Flat
- Heart shaped in high grade slip
d/t sacral prominence.
• Sacrum – more vertical
- appears to extend to the waist
• Lumbar hyperlordosis above the level of the slip to compensate for
the displacement.
• Transverse loin crease
• With severity- absence of waist line
• Peculiar spastic gait
-due to hamstring tightness and lumbosacral kyphosis.
CLINICAL EVALUATION

CLINICAL EVALUATION
absence of waist lineTransverse loin creaseLumbar hyperlordosis

Scoliosis – esp in children – 3 types:
a) Sciatic : Lumbar curve caused by the muscle spasm
.resolve with symptoms
b) Olisthetic : Due to asymmetrical slipping of vertebra
c) Idiopathic :
In Olisthetic crisis with total canal occlusion- typical posture–
decrease nerve root tension by supporting trunk wt with
hands on knee.
In spondyloptosis- shortening of lumbar spine
CLINICAL EVALUATION

FEEL :
Palpable step
Tenderness over Pars defect
Hamstring tightness on leg raising.
MOVE :
Usually normal in young pts.
May be – Hamstring + Paraspinal muscle tightness- limiting
forward bending and hip flexon.
Degenerative type: spine-often stiff.
Positive nerve root tests if root compression.
CLINICAL EVALUATION

Radiographic Findings
Anteroposterior views, standing lateral views, and a
Ferguson coronal view.
Flexion-extension lateral views :- may reveal instability,
The Ferguson coronal view is obtained by angling the x-ray
beam parallel to the L5-S1 disc. With this view, the profile of
the L5 pedicles, transverse processes, and sacral ala is more
easily seen.

Radiographic Findings
Lowe et al. found a 26% increase in slipping on standing films
compared with recumbent films.
Oblique views of the lumbar spine can put the pars area in relief
apart from the underlying bony elements, making viewing of the
defect easier.
Lateral bending films should be obtained for coronal deformities .

Demonstrates
a bilateral break in the pars
interarticularis or spondylolysis (lucency
shown by black arrow) that allows the L5
vertebral body (red arrow) to slip orward
on the S1 vertebral body (blue arrow).
The normal pars interarticularis is shown by
the white arrow.

SPECT And CT Scan
A Single-photon Emission Computed Tomography bone scan is
necessary to show whether uptake is increased in the pars. A
SPECT scan is helpful in determining whether the process is
acute or chronic.
If increased uptake is confirmed, a CT scan can be obtained to
evaluate whether there are thickened cortices consistent with a
stress reaction or whether there is an acute stress fracture.

A CT scan with arrow pointing to the
pars fracture.

Radiographic Grading
Meyerding system of grading , the slip grade is calculated
by determining the ratio between the anteroposterior
diameter of the top of the first sacral vertebra and the
distance the L5 vertebra has slipped anteriorly

Percentage of slipping calculated by measurement of distance from line parallel to
posterior portion of first sacral vertebral body to line parallel to posterior portion of
body of L5; anteroposterior dimension of L5 inferiorly is used to calculate percentage of
slipping.

Meyerding System
Grade I spondylolisthesis is displacement of 25% or less;
Grade II, between 25% and 50%;
Grade III, between 50% and 75%; and
Grade IV, more than 75%. A
Grade V represents the position of L5 completely below the top of
the sacrum -SPONDYLOPTOSIS.

Modified Newman Spondylolisthesis Grading
System.
Better define the amount of anterior roll of L5.
The scoring is based on the position of the posterior inferior
corner of the body of the fifth lumbar vertebra with respect to
the dome of the sacrum. The second number indicates the
position of the anterior inferior corner of the body of the L5
vertebra with respect to the anterior surface of the first sacral
segment.

Modified Newman spondylolisthesis grading system. Degree of slip is measured by
two numbers—one along sacral endplate and second along anterior portion of
sacrum:A = 3 + 0; B = 8 + 6; and C = 10 + 10.
Modified Newman Spondylolisthesis Grading
System.

Boxall Et Al., The Angular Relationships
Are the best predictors of instability or progression of the
spondylolisthesis deformity.

These relationships are expressed as the slip angle, which is
formed by the intersection of a line drawn parallel to the inferior
or superior aspect of the L5 vertebra and a line drawn
perpendicular to the posterior aspect of the body of the S1
vertebra .
. A, Standard method of measurement.
B, Method used when inferior L5 end
plate is irregularly shaped

The normal slip angle in a patient without spondylolisthesis
should be lordotic. With a high-grade spondylolisthesis, the
angle is commonly kyphotic.
A slip angle greater than 55 degrees is associated with a high
probability and increased rate of progression.

Magnetic Resonance Imaging
Allows for additional visualization of soft tissue and neural
structures and is recommended in all cases associated with
neurologic findings.
In the early course of the disease, MRI helps in identifying the
stress reaction at the pars interarticularis before the end-stage
bony defect.
MRI may show the degree of impingement of neural elements
by fibrous scar tissue at the spondylolytic defect.
Status of disc

Management
Goal
Pain relief,
Core muscle strengthening, and
Restoration of full lumbar range of motion.

Management
Nonoperative Treatment
Operative Treatment

Includes complete cessation of activity, rehabilitation with
strengthening of the abdominal and paraspinal musculature,
minimization of pelvic tilt, and antilordotic bracing.
The brace is worn for 23 hours/day for minimum of 3 to 6
months. If clinical symptoms improve, the brace can be
gradually weaned through a period of part-time wear.
Conservative Management

Vigorous activities are restricted and back, abdominal and core
strengthening exercises are prescribed.
If the symptoms are more severe, a brief period of bed rest or
brace immobilization may be required. Once the pain has
improved and the hamstring tightness has lessened, the child is
allowed progressive activities.
Yearly examinations with standing spot lateral radiographs of
the lumbosacral spine are advised to rule out the development of
spondylolisthesis.
If the patient remains asymptomatic, limitation of activities or
contact sports is not necessary.

If the SPECT scan reveals metabolic activity and a CT scan
shows thickening of the pars, avoidance of aggravating activity
and core strengthening exercises are recommended.
If the SPECT scan is metabolically active and CT indicates an
acute stress fracture, a 3-month trial of orthotic treatment is
warranted.
If the defect has not healed in 3 months, continued orthotic wear
is not indicated. The CT scan is the most helpful radiographic
technique to determine the presence or absence of healing.

Have excellent relief of symptoms or only minimal discomfort at
long-term follow-up.
If a child does not respond to conservative measures, other
causes of back pain should be ruled out. Special attention
should be paid to children whose symptoms do not respond to
bed rest or who have objective neurological findings.
A very small percentage of children with spondylolysis who do
not respond to conservative measures and in whom the other
possible causes of back pain have been eliminated may require
OPERATIVE TREATMENT.

OPERATIVE TREATMENT
Indications
Persistent symptoms despite 9 months to 1 year of conservative
treatment,
Persistent tight hamstrings, abnormal gait, and pelvic-trunk
deformity.
Development of a neurological deficit .
In a skeletally immature patient with slippage greater than 50%
or a mature adolescent with a slip greater than 75%, even if the
patient is asymptomatic.

Broadly divided into two categories:
Direct repair of the pars defects
Arthrodesis of the involved segments
OPERATIVE TREATMENT OF PARS INTARARTICULARIS

Operative Treatment
Procedures :- Buck technique, Scott wiring, and repair with an
ipsilateral pedicle screw and hook.
Principles:-
• Débridement,
• Grafting of the site with autogenous bone graft, and
• Compression across the fracture.

BUCK TECHNIQUE
Open technique
Fibrous tissue at the pars defect is identified, thoroughly
débrided, and stabilized with a 4.5-mm stainless steel cortical
screw in compression.
This technique was indicated only in cases in which the gap
was smaller than 3 to 4 mm.

Is a demanding procedure.
The narrowness of the lamina, a minimal displacement or
malposition of the screw can lead to implant failure or
complications Such as nerve root irritation, injury to the posterior
arch Or dura, or pseudarthrosis.

Scott Technique
A stainless steel wire is looped from the transverse processes to
the spinous process of the level involved and tightened, in
conjunction with local iliac crest bone graft.
This wire creates a tension band construct, placing the pars
defect under compression, and holds the bone graft in place.

Bradford and Iza reported 80% good to excellent results and
90% radiographic healing of the defects.
This technique requires greater surgical exposure, with extensive
stripping of the muscles to expose the transverse process.
Complications such as wire breakage are common with this
technique.

Salib And Pettine Technique
Modified SCOTT TECHNIQUE in which a wire is passed
around the cortical screws introduced into both pedicles and
tightening it beneath the spinous process.
Biomechanical tests show that fixation of the wire to the pedicle
screw does not increase the stiffness of the system.
This techniques have defect healing rates of 86% to 100%.

A, Posterior view of lumbar
spine model showing 6.5 × 25-
mm cancellous screw placed
approximately two thirds into
ipsilateral pedicle; 18-gauge
wire has been looped around
screw head and passed through
hole in base of spinous process.
B, Oblique view of lumbar
model with wire ends passed
through metal button and
twisted tightly against metal
button.

Kakiuchi Technique
With this technique, hooks are fixed at the lamina and connected
with a rod to an ipsilateral pedicle screw after compression

Pseudarthrosis Repair /Direct Repair
Area of soft-tissue
removal without
decortication
Area of
decortication
Location
of pedicle
Spondylolytic
defect
Recipient bed prepared for autogenous cancellous bone graft

Area of excision of
Posterior elements
Ligamentum
flavum not to
be excised
Nerve root before
decompression
Posterior elements overlying affected nerve root are excised.

Head of variableangle
screw
Area of
bone graft
Starting point of
screw insertion
Variable-angle pedicle screw and bone graft inserted

Rod
Laminar
hook
Rod attached to head of screw with variable angle eyebolt. Laminar hook attached to rod.

For a pediatric patient with grade I or II spondylolisthesis,
dysplastic spondylolisthesis at the lumbosacral junction, or a slip
secondary to a defect of the L5 pars who has failed conservative
treatment, posterior in situ fusion is recommended from L5 to
S1.
Most authors agree that slippage of more than 50% requires
fusion.
OPERATIVE TREATMENT

Operative options
Posterior in situ fusion, adding instrumentation to a posterior in
situ fusion;
Posterior decompression, partial reduction, instrumentation, and
fusion;
Posterior decompression, complete reduction, instrumentation,
and posterior fusion;
Posterior fusion with postoperative cast reduction;
Posterior instrumentation and fusion combined with posterior
Lumbar interbody fusion;
Anterior release;
Intradiscal Graft or structural cage combined with posterior
instrumentation And fusion; and reduction and circumferential
fusion With or without instrumentation.

Reduction And Fusion In High Dysplastic
Spondylolisthesis With Internal Fixation

The method of immobilization after an in situ posterior fusion
ranges from bed rest to bilateral pantaloon spica casts for 6
months.

TREATMENT OF SPONDYLOPTOSIS
L5 VERTEBRECTOMY
Resection of the L5 vertebra with reduction of L4 onto S1 described by
Gaines and Nichols in 1985

References
1) Campbells operative orthopedics
2) Chapmans orthopedic surgery
4) Rothman spine
3) Apleys System of orthopedics and
fracture.
4) Millers review of orthopedics.

Spondylolisthesis

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Spondylolisthesis

Similar to Spondylolisthesis (20)

Recently uploaded

Recently uploaded (20)

Spondylolisthesis