3. INTRODUCTION:
⢠Greek Spondylos (vertebra) &
olisthenin(to slip)
⢠Herbinaux (1782) : L5
slippage over S1
⢠Killian (1854): Coined the
term Spondylolisthesis
4. Terms:
⢠Spondylolisthesis:Anterior
translation of the cephalad vertebra
relative to the adjacent caudal
vertebra
⢠Spondylolysis: Defect in pars
interarticularis
⢠Spondylosis: Degenetarive changes
of spine
⢠Spondyloptosis: Complete fall of
L5 vertebra into the pelvis
⢠Spondylitis: Inflammation of spine
6. Anatomic structures that resist
anteriorly directed force are:
⢠Facets
⢠Annulus fibrosis
⢠Posterior bony arch
⢠Pedicles
7. Hook & catch concept:
⢠Hook:
ďPedicles
ďPars-interarticularis
ďInferior process of cephalad level
⢠Catch:
ďSuperior process of caudal level
8. EPIDEMOLOGY :
⢠Incidence : 7 % by age of 18 years
⢠L5/S1- 82% , L4/L5-11%
⢠Degenerative spondylolisthesis: Common in women
> 50 years
⢠Isthmic spondylolisthesis- Familial association:
26% in first degree relatives
Source:https://pubmed.ncbi.nlm.nih.gov/31078236/
9. Classifications:
ďąWiltse, Newmann, Macnab classification
(Aetiological & topographical)
ďąMeyerding classification(% of slip in lateral
radiograph)
ďąMarchetti-bartolozzi classification(based on
developmental & acqired)
10. I) Wiltse Classification:
⢠Type âI : Dysplastic 20 %(congenital abnormalities
of upper sacral facet or inferior facet of L5)
⢠Type-II : Isthmic 50% (defect in pars
interarticularis)
⢠Type III :Degenerative25 %(intersegmental
instability)
⢠Type IV : Traumatic(# in bony hook)
⢠Type V :Pathologic (eg: osteogenesis imperfect)
⢠Type VI : Iatrogenic (added later)
12. Meyerding Classification :Divides superior endplate of
caudal vertebra into 4 equal portion, allow 5 possible
grades,based on position of posterior inferior corner of
cephalad vertebra
13. III)Marchetti â Bartolozzi classification:
1) Developmental
A) High dysplastic:
ďWith lysis
ďWith elongation
A) Low dysplastic:
ďWith lysis
ďWith elongation
2) Acquired
A) Traumatic:
ďAcute fracture
ďStress fracture
B)Post surgical
ďDirect surgery
ďIndirect surgery
C) Pathological
ďLytic pathology
ďSystemic pathology
D) Degenerative
ďPrimary
ďsecondary
14. DYSPLASTIC SPONDYLOLISTHESIS
ďMalformation of posterior elements
(inferior facet of cephalad vertebra & superior
facet of caudal vertebra)
ďSacrum dome shaped or hypoplastic
ďLoss of buttressing effect to resist anterior and
caudally directed forces
ďM/C occur in lumbopelvic junction
ďA/W anamolies :spina bifida occulta
15. ISTHEMIC SPONDYLOLISTHESIS
ďľHallmark : defect in pars interarticularis
ďľDefect : lytic(stress fracture) or microfracture
ďľMost common type with Common : L5-S1
ďľAge: 5- 50 years
ďľFirst occur during or just before adolescence
ďľMay progress until skeletal maturity
ďľIIA : disruption of pars due to stress #
ďľIIB : Elongation of pars without disruption due
to healed micrfractures
ďľIIC: Acute # through pars
16. DEGENERATIVE
SPONDYLOLISTHESIS
ďľ2nd most common type
ďľCommon : L4- L5 level
ďľResults from segmental instability as a result
of disc degeneration & facet remodeling
ďľFemale =5 times Male
ďľAge > 50 yrs
17. Risk factors for the progression:
1) Young age at presentation
2) Female gender
3) Slip angle > 30 degree
4) High grade slip
5) Dome shaped or significantly inclined sacrum
6) Increased pelvic incidence
7) Disc degeneration
18. CLINICAL FEATURES :
ď Usually asymptomatic : Incidental finding in X ray
ďSymptoms depend on the severity of slip
ďDue to :
1) Chronic muscle spasm
2) Tears in the Annulus Fibrosus
3) Compression of the nerve roots
19. C/F (according to age):
In Children
ďAsymptomatic usually
ďParent noticed unduly protruding abdomen
ďPecular stance
In Young adults :
ďLow back pain- on movement (Hyperextension),
Intermittent
ďHamstring pain due to irritation of L5 nerve root
ďRadiculopathy â may occur in one or both legs.
20. C/F :
In patients > 50 yrs:
⢠Backache â episodes of backache
⢠Sciatica
⢠Pseudoclaudication d/t spinal stenosis
⢠Other signs of nerve root compression- motor
weakness, reflex changes and sensory deficits.
21. ON EXAMINATION:
A) LOOK:
ď Buttocks â Flat
- Heart shaped in high grade slip
- d/t sacral prominence
ď Sacrum â more vertical
- appears to extend to the waist
ďLumbar hyperlordosis above the level of the slip to
compensate for the displacement
ďTransverse loin crease
ďWith severity- absence of waist line
ďPeculiar spastic gait -d/t hamstring tightness and
lumbosacral kyphosis (late stage)
23. O/E:
B) FEEL :
ďľ Palpable step
ďľ Tenderness over Pars defect
ďľ Hamstring tightness on leg raising
C) MOVE :
ďľ Hamstring + Paraspinal muscle tightness limiting
forward bending and hip flexon.
ďľ Degenerative type: spine stiff.
ďľ SLRT +ve( lower lumber nerve root compression)
24. Radiographic assessment ( X-ray)
⢠AP View:
ďInverted Napoleonâs hat sign
(in severe Spondylolisthesis)
ď Standing lateral view: Vertebral
subluxation and pars defect
(15% deformities reduce on supine
imaging)
25. Ferguson coronal view:
ďBy angling
(30°cephalad tilt & the x-
ray beam parallel to L5-
S1disc)
L5 pedicles, transverse
process and sacral ala is
more visible
26. X-RAY (upright lateral Flexion and
extension views):
ďľ Show excessive
movement across the
site of pseudoarthrosis
in pars
ďľ Subluxation of vertebral
body as patient moves
from extension to
flexion
ďľ For operative decision
27. ďľ X-RAY Oblique view:SCOTTY DOG SIGN:
âSCOTTY DOG SIGNâ (decapitated dog )
Pars area is in relief apart from underlying bony
elements
28. Bone scintography/ SPECT:
⢠Detects stress reaction
before fracture
⢠Uses: Symptomatic
patient without
radiological cahnges
⢠Findings: Increase bone
metabolic activity in
acutely injured pars
interarticularis
29. CT myelography:
⢠Indication:
⢠Radicular complaints and
multiple foci of pathology
on MRI
⢠Continued radiculopathy in
absence of MRI finding
⢠Radiculopathy & significant
spinal deformity that
precludes the use of MRI
30. MRI:
⢠Very useful in pre-op
evaluation
⢠Non- invasive
⢠Indication:
⢠Detection of compression
on neural elements
⢠Early detection of disc
dessication
31. Treatment options:
1) Non- operative:
A) Activity modification
B) NSAIDs
C) Physiotherapy
D) Steroid injection
E) Spinal orthosis
2) Operative Treatment:
32. Physiotherapy :
ďRestriction of
vigorous activities
ďAbdominal &
paraspinal core
muscles
sstrengthening
exercises
ďAvoid extension
exercise
ďHamstring
stretching
ďUST for short time
33. OPERATIVE TREATMENT:
Indications :
ďPersitent symptoms despite 6 months of
conservative treatment
ďPersistent abnormal gait with pelvic-trunk
deformity
ďProgressive Neurological deficit
ďAsymptomatic patient with slippage > 50 %
(skeletally imature) & > 75 % in adult
35. Operative options:
⢠Direct repair of pars defect
⢠Decompression & fusion without fixation
⢠Decompression & fusion with pedicle screw
fixation
⢠Posterolateral insitu fixation
⢠PLIF (Posterolateral Interbody Fusion &
Fixation)
⢠TLIF (Trans Foraminal Interbody Fusion)
⢠ALIF(Anterior interbody fusion)
36. Direct repair of pars interaticulais:
â˘Radiographic Criteria for direct
repair:
ďAbsence of spondylolisthesis
ďAbsence of degenerative change at involved
disc level
ďAbsence of degenerative facet changes
ďAbsence of dysplastic changes such as spina
bibida
37. Direct repair of pars interaticulais:
â˘TECHNIQUE:
ďBuck technique:
ďIndicated : gap < 3 mm
ď§Fibrous tissue at pars defect
debrided
ď§Stabilized with 4.5 mm cortical
screw
38. Direct repair of pars interaticulais:
â˘Other techniques are:
ďScott wiring & modified scott
technique
ďKakiuchi procedure( repair with
ipsilateral pedicle screw & hook
39. Repair of pars defect V-rod technique:
In situ posterolateral instrumented fusion
⢠Debride lytic defect
Exposure & bone harvest
⢠Pedicle screw
fixation(polyaxial pedicle)
⢠Approach: Wiltse & Spencer
40. Interbody fusion
⢠Interbody fusion promote fusion between the
vertebral bodies by
a) Device( with instrumentation)
b) Bone graft
GOAL : Elimination of pathological segemnt
⢠Acc to Surgical approach used during device:
ď Anterior lumbar interbody fusion (ALIF)
ďTransforaminal lumbar interbody fusion (TLIF)
ďPosterior lumbar interbody fusion (PLIF)
41. Transforaminal lumbar interbody
fusion (TLIF):
⢠Ideal for grade I or II
spondylolisthesis with
unilateral symptoms
⢠Improved fusion rates d/t
circumferential support
⢠Single bone graft between
vertebra from side
42. Posterior lumbar interbody fusion
(PLIF)
3 surgical steps:
ďLaminectomy or laminotomy
with partial or complete
facetectomy
ďRemoval of intervertebral disc
ďFusion
44. Decompression (in degenerative
type)
⢠Gill procedure= removal of loose laminar
arch
⢠Foraminotomy
⢠Faectectomy
⢠Common : Decompression & fusion with or
without instrumentation
45. Studied from NewYork USA by Andre M Samuel published in 2017
Conclusion:Current evidence supports surgical treatment of degenerative
spondylolisthesis. Posterolateral spinal fusion remains the treatment of choice, the
use of interbodies and decompressions without fusion may be efficacious in
certain populations. However, additional high-quality evidence is needed,
especially in newer areas of practice such as minimally invasive techniques and
sagittal balance correction.
46. ⢠Published in 2021
⢠Result:This research found that both surgical techniques, TLIF
and PLIF, are suitable for DLS treatment. The two methods
differed in postoperative complications which were less frequent
in TLIF. There were no significant differences in the
postoperative quality of life
47. ⢠Long-Term Results of Surgery Compared with Nonoperative Treatment for
Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes
Research Trial (SPORT) from Lebanon in 2018
⢠For patients with symptomatic DS, patients who received surgery had
significantly greater improvements in pain and function compared to
nonoperative treatment through eight years of follow-up. Fusion technique did
not affect outcomes.
48. ⢠Studied from Mubai India by Kulkarni et. al published in 2020
⢠In recent years, there is increasing trend towards minimal access surgery in spine,
which is associated with improvement in implants, navigation technology and use of
newer imaging modality. Although MIS techniques have historically been commonly
implemented for limited indications in spine with technological advancement and
increased surgeon experience, can adopt MISS for wide range of surgeries including
high grade spondyloisthesis and spondyloptosis.
49. Take Home Messages:
ďźIsthimic type is m/c type of spondylolisthesis with
hallmarks of pars defect
ďźRisk factors for progression are early age of
presentation with female gender
ďźTransverse loin crease, absence waist line with
palpable step in spine is key to clinical diagnosis
ďźAP view along with Ferguson coronal view, upright
lateral Flexion and extension views and oblique
views X-ray are needed
ďźRecent advance in treatment for high grade
spondyloisthesis and spondyloptosis is MIS