Spondylolisthesis in adults and children

spondylolisthesis

1. Spondylolisthesis Presentor : Dr Sharanprasad A H

2. introduction Definition: Anterior or posterior translational displacement of one vertebral body over another . Spondylo – vertebra Olisthesis – to slide on an incline Spondylolysis  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. CLASSIFICATION MARCHETTI AND BARTOLOZZI (1997) Etiology-based system Importance of high and low grade developmental spondylolisthesis Permitting early recognition and treatment

6. LOW 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

7. HIGH 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

8. CLASSIFICATION MARCHETTI AND BARTOLOZZI (2005) 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

9. CLASSIFICATION WILTSE , NEWMAN AND MACNAB Dysplastic Isthemic IIA - Lytic IIB - Elongated pars IIC - Acute pars fracture Degenerative Post traumatic Pathologic Iatrogenic

10. DYSPLASTIC SPONDYLOLISTHESIS Dysplasia/aplasia of posterior facet joints of the L5/S1 levels. The pars interarticularis remains intact the posterior arch translates forward with vertebral body this cause kinking of dural sac. If slip exceeds >35% cauda equina symptoms occur. Commonly associated with congenital spinal anomalies.

11. Dysplastic forms Slippage occurs at an age when growth is not complete Affecting growth of involved vertebrae Vertebral elements exposed to excessive forces growing less than non stressed vertebrae

12. Isthemic spondylolisthesis The lesion is in the isthmus or pars interarticularis , Repetitive cyclical extension/torsion of the spine Repetitive infraction fatigue failure of the pars High prevalence rate Highest biomechanical forces on the pars at l5/s1 level

13. The isthmic defect happens as a result of compression caused by the lower articular process of the superior vertebra on the isthmic region in hyperlordosis The isthmus of L5 is more horizontal than upper levels

14. Lumbar hyperflexion L5 is caught between the L4 inferior and S1 articular surface Resulting stress force on pars interarticularis

15. Isthemic lysis is due to anterioposterior postural imbalance and secondary spondylolisthesis is readjacent mechanism to adapt to postural imbalance

16. Type II A: Lytic or stress spondylolisthesis and is most likely caused by recurrent micro-fractures caused by hyperextension. It is also called a "stress fracture" of the pars interarticularis and is much more common in males

17. Type II B probably also occurs from micro-fractures in the pars. However , in contrast to Type II A, the pars interarticularii remain intact but stretched out as the fracture fill in with new bone Pars is compared to pulled toffee in this condition

18. Type II C It is very rare in occurrence and is caused by an acute fracture of the pars. Nuclear imaging may be needed to establish diagnosis

19. DEGENERATIVE SPONDYLOLISTHESIS incompetence of the posterior facet joints or intersegmental stability Inferior articular process allows anterior translation and leads to a change in orientation of the articular process Common at L4 – 5 than L5 – S1 And more common in females In an L4-L5 degenerative spondylolisthesis the L4 root is commonly trapped between L4 inferior facet and L5 body. Resulting translation posteriorly than anteriorly

20. Pathogenic Degenerative destruction of posterior joints Degenerative disc can no longer maintain vertebral relationship Displacement occurs Inferior joints of cephalad vertebrae contract and expand due to instability of superior articular process of inferior vertebrae Compensatory hypertrophy

21. Traumatic spondylolisthesis acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis Should not be part of the generic spondylolisthesis classification

22. Traumatic listhesis is rare condition. Results from Acute fracture of the posterior element other then pars interarticularis It is fracture dislocation of the spine involving all three columns It is the shear forces which cause break in the posterior stabilizers and the force is transmitted at the level of Intervertebral disc resulting in anterior or posterior displacement of the vertebral body.

23. Pathological spondylolisthesis Due to metabolic bone disease such as osteogenesis imperfect and osteomalacia These processes allow attenuation and elongation of the pedicles with resultant forward translation of vertebra Occasionally Metastasis and rheumatoid disease are the more common causes Disease of the whole motion segment rather than the pars in particular

24. iatrogenic this type of spondylolisthesis is seen after surgery causing your vertebra to slip forward. It's also known as iatrogenic spondylolisthesis, and it's caused by a weakening of the pars, often as a result of a laminectomy ( a typical back surgery, but type VI spondylolisthesis isn't a typical result of the surgery)

25. Clinical presentation Dysplastic and isthmic spondylolisthesis present during late childhood and adolescence Early stages - low back pain is the only consistent clinical feature Occasionally there is leg pain in L5 or S1 distribution Abnormal gait Hamstring weakness Hips cannot b flexed Knee extended Walk with waddle Take short strides because pelvis is thrust forward , postural deformity Some develop transverse abdominal crease with flattening of the buttocks

26. degenerative spondylolisthesis 3 main pain patterns Back pain as a result of degenerative arthritis and segmental instability claudication pain due to spinal stenosis Leg pain due to compression neuropathy resulting from foraminal stenosis

27. Physical examination Palpable step may be felt over the spinous process at the level above the slipped vertebra In type I and type II The posterior arch of the vertebra translated forward remains in its usual positin Thus step is felt Due to hamstring tightness SLRT may cause pain but there are usually no true nerve root tension signs Neurologic examination Sacral anaesthesia – cauda equine compression Tibialis anterior most common

28. diagnosis Step off sign at adjacent spinous process Tenderness on midline Neurological signs Contracture of quadriceps and ischiocrural muscles

29. Degree of spondylolisthesis Measured by 2 technique Myerding technique It involves dividing the superior aspect of the vertebrabelow the slip into four equal divisions Depending upon the position grading is done If the vertebra lies entirely anteriorly then its called Grade 5 spondylolisthesis or spondyloptosis

30. grading

31. Another technique measuring degree translation the percentage slip is calculated. A ratio is constructed of the distance from the posterior vertebral body below the slip to a line drawn parallel to the posterior body of spondylolisthetic vertebra Later then divided by th anteroposterior size of the slipped vertebral body

32. As the degree and slip angle become greater The body of the spondylolisthetic vertebra becomes increasingly parallel to the cassette Which gives rise to napoleon’s hat

33. Oblique x – rays are the optimal views for assessing the integrity of the pars interarticularis A defect in the neck of scotty dog will b identified in type II A And excellent way of assessing the degree of resultant foraminal stenosis in degenerative spondylolisthesis Flexion – extension view Assess the degree of mobility at the area of the slip

34. treatment Easly managed conservatively Young patients presenting with pain and grade I and II spondylolisthesis Modify their activities Bracing For type II c traumatic pars defect Plaster cast in corporating at least one hip Thoracolumbosacral orthoses Unilateral heal easily and faster than bilateral

35. Surgery is considered despite adequate non operative treatment In grade I or II whom pars interarticularis defects Direct repair of pars Grafting alone Screw repair Figure of 8 wiring Hook screw implants In long standing slips the disc at the level above the listhesis may be abnormal

36. In grade II or III A single level posterolateral fusion But in presence of severe slip has an extremely high associated non union rate thus 2 levels are recommended for fusion If pain associated with radiculopathy Surgery is the option of choice with decompression If decompression is extensive it will tend to further destabilize the area and may lead to progression of the slip post-operatively

37. Cervical spine Most common C2, C4 and C6 Cause is pedicles or pars lateralis Always associated with other anomalies Traumatic fracture of C2 is called hangman’s fracture

38. Hangmans fracture 3 types Type 1- non displaced fracture Treated with orthosis Type 2- variable degree of angulation, displacement, or both But the anterior longitudinal ligament anf C2-C3 intervertebral disc remain intact Skeletal traction then a halo vest may be used to allow ambulation with post traction immobilization Type 3- unilateral or bilateral facet joint dislocation Surgically managed

39. Spondylolisthesis in children C2 to C6 most common Mechanism – either hyperextension and flexion axial loading injury Signs and symptoms – anterosuperior avulsion or compression fracture of vertebral body Xray AP lateral oblique

40. Non operative Cervical orthosis or halo brace Operative Surgery with fixation If truly unstable or non union But neurologic involvement is rare

41. Thank you