Spondylolisthesis

Herbinaux 1782

Greek: Spondylo + olisthesis

DefinitionsSpondylolisthesis-Anterior or posterior

slipping or displacement of one vertebra on another.

Spondylolysis- dissolution of, or a defect in, the pars interarticularis of a vertebra.

Spondyloptosis-vertebra that is completely or essentially completely dislocated.

EtiologyHereditary – DysplasticFailure of union of separate ossification

centres Birth fracturesStress fracturesDegenerative changes

Classification

Wiltse McNab and Newman

Marchetti and Bartolozzi

PathophysiologyDysplastic

Congenital defect in Hook or catchSecondary deformity

Traumatic

Extension of Lumbar spinePars impactionRepetitive loading – pars fails

Degenerative

Intersegmental instability and remodelling

Iatrogenic

Incidence : 6%

Racial : EskimosSpondylolysis 15-70 % 1st Deg relatives

Dysplastic more in FemalesLysis 2-3 times more in Males

Slip occur during growth spurt

Clinical features

Children: asymptomaticPostural/gait abn : Pelvic Waddle

Adolescents: Activity related painTraumatic History in 40 %

LBA

Thigh/Leg - pain/Weakness

Bowel/Bladder symptoms

Scoliosis- sciatic/olisthetic/idiopathic

Lumbar spine – foreshortening.

Buttocks- heart shaped

Phalen- Dickson sign

Step off sign

Hamstring tightness.

Tenderness over pars defect

Reduced lumbar movements.

Nerve root compression

Central canal compressionB/B symptomsB/L Leg symptomsB/L SLR +Crossed SLR +

Investigations

Pelvic Incidence

Sacral Slope

Pelvic tilt

Ullman sign

High dysplasticL5 - body TrapezoidS1 - Dome shaped

Sweet heart PelvisSacral verticalisation

Lumbosacral kyphosisCompensatory hyperlordosis

Bone Scan

CT

SPECT

MRI

Treatment

Conservative

Surgical

Factors affecting Progression

Congenital alterationsSeverity of anatomic deficitsGrowthWeightbearingAge and Gender

Max slip- Spurt- 9-15 yrs

< 10 yrs- monitor every 6 months till 15yrsthen every Yr till compl of

growth

Asymptomatic upto 25 %

No Treatment

SymptomaticRestActivity ModificationNSAIDSExercisesSteroid injectionsTLSO Brace

Surgical IndicationsProgression >25%

High grade slip >50 %

Intractable pain or Neuro deficits

Progressive postural/gait abn

Insitu fusionWith Autogenous graft

Repair of Pars defect Pedicle screwBone graftingSublaminar hook

DecompressionLaminectomyRemove loose posterior element (Gill’s)

With instrumentationTLIF

PLIF

ALIF

Combined anterior and posterior

ComplicationsProgression of deformityIncreased slip anglePseudoarthrosisNeurologic injuriesA/c and delayed Cauda equinaBack pain and gait disturbances

Reduction: Indications

Slip angle > 45 degLumbosacral kyphosisPostural imbalanceRequiring decompressionSlip progression after fusionUnacceptable appearance

Spondyloptosis

Vertebrectomy

Reduce L4 onto sacrum

Ant + Post (Gaines)