Spondylolisthesis and DDx

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SpondylolisthesisSpondylolisthesis
Mohammed Nabil Al Ali, Majid AL-DanDan ,
Hassan Mohammed Al Awadh, Ahmed Faisal Alkhazal ,
Mohammed Saleh Al Saeed, Mohammed Faisal Alkhazal
5th Year Medical Students , At King Faisal University , AlHassa

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- OVERVIEW
- PATHOPHYSIOLOGY and TYPES
- EPIDEMIOLOGY
- CLINICAL PRESENTATION
- PHYSICAL EXAMINATION
- DIAGNOSIS
- DIAGNOSTEC TESTS
- DIFFERENTIAL DIAGNOSIS
- TREATMENT
- SUMMARY
Outlines Outlines ::

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• It is a descriptive term referring to slippage
(usually forward) of a vertebra and the spine
above it relative to the vertebra below it
The word spondylolisthesis is derived from
the Greek words spondylo , meaning spine,
and listhesis , meaning to slip or slide.
OVERVIEW (definition)
• It lead to a deformity of the spine as well as a
narrowing of the spinal canal (central spinal
stenosis) or compression of the exiting nerve
roots (foraminal stenosis).

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Pars
interarticulars
Spinous
process
OVERVIEW ( Anatomy )
Articular process
(inferior)

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OVERVIEW ( Anatomy )

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A
N
A
T
O
M
Y
OVERVIEW (Dermatomes)

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OVERVIEW (Dermatomes)

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PATHOPHYSIOLOGYPATHOPHYSIOLOGY
and
TYPESTYPES

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•Spondylolisthesis occurs
when there’s bilateral
defects in the vertebral
pars intrarticulariss which
permit the vertebral body to
slip anteriorly. Usually
occurs at level (L5,S1)
• Spondylolysis is the
most common cause for
spondylolisthesis. It’s a
unilateral or bilateral defect
in the vertebral pars
interarticularis result from
stress fracture.
PATHOPHYSIOLOGYPATHOPHYSIOLOGY

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•spondylolysis typically is acquired as the
bone "fatigues" from recurrent
microtrauma during excessive lumbar
hyperextension or repeated lumbar
flexion and extension.
• rebeated Hyperflextion and extension of
the joints are more common in athletes.
•(diving, weight lifting, wrestling and
football)

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• Spondylolysis progresses to
spondylolisthesis in approximately
15% of cases. Progression to
spondylolisthesis is correlated with
persistent pain and lack of healing.

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It can be classified into 6 distinct
categories as the following
( developed by Wiltse, Macnab, and Newman ):
Type I: Congenital spondylolisthesis
Type II: Isthmic spondylolisthesis
Type III: Degenerative spondylolisthesis
Type IV: Traumatic spondylolisthesis
Type V: Pathologic spondylolisthesis
Type VI : Postsurgical
TYPES TYPES ( ( according to etiology according to etiology ))

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•characterized by presence of dysplastic
sacral facet joints allowing forward
translation of one vertebra relative to
another.
Type I: Congenital spondylolisthesis
•Caused by the development of a stress
fracture of the pars interarticularis.
•It is also further divided into 3 subtypes :
Type IIA , type IIB and type IIC .
Type III: Degenerative spondylolisthesis
It is commonly caused by intersegmental
instability produced by facet arthropathy.
Type II: Isthmic spondylolisthesis

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Type IV: Traumatic spondylolisthesis
Caused by fracture or dislocation of the
lumbar spine, not involving the pars

Type VI : Postsurgical (iatrogenic)
Type V: Pathologic spondylolisthesis.
Caused by malignancy, infection, or other
types of abnormal bone

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EPIDEMIOLOGY
- Generally
- Mortality/Morbidity
- Race
- Sex
- Age

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• Heavy Athletic activities requiring predispose
some athletes to developing pars defects.
Generally
•Approximately 82% of cases of isthmic
spondylolisthesis occur at L5-S1.

Another 11.3% occur at L4-L5.
• Degenerative spondylolisthesis occurs more frequently
with increasing age.
• The L4-L5 interspace is affected 6-10 more times than
any other level.

• Sacralization of L5 is frequently seen with L4-5
degenerative spondylolisthesis .

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• Increased mortality is not associated with
spondylolisthesis.
• The most common morbidity is persistent
low back pain or nerve impingement.
• Degenerative spondylolisthesis produces
characteristic arthritic symptoms that may
worsen with age.
Mortality/Morbidity

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Isthmic spondylolytic defects
affect roughly 1.1% of black females.
• The most commonly affected group is the white
male with an incidence of 6.4%.
• Arkara Plains Indians and Aleut people groups
have a very high incidence of spondylolytic defects,
due to a combination of genetic and environmental
factors.
Degenerative spondylolisthesis
affects black females more
commonly than white females( females more
affected than males).
Race

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• Congenital spondylolisthesis (dysplastic type)
• Degenerative spondylolisthesis

occurs more commonly in females with a 5:1
female to male ratio. The incidence increases
after age 40 years.
occurs with a 2:1 female to male ratio with
symptoms beginning around the adolescent
growth spurt. These comprise about 14-21%
of all cases of spondylolisthesis
Sex

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•Acute isthmic spondylolysis often occurs
during the first and second decades of life.
Most cases occur before the patient reaches
age 15 years.
• Younger patients are at higher risk than
older patients for developing progressive
spondylolisthesis.
•But the risk for progression in adults is rare
when the lesion is at L5..
Age

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•Congenital/dysplastic spondylolisthesis has
been documented in children as young as 3.5
months. More commonly, congenital
spondylolistheses go undiagnosed until later
in life after an individual has been ambulating
for quite some time.
•Degenerative spondylolisthesis occurs most
commonly after age 40 years.
• In contrast, lesions at L4-5 may progress
into adulthood because of increased sagittal
rotation, shear translation, and axial
rotation at this segment

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CLINICAL PRESENTATION
- Symptoms .
- Signs .

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1-The patient is usually asymptomatic.
2- unlikely cause back pain in adults (especially
after age 40 y) with no history of symptoms before
age 30 years
3-Low back pain is the most common
symptom , and it is often exacerbated by
motion, The patient may report relief of pain
with extended periods of rest.
4- it is associated with numbness and tingling
in the legs (L5 or S1 distribution) and leg pain.
Symptoms

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1-Tenderness to deep palpation of the
spinous process above the slip (typically L4)
& causes radicular pain due to palpation.
2- muscle tightness (Tight hamstrings muscle)
that is associated with all grades of
spondylolisthesis occurs at a rate of 80%.
It commonly results in an abnormal gait
& inability of the patient to flex the hip
with the knees extended.
Signs

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3- Paraspinal muscle spasm and tenderness
are usually present.
4- Limited forward flexion of the trunk is
common with reduced straight-leg raising,
which may cause pain
5- Postural deformity and a transverse
abdominal crease are seen as a result of the
pelvis being thrust forward.

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6- Patients with degenerative spondylolisthesis
(DSPL) are characterized by an increased
pelvic tilt (PT) and decreased sacral slope
(SS) than the control population, suggesting
the presence of a pelvic compensation

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1-Phalen-Dickson sign:
bent-knee, hip-flexed posture with high-grade
spondylolisthesis
2-One-legged hyperextension test (stork test):
Use To differenation between
spondylolysis (+) and spondylolisthesis(-)
PHYSICAL EXAMINATION

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With increasing slippage, the sacrum
becomes relatively more vertical, impairing
hip extension and compelling the patient to
walk with a knee-flexed, hip-flexed gait
1-Phalen-Dickson sign:

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A positive one-legged hyperextension test
while standing on one leg and bending
backward, pain is experienced in the
ipsilateral back.
2-One-legged hyperextension test (stork test):

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In most cases it is not possible to see visible
signs of spondylolisthesis by examining a
patient.
Patients typically have complaints of pain in
the back with intermittent pain to the legs.
Spondylolisthesis can often cause muscle
spasms, or tightness in the hamstrings.
Spondylolisthesis is easily identified
using plain radiographs.
DIAGNOSIS

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Grades ( Myerding Classification)

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1- Radiography:
lateral view of lumbar spine is especially useful
in detection Spondylolisthesis.
2- Computed Tomography:
CT SCANNING axial or sagittal image of the
lumbar spine can be performed with or without
contrast enhancment.
3- Magnetic Resonance Imaging(MRI):
has the distinct advantage of imaging of the
spine in any plane. Typically, the axial and
sagittal planes are used.

DIAGNOSTEC TESTS

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Spondylolisthesis. Oblique projection radiograph shows the presence of
bilateral pars defects (arrows), with an appearance resembling a Scottie
dog with a collar. (The collar is the pars defect.)

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A)-Lateral lumbar spine. Note the pars defects (arrow)
and anterior displacement of the L5 vertebra.
B)-Oblique lumbar spine. Observe the clearly visible
lucent collar (arrow).

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Sagittal CT reconstruction
image shows the pars
defect along with grade 1
spondylolisthesis.
Spondylolisthesis. Axial CT image
shows bilateral spondylolysis
(arrows). Note elongation of the
spinal canal at this level

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DIFFERENTIAL DIAGNOSES


•Lumber facet-arthropathy .
•Coccyx pain.
•Mechanical low back pain .
•Overuse Injury.
•Lumber compression Fracture.
•Lumber canal stenosis .
•Lumbar disk herniation .

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•is degenerative arthritis affecting the
facet joints in the spine
•Low back pain can radiate to gluteal,
back of the thigh and rarely below the
knee.
•was no numbness, no muscle
weakness and the reflexes were
normal.
•Stiffness
•Poor posture
•Radiography: CT and X-ray
Lumber facet-arthropathy

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Axial CT
marked osteophytosis and joint space narrowing
severe osteoarthritis

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X-ray
A mild scoliosis was
clearly present.
marked fixation in the
opposite (right) sacroiliac
joint, and at the L5-S1
joint (the lumbo-sacral
joint). L4 was tender on
palpation.
Forward bending caused
moderate pain in her
back and gluteal.

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•Coccydynia is inflammation localized
to the tailbone pain and tenderness
at coccyx.
•The pain is often worsened by sitting.
•Patient leaning against the buttocks
•Radiography: CT and X-ray
Coccyx pain

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Lateral radiograph (a) and sagittal CT reconstruction (b)
demonstrating a fractured coccyx in a patient who was
diagnosed with coccydynia following a ground-level fall
6 months earlier

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•fracture of lumber spine due to
trauma or pathological fracture in
osteomyelitis.
•Common in woman who is near
or over age 50 .
• Sudden back pain radiate to
lower limb. numbness and motor
weakness in lower limb if nerve
roots is affected
•Radiography: CT and X-ray
Lumber compression Fracture

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•congenital narrowing of the lumbar
spinal canal.
•low back pain,
•weakness, numbness, pain, and loss of
sensation in the legs.
•worse pain in standing or walking and
backward. It is relieved by sitting and
forward.
•sphincteric function impairment.
• Negative straight leg raising test
•Radiography: X-ray, CT and MRI
Lumber canal stenosis

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X-ray
•loss of the normal
intervertebral disc height
• the presence of bone
spurs (osteophytes)
•spinal instability
(abnormal motion
between the vertebrae).

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CT and MRI

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•Herniation of the nucleus pulposus
(HNP) through an anular defect due to
wear and tear or a sudden injury
I.Low back pain.
II.Leg pain
–Coughing and sneezing aggravates the
leg pain.
–aggravated by sitting, prolonged
standing.
–relieved by walking, lying down
Disk Herniation

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IV. Nerve-related symptoms:
-Numbness and weakness in the area which
the nerve supply
-in the lower part of lumbar spine: sciatica .
-in the upper part of the lumbar spine: pain in
the front of the thigh
-loss of bladder and/or bowel control, which
are symptoms of a specific and severe type
of nerve root compression called cauda
equina syndrome.

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•In Lateral disc herniation:
In L5 root affection: pain radiates on the dorsum and
the base of the big toe.
in S 1 root affection: pain radiate to the sole of the foot.
•In central disc herniation:
•hyposthesia bilaterally
•ankle reflex is lost bilaterally and also may be
the knee reflex.
•a foot drop with bilateral dorsi flexor weakness
In Physical Examination:
•Straight leg raise (SLR) test. +ve
•Femoral stretch test +ve
•Difficult tip toe walking and heel walking
Radiography: MRI and CT

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MRI
HNPs appear as focal, asymmetric
protrusions of disk material beyond
the confines of the annulus
high signal intensity in the posterior
anulus is often seen on sagittal T2-
weighted

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CT

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TREATMENTTREATMENT
1. Conservative .
2. Surgery and Complications
3. Complications

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Treatment for spondylolisthesis
depends on several factors,
including the age and overall health
of the person, the extent of the slip,
and the severity of the symptoms.
Treatment most often is conservative
and more severe spondylolisthesis
might require surgery.

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oBed rest.
oAvoidance of activities if there is >25% slippage.
oNon-steroidal anti-inflammatory drug (NSAID).
o Epidural steroid injections(ESI)
Generally, an ESI is given only when other
treatments aren't working.
1.Conservative treatment
oA brace or back support might be used to
help stabilize the lower back and reduce pain.

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o Physical therapy:
Stabilization exercises are the
mainstay of treatment. These exercises
strengthen the abdominal and/or back
muscles, minimizing bony movement of
the spine.
These measures only provide
temporary relief.

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Surgery might be necessary if the
vertebra continues to slip or if the pain is
not relieved by conservative treatment
and begins to interfere with daily
activities.
The main goals of surgery for
spondylolisthesis are:
1)to relieve the pain associated with an irritated
nerve,
2) to stabilize the spine where the vertebra has
slipped out of place,
3)and to increase the person’s ability to function.
2. Surgical treatment

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The main types of surgical
treatmen for spondylolisthesis
include:
1)laminectomy (decompression)
2)Fusion

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1.Laminectomy
When the vertebra slips forward, the
nearby nerves that exit the spine can
become pinched or irritated.
In addition, the size of the spinal
canal in the problem area shrinks,
placing pressure on the nerves
inside the canal.
The goal is remove the lamina and
release pressure on the nerves .

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B.METRx Minimally Invasive
Hemilaminectomy:
It involves removing part of one of the
two laiminae on a vertebra to relieve
excess pressure on the spinal nerve(s) in
the lumbar spine.
A.traditional open lumbar
laminectomy :
the two laminae and spinous process
of a vertebra are removed to relieve
excess pressure on the spinal nerves
in the spine.
Types of laminectomy :

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2.Fusion
A spinal fusion is normally done
immediately after laminectomy for
spondylolisthesis.

It is designed to fuse the two vertebrae
into one bone and stop the slippage from
worsening.
The fusion is used to lock the vertebrae
in place and stop movement between
the vertebrae.
•Types :
A. Traditional Fusion
B. Minimally invasive surgical spine fusion

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A.Traditional Fusion
The vertebrae are affixed to one another
using surgical instrumentation.
Bone graft is then placed between the
vertebrae allowing them to "fuse" together
over time.
This stabilizes the painful joint segment
and relieves pressure from the painful
spinal nerves
Examples :
1.Postero-lateral fusion (PLF)
2.Posterior Lumbar Interbody Fusion(PLIF)

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1.posterolateral fusion (PLF)
posterolateral fusion is the grandfather of fusion
technique as it was developed just over 100
years ago.
In a posterior approach to lumbar fusion, the
surgeon makes an incision down the middle of
the lower back.
One of the criticisms of PLF is that it involves an
extensive dissection (the stripping of muscle and
fascia off of bone) of the adjacent transverse
processes, facet(s) and sometimes lamina.
After the decompression, the surgeon will place
graft material along the sides of the vertebrae to
stimulate bone growth.
Titanium screws and rods are often used to
provide immediate stability to the spine until a
solid fusion has been achieved.

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2.Posterior Lumbar Interbody
Fusion(PLIF):
In this procedure, the problem vertebrae are
fused from the anterior (front) and posterior
(back).
The surgeon works from the back of the spine
and removes the disc between the problem
vertebrae.
Bone graft material is inserted from the back
of the spine into the space between the two
vertebrae where the disc was removed (the
interbody space)
Transpedicular instrumentation is attached to
stabilize the motion segment while fusion
occurs.

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B.Minimally invasive surgical
spine fusion
It allows the surgeon to make smaller
incisions in the skin and avoid large
muscle retraction.
oIt is arguably an important improvement on
traditional PLIF, because it minimizes nerve root
and thecal sac retraction/damage and necessitates
less osseous and soft tissue dissection.
oThis technique approaches the epidural space from a more
posterolateral direction, taking out the facets on one side and
only part of the lamina.
o The bony endplates are scraped until rough and the space
is filled with a plastic or metal cage and bone chipes to
achieve a fusion between the vertebral bodies.
•Transforaminal Lumbar Interbody Fuision (TLIF):

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oImplant failure.
oPseudoarthrosis.
oNonunion.
oFoot drop.
oSpinal compression.
oAcute bowel ischaemia
Complications of surgical repair

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- Spondylolisthesis is a forward or backward
slippage of one vertebra on an adjacent vertebra.
- Causes of spondylolisthesis include trauma,
degenerative, tumor, and birth defects.
- Symptoms of spondylolisthesis include lower
back or leg pain, hamstring tightness, and
numbness and tingling in the legs.
- diagnosis is mainly based on imaging .
- Most people with spondylolisthesis can be treated
conservatively, without the need for surgery.
- Patients who fail to improve with conservative
treatment may be a candidate for surgery.
SUMMARY

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REFERENCES
-Emedicine
-Uptodate
-http://www.mdguidelines.com/spondylolisthesis
[
-medicinenet
All refrences are written under each side
but mostly we depended on :

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Thank youThank you