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Flashcards in Paedriatric Deck (14):
1

what does paediatric spondylolisthesis and spondylolysis cause?

  • Back pain in children/adolsescents

2

What is spondylosis?

  • Antomical Defect in pars interarticularis with adjacent bone sclerosis
  • one of most common cuases of back pain in children/adolscents
  • defects are not Present at birth- not congential
  • develop over time

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3

What is aetiology of spondylosis in paeds pts?

  • Reptitive hperextension
  • prevalence as high as 47% in gymnasts

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4

Define spondylolylisthesis?

  • Forward translation of one vertebra on another
  • 15% of those children with spondylosis progress onto spondylolythesis

5

What level of spondylolytheis is common in children?

  • L5-S1 in children ( L4/5 in adults)

6

What is the risk of progression in spondolythesis?


  • the larger the slip the more likely the progression 



  • dysplastic slips are likely to progress
     

7

what is the spondolylisthesis classification?

  • Wiltse and Newman
  • Type 1- dysplastic
  • Type
    • 2a- Isthmic- fatigue fracture pars interarticularis
    • type 2b- Isthmic- elongated pars
    • type 2c- Isthmic- acute fracture pars
  • Type 3- degenerative
  • Type 4- traumatic
  • type 5- neoplastic

8

Describe the grade of spondylolithesis?

  • Myerding
  • grade 1- <25%
  • Grade 2 25-50%
  • Grade 3 50-75%
  • Grade 4 75-100%
  • Grade 5- spondyloptosis

9

What are the signs and symptoms of spondylolythesis and spondylolysis?

Symptoms

  • most spondylolysis are asymptomatic
  • activity related back pain/buttock pain
  • Hamstring tightness
  • radicular pain- L5 nerve root
  • bowel & bladder symptoms
  • Listhetic crisis
    • back pain worsened by extension , relief by rest
    • hamstring spasm walk with crouched gait

Signs

  • Flattening of lumbar lordosis
  • palpable step off of spinous process
  • limitation of flexion/extension
    • pain with single leg standing lumbar extension
    • politeal angle for hamstring tightness
  • Neuro exam

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10

What imaging is useful in spondylolithesis/ spondylolysis?

Xray Spondylosis

  • Lateral
    • defect in pars- 80%
  • Oblique
    • may show elongation in pars and sclerosis- scotty dog sign
  • AP
    • may see sclerosis of the stress rxn

Bone Scan


  • Most sensitive- lesion maybe cold

    excellent screening tool for children with lower back pain
     

CT


  • delinate the anatomy of the lesion

    pars stress reaction will show up as sclerosis on xray+ CT
     

SPECT- single photon emission computer tomography


  • best when xrays are negative
     

 

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11

What imaging is useful for spondolyothesis?

  • Xray
    • lateral to measure slip and grade
    • Slip grade = measure angle between superior endplate L5 and a line perpendicular to posterior border of sacrum
    • Slip angle >50o greater risk of slippage 
    • pelvic incidence
    • pelvic tilt
    • pelvic slope
  • CT 
    • to delinate anatomy of pars
  • MRI
    • if neurology

12

What is the tx for spondylolysis/ spondylothesis?

Non operative

  • observations with no activity limitations
    • asymptomatic pt with low grade spondylolysis/spondylothesis
  • PT and activity restriction
    • symptomatic isthmic spondylolysis
    • symptomatic low grade spondylothesis
  • TSLO bracing 6-12 wks
    • acute pars stress rxn spondylolysis

Operative

  • pas interarticularis repair
    • for L4 & above to L1 isthmic defect that has failed non op mx
    • multiple pars defects
    • Midline approach, repair with screw, tbw sublaminar hook
    • only decompress if signs of stenosis
  • L5-S1 insitu- posterolateral fusion with bone grafting
    • L5 spondylolysis that failed non op tx
    • low grade spondylolithesis myerding grade 1-2
      • failed non op tx
      • is progressive
      • neurological deficits
      • dysplastic due to high propensity for progression
      • midline incision
      • insitu fusion without instrumentation preferred method
      • immobilise in TLSO post op
  • L4-S1 posterolateral fusion+/- reduction +/- ALIF
    • high grade isthmic spondylithesis - Myerding 3-5
    • Reduction is extremely controversial - no accepted guidelines

 

13

What are the risks of reduction of the spondylolisthesis?

pros

  • Can restore sagittal alignment adn reduce lumbrosacral kyphosis

Disadvantage

  • Risk of complication 8-30%
    • L5 most common nerve root injury with reduction
    • Sexual dysfunction
    • Catastrophic neurological injury

14

What are the complications of Spondylolithesis?

  • Neurological deficits
  • Pseudoarthrosis
  • Progression of slippage
  • Hardware failure