Spondylisthesis by dr venkata rama krishnaiah vapms cop

about spondylesthisis

1. Spondylolisthesis DR. V Venkata RamaKrishnaiah Mpt O rtho,MSc phycology

2. DEFINATION The term spondylolisthesis is derived from the Greek words spondylo = vertebra, and olisthesis = translation. Spondylolisthesis is defined as a translation of one vertebra over the adjacent caudal vertebra . This can be a translation in the anterior ( anterolisthesis ) or posterior direction ( retrolysthesis ) or, in more serious cases, anterior-caudal direction.

3. CLASSIFICATIONS According to Wiltse -Newman , It is classified in six types on the basis of aetiology. These are : Dysplastic (congenital), Isthmic , D egenerative , T raumatic , P athologic and I atrogenic spondylolisthesis .

4. Type 1 : Congenital spondylolisthesis ( Dysplastic ) An elongation of the pars interarticularis can be seen in congenital spondylolisthesis , in which the pars lesion is due to a congenital anomaly of the L5-S1 facet articulation. Secondary to congenital abnormalities of lumbosacral articulation including mal-oriented or hypoplastic facets, sacral deficiency, poorly developed pars As the slip progresses, the pars elongates in response to the deformity. Therefore, with an elongated pars, it is important to evaluate the lumbosacral facets to properly classify the lesion. The symptoms usually develop during the adolescent growth period.

5. Type 2: Isthmic spondylolisthesis Isthmic spondylolisthesis , or spondylolisthesis due to a lesion of the pars interarticularis , is a common source of pain and disability in both pediatric and adult population . The basic lesion in isthmic spondylolisthesis is in the pars interarticularis and mainly appears at the lumbosacral level (L5-S1 ). It is characterized by high lordosis angles and lordotic wedging of the affected vertebra (L5) and very high L4-5 intervertebral disc wedging.

6. Isthmic spondylosithesis is typically considered as a pediatric condition. Spondylolisthesis is mostly often caused by spondyloslysis . Spondylolysis is considerd a stressfracture caused by an eccesive amount of mechanical stress that affects the isthmus. This part of the vertebrae forms the connection between the corpus and the facet joints, at the back of the vertebrae. Therefore, a load for the facet joints result in a stressor for the isthmus. The stress on the pars interarticularis is the highest with extension and rotation. Anterior pelvic tilt, abdominal muscle weakness and hamstring thightness magnify these biomechanical forces.

7. Wiltse et al. divided this category into three subtypes: The lytic lesion of the pars (Type II-A ) is the most common cause of spondylolisthesis and is termed spondylolysis . This defect is present in 6% of the population by young adulthood.  The elongation of the pars interarticularis (Type II-B)  is thought to be due to repetitive microfractures with subsequent healing in an elongated position. Elongation of the pars can also be seen in congenital spondylolisthesis . An acute fracture of the pars (Type II-C),   the third subtype, resulting from a single traumatic episode. Wiltse et al. suggested that this type of isthmic spondylolisthesis could also be classified as traumatic spondyloslisthesis .

8. Type 3 : Degenerative spondylolisthesis Degenerative spondylolisthesis is most common in adults.In this type the L4–L5 vertebral space is affected 6 to 9 times more commonly than other spinal levels. It is characterized by a significant constriction of the cauda equina , combined with a diminished cross-sectional area of the vertebral canal, thickening and buckling of the ligamentum flavum and hypertrophy of adjacent facet joints It is also a common condition in the elderly (>50 years).

9. The main causes are: • Disc degeneration ; • Facet joint arthrosis ; • Malfunction of the ligamentous stabilizing component ; • Ineffectual muscular stabilization . Degenerative spondylolisthesis is believed to result from chronic intersegmental instability. Degenerative changes to both the facet joints and the intervertebral disk cause the slip. Sagittal orientation of the facet joints and facet tropism also have been related to the development of degenerative spondylolisthesis . 

10. Type 4: Traumatic spondylolisthesis Traumatic spondylolisthesis is caused by a fracture in a region other than the pars. This fracture leads to slippage of the vertebrae. Type 5: pathological spondylolisthesis Pathological spondylolisthesis is due to generalized or localized musculoskeletal processes affecting the posterior elements and causing instability. Diffuse or local disease compromises the usual structure integrity that prevents slippage. Type 6: iatrogenic spondylolisthesis Iatrogenic spondylolisthesis results from excessive removal of the posterior elements after laminectomy .

11. According to Marchetti-Bartolozzi Classification : Developmental – including Wiltse 1 and 2 Acquired – by traumatic , postsurgical, pathological, degenerative

12. Myerding Classification Grade1- <25% Grade 2- 25 – 50% Grade 3- 50-75% Grade 4- 75-100% Grade 5- spondyloptosis

13. Symptoms and findings Low-back Pain and leg pain    Trophic changes  Atrophy of the muscles, muscle weakness  Tense hamstrings, hamstrings spasms  Disturbance in patterns  Diminished ROM (spine)  Disturbances in coördination and balance  Neurological symptoms (possible evolution towards cauda equine syndrome)  Dull pain, typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine.

14. Patients usually report that their symptoms vary as a function of mechanical loads (such as in going from supine to erect position) and pain frequently worsens over the course of the day . Radiation into the posterolateral thighs is also common and is independent of neurologic signs and symptoms. The pain could be diffuse in the lower extremities, involving the L5 and/or L4 roots unilaterally or bilaterally, but generally bilaterally . Symptoms decrease with sitting or standing with lumbar flexion and with lying. As symptoms worsen patients are more and more limited in their activities and walking distance. This relationship is known as neurogenic intermittend claudication .

15. Differential Diagnosis Spondylolysis Metastatic disease   Low back pain   Osteoarthritis  Neuroforaminal stenosis Spinal Stenosis  

16. Diagnosis Radiographic examination provides the best diagnostic information when spondylolisthesis (or spondylosis ) is suspected. Standard lumbar anteroposterior and lateral views are needed, but for a better look at the problem oblique views are essential to visualize the pars interarticularis directly. These views may demonstrate a pars interarticularis abnormality,

17. X-ray Overall X-ray of the spine and lumbosacral X-ray are seen as the golden standard for diagnosis.There are multiple views used with the most common one being the anteroposterior , lateral and oblique views. Multiple characteristics can be seen, such as the degree of the slip or the slip angle. The most prominent sign remains the defect of the pars interarticularis , or more commonly named the broken collar or neck of the “Scottie Dog ”. CT and MRI Advanced imaging techniques like MRI and CT have to be used when neurological symptoms are present, and when surgical intervention is indicated. CT and MRI, which give an accurate localization and a better illustration of the lesion , are taken when one of the following signs are present: • Significant and progressing neurologic claudication   • Radiculopathies and the clinical suspicion that another condition may be causative • Bladder or bowel complaints • Metastatic disease 

18. Medical Management General: Initially resting and avoiding movements like lifting, bending and sports. Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-inflammatory effect on nerve root and joint irritation. Epidural steroid injections can be used to relieve low back pain, lower extremity pain related to radiculopathy and neurogenic claudication . A brace may be useful to decrease segmental spinal instability and pain.

19. Surgery Patients with chronic and disabling symptoms, who fail to respond to conservative management may be referred for surgery. When the condition of spinal instability is very severe, a surgical intervention may be necessary to attach the vertebras together. It can help the patient to reduce pain, improve spinal function and increase the quality of life. The goal of surgery is to stabilize the segment with listhesis , decompress the neural elements, reconstruction of the disc space height and restoration of normal sagittal alignment . When evaluating a patient, many factors, such as age, degree of slip and risk of slip progression, must be considered.

20. There are several different options for surgical treatment; one of them is fusion (e.g. posterolateral fusion ). Other treatment options include decompression (Gill laminectomy ), supplemental instrumentation and supplemental anterior column support. 

21. Physical Therapy Management Spondylolisthesis  should be treated first with conservative therapy, which includes physical therapy, rest, medication and braces . Exercise therapy: exercise therapy, which consists of strengthening exercises of the deep abdominal musculature. In addition, isometric and isotonic exercises may be beneficial for strengthening of the main muscle groups of the trunk, which stabilize the spine. These techniques may also play a role in pain reduction. In order to improve the patient’s mobility, physical therapy includes stretching exercises of the hamstrings, hip flexors and lumbar paraspinal muscles. Furthermore endurance training is effective for chronic low back pain . There is evidence that suggests that specific stabilization exercises and core stability exercises can be useful in reducing pain and disability in chronic low back pain in patient with  spondylolisthesis .

22. There is evidence that suggests that specific stabilization exercises and core stability exercises can be useful in reducing pain and disability in chronic low back pain in patient with  spondylolisthesis .

23. Lumbosacral braces or corset Posture and lifting techniques Massage therapy Kinesiotaping Maitland mobilisation Muscle energy techniques etc...