SPONDYLOLISTHESIS

1. SPONDYLOLISTHESIS
Presented by :
Dr. Mohit Sharma

2. RELEVANT ANATOMY:

3. Definition:
• The term "Spondylolisthesis" refers to a
condition where one of the vertebrae (usually
L5) becomes misaligned anteriorly (slips
forward) in relation to the vertebra below. This
forward slippage is caused by a problem or
defect within the pars interarticularis.
• Greek word spondylos- Spine and olisthanein-
to slip.

4. SPONDYLOLISTHESIS

6. HISTORY:
• Herbiniaux:- first described spondylolisthesis.
• Term coined by:- Killian.
• FIRST DESCRIBED AS
PSUEDOSPONDYLOLISTHESIS BY
JUNGHANNS.
• Newman in 1963:- coined the phrase
Degenerative spondylolisthesis.

7. INCIDENCE:
• PATIENTS OLDER THAN 40 YEARS.
• L4-L5 MORE THAN OTHER LUMBAR LEVELS
• L3-L4 MORE AFFECTED THAN L5-S1.
• WOMEN> MEN.
• SAGGITAL FACET ANGLES OF MORE THAN 45
DEGRESS.
• DIABETES – ROLE UNCLEAR.
• ESTROGEN – ROLE UNCLEAR.

8. THEORIES:
 The first theory proposed a failure of ossification during
embryonic development, leading to a pars interarticularis
defect at birth
 The second theory demonstrated that the pars defect
began to appear around age six and became progressively
more common till age 16. After age 16, the incidence fell
and rarely developed after adolescence
 Saggital Facet theory predilection of slippage because of
facet orientation that does not resist anterior translation.
 Disc degeneration theory disc narrows-> overloading of
facets -> secondary remodelling -> anterolisthesis.
 It is currently thought that the defect develops from
small stress fractures that fail to heal and form a
chronic nonunion.

9. NEWMAN AND STONE
CLASSIFICATION:
• CONGENITAL,
• SPONDYLOTIC,
• TRAUMATIC,
• DEGENERATIVE,
• PATHOLOGICAL.

10. Type Name Description
I Congenital Dysplastic abnormalities
II Isthmic
A Lytic (stress fracture)
B Healed fracture (elongated, intact)
C Acute high energy fracture
III Degenerative Segmental instability
IV Traumatic Fracture of hook other than pars
V Pathologic Underlying pathology
VI Iatrogenic Surgical excision of posterior
elements
WILTSE,NEWMAN AND MC NAB
CLASSIFICATION:-

11. Marchetti And Bartolozzi Classification:
TYPES Sub Types: Causes/Etiology
Developmental Lysis.
Elongation
Acquired Traumatic Stress fractures
Acute fractures
Iatrogenic
Pathologic
Degenerative

12. Pathophysiology
• Dysplastic pathway
• Traumatic pathway

13. Dysplastic pathway Traumatic pathway
Weakness in the hook &
catch mechanism
Body weight
transmitted through
weak zone
Soft tissue restraints:
plastic deformation
Growth plate
overloaded
Repetitive cyclic loads
(sports)
Stress fracture of a
Normal pars
Hard cortical pars pre-
disposes to fatigue
fracture and non-union
Predisposes to a vertical
subluxation

14. Dysplastic changes
• Proximal sacral rounding
• Trapezoidal L5
• Vertical sacrum
• Junctional kyphosis
• Compensatory hyper-lordosis
Contributes to the mechanics of
progression, but not causation

15. Proximal sacral rounding

16. CLINICAL EVALUATION:
• Mostly asymptomatic ,
• LEG PAIN,
• Tiredness and
• NEUROGENIC CLAUDICATION.
• Unilateral sciatica,
• Sense of instability.

17. CLINICAL SIGNS:
• Gait:- pelvic waddle gait.
• Above slip level- Lordotic posture,
• Below slip-Kyphosis of lumbosacral junction,
• Heart shaped buttocks,
• Shortening of trunk with complete absence of waist
line,
• Z deformity,
• Step sign,
• Hamstring tightness,
• Objective signs of motor weakness, reflex change and
sensory deficit only seen with Severe slips.

19. DIAGNOSTIC IMAGING:
• XRAYS- FERGUSON AP VIEW
(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. )
• LATERAL VIEW.
• OBLIQUE VIEWS.
• FLEXION AND EXTENSION VIEWS IN LATERAL
VIEWS.

22. MEYERDING GRADING SYSTEM:
GRADING
GRADE 1 displacement of 25% or less;
GRADE 2 between 25% and 50%
GRADE 3 between 50% and 75%;
GRADE 4 more than 75%
GRADE 5 the position of L5 completely
below the top of the sacrum -
SPONDYLOPTOSIS.

25. ULLMANS SIGN
A LINE DRAWN UPWARD FROM THE
ANTERIOR SURFACE OF SACRUM
NORMALLY IS PROJECTED AT OR IN
FRONT OF THE ANTEROINFERIOR
ANGLE OF BODY OF LAST LUMBAR
VERTEBRA.
WHEN ITS INTERSETED IT SHOWS
FORWARD DISPLACEMENT.

26. PERCENTAGE SLIP:
DISTANCE FROM LINE DRAWN
PARALLEL TO POSTERIOR PORTION OF
FIRST SACRAL VERTEBRAE TO LINE
PARALEL TO POSTERIOR PORTION OF
BODY OF L5.

27. SLIP ANGLE:
BY INTERSECTION OF A LINE DRAWN
PARALLEL TO INFERIOR ASPECT OF L5
BODY AND LINE DRAWN
PERPENDICULAR TO POSTERIOR
ASPECT OF BODY OF S1.
BOXALL ET AL
Are the best predictors of instability or
progression of the spondylolisthesis
deformity.

28. OTHER DIAGNOSTIC INVESTIGATIONS:
• CT, Myelography and MRI,
• Discography,
• Bone scan,

29. TREATMENT
OPTIONS:-
NON
OPERATIVE
Epidural
steroid
Neurogenic
claudication
NSAIDS,
antidepressants,
muscle relaxants
Manipulation ,
traction and
braces
Rehabilitation

30. RISK FACTORS FOR PROGRESSION OF
SPONDYLOLISTHESIS:
RISK FACTORS RISK FACTORS
Clinical Roentgenographic Risk factors
9 to 15 years Dysplastic
Girls > Boys Dome shaped, vertical sacrum
Episodes of back pain Trapezoid shaped L5
Postural deformity or gait
deformity due to hamstring
spasms
more than 50% slip(grade3
and 4)
Increasing slip angle
Instability

31. SURGICAL TREATMENT :
• Guidelines:
• For most patients with back pain and leg pain
with spondylolisthesis.
• For patients with failure of previous posterior
fusion.
• For patients over age 60 years with good
stability of the L5 vertebrae body but with
signs and symptoms of nerve root
compression.

32. Operative treatment for DEG.
Spondylolisthesis:
• For unremitting back and leg pain after
adequate Non operative treatment.
*(only 10-15% require surgery).
• Decompression,
• Decompression With Fusion,
• PLIF and TLIF,
• Anterior spinal fusion,
• Decompression and combined fusion.

33. DECOMPRESSION:
• In patients with significant disc collapse and
no pathological motion dynamic X -rays.

34. DECOMPRESSION WITH FUSION:
• CLAUDICTORY PAIN AND LEG PAIN,
• PRESERVED DISC HEIGHT,
• OSTEOPOROSIS(PARS FRACTURE),
• ABSENCE OF OSTEOPHYTE AND DYNAMIC
MOTION PRESENT.
*(Fusion status and presence
or absence of comorbid disease.)

35. PLIF AND TLIF:
• Discographically concordant single level axial back
pain with radiculopathy,
• Minimal disc degenerative changes,
• Preserved disc height,
• For revison surgeries with inadequate posterior
fusion,
• For patients with hypermobile levels,
• For small or absent transverse process at the
levels to be fused.

36. ANTERIOR SPINAL FUSION:
• Only if some indirect spinal decompression is
provided by eradication of disc , restoration of
disc height and ligamentotaxis by placement
of structural bone grafts or cage after
distraction of disc space and tensioning of
posterior ligamentous structures.

37. DECOMPRESSION AND COMBINED
FUSION:
• For Anterior interbody fusion:
• Kyphosis and
• Posterior saggital vertical axis,
• For posterior interbosy fusion:
• For saggitally neutral or lordotic spines with
intac disc

38. Developmental
Less than 50% slip
PL fusion
Spondylotic defect VAN DAM Technique
More than 50% slip • Bilateral PL fusion
• Reduction with anterior spinal
fusion
• Reduction with posterior spinal
instrumentation
In children Cast reduction and fusion by Scagleitti
technique
Neurological less than 50% slip L5-S1 PL fusion
Neurological with more than 50% slip L4-S1 PL fusion
For spondyloptosis or grade 5 Vertebrectomy with posterior spinal
instrumentaion with L4-S1 fusion.

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

40. 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

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

42. Pseudarthrosis Repair /Direct Repair
Head of variableangle
screw
Area of
bone graft
Starting point of
screw insertion
Variable-angle pedicle screw and bone graft inserted

43. Pseudarthrosis Repair /Direct Repair
Rod
Laminar
hook
Rod attached to head of screw with variable angle eyebolt. Laminar hook attached to rod.

44. L 5 VERTEBRECTOMY:
Resection of the L5 vertebra with reduction of L4 onto S1 described by Gaines
and Nichols in 1985