Lordosis: Spondylolysis and Spondylolisthesis

Question 1

Surgical Intervention

Answer 1

Indications: persistent back pain despite conservative measures, gait deviations, greater than 50% slippage, marked instability, neurologic deficit/radiculopathy, hamstring contracture

Goals: Prevent further slippage, immobilization of unstable segment, prevention of further neuro deficit, relieve nerve root irritation, correct clinical symptoms of poor posture, gait, and decreased hamstring length

Surgical Approaches:

• Posterolateral arthrodesis
• Anterior arthrodesis
• decompression- performed when there is neuro deficit
• reduction and instrumentation- performed when the sacrum is in a vertical position resulting in severe lumbosacral kyphosis that displaces lumbar spine anteriorly—results in compensatory lumbar lordosis
• fusion extends from L4-S1 performed with iliac bone graft

Question 2

Nonsurgical Intervention

Answer 2

Observation = Rx of choice with asymptomatic low grade spondylolisthesis ( < 50% slippage)

Routinely followed 2 x/year with clinical and xray exam

Symptomatic spondylolysis or low grade spondylolisthesis respond well to activity restriction, PT, and spinal bracing

PT: lumbar stabilization exercises, strength training of TA, multifidus, and internal oblique
- incorporate co contraction of stabilizers into functional activities to support lumbar spine and decrease LBP

Immobilization with TLSO

• indicated when stress fx of pars or well-defined spondylitic defect
• wear ranges from 6-12 weeks, may continue up to 6 months

Return to Play: painless spinal mobility, resolved hamstring spasm/contracture, return to activities without pn

Surgery indicated if symptoms persist

Question 3

Risk of Progression

Answer 3

Low risk of progression in spondylolysis and spondylolisthesis, < 3%

Adolescents who are asymptomatic = higher risk of slippage during growth spurt

• females at greater risk than males
• patients with lig laxity also at risk (DS, marfan’s)

Risk for increased slippage:

• 50% slippage
• slip angle greater than 55d in skeletally immature
• bony instabilities or decrease anatomic stability of L5-S1

Question 4

Clinical Symptoms

Answer 4

Mild Slippage- poor posture, increased lumbar lordosis

High grade slippage- flattened lumbar spine, vertically oriented sacrum, visible and palpable step off at involved level

Symptoms: LBP relieved by rest, sciatic type pn, hamstring spasm or tightness
– severe cases- torso shortening

Question 5

Types of Spondylolysis and Spondylolisthesis

- Dysplastic and Isthmic m/c in peds

Answer 5

1. Dysplastic - secondary to congenital malformations of sacrum and posterior arch of L5
   - - Malformations include: hypoplasia of superior S1, hypoplasia of facts, elongation of pars, spina bifida
   - - Malformations decrease stability
   - - Degree of slippage usually severe with neuro deficits
2. Isthmic- slip secondary to elongation of pars, break in pars, or combo of both with facets intact
   - - stress fx
   - - elongation occurs d/t result of repeated microfx that heal the pars in elongated position
   - - may also occur d/t acute fx of pars
3. Degenerative- older adults ( > 50y/o), structural destruction of capsules and ligs of posterior joints resulting in hypermobility of segment
4. Traumatic- fracture of posterior arch, may occur at pedicle, laminae, or facet, leaving pars intact
5. Pathologic- occurs secondary to infectious disease that destroys posterior arch of vertebrae

Question 6

Spondylolysis (pars fx)

Spondylolisthesis (pars fx with slippage)

Answer 6

Cause: genetic predisposition, sports with repetitive hyperextension and rotational loading (gymnastics, diving)

Spondylolisthesis- usually occurs at 5th vertebrae, anterior slippage

Question 7

Spondylolisthesis Grades

Answer 7

I: Mildest, less than 25% slip
II: 25-50% slip
III: 50-75% slip
IV: greater than 75% slip