Spondylolisthesis

spine

1. Spondylolisthesis Presented by – Dr. Mahak Jain Chairperson – Dr. Akshay Jain 12/11/14

2. Spondylolisthesis Forward translation of one vertebra on another in the sagittal plane of the spine S pondylolysis defect in the pars interarticularis of lumbar vertebra most commonly due to repeated and increased stress on the pars interarticularis

3. Anatomy Pars region between the superior and inferior articulating facet of the vertebra weakest area in the neural arch susceptible to stress fracture

4. Pars defects not observed in newborns or nonambulatory patients lysis or elongation does not occur in primates that do not have an upright bipedal gait presence of lumbar lordosis (unique in humans) is necessary for spondylolisthesis to occur

5. Embryology and Ossification Centres pars ossify at 12-13 weeks gestation via endochondral ossification Lumbar Vertebrae ossification centre in the region of the pars uneven trabeculation and cortication ossification centre that arises at the upper end of pedicle uniform trabeculation throughout the pars potential stress riser which could be susceptible to fatigue fracture

6. Classification

7. Classification Wiltse , Newman and Macnab 1976 Type I: Dysplastic (child) Type II: Isthmic (5-50 yrs ) Type III: Degenerative (older) Type IV: Traumatic Type V: Pathologic

8. Dysplastic spondylolisthesis D ysplasia/aplasia of posterior facet joints of the L5/S1 levels C onstant spina bifida occulta at the L5 level – congenital nature C oncomitant elongation of the pars interarticularis --- frank lysis C ondition is strongly familial, with as many as a third of first-degree relatives affected with the dysplastic form

9. Lateral radiograph rounding of the top of the sacrum as L5 has rolled round anteriorly due to poorly formed posterior facet joints AP view ' Napoleon's hat' appearance of L5 superimposed through the sacrum

10. Isthmic spondylolisthesis R epetitive cyclical extension/torsion of the spine R epetitive infraction fatigue failure of the pars H igh prevalence rate H ighest biomechanical forces on the pars at L5/S1 level commonest site of a lytic spondylolysis

11. Lateral radiograph of a lytic spondylolisthesis Oblique radiograph of a lytic spondylolisthesis

12. Degenerative spondylolisthesis Incompetence of the posterior facet joints Features of canal stenosis 10x more common at the L4/5 than the L5/S1 N ot encountered in the under 50-year-old T he degree of slippage in the sagittal plane is no good guide to the amount of neural compression T ime is important degenerative process going on for years and years patients are much more readily able to adapt to neural compression than for example with a rapidly growing tumour

13. CT scan level of a degenerative spondylolisthesis facets have come forward to contact the back of the vertebral body and completely close off the epidural space Degenerative spondylolisthesis

14. Traumatic spondylolisthesis acute vertebral fractures do not occur through the pars, but through pedicles , bodies, discs so -called 'traumatic spondylolistheses ' are not discrete entities should not be part of the generic spondylolisthesis classification Pathological spondylolisthesis metastasis and rheumatoid disease are the more common causes disease of the whole motion segment rather than the pars in particular

15. Classification Marchetti and Bartolozzi 1997 etiology-based system importance of high and low grade developmental spondylolisthesis permitting early recognition and treatment

16. L ow grade spondylolisthesis low grade variety present in young adults frequently associated with spina bifida slip is characterized by translation without any angulatory or kyphotic component

17. H igh grade spondylolisthesis Usually at L5-S1 and become symptomatic in adolescents wedge shaped L5 and a domed vertical sacrum anterior translation of L5 associated with angulation --true lumbosacral kyphosis potential to develop into spondyloptosis if untreated or mismanaged

18. Classification by Marchetti and Bartolozzi based on etiology clearly distinguishes between developmental and acquired forms of this deformity highlights the pathogenesis of the different types of spondylolisthesis potentially has the most relevance to natural history, risk of progression, and implications for treatment

19. N atural H istory wide spectrum of clinical presentation dysplastic and isthmic spondylolisthesis present during childhood and adolescence dysplastic variety usually at a younger age than isthmic early stages - low back pain is the only consistent clinical feature immature patient - high index of suspicion should be raised about the possibility of an underlying spondylolisthesis

20. N atural H istory h amstring tightness, spinal deformity, gait abnormality frank neurology severe degrees of spondylolisthesis u sually dysplastic variety - lower lumbosacral nerve roots can be compressed behind the upper back of the sacrum isthmic spondylolisthesis some degree of L5 radicular pain is not uncommon hypertrophic callus around the lysis degenerative spondylolisthesis spinal claudication in association with low back pain

21. Phalen -Dixon sign sciatic crisis typically seen in high grade adolescent spondylolisthesis sign includes sciatic pain vertical sacrum and pelvis lumbosacral kyphosis tight hamstrings hyperlordotic lumbar spine waddling gait

22. Back pain in Spondylolisthesis The cause of back pain is unclear and is multifactorial The pain may be due to disc degeneration facet degeneration chronic nerve root irritation from compression or traction patient may have accompanying spinal stenosis

23. Radiography

24. AP View

25. Lateral View

26. Oblique View Defect in the pars interarticularis – ‘ collar ’ around the ‘ neck ’ of an illusory ‘ dog ’ - oblique xray

27. Bending F ilms D emonstrate persistent motion and instability E specially in the presence of degenerated disc disease at the level of spondylolisthesis D isc degeneration and collapse of the disc space is an attempt to stabilize the motion segment

28. R adiological E xamination L arge number of suggested and preferred radiological parameters to assess spondylolisthesis Only 2 are of any great importance ( Wiltse LL et al ) The amount of displacement The slip angle (the angular relationship between L5 and S1 in the dysplastic form of spondylolisthesis ) Percentage slip ( x/y(x 100) slip angle or angle of sagittal rotation

29. R adiographic I ndex Slip Angle of Boxall S uperior border is chosen more constant not affected by adaptive changes commonly occur in the inferior end plate R epresent local kyphosis across the L5-S1 motion segment

30. R adiographic I ndex Meyerding Classification T he degree of slips or transitional displacement

31. R adiological E xamination CT scan Helpful in preoperative planning especially in cases with severe dysplasia MRI A ssess neural foramen on the sagittal views D etermine extent of associated disc disease D isc herniation is common 25 % cases occur at the level above the slip 15 % occur at the level of the slip itself R ule out tumor or infection

32. Management

33. Predictors of slip progression F emale gender P re-pubescence T rapezoidal L5 D omed and vertical sacrum and sagital rotation S lip angle > -10 o H igh grade slip (>50% slip progression) I nclined sacrum (>30 o beyond vertical)

34. Indications for surgery Slip progression more common in skeletally immature patients who have not reached the adolescent growth spurt t he higher the grade of slip , the more likely it is to progress s lip progression rarely occurs in adults High-grade slip with significant lumbosacral kyphotic deformity causing sagittal imbalance

35. Indications for surgery Neurological deficit In most cases, the L5 nerve root is involved Low back pain unresponsive to a prolonged course of conservative treatment Radicular pain with associated nerve root compression on imaging studies that is not responsive to conservative treatment

36. Conservative treatment D irected at symptomatic relief Rest anti-inflammatory agents lumbar corset Physical therapy abdominal strengthening exercises hamstring stretching avoidance of extension exercises which will exacerbate the symptoms Sinaki et al showed 3-year outcomes were significantly better in patients who followed the flexion exercise program compared to extension exercise

37. Surgical treatment D irected towards symptoms and etiology R adiculopathy N eurologic deficit from spinal stenosis I nstability pain D iscogenic pain M ainstay of treatment is Decompression Fusion Instrumented Non instrumented

38. Isthmic Spondylolisthesis Treatment Findings Treatmennt Grade I observation Grade II Asymptomatic: Observe Symptomatic: Activity modification Failed: Surgery Grade III-IV Surgery

39. Isthmic Spondylolisthesis Operative Treatment procedure advantage/disadvantage results Defect repairs Preserve motion Technically difficult Variable 60-90% Laminectomy (Gills) Increase instability Poor long term outcome abandoned Posterolateral fusion (in situ) Improved symptoms Children Adult: variable Reduction and fusion Allow correction Add stability Slippage >60% Slip angle >50 degree Age 12 to 30 (Bradford 1988) Anterior and posterior fusion Additional stability 360 degree fusion Difficult surgery

40. Role of Reduction H igh-grade spondylolisthesis causes lumbosacral kyphosis --- sagittal imbalance R eduction procedure controversial literature support both sides of the argument H igh rate of neurologic complications R eserved for patients with loss of global sagittal balance because of significant lumbosacral kyphosis C ircumferential fusion and stable fixation with iliac screws are strongly recommended to prevent slip progression and pseudarthrosis

41. Degenerative Spondylolisthesis Operative Treatment Options Decompression & laminectomy Decompression with posterolateral fusion Decompression with instrumented fusion Long-term follow-up in patients with degenerative spondylolisthesis reveals a positive correlation between fusion and improved clinical outcome

42. Fusion O ptions A chieve posterior column stability P osterolateral intertransverse fusion (PIF) A chieve anterior column stability A nterior lumbar interbody fusion (ALIF) A chieving a circumferential fusion P osterior lumbar interbody fusion (PLIF) T ransforaminal interbody fusion (TLIF) N o consensus of what constitutes optimal surgical treatment S urgical option must be individualized

43. Posterior intertransverse fusion H istorically most popular way of performing fusion D irect decompression of the neural elements D eformity correction S tability with pedicle screw instrumentation D isadvantages are L ess optimal fusion rate: graft under tension A s it does not address the anterior column: persistent discogenic low back pain is common

44. Anterior Lumbar Interbody Fusion A llows for complete discectomy P ermits placement of a large interbody graft F acilitate slip angle correction R econstructs the disc space height A nterior graft B iomechanically compressive environment A llowing optimal fusion

45. Anterior Lumbar Interbody Fusion The disadvantages related to the approach risk of injury to major vessels, retroperitoneal and intraperitoneal structures in males, the sympathetic plexus can be damaged and cause retrograde ejaculation does not allow direct nerve roots decompression Suk et al. anterior support would be helpful for preventing reduction loss in cases of spondylolytic spondy - lolisthesis of the lumbar spine

46. Circumferential fusion the benefits of anterior and posterior surgery ( TLIF/PLIF) circumferential stability obviously promotes high fusion rate Open or MIS

47. SPONDYLOPTOSIS severe symptoms of low back pain, deformity, and neurologic symptoms or deficits Surgical options in situ circumferential fusion technique described by Smith and Bohlman Gaines procedure (resection of L5 and reduction of L4 onto the sacrum through a combined anterior and posterior approach) Gaines technique is associated with a high rate of postoperative neurologic deficits and is generally reserved for the most severe deformities

48. Gaines Procedure resection of L5 and reduction of L4 onto the sacrum combined anterior and posterior approach

49. Thank You

50. Operative Vs Non-operative

51. multicenter, prospective study highest level of evidence guide decision-making on operative vs nonoperative care for the specific disorder of degenerative spondylolisthesis treatments compared were lumbar laminectomy with a single level fusion vs nonoperative treatment treating surgeon determined type of fusion ( uninstrumented posterolateral fusion, instrumented posterolateral fusion, circumferential fusion)

52. Conclusion patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically

53. Degenerative Spondylolisthesis Operative Treatment Options D ecompression alone or decompression with segmental arthrodesis ? higher proportion of patients with good or excellent outcomes among patients who underwent decompression and arthrodesis compared with those underwent decompression alone ( Herkowitz et al)

54. Degenerative Spondylolisthesis Operative Treatment Options Instrumentation or non-instrumented fusion in degenerative spondylolisthesis Martin et al ( systematic review ) significantly higher rate of achieving a solid fusion in patients treated with instrumentation compared with those treated without instrumentation Kornblum et al solid arthrodesis is associated with less segmental instability and better outcomes than pseudarthrosis supports the use of instrumentation for fusion rates

55. Degenerative Spondylolisthesis Operative Treatment Options Videbaek et al showed significant improvement of clinical outcomes and fusion rates in patients treated with circumferential arthrodesis of the spine compared with posterolateral only fusion Soegaard et al demonstrated that circumferential fusion was both less costly and led to better out- comes than posterolateral fusion alone Fritzell et al more complications in patients treated with circumferential arthrodesis compared with posterolateral fusion in patients with lumbar degenerative conditions without a concurrent difference in clinical outcomes between the groups