Degenerative Spondylolisthesis

Degenerative spondylolisthesis..guidelines based management

1. Degenerative Spondylolisthesis Dr. Ramkrishna Dahal Fellow Spine Reconstructive Surgery Grande International Hospital

2. Spondylolysis :defect in pars interarticularis Spondylolisthesis comes from Greek spondylos (vertebra) and olisthanein (to slip or fall) Spondyloptosis : the most severe form of spondylolisthesis , when the body of L-5 has slipped into the pelvis and is positioned directly anterior to the sacrum Introduction

3. Term Coined by Kilian First described by Herbiniaux who reported a bony prominence anterior to the sacrum impediment to vaginal delivery Robert in 1855 suggested that listhesis was possible only after lysis of the neural arch Neugebauer “ Spondylolisthesis with intact neural arch but with elongation “ Spondylolisthesis

4. Junghanns first described degenerative spondylolisthesis in 1930 as pseudospondylolisthesis Mcnab – “ Spondylolisthesis with intact Neural arch” Renamed by Newman as degenerative spondylolisthesis because of the associated arthritic changes Diabetes and oophorectomy predisposes to this condition Degenerative spondylolisthesis

5. Wiltse , Newman, and Macnab’s classification Five types of spondylolisthesis : Type I Dysplastic Type II Isthmic Type III Degenerative Type IV Traumatic Type V Pathological Classification

6. Prevalence (Copenhagen OA study in 4500 patients) 2.7% in men 8.4% in woman More common in African Americans, diabetics, and woman over 40 years of age Risk Factors: Sacralization of L5 Sagittal orientation of facet If sagittal orientation of facet >45 deg, there is 25 times more chance of DS than those with <45 deg. Epidemiology

7. Degenerative Spondylolisthesis Intersegmental instability is present as a result of degenerative disc disease and facet arthropathy . [SPONDYLOSIS] The slip occurs from progressive spondylosis within this 3-joint motion complex. The L5 nerve root is usually compressed from lateral recess stenosis as a result of facet and/or ligamentous hypertrophy Pathophysiology

8. 3 joints motion complex in Spine

9. Kirkaldy -Willis cascade of degeneration

10. Not simply sagittal slippage Rotatory deformity Asymmetric facet subluxation

11. Differentiated from isthmic by intact pars Because the arch is intact and moves forward with the L4 vertebral body, progressive spinal stenosis occurs in addition to facet degenerative changes Thories to explain the occurance of degenerative spondylolisthesis include sagittal facets and disc degeneration Degenerative spondylolisthesis

12. Clinical presentation backache leg pain neurologic claudication (68%) radiculopathy (32%) cauda equina (3%) Presentation

13. Feel: Palpable step-off in higher-grade slips Move: Usually preserved spinal motion Hamstring tightness Gait difficulty (worse with high-grade slips)

14. Xray : typical anterolisthesis at L4-L5 with disc space narrowing Standing Lat view 22% of L4-5 slips detected on standing lat view were not detected in supine MRI Flexion and extension lateral views: instability (>4mm translation, >10 degrees sagittal rotation)

15. Is Xray necessary even after doing MRI LS spine???

16. Wrong surgeries were done exacerbating the patients symptoms!!! Only decompression done instead of decompression with fusion with undetected DS compromising further stability. What is Role of Standing Lat Xray ???

17. Morphology subgroups: Type A: advanced disc space collapse without kyphosis Type B : disc partially preserved with translation of 5 mm or less Type C : disc partially preserved with translation of more than 5mm Type D : kyphotic alignment Leg pain modifier; No leg pain – 0 Unilateral leg pain – 1 Bilateral Leg pain -2 Kepler

18. Distal lumbar flexion can result in pelvic retroversion therefore, in cases of flexible sagittal imbalance, pelvic retroversion may be compensatory for lumbar canal stenosis

19. The majority of patients do well with conservative care. Progression of slip correlates with jobs that require repetitive anterior flexion of the spine. Slip progression is less likely to occur when the disc has lost over 80% of its native height and intervertebral osteophytes have formed. Progression of clinical symptoms does not correlate with progression of the slip. Natural history

20. Nonoperative NSAIDS Trunk stabilizing exercise/ Spinal flexor exercises and low impact aerobic exercise seem to benefit the patients Epidural steroid injection Treatment

21. No RCTs or Placebo controlled trails Grade of recommendations: Insufficient Satisfactory short term pain relieve especially in radiculopathy 1 st episode ineffective without fluoroscopy Try next episode under fluoroscopy 1st episode ineffective under fluoroscopy Do not try next 1 st episode partially effective try next episodes Facts and Myths about Epidural injection

22. Operative treatment For unremitting back and leg pain after non operative treatment 10-15% patients

23. Decompression Significant disc collapse without pathological motion on dynamic x ray Operative treatment

24. Patients with preserved disc height Absence of osteophytes on x ray Small degree of motion on dynamic x ray Fusion can be supplemented by instrumentation Decompression and fusion

25. Fusion can be achieved by posterior lumbar interbody fusion ( PLIF ) transforaminal lumbar interbody fusion ( TLIF ) anterior spinal fusion circumferential fusion/360 degree fusion

26. Post op Xray TLIF

27. Longer-term follow-up has shown that obtaining a radiographically solid fusion improves clinical results 86% good or excellent results in solid fusions and 56% in pseudarthrosis The necessity of instrumentation in the treatment of lumbar stenosis with spondylolisthesis remains an area of intense investigation Concern of adjacent segment “transition syndromes”

28. Anterior Spinal Fusion Results are similar to those obtained with decompression and instrumented fusion Additional morbidity associated with the anterior approach, depending on surgeon’s experience

29. When indicated ??? In revision cases with pseudoarthrosis Typical Complication Retrograde ejaculation: injury to superior hypogastric plexus Must Know: ALIF

30. Decompression and Combined Fusion (360-degree Fusion) Posterior interbody procedures often do not allow safe excision of a contracted anulus and anterior longitudinal ligament for height restoration. The objective of interbody grafts at L4-L5/L5-S1 is to re-create the segmental lordosis of 20 to 30 degrees

31. After repeated discectomies Unstable: >10 deg in flex/ext lat radiographs Back pain> leg pain B/L facetectomy Fusion : Indications

32. Pseudoarthrosis 5-30% CT more reliable than MRI Adjacent segment disease 2-3% Dura tear Positioning Neuropathy Complications

33. Evidence based guidelines regarding treatment of Degenerative Spondylolisthesis Enigma of Listhesis Treatment

34. What is the role of injections for the treatment of degenerative lumbar spondylolisthesis ? There is insufficient evidence to make a recommendation for or against the use of injections for the treatment of degenerative lumbar spondylolisthesis . Grade of Recommendation: I (Insufficient Evidence)

35. Does surgical decompression alone improve surgical outcomes in the treatment of degenerative lumbar spondylolisthesis compared to medical/interventional treatment alone?

36. Direct surgical decompression may be considered for the treatment of patients with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment. Grade of Recommendation: C

37. For symptomatic single level degenerative spondylolisthesis that is low-grade (< 20 %) and without lateral foramina stenosis , decompression alone with preservation of midline structures provides equivalent outcomes when compared to surgical decompression with fusion. Grade of Recommendation: B (Suggested)

38. The addition of instrumentation is suggested to improve fusion rates in patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis . Grade of Recommendation: B

39. The addition of instrumentation is not suggested to improve clinical outcomes for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis . Grade of Recommendation: B

40. There is insufficient evidence to make a recommendation for or against the use of reduction with fusion in the treatment of degenerative lumbar spondylolisthesis . Grade of Recommendation: I (Insufficient Evidence) Role of reduction

41. There is insufficient evidence to make a recommendation for or against the use of autogenous bone graft or bone graft substitutes in patients undergoing posterolateral fusion for the surgical treatment of degenerative lumbar spondylolisthesis . Grade of Recommendation: I (Insufficient Evidence) Autogenous Bone graft vs Cage

42. Facet joint effusion greater than 1.5mm on supine MRI may be suggestive of the presence of degenerative lumbar spondylolisthesis . Further evaluation for the presence of degenerative lumbar spondylolisthesis should be considered, including using plain standing radiographs. New recommendation statement Grade of Recommendation: B

43. There is insufficient evidence to make a recommendation for or against the use of indirect surgical decompression for the treatment of patients with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment. Grade of Recommendation: I (Insufficient Evidence)

44. Surgical decompression with fusion is suggested for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis to improve clinical outcomes compared with decompression alone in single level disease. Grade of Recommendation: B

45. There is insufficient evidence to make a recommendation for or against efficacy of surgical decompression with fusion, with or without instrumentation, for treatment of multi-level degenerative lumbar spondylolisthesis compared to medical/interventional treatment alone. Grade of Recommendation: I (Insufficient Evidence)

46. While both minimally invasive techniques and open decompression and fusion, with or without instrumentation, demonstrate significantly improved clinical outcomes for the surgical treatment of degenerative lumbar spondylolisthesis , there is conflicting evidence which technique leads to better outcomes. Grade of Recommendation: I (Insufficient/Conflicting Evidence)

47. L4-L5 most common 4-5 times more common in female Differentiate from vascular claudication Standing Lat xray mandatory before any spinal surgery Do not treat Xray , Treat patient THMs

48. No correlation between slip progression and clinical symptoms Non operative treatment : Main stay of treatment 10-15 % ultimately need surgery Decompression with Fusion with/out instrumentation has better outcome (Gr. B ) THMs contd …..

49. Thank you