What is spondylolisthesis?
Forward slippage of one vertebra on another
Can you name the types of spondylolisthesis?
*DYSPLASTIC - CHILD- congenital dysplasia S1 sup facet *ISTHMIC - 5-50 - predipostn->elongatn/fracture pars L5-S1 *DEGENERATIVE - >40-facet arthrosis->subluxL4/5 *TRAUMATIC - any age- acute fracture other than pars *PATHOLOGICAL- any age- incompetence of bony elements POSTSURGICAL- adult- excessive resection of neural arches/facets DID TOMMY PAST POINT!!!
Whose's classification is that?
NEWMAN, WILTSE AND MCNAB
How is the severity of the slip classified?
Based on the amount/ degree compared with S1 width
Can you describe this severity score?
Grade I- 0-25% Grade 2- 25-50% Grade 3 50-75% Grade 4 >75% Grade V- >100% = SPONDYLOPTOSIS
Whose' grading system is this?
What other measurements can be made to quantify the slippage? Can you describe how is it measured?
The slip angle it is measured from the superior border of L5 and a perpendicular line from the post edge of the sacrum
What is the natural hx of the disorder ?
unilateral pars defects almost never slip and that porgession of SPONDYLOLITHESIS slows over time yet in adulthood DEGENERATION AND NARROWING of the disc - usually L5/S1 are common-> narrowing of neural foramen and compression of exciting L5 root that -> radicular symptoms
How do children present with spondylolithesis?
Back pain- >25% slip, or l4-5, L3-4 spondylolitheis higher rate of pain cf general population hamstring tightness Palpable step off Alteration in gait- waddle severe slips rare- assoc radiculopathy l5
What is the age and gender of presentation of a child with spondylolithesis?
Age 4-6 > in white boys who participate in hyperextension activities > some eskimo tribes
What level is normally effected in a child with spondylolithesis?
What is its aetiology?
SHEAR STRESS at the PARS INTERARTICULARIS associated with repetitive hyperextension.
Children with the dysplastic type of spondylolithesis are at risk of what?
higher risk of SLIP PROGRESSION and development of CAUDA EQUINA DYSFUNCTION as the NEURAL ARCH IS INTACT
What conditions have been associated with spondylolithesis?
SPINA BIFID OCCULTA THORACIC HYPERKYPHOSIS SCHEUERMANN DISEASE
What is the treatment of low grade spondylolithesis (<50% slip)?
USUALLY RESPONDS TO NON OP TX= ACTIVITY MODIFICATIONS EXERCISE grade I can return to sport when symptomatic grade II are restricted from football/gymnastics
What are the risk factors for progression?
Young age at presentation female gender- a slip angle of >10degrees dome shpaed or inclined sacrum
What would surgery for a low grade slip involve?
L5-S1 postrolateral fusion INSITU for those with intractable pain in whom non op failed or further slippage
What spondylolithesis (grades III-IV) present with ?
Neruological abnormalities L5-S1 isthmic spondylolithesis -> L5 radiculopathy (cf s1 radiculopathy in L5S1 HNP)
What is the treatment of high grade spondylolithesis?
Prophylastic FUSION in growing children with slippage >50% Usually requires INSITU BILATERAL POSTEROLATERAL FUSION L4-S1 WITH OR WITHOUT INSTRUMENTATION- excellent results
Would nerve root exploration be done in such a setting?
Controversial USUALLY LIMITED TO children with CLEAR CUT RADICULAR PAIN or significant WEAKNESS
Would the spondylolithesis be reduced?
maybe ? It is ssociated with 20-30% incidence of L5 root injuries- normally transient but it is to be used cautiously
what does a in situ fusion leave the pt with ?
A high grade slip, lumbosacral kyphosis with severe compensatory hyperlordosis above the fusion -> longterm problems so reduction in high grades is gaining widespread acceptance.
How would a slip be reduced ?
Close neurological monitoring ia neede during the procedure and for several days after
What is the tx of grade V- spondyloptosis?
Vertebrectomy and fusion
Who normally suffers form degenerative spondylolithesis?
African americans diabetes Women >40 yrs people with transitional L5 vertebra and sagittally orientated facet joints
Which vertebra level is most effected?
How do pt normally present with degenerative spondylolithesis?
L5 RADICULOPATHY- from central and lateral recess stenosis causing root compression in the lateral recess between the hypertrophic and subluxed inferior facet of L4 and the postsup body of L5
What is the tx for a pt with degenerative spondylolithesis?
NON OP- same as stenosis surgery= DECOMPRESSION OF THE NERVE ROOTS NAD STABILISATION BY POSTLATERAL FUSION
What are the outcomes for a pt with degenerative spondylolithesis?
SPORT trial= 4 yr follow up there was SIGNIFICANT IMPROVEMENT IN PRIMARY OUTCOME MEASURES FOR OPERATIVE CF NON OPERATIVE
What do adult pt with ISTHMIC spondylolithesis present with?
lower back pain L5 radicular pain
What is the aetiology of adult ISTHMIC spondylolithesis?
*FORAMINAL STENOSIS- BY a)hypertrophy of fibrous repair at the site of the pars defect b) ucinate spur formation on post L5 body c) bulging of L5/s1 disc * LATERAL RECESS STENOSIS- FACET ARTHROSIS and hypertrophy of ligamentum flavum * CENTRAL STENOSIS- rare ASSOCIATED WITH INCREASE PELVIC INCIDENCE 70-80 DEGREES (n 50-55- a line drawn from centre of s1 endplate to centre of femoral head, a second line is drawn perpendicular to line drawn along s1 endplate, insecting the point at centre of s1 endplate. angle between 2 lines= PI) as pelvic incidence increases-> SACRAL SLOPE INCREASES-> greater LUMBAR LORDOSIS *PARS DEFECT
What vertebral level is most commonly effected in isthmic spondylolithesis?
L5/S1 -> compression of existing L5 nerve root by a)hypertrophy of fibrous repair at the site of the pars defect b) ucinate spur formation on post L5 body c) bulging of L5/s1 disc
What is the tx of isthmic spondylolithesis?
NON OP- hamstring stretching, core strengthening, lumbar flexion exercises NSAIDS OP-FORAMINAL DECOMPRESSION INSITU L4, L5-S1 POSTLAT FUSION
What is isthmic spondylolithesis caused by ?
A defect in the PARS INTERARTICULARIS usually acquired from MICROTRAUMA