Spondylolisthesis

spondylolisthesis classification management ppt

1. Spondylolisthesis Presented by : Dr. RATISH MISHRA Post Graduate, M.S ( Orthopedics ) Moderator: Director. (Prof). Dr. Ramesh Kumar Director, Central Institute of Orthopedics VMMC & Safdarjung Hospital, New Delhi

2. definition SPONDYLOLISTHESIS is defined as the translation of one vertebra on its adjacent caudal segment. Anterior translation –ANTEROLISTHESIS Posterior translation-POSTEROLISTHESIS In 1782, Herbiniaux , a Belgian obstetrician, noted a bone prominence in front of the sacrum that caused problems in delivery. In 1854, Kilian coined the term spondylolisthesis , derived from the Greek spondylos , meaning “vertebra,” and olisthenein , meaning “to slip.”

3. DEFINITIONS Spondylolysis :is a defect in pars interarticularis Spondyloptosis : used to describe as fall of L5 vertebra into the pelvis and lie anterior to sacrum. Spondylitis  :is a term used to describe several spine conditions that cause swelling and inflammation in the joints and vertebrae of the spine. Spondylosis  is an umbrella term used to describe pain from degenerative conditions of the spine. 

4. Relevant anatomical structures

5. PARS INTERARTICULARIS Part of a vertebra located between the inferior and superior articular processes of the facet joint. On an anterior oblique radiograph of the lumbar spine, imaginary Scottie dog SIGN ; NECK-PARS eye - pedicle , nose - transverse process , ear - superior articular facet forelegs -inferior articular facet . hindlegs - spinous process ,

6. Hook: Pedicle Pars inter- articularis Inferior process of the cephalad level Catch: Superior process of the caudal level Hook and catch concept

7. classification Wiltse , Newman and Macnab (Based on location of defect of posterior element that allows listhesis ) Meyerding Classification ( based on percentage of slip in lateral radiograph) Marchetti and Bartolozzi ( based primarily on etiology- developmental or acquired) Spinal Deformity Study Group /SDSG classification

8. Type Name Description I Congenital Dysplastic abnormalities II Isthmic A Lytic (stress fracture) B Healed fracture (elongated, intact) C Acute high energy fracture III Degenerative Segmental instability IV Traumatic Fracture of hook other than pars V Pathologic Underlying pathology VI Iatrogenic Surgical excision of posterior elements Wiltse , Newmann , MacNab Clin Orthop 1976

9. Wiltse , Newman, and Macnab's classification Type I, Dysplastic (20%) Occurs only at L5-S1 level Primary congenital dysplasia of posterior elements particularly L5-S1 facet joints. Typically the inferior facet of L5 is dysplastic and the sacral facet absent. No pars interarticularis defect Frequent association with spina bifida occulta of L5 and sacrum.(70%) More common in females. Increased incidence in first degree relatives of patients: genetic Even though these anamolies are present at birth , spondylolisthesis occur after the child is able to ambulate..erect posture

10. DYSPLASTIC PATHWAY Initiated by the Congenital malformation of posterior elements (facet joint, pars ,spina bifida occulta) in the bony hook or its catch. Inability of L5 vertebra to resist anterior and ventral forces created by upright posture on lordotic spine Plastic deformation of soft tissue restrains: IV Disc, Antr and Postr Ligament complex Subluxation of vertebra

11. DYSPLASTIC PATHWAY With continuous growth they lost their ability to resist anteriorly directed forces Slippage and abnormal growth in the involved vertebral bodies or sacrum Changes seen: -Trapezoid shape of L5 and its anterior translation - Rounding of supero anterior aspect of sacrum(doming) - Vertical orientation of the sacrum - Junctional kyphosis at involved segments - Compensatory hyperlordosis at the adjacent levels

12. Wiltse , Newman, and Macnab's classification Type II: Isthmic(50%) Defect in pars interarticularis(spondylolysis) that allows forward slippage of L5 over S1 Three Types: A. Lytic:- stress fracture of pars interarticularis B. Healed version of Lytic- pars interarticularis intact but elongated due to bone remodelling C. Acute fracture of pars interarticularis due high energy injury. Spondylolisthesis most common at L5-S1(87%), L4-L5(10%), L3-L4(3%) Often occur in children ,adolescents and young adults . The incidence tends to stabilize in adulthood .

13. Etiology: isthmic spondylolisthesis : Due to upright walking and wt . bearing. M=F: 2:1 ( more common in males) Risk factors: Gymnastics / Football/wt. lifting, dancing and others with excessive lordosis or hyperflexion of the lumbar spine. Incidence of spondylolysis is 0% at birth and increase to 7% by age of 18. 80% acquire fracture of pars (spondylolysis) between age of 5 to 10 year , remaining 20% of fracture before age of 20 years

14. 7%of population has spondylolysis with or without spondylolisthesis. Most develop only grade 1 anterolisthesis over time. High grade slip (>50%) develop in patient with additional risk factor like disc degeneration, High slip angle , Increased pelvic incidence. Most are asymptomatic. Patients presents with complain of low back ache and radicular pain in L5 distribution Genetic and familial assosciation : 26% of patients with isthmic spondylolisthesis had first degree relatives with same disease .

15. Isthmic pathway In Erect posture-Center of Gravity is anterior to LS joint Lumbar spine-forward force and rotate anteriorly into flexion about the sacral dome. Initiated by the repetitive cyclic loading Sup. and inf. articular process impingement creates a bending moment that is resisted by the Pars. Repetitive impingement- fatigue

16. Stress fracture of Pars and post. neural arc separates from body Gap occupied by the fibrous tissue( Pseudoarthrosis ) Non union Increased shear load to disc though axial load remains unchanged Premature disc degeneration ,loss of disc height height , psudoherniation of disc and psedarthrosis of pars cause decreased foramen cross-sectional area , nerve compression Vertebral subluxation

17. Wiltse , Newman, and Macnab's classification Type III: Degenerative(25%): Most common type Due to intersegmental instability as a result of disc degeneration and facet remodeling and subsequent remodelling of the articilar process. Often accompanied by spinal stenosis centrally and in lateral recess older than 40 years Most common at L4-5 (six times more) Women ( four to six times ) They have dynamic component to their deformity i.e. amount of translation is affected by body posture.

18. slip progression occurred in 34%, and is usually mild and further disc space narrowing continued in the patients without further slip. Low back pain improved in patients with continued disc space narrowing: autostabilization . Risk factor for progression – presentation before 60, female sex facet sgittalization Degenerative spondylolisthesis result from degenerative cascade as described by kirkaldy – willis .

19. DEGENERATIVE CASCADE BY KIRKALDY -WILLIS

20. DEGENERATIVE SPONDYLOLISTHESIS Sagital facets degeneration No resistance for anterior translation force(contraction of posterior erector spinae muscle and force of gravity acting on lordotic lumbar spine) Predilection for slippage Anterolisthesis Boden et al - sagital facet angles of > 45 degree at L4-L5 - 25 times greater likelihood of degenerative spondylolisthesis .

21. Degenerative spondylolisthesis Disc degeneration Disc narrowing and subsequent overloading of facets Loss of disc height allow cephalad vertebra to translate Accelerated arthritic changes Secondary remodelling Anterolisthesis

22. Type IV :- Traumatic fracture in the area of the bony hook other than pars, ie pedicle, laminas or facets. Type V :- Pathological : Due to generalized or localized bone disease, eg : osteogenic imperfecta, multiple myeloma, infection pagets disease. Type VI Post surgical : Due to loss of posterior elements secondary to surgery. eg : transection of pars with facetectomy , fusion of segments Wiltse , Newman, and Macnab's classification

23. Post surgical Laminectomy Removal of >1/2 or entire articular process Destabilize the spine. Fracture of pars. subluxation

24. Post surgical Fusion of segments Resection of capsular, Supraspinous and Interspinous ligaments Increasing motion demand subluxation

25. Meyerding classification Based on amount of translation of superior vertebra over inferior vertebra Superior end plate of caudal vertebra is divided into 4 equal portion Distance between the posterior edges of Superior and inferior vertebral bodies is reported as percentage of total length of superior end plate of inferior vertebra grade I : 0-25% grade II : 26-50%  grade III : 51-75%  grade IV : 76-100%   grade V  ( spondyloptosis ) : >100%

26. MARCHETTI-BARTOLOZZI CLASSIFICATION

27. MARCHETTI-BARTOLOZZI CLASSIFICATION m Based on etiology - developmental ( dysplasia) or acquired( trauma , post surgery, pathological or degenerative) DEVELOPMENTAL SPONDYLOLISTHESIS: HIGH DYSPLASTIC- major deficiency of posterior arch, intervertebral disc, rounded upper end plate of S1, trapezoidal L5 body, pars lytic or elongated , high risk of progression LOW DYSPLASTIC- mild dysplastic changes, flat s1 end plate, L4 L5 bodies remain rectangular, pars lytic or elongated, low risk of progression

28. ETIOLOGY: DEVELOPMENTAL SPONDYLOLISTHESIS WITH LYSIS It is due to stress fracture in children with genetic predisposition for the defect. Wiltse et al : normal flexon contracture of the hip in childhood causes increased lumbar lordosis leading to 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

29. SPINAL DEFORMITY STUDY GROUP(SDSG) CLASSIFICATION <50% SLIP >50% SLIP

30. SPINAL DEFORMITY STUDY GROUP(SDSG) CLASSIFICATION LOW-GRADE SPONDYLOLISTHESES , (grades 0, 1 and 2, or <50% slip) Type 1, “nutcracker”, a subgroup with low PI (<45°); Type 2, a subgroup with normal PI (between 45° and 60°); and Type 3, a shear type, a subgroup with high PI (>60°). HIGH-GRADE SPONDYLOLISTHESIS , (grades 3, 4 and spondyloptosis , or ≥50% slip) Each case must first be classified as if presenting a balanced or unbalanced sacro -pelvic, using values of PI and SS. The spino - pelvic balance is determined with the use of the plumb line of C7. If this line falls on or behind the femoral head, the column will be balanced; if it falls in front of the femoral head, the column will be unbalanced.

31. LOW GRADE SPONDYLOLISTHESIS TYPE 1:those patients with low PI and SS may present clamping of the posterior elements of L5 between L4 and S1 during extension, which eventually causes an effect in “nutcracker” on the  pars articularis  of L5  TYPE 3: patients with high PI and sacral slope (SS) show an increase in the shear forces incident at the lumbosacral junction, which causes further tension on the  pars articularis  of L5: the shear type ( Fig. 5 ).

32. SACRO-PELVIC ALIGNMENT   The “balanced” group includes patients who in the orthostatic position show high SS and low pelvic tilt (PT). Patients in the group “unbalanced” include those who in the orthostatic position have retroverted pelvis and verticalized sacrum, which corresponds to a low SS and high PT. It has been shown that patients with high degree of vertebral slippage have a mean PI >60°. Increased PI is associated with increased lumbar lordosis, which predisposes to mechanical changes of the lumbar and lumbosacral junction and increases the risk of spondylolisthesis .This contrasts with those with low-grade spondylolisthesis, in whom PI values are low, normal or high.

33. SPINO-PELVIC ALIGNMENT/ SAGGITAL BALANCE The spino -pelvic balance is determined with the use of the plumb line of C7. If this line falls on or behind the femoral head, the column will be balanced; if it falls in front of the femoral head, the column will be unbalanced. sagittal balance is measurement of the C7 plumb line from upper posterior border of S1 This line should pass through the superior endplate of  S1 , or more precisely within 2 cm (some use 1.7 cm) of the posterosuperior corner of the S1 vertebral body .

34. The position of this line is termed positive, neutral or negative according to its distance from posterosuperior corner of S1 Sagittal balance was significantly increased (>3 cm) in those with retroverted posture (unbalanced); this suggests that the positive sagittal imbalance may be associated with this type of spino -pelvic alignment.(type 6)

35. nutcracker shear Low PT High SS high PT Low SS C7PL-BALANCED SPINE high PT ,Low SS C7PL-UNBALANCED SPINE

36. De wald Modified Newman Spondylolisthesis Grading System Better define the amount of anterior roll of L5. The dome and the anterior surface of the sacrum is divided into 10 equal parts. The scoring is based on the position of the posterior inferior corner of the body of the L5 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.

37. 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.

38. NATURAL HISTORY Risk factors for the progression : 1)Young age at presentation( diagnosed before adolescent growth) 2)Female gender 3)A slip angle of > 10 degree, increased pelvic incidence 4)A high grade slip(greater than 50%) 5)Dome shaped or significantly inclined sacrum(SDSG INDEX >25%)

39. Natural History is predominantly determined by Developmental or acquired spondylolisthesis Low or high dysplasia Quality of pedicle , 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

40. 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 .

41. NATURAL HISTORY OF ISHTHMIC SPONDYLOLISTHESIS : No progression of slip Progression of slip < 10% displacement >25% slip Asymptomatic symptomatic No progression after Risk of slip progression adulthood No backache later in life .Backache in later life

42. - 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 signs and symptoms deteriorated Natural history of Degenerative Spondylolisthesis :

43. CLINICAL EVALUATION of SPONDYLOLISTHESIS -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.

44. CLINICAL EVALUATION 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

45. In patients > 50 yrs: Backache 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

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

47. ON INSPECTION: 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

48. Inspection findings absence of waist line Transverse loin crease Lumbar hyperlordosis

49. 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 with hands on knee. In spondyloptosis - shortening of lumbar spine CLINICAL EVALUATION

50. CLINICAL EVALUATION

51. PALPATION : Palpable step Tenderness over Pars defect Hamstring tightness on leg raising. MOVEMENTS : 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

52. L5 compression / traction Abnormal motion Facet joint arthrosis Pars scar The disc above far-lateral The pain generators: Leg pain

53. Imaging Radiographs: AP view Standing Lateral view including the hips.(15% of deformities spontaneously reduce on supine imaging.) Oblique view : help in viewing pars interarticularis defect( decapitated scotty dog) Lateral flexion and extension views : determination of translational instability. Flexion-extension lateral views may reveal instability, which is considered to be present when 4 mm of translation or 10 degrees of sagittal rotation greater than the adjacent level is identified Fegurson view depicts the L5 pedicles, transverse processes and sacral ala more clearly

54. Fegurson view(20 degrees caudo cephalic ap view)

55. radiographs

56. Flexion Extension X rays

57. 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.

58. Inverted napoleon’s hat sign   indicates the presence of bilateral spondylosis   and significant spondylolisthesis . The dome of the hat is formed by the overlying body of L5 vertebra and the brim is formed by transverse processes.

59. Scotty dog sign on anterior oblique views

60. Other investigations CT myelography and MRI are used as indicated for the evaluation of spinal stenosis and may show facet overgrowth, hypertrophy of the ligamentum flavum , and, rarely, disc herniation, tumors, etc. SPECT : most senstive for impending spondylolysis., Can determine the chronicity of lytic defect. High resolution CT confirms spondylosis…it differentiate stress reaction from lytic defect.. as treatment is different NCV, EMG : to rule out peripheral neuropathy Arterial doppler/ CT angiography : to rule out vascular causes of claudication

61. ROLE OF SPECT 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.

62. 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

63. Disc degeneration: MRI Pfirrmann et al Spine 2001 Grade I Grade II Grade III Grade IV Grade V

64. Important Radiological parameters SLIP ANGLE(by Boxall et.al): The slip angle is angle formed between line perpendicular to posterior aspect of upper sacrum and line parallel to L5 inferior or superior end plate. Angle greater than 30 degrees associated with greater risk of slip progression, instability, and development of postoperative pseudarthrosis. It is the best predictor of progression of slip. A slip angle greater than 55 degrees is associated with a high probability and increased rate of progression

65. Pelvic incidence (pi) Pelvic incidence: A line perpendicular to the midpoint of the sacral end plate is drawn. A second line connecting the same sacral midpoint and the center of the femoral heads is drawn. The angle subtended by these lines is the pelvic incidence Pelvic incidence: Pelvic tilt + sacral slope normal, ≈50 degrees) Unaffected by posture Increased PI may predispose to spondylolisthesis. Seen in degenerative and dysplastic case Does not predict progression of slip

66. PELVIC TILT (PT) Pelvic tilt:. A line from the midpoint of the sacral end plate is drawn to the center of the femoral heads. The angle subtended between this line and the vertical reference line is the pelvic tilt. Higher pelvic tilt predisposes to spondylolisthesis .

67. SACRAL SLOPE(SS) Sacral slope: A line parallel to the sacral end plate is drawn. The angle subtended between this line and the horizontal reference line is the sacral slope. Vertical sacrum (SS<100 degrees) is causes progression in slippage.

68. L5 incidence Alpha angle L5 incidence : A line from the midpoint of the upper end plate of L5 is connected to the center of the femoral heads. A second line perpendicular to the upper L5 end plate is drawn from the midpoint of the end plate. The angle subtended by these two lines (α) is the L5 incidence. Higher values are associated with spondylolisthesis /unbalanced pelvis

69. MEYERDING XRAY GRADING OF SPONDYLOLISTHESIS 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. Grade I: 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.

70. Clinical Growth yrs (9 – 15) Girls > Boys symptomatic Postural or gait abnormality Radiographic Type 1 (dysplastic) Vertical sacrum >50 % slip Increasing slip angle Instability on flex/ ext views Risk factors for slip progression in spondyolisthesis ( Hensinger 1989)

71. Management of SPONDYLOSIS Nonoperative Treatment :- If SPECT scan is positive but HRCT is negative( no pars defect) suggest stress reaction– treatment is avoidance of sports and other high intensity exercise for 4-6 week. Rehabilitation with strengthening of the abdominal and paraspinal musculature, minimization of pelvic tilt, and antilordotic bracing If SPECT is positive with pars defect in CT ( spondylosis)– treatment is rigid orthosis while upright for 6 weeks.

72. REPAIR OF PARS INTERARTICULARIS Operative Treatment :- Indication:- patient remain symptomatic for > 3 month with conservative treatment Non union of pars Prerequisites :-Absence of spondylolisthesis, absent degenerative changes of disc and facet joint , absence of any dysplastic changes on MRI and CT SCAN Principles : Debridement, Grafting of the site with autogenous bone graft, and Compression across the fracture.

73. REPAIR OF SPONDYLOLYTIC DEFECT Procedures : Buck technique-- REAPIR OF PARS INTERARTICULARIS DEFECT IS DONE BY PEDICLE SCREW INSERTION AND BONE GRAFTING Scott wiring and Modified Scott Technique Kakiuchi procedure (repair with an ipsilateral pedicle screw and hook).

74. BUCK TECHNIQUE : DIRECT REPAIR OF PARS INTERARTICULARIS 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. 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 . Better clinical results have been obtained in patients younger than age 30 years, possibly because chronic instability leads to degenerative disc disease in older patients, which causes continued symptoms despite fusion of the defect

75. (a) Preoperative lateral radiograph (b) axial CT scan showing unilateral defect of the pars interarticularis of the L4 vertebra. (c) Sagittal T2 weighted MRI demonstrating the normal L4-L5 disc without any degeneration. Follow-up lateral dynamic radiographs in (d) flexion and (e) extension, showing complete healing of the defect without signs of instability . (f) Postoperative axial CT scan demonstrating complete healing of the spondylolytic defect

76. 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. 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.

77. Scott wiring technique

78. Modified scott 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%.

79. Modified scott technique

80. Kakiuchi Technique Kakiuchi reported successful union of pars defects with the use of a pedicle screw, laminar hook, and rod system. A pedicle screw is placed in the pedicle above the pars defect. The pars defect is bone grafted. A rod is placed in the pedicle screw and then into the caudal laminar hook, and compression is applied. This gives a more stable construct than that afforded by wire techniques

81. Comparative studies

82. Management of isthemic spondylolisthesis NON OPERATIVE:- If patient has spondylolisthesis of more than 1-2 mm– no orthosis is required as healing of pars defect is unlikely If no neurologic symptom– brief period of rest , anti inflammatory medication, muscle relaxant…..f/b low impact aerobic exercise, trunk stabilisation avoiding extension, and hamstring stretching …full activity after 8-12 week

83. 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. Pars defect of more than 1-2 mm—fracture healing is unlikely Before surgery –asses patient global balance by standing lateral and AP radiographs Slip angle , sacral end plate morphology, l5 transverse process should have 2cm2 surface area assessed on CT MRI for radicular symptom and disc assesment

84. Surgical goals Address the pars defect & the rattler( Loose laminar arch) Decompress the foraminal stenosis Address the degenerate disc/s Address the dynamic instability

85. Operative management Isthemic spondylolisthesis without neurological complain with normal l5 tranverse process and good spinal alignment— IN SITU INSTRUMENTED POSTERO LATERAL FUSION If l5 is transverse process is hypolastic (<2 cm2 surface area)- POSTERIOR LUMBAR INTERBODY FUSION(PLIF)/ TRANSFORAMINAL LUMBAR INTERBODY FUSION(TLIF) or ANTERIOR LUMBAR INTERBODY FUSION(ALIF) WITH POSTERIOR SUPPLEMENTAL FIXATION With neurological symptom —DIRECT DECOMPRESSION with PLIF WITH INSTRUMENTED POSTERO LATERAL FUSION OR INDIRECT DECOMPRESSION WITH TRANS FORAMINAL LUMBAR INTERBODY FUSION AND INSTRUMENTED POSTERO LATERAL FUSION INDIRECT DECOMPRESSION- is realignment and reestablishment of disc height using interbody spacer device and bone graft INTERBODY SPACER DEVICES include femoral cortical allograft, PEEK cages(poly-ether-ether-ketone), titanium mesh cages, expandable cages, carbon fiber devices

86. IN SITU POSTEROLATERAL INSTRUMENTS FUSION: WILTSE SPENCER APPROACH  midline skin incision and the two paravertebral fascia incisions. create intermuscular plane: the multifidus is medially located, the longissimus is lateral joint facet and the transverse process is exposed All pedicle screws are placed utilizing fluoroscopic guidance followed by application of the rods Decortication of the transverse processes, pars, and lateral facets are performed with a high-speed drill, following which bone graft is applied Wiltse MIS paraspinal approach is muscle-sparing and has lower infection rates, Improvement in leg pain even when not decompressed

87. In-situ pedicle screw fixation with bone grafting

88. PLIF( POSTERIOR LUMBAR INTERBODY FUSION) After the levels of interest are exposed, the posterior spinal elements are removed to expose the traversing nerve roots and lateral extent of the disc space. The dorsal third of the interspinous ligament may be preserved to act as a fulcrum for a dural retractor and to preserve a tension band posteriorly. The thecal sac and traversing nerve roots are mobilized and retracted to the midline, with care taken to protect the dural and neural contents with a retractor. After exposure of the posterior annulus, a complete discectomy is performed using rongeurs, disc shavers, and down biting curved curettes. Only by completely removing the disc and denuding the cartilaginous endplates can an environment conducive to fusion be provided. PLIF TLIF ROUTE OF ACCESS TO INTERVETEBRAL BODY SPACE IN PLIF AND TLIF

89. PLIF In addition, disc height may be restored through the use of distractors with serially increasing heights. By increasing the disc height, tension is placed on the annulus fibrosis, and the bone graft is placed under a compressive load, which will help the fusion process. After the interbody graft construct is placed, pedicle screws are then inserted and attached to the rods. Once in place, the pedicle screws are compressed along a lordotic rod in an attempt to reduce any kyphosis caused by interdiscal distraction. The transverse processes are then decorticated, and the bone graft is placed over them for a posterolateral fusion. A standard closure in layers is then performed. DISADVANTAGE: Dural tear and injury to the nerve roots or conus medullaris angle of interbody graft insertion for the PLIF procedure ( top, medial ) and TLIF procedure ( bottom, lateral ) TLIF PLIF

90. Radiological result( plif with titanium mesh cage)

91. TLIF(TRANSFORAMINAL INTERBODY FUSION ) making a vertical incision over the section to be fused. The skin, muscles, and soft tissues are gently retracted to expose the lateral aspect of the spinous process, the lamina, and the facet joint . Depending on the clinical presentation, a laminectomy, facetectomy, or both may be performed. After adequate decompression of the neural elements has been performed, pedicle screws are placed in the standard fashion. The disc space can be gradually distracted by using the pedicle screws or an intralaminar spreading device. The placement of the distractor and screws does not interfere with the dissection and, in fact, this system allowed for easy visualization of the nerve roots, thecal sac, and disc space . TLIF TLIF

92. TLIF To facilitate complete removal of the cartilaginous endplate and a more extensive disc excision, the posterior lip of each endplate is removed with the use of a 1/4-inch osteotome, while carefully protecting the thecal sac and nerve roots  An interbody device(s) of appropriate size is then placed while protecting the dura with a small retractor . The thecal sac may be minimally retracted (when necessary, the retractor is used to protect the exiting nerve root) while the mesh construct is put in place . Originally, the technique was described using two titanium mesh cylinders. However, single “banana”-shaped or rectangular devices have been designed to cover the disc space with a single device. Once the graft has been placed within the interbody space, pedicle screws are then attached to lordotic rod and carefully compressed to restore lumbar lordosis while maintaining the restored disc height. The contralateral facet joint may be decorticated, and the bone graft is placed over them for a posterolateral fusion if there is any instability. A standard closure in layers is performed.

93. ALIF ( anterior lumbar interbody fusion) Indication :- high grade spondylolisthesis Salvage procedure who had in situ posterolateral fusion but developed non union Risk of vascular , bladder, bowel injury ,retrograde ejaculation

94. Inter-body fusions: theoretical considerations Anterior column support Bio- mecahnically superior: Large area for fusion Grafts under compressive loads Degenerate disc removed consider disc height Build in the lordosis

95. DEGENERATIVE SPONDYLOLISTHESIS MANAGEMENT NON OPERATIVE :- SYMPTOM LOWBACK ACHE AND LOWER EXTREMITY PAIN AND WEAKNESS ARE CLAUDICATORY IN NATURE..BECOME STABLE OVER TIME OR PROGRESS SLOWLY. NEUROLOGIC SYMPTOM ARE RELATED TO SPINAL STENOSIS LOW BACK ACHE RESPOND TO PHYSIOTHERAPY WITH CORE STRENGTHENING WITH AVOIDANCE OF EXTENSION EXCERCISES, AEROBIC CONDITIONING, ANTIINFLAMMATORY DRUGS. PATIENT WITH NEUROGICAL SYMPTOM (RADICULOPATHY)—EPIDURAL STEROID INJECTION

96. OPERATIVE:- Indication :- progressive spondylolisthesis (occur in 30-34% patient) Worsening symptom after 12 week of physical therapy Progressive neurologic deficit or no response to epidural injection Only 10-15% patient require surgery. Planning :- rule out vascular claudication, degenerative hip arthritis, peripheral neuropathy Standing lateral and AP view xray —instability( 4 mm of translation or 10 degree sagittal rotation greater than adjacent level) Disc space narrowing. Upright flexion extension view– translational motion Ferguson ap view –degenerative changes in lumbosacral joint, l5 transverse process is observed MRI and CT- look for disc herniation, intraforaminal stenosis, facet joint effusion>2mm suggest instability,

97. Operative options Decompression alone Decompression and posterolateral fusion without fixation Decompression and fusion with fixation FUSION can be done by:- Posterolateral in situ fixation Posterolateral interbody fusion /PLIF Trans foraminal interbody fusion/TLIF Anterior interbody fusion/ALIF Note: -all these procedure found similar fusion rate and satisfaction rate BUT Posterior instrumentation allows Better fusion rate, better clinical outcomes Preffered is B/ Ldecompression and fusion with posterolateral instrumentation

98. Decompression: absolute indications Neurological deficit Non relieving Leg pain Sphincter dysfunction Claudication DECOMPRESSION ALONE DONE IN elderly patient or with co morbidities who may not tolerate added morbidity of fusion and instrumrentation , osteoporotic bones

99. Decompression: The Gill procedure: Removal of the loose laminar arch(laminectomy) and Foraminotomy + facetectomy , removal of fibro-cartilaginous masses at the pars defects, removal of adhesions of the dura and ligamentum flavum, and careful dissection of the nerve root to be freed through the intervertebral foramen.  Associated with ↑ pseudarthrosis rate Carragee JBJS Am 1997

100. TREATMENT OF SEVERE (HIGH DYSPLASTIC) SPONDYLOLISTHESIS Most authors agree that slippage of more than 50% requires fusion. the reduction of spondylolisthesis with instrumentation improves the chance of fusion, but these procedures have many risks and potential complications/neurological injury fusion in situ should be considered a method of choice in severe L5 isthmic spondylolisthesis . Remember: in severe spondylolisthesis , the sacral roots are stretched over the back of the body of S1 and are sensitive to any movement of L5 on S1

101. Grob’s technique: Direct pediculo -body fixation “ In situ” fusion in high grade spondylolisthesis low incidence of neurological complication

102. GROB TECHNIQUE In situ fusion is a relatively safe and reliable procedure associated with a high rate of arthrodesis and at lower risk of neurologic injury . Fixation of the segment is achieved by two cancellous bone screws inserted bilaterally through the pedicles of the lower vertebra into the body of the upper slipped, vertebra In advanced intervertebral disc degeneration

103. INSTRUMENTED REDUCTION AND FIXATION

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

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

106. Decompression and interbody fibular graft fixation for spondyloptosis

107. Post op complication PSEUDOARTHROSIS:- most common complication - more in smoker, vit d deficiency, pre op large slip angle, high grade translational deformity, uncorrected segmental kyphosis, hypoplastic L5 treansverse process , inadequate preparation of fusion bed, inadequate anterior column support. NEUROLOGIC DEFECT:- injury during dissection around compromised nerve root,mal positioned hardware, cauda equina syndrome due to hematoma Vascular complication Infection POST OP CARE:- PATIENT IS MOBILISED WITHOUT BRACE FIRST POST OP DAY

108. THANKS FOR YOUR KIND ATTENTION