Spondylolisthesis

1. SPONDYLOLISTHESIS By Dr Gajendra Mani Shah Orthopedics Department NAMS, Bir Hospital

2. Introduction Herbiniaux , a Belgian obstetrician, noted a bone prominence in front of the sacrum that caused problems in delivery. Credited with having first described spondylolisthesis . The term spondylolisthesis was used by Kilian in 1854 and is derived from the Greek spondylos , meaning “vertebra,” and olisthenein , meaning “to slip.” Spondylolisthesis is defined as anterior or posterior slipping of one segment of the spine on the next lower segment .

3. ANATOMY OF LUMBAR VERTEBRA

4. SPONDYLOLYSIS SPODYLOLISTHESIS SPONDYLOPTOSIS

5. Classification Wiltse , Newman, and Macnab's classification Marchetti and Bartolozzi

6. Wiltse , Newman, and Macnab's classification Based on a mixture of etiological and topographical criteria.

7. Type I, Dysplastic ( 20%) Congenital abnormalities of the upper sacral facets or inferior facets of the fifth lumbar vertebra that allow slipping of L5 on S1. No pars interarticularis defect Wiltse , Newman, and Macnab's classification

8. Type II: Isthmic (50%) Defect in pars interarticularis that allows forward slippage of L5 over S1 Three Types: Lytic :- stress # of pars interarticularis Healed version of Lytic - pars interarticularis intact but elongated Acute # of pars interarticularis due high energy injury. Wiltse , Newman, and Macnab's classification

9. Type III: Degenerative(25%):- Due to intersegmental instability of long duration and subsequent remodelling of the articilar process. Wiltse , Newman, and Macnab's classification

10. Type IV :- Traumatic # in the area of the bony hook other than pars, ie pedicle, laminas or facets. Wiltse, Newman, and Macnab's classification

11. Type V :- Pathological :- D/t generalized or localized bone disease, osteogenic imperfecta , multiple myeloma, TB. Wiltse, Newman, and Macnab's classification

12. Type VI Post surgical :- Due to loss of posterior elements secondary to surgery. Wiltse, Newman, and Macnab's classification

13. Two drawbacks of Wiltse et al classification : Difficult to predict the progression or response to surgery. Difficult to identify the type precisely. Wiltse, Newman, and Macnab's classification

14. Marchetti – Bartolozzi classification Developmental Acquired High dysplastic Traumatic  With lysis  Acute fracture  With elongation  Stress fracture Low dysplastic Postsurgery  With lysis  Direct surgery  With elongation  Indirect surgery Pathological  Local pathology  Systemic pathology Degenerative   Primary /Secondary  

15. ETIOLOGY Prevalance : - 5%, M= F; However-in Eskimos- 50%; White males- 6-7%; Black females 1.1% ; indicates definite genetic predisposition. Spondylolysis :- in 15-70% of the 1st degree relatives. - 2-3 times more common in boys than girls but Slippage 2-3 times more common in girls.

16. ETIOLOGY CONTD… DEVELOPMENTAL SPONDYLOLISTHESIS with lysis :- due to stress # in children with genetic predisposition for the defect. Wiltse et al :- normal flexon contracture of the hip in childhoods- increased lumbar lordosis :– increased force at Pars interarticularis . Lett et al :- shear stress greater at pars when lumbar spine is extended. Cryon and Hutton :- Pars is thinner and vertebral disc is less resistant to shear in children and adolescents than in adults.

17. ISTHMIC SPONDYLOLISTHESIS : Due to upright walking and wt . bearing. M=F: 2:1 Risk factors: Gymnastics / Football/wt. lifting, dancing and others with excessive lordosis or hyperflexion of the lumbar spine. ETIOLOGY CONTD…

18. DEGENARATIVE SPONDYLOLISTHESIS : TWO THEORIES a) Sagital facet theory : Facet oriented in such a way that it doesn’t resist Intratranslation forces over time LEADING TO degenaration and Spondylolisthesis b) Disc degeneration theory : Disc narrows first- overloading of facets .Accelerated arthritic changes .Secondary remodelling . Anterolisthesis ETIOLOGY CONTD…

19. TRAUMATIC : Acute fracture other than Pars POST SURGICAL : Laminectomy , Intervertebral fusion. ETIOLOGY CONTD…

20. PATHOPHYSIOLOGY TRAUMATIC PATHWAY DYSPLASTIC PATHWAY DEGENERATIVE PATHWAY

21. TRAUMATIC PATHWAY Erect posture-CG anterior to LS joint Lumbar spine-forward force and rotate Anteriorly into flexion about the sacral dome. Initiated by the repetitive cyclic loading Supr and infr articular process impingement creates a bending moment that is resisted by the Pars. Repetitive impingement- fatigue

22. TRAUMATIC PATHWAY Stress # of Pars and post. neural arc separates from body Gap occupied by the fibrous tissue Non union Increased shear load to disc though Vertebral axial load remains unchanged Subluxation Premature disc degeneration

23. DYSPLASTIC PATHWAY Initiated by the cong. defect (dysplasia) in the bony hook or its catch. -pedicle - supr articular facet - infr articular facet Repeated loading unopposed by bony constraints Plastic deformation of soft tissue restrains: IV Disc Antr and postr Long. L Postr Ligament complex Subluxation of vertebra

24. DYSPLASTIC PATHWAY With continuous growth Slippage and abnormal growth in the involved vertebral bodies or sacrum eg -Trapezoid shape of L5 - Rounding of supero anterior aspect of sacrum - Vertical orientation of the sacrum - Junctional kyphosis at involved segments - Compensatory hyperlordosis at the adjacent levels

25. DEGENERATIVE SPONDYLOLISTHESIS Sagital facets Disc degeneration No resistance for anterior Disc narrows translation force Subsequent overloading of facets Predilection for slippage .Accelerated arthritic changes .Secondary remodelling . Anterolisthesis Boden et al - sagital facet angles of > 45 degree at L4-L5 - 25 times greater likelihood of degenerative spondylolisthesis .

26. Whatever the inciting event - Facet arthritis - Disc degeneration and - Ligamentous hypertrophy All contribute to produce the symptoms. True deformity of degn spondylolisthesis – Rotatory deformity – not pure translation Distort dura and its contents Exaggerate the appearance of spinal stenosis DEGENERATIVE SPONDYLOLISTHESIS

27. PATHOLOGICAL SPONDYLOLISTHESIS Due to local or systemic pathological process causing a defect in the neural arch Vertebral Subluxation

28. TRAUMATIC SPONDYLOLISTHESIS High energy trauma Translational deformity Fracture of bony hook other than Pars ie : Pedicle, Superior and Inferior articular facets Associated multiple bony and STI Subluxation

29. POST SURGICAL Laminectomy : Fusion of segments Removal of > ½ or entire Resection of capsular, Supraspinous articular process and Interspinous ligaments Destabilize the spine Translational deformity Increasing motion demand the next SUBLUXATION Compression of nerve roots

30. NATURAL HISTORY Risk factors for the progression : 1)Young age at presentation 2)Female gender 3)A slip angle of > 10 degree. 4)A high grade slip 5)Dome shaped or significantly inclined sacrum

31. Natural History is predominantly determined by Developmental or acquired spondylolisthesis Low or high dysplasia Quality of pedical , pars and facets Age when diagnosis is made Degree of lordosis and position of gravity line Degree of secondary or remodeled deformity Competency, hydration and height of the disc

32. NATURAL HISTORY 1) Dysplastic spondylolisthesis : Early age; usually asymptomatic Severe slip(9-15,seldom after 20) Risk of neurological complications Higher risk of slip progression- cauda equina syndrome as the neural arc is intact. 2) Isthmic spondylolisthesis : No progression of slip Progression of slip < 10% displacement .Asymptomatic >25% slip .No progression after .Risk of slip progression adulthood .No backache later in life .Backache in later life

33. 3)Degenerative Spondylolisthesis : . Rare before 50. . Matsunaga et al 10 yrs prospective study- -34% showed progression of the slippage-though no significant effect in the clinical outcome -further disc space narrowing continued in those without slip However back pain improved ( Autostabilisation ) -83% of the pts with neurological S/S deteriorated NATURAL HISTORY

34. CLINICAL EVALUATION Usually asymptomatic – Incidental finding in X ray. Symptoms depend on the severity of slip and is caused by : 1)Chronic muscle spasm : Body limits motion around a painful pseudo- arthrosis of facet and its Pars . 2) Tears in the Annulus Fibrosus of the degenerated discs. 3) Compression of the nerve roots.

35. When symptomatic : In Children and Young adults : Back fatigue and back pain-on movement (Hyperextension) due to instability of the affected segment. Hamstring fatigue and pain due to irritation of L5 nerve root. Sciatica – may occur in one or both legs CLINICAL EVALUATION

36. In patients > 50 yrs: Backache – episodes of back “giving out” Sciatica Pseudoclaudication d/t spinal stenosis when subluxation is severe. Other signs of nerve root compression- motor weakness, reflex changes and sensory deficits . CLINICAL EVALUATION

37. Compression of central canal : Features: Bladder and bowel dysfunction Bilateral leg symptoms + ve SLRT B/L + ve crossed SLRT CLINICAL EVALUATION

38. ON EXAMINATION: LOOK : Buttocks – Flat - Heart shaped in high grade slip d/t sacral prominence. Sacrum – more vertical - appears to extend to the waist Lumbar hyperlordosis above the level of the slip to compensate for the displacement. Transverse loin crease With severity- absence of waist line Peculiar spastic gait -due to hamstring tightness and lumbosacral kyphosis . CLINICAL EVALUATION

39. CLINICAL EVALUATION absence of waist line Transverse loin crease Lumbar hyperlordosis

40. Scoliosis – esp in children – 3 types: a) Sciatic : Lumbar curve caused by the muscle spasm .resolve with symptoms b) Olisthetic : Due to asymmetrical slipping of vertebra c) Idiopathic : In Olisthetic crisis with total canal occlusion- typical posture– decrease nerve root tension by supporting trunk wt with hands on knee. In spondyloptosis - shortening of lumbar spine CLINICAL EVALUATION

41. CLINICAL EVALUATION

42. FEEL : Palpable step Tenderness over Pars defect Hamstring tightness on leg raising. MOVE : Usually normal in young pts. May be – Hamstring + Paraspinal muscle tightness- limiting forward bending and hip flexon . Degenerative type: spine-often stiff. Positive nerve root tests if root compression. CLINICAL EVALUATION

43. Radiographic Findings Anteroposterior views, standing lateral views, and a Ferguson coronal view. Flexion-extension lateral views :- may reveal instability, The Ferguson coronal view is obtained by angling the x-ray beam parallel to the L5-S1 disc. With this view, the profile of the L5 pedicles, transverse processes, and sacral ala is more easily seen .

44. Radiographic Findings Lowe et al. found a 26% increase in slipping on standing films compared with recumbent films. Oblique views of the lumbar spine can put the pars area in relief apart from the underlying bony elements, making viewing of the defect easier. Lateral bending films should be obtained for coronal deformities .

45. Demonstrates a bilateral break in the pars interarticularis or  spondylolysis  ( lucency shown by black arrow) that allows the L5 vertebral body (red arrow) to slip orward on the S1 vertebral body (blue arrow).  The normal pars interarticularis is shown by the white arrow.

46. SPECT And CT Scan A Single-photon Emission Computed Tomography bone scan is necessary to show whether uptake is increased in the pars. A SPECT scan is helpful in determining whether the process is acute or chronic. If increased uptake is confirmed, a CT scan can be obtained to evaluate whether there are thickened cortices consistent with a stress reaction or whether there is an acute stress fracture.

47. A CT scan with arrow pointing to the pars fracture.

48. Radiographic Grading Meyerding system of grading , the slip grade is calculated by determining the ratio between the anteroposterior diameter of the top of the first sacral vertebra and the distance the L5 vertebra has slipped anteriorly

49. Percentage of slipping calculated by measurement of distance from line parallel to posterior portion of first sacral vertebral body to line parallel to posterior portion of body of L5; anteroposterior dimension of L5 inferiorly is used to calculate percentage of slipping.

50. Meyerding System Grade I spondylolisthesis is displacement of 25% or less; Grade II, between 25% and 50%; Grade III, between 50% and 75%; and Grade IV, more than 75%. A Grade V represents the position of L5 completely below the top of the sacrum - SPONDYLOPTOSIS. Radiographic Grading

51. Radiographic Grading

52. Modified Newman Spondylolisthesis Grading System. Better define the amount of anterior roll of L5. The scoring is based on the position of the posterior inferior corner of the body of the fifth lumbar vertebra with respect to the dome of the sacrum. The second number indicates the position of the anterior inferior corner of the body of the L5 vertebra with respect to the anterior surface of the first sacral segment.

53. Modified Newman spondylolisthesis grading system. Degree of slip is measured by two numbers—one along sacral endplate and second along anterior portion of sacrum:A = 3 + 0; B = 8 + 6; and C = 10 + 10. Modified Newman Spondylolisthesis Grading System.

54. Boxall Et Al., The Angular Relationships Are the best predictors of instability or progression of the spondylolisthesis deformity. Radiographic Grading

55. These relationships are expressed as the slip angle, which is formed by the intersection of a line drawn parallel to the inferior or superior aspect of the L5 vertebra and a line drawn perpendicular to the posterior aspect of the body of the S1 vertebra . Radiographic Grading Boxall Et Al., The Angular Relationships . A, Standard method of measurement. B, Method used when inferior L5 end plate is irregularly shaped

56. The normal slip angle in a patient without spondylolisthesis should be lordotic . With a high-grade spondylolisthesis , the angle is commonly kyphotic . A slip angle greater than 55 degrees is associated with a high probability and increased rate of progression. Radiographic Grading Boxall Et Al., The Angular Relationships

57. Magnetic Resonance Imaging Allows for additional visualization of soft tissue and neural structures and is recommended in all cases associated with neurologic findings. In the early course of the disease, MRI helps in identifying the stress reaction at the pars interarticularis before the end-stage bony defect. MRI may show the degree of impingement of neural elements by fibrous scar tissue at the spondylolytic defect. Status of disc

58. Management Goal Pain relief, Core muscle strengthening, and Restoration of full lumbar range of motion.

59. Management Nonoperative Treatment Operative Treatment

60. Includes complete cessation of activity, rehabilitation with strengthening of the abdominal and paraspinal musculature, minimization of pelvic tilt, and antilordotic bracing. The brace is worn for 23 hours/day for minimum of 3 to 6 months. If clinical symptoms improve, the brace can be gradually weaned through a period of part-time wear. Conservative Management

61. Vigorous activities are restricted and back, abdominal and core strengthening exercises are prescribed . If the symptoms are more severe, a brief period of bed rest or brace immobilization may be required. Once the pain has improved and the hamstring tightness has lessened, the child is allowed progressive activities. Yearly examinations with standing spot lateral radiographs of the lumbosacral spine are advised to rule out the development of spondylolisthesis . If the patient remains asymptomatic, limitation of activities or contact sports is not necessary. Conservative Management

62. If the SPECT scan reveals metabolic activity and a CT scan shows thickening of the pars, avoidance of aggravating activity and core strengthening exercises are recommended. If the SPECT scan is metabolically active and CT indicates an acute stress fracture, a 3-month trial of orthotic treatment is warranted. If the defect has not healed in 3 months, continued orthotic wear is not indicated. The CT scan is the most helpful radiographic technique to determine the presence or absence of healing. Conservative Management

63. Have excellent relief of symptoms or only minimal discomfort at long-term follow-up. If a child does not respond to conservative measures, other causes of back pain should be ruled out. Special attention should be paid to children whose symptoms do not respond to bed rest or who have objective neurological findings . A very small percentage of children with spondylolysis who do not respond to conservative measures and in whom the other possible causes of back pain have been eliminated may require OPERATIVE TREATMENT. Conservative Management

64. OPERATIVE TREATMENT Indications Persistent symptoms despite 9 months to 1 year of conservative treatment, Persistent tight hamstrings, abnormal gait, and pelvic-trunk deformity. Development of a neurological deficit . In a skeletally immature patient with slippage greater than 50% or a mature adolescent with a slip greater than 75%, even if the patient is asymptomatic.

65. Broadly divided into two categories: Direct repair of the pars defects Arthrodesis of the involved segments OPERATIVE TREATMENT OF PARS INTARARTICULARIS

66. Operative Treatment Procedures :- Buck technique, Scott wiring, and repair with an ipsilateral pedicle screw and hook. Principles:- Débridement , Grafting of the site with autogenous bone graft, and Compression across the fracture.

67. BUCK TECHNIQUE Open technique Fibrous tissue at the pars defect is identified, thoroughly débrided , and stabilized with a 4.5-mm stainless steel cortical screw in compression. This technique was indicated only in cases in which the gap was smaller than 3 to 4 mm.

68. Is a demanding procedure. The narrowness of the lamina, a minimal displacement or malposition of the screw can lead to implant failure or complications Such as nerve root irritation, injury to the posterior arch Or dura , or pseudarthrosis .

69. Scott Technique A stainless steel wire is looped from the transverse processes to the spinous process of the level involved and tightened, in conjunction with local iliac crest bone graft. This wire creates a tension band construct, placing the pars defect under compression, and holds the bone graft in place.

70. Bradford and Iza reported 80% good to excellent results and 90% radiographic healing of the defects. This technique requires greater surgical exposure, with extensive stripping of the muscles to expose the transverse process. Complications such as wire breakage are common with this technique.

71. Salib And Pettine Technique Modified SCOTT TECHNIQUE in which a wire is passed around the cortical screws introduced into both pedicles and tightening it beneath the spinous process. Biomechanical tests show that fixation of the wire to the pedicle screw does not increase the stiffness of the system. This techniques have defect healing rates of 86% to 100%.

72. A, Posterior view of lumbar spine model showing 6.5 × 25-mm cancellous screw placed approximately two thirds into ipsilateral pedicle; 18-gauge wire has been looped around screw head and passed through hole in base of spinous process. B, Oblique view of lumbar model with wire ends passed through metal button and twisted tightly against metal button.

73. Kakiuchi Technique With this technique, hooks are fixed at the lamina and connected with a rod to an ipsilateral pedicle screw after compression

74. Pseudarthrosis Repair /Direct Repair Area of soft-tissue removal without decortication Area of decortication Location of pedicle Spondylolytic defect Recipient bed prepared for autogenous cancellous bone graft

75. Pseudarthrosis Repair /Direct Repair Area of excision of Posterior elements Ligamentum flavum not to be excised Nerve root before decompression Posterior elements overlying affected nerve root are excised.

76. Pseudarthrosis Repair /Direct Repair Head of variableangle screw Area of bone graft Starting point of screw insertion Variable-angle pedicle screw and bone graft inserted

77. Pseudarthrosis Repair /Direct Repair Rod Laminar hook Rod attached to head of screw with variable angle eyebolt. Laminar hook attached to rod.

78. For a pediatric patient with grade I or II spondylolisthesis , dysplastic spondylolisthesis at the lumbosacral junction, or a slip secondary to a defect of the L5 pars who has failed conservative treatment, posterior in situ fusion is recommended from L5 to S1 . Most authors agree that slippage of more than 50% requires fusion. OPERATIVE TREATMENT

79. Operative options Posterior in situ fusion, adding instrumentation to a posterior in situ fusion; Posterior decompression, partial reduction, instrumentation, and fusion; Posterior decompression, complete reduction, instrumentation, and posterior fusion; Posterior fusion with postoperative cast reduction; Posterior instrumentation and fusion combined with posterior Lumbar interbody fusion; Anterior release; Intradiscal Graft or structural cage combined with posterior instrumentation And fusion; and reduction and circumferential fusion With or without instrumentation.

80. Reduction And Fusion In High Dysplastic Spondylolisthesis With Internal Fixation

81. The method of immobilization after an in situ posterior fusion ranges from bed rest to bilateral pantaloon spica casts for 6 months.

82. TREATMENT OF SPONDYLOPTOSIS L5 VERTEBRECTOMY Resection of the L5 vertebra with reduction of L4 onto S1 described by Gaines and Nichols in 1985

83. THANK YOU

84. References 1) Campbells operative orthopedics 2) Chapmans orthopedic surgery 4) Rothman spine 3) Apleys System of orthopedics and fracture. 4) Millers review of orthopedics.