Spondylolisthesis.pptx

Physiotherapist

1. Spondylolisthesis (spondylo = spine, listhesis = slippage) PRESENTED BY Divya Singh MPT(Orthopedics) 2nd year

2. Definition Anatomy Lumbo-sacral biomechanics Pathology Mode of Injury Predisposing factors Types of lesthisis Clinical presentation Diagnosis

3. Radiological finding Management a) Conservative b) surgical

4. Spondylolisthesis Forward displacement of a vertebrae over the one below it is called as antero-listhesis. In case if the displacement is backwards it is called as Retro-listhesis. Commonest level of listhesis is L5-S1 & L4-L5. (Rarely seen in lower cervical region also). Responsible anatomical factor is LS articular surface & the biomechanical factor is the shear stresses acting at LS junction.

5. LS Junction Biomechanics LS junction – The first sacral segment is directed slightly downward, so that the discal surface of S1 forms an angle with an imaginary horizontal line & this angle is called as LS angle. Increased anterior Pelvic tilt (as in case of obesity) = Increased LS angle = Increase L lordosis = Increased shear forces acting at LS junction = predisposition for Displacement of one vertebrae over another. Correlation = Rx

6. LS Junction Stabilization LS junction – between a mobile (Lumbar) & a least mobile segment (sacral), makes the it prone for injury. Junction between lumbar lordosis & sacral kyphosis, makes the LS junction prone for abnormal shear stresses. Bone check mechanism - Forward displacement or translation of one vertebrae over another is normally prevented by engagement of its articular processes with that of the vertebrae below. Disc and the major longitudinal ligaments also helps to some extend in this check mechanism. Role of Inter-transverse ligament (illio-lumbar ligament of LS junction)

7. Inter-transverse or Iliolumbar Ligament

8. PATHOLOGY Forward displacement or translation of one vertebrae over another is normally prevented by engagement of its articular processes with that of the vertebrae below. (Bone check mechanism) Disc and the major longitudinal ligaments also helps to some extend in this check mechanism. Any defect in this check mechanism will lead to S-listhesis.

9. Cont. Resultant segmental instability Altered position of slipped vertebrae changes its relative position with adjacent vertebrae & surrounding soft structures, creating abnormal mechanical stresses over them. Clinical pictures correlates with the degree of displacement (Nerve root compression, central canal stenosis or spinal cord injury)

10. PIA stresses Pars-inter-articularis - as the name suggest it is the part of vertebrae bridging the superior & inferior articular projections of a vertebrae. There are two main theories on what causes the increased stresses on pars interarticularis: 1) Repeated Hyperextension and 2) Repeated Hyperflexion

11. M ode Of Injury The mechanism involves repeated bending stresses around the thinnest part of the vertebrae (pars interarticularis) eventually resulting in a break in the vertebra i.e. Spondylolysis . In more severe cases, the involved vertebra may slip forward, ie. Spondylolisthesis

12. Predisposing Factors Physical/ mechanical shear stresses to LS spine Repeated forcefull flexion & extension Direct/ indirect trauma increasing LS angle – such as Obesity / Pregnancy/ Poor posture

13. Spondylolysis Spondylolisthesis

14. Pelvic cross syndrome & LS angle

15. Spondylolisthesis Traumatic Congenital or Dysplastic Acquired Isthemic Degenerative Pathological

16. ISTHEMIC Commonest category (50% of cases) fracture or lesion of the pars inter-articularis. Sub-types - Acute # of PIA (Single episode of trauma) Lytic or Fatigue # of PIA(repeated stress)

17. OTHER TYPE 2. Degenerative – Due to degeneration of discs and facet joints. common in old age and in females. A slow process thus usually does not produces any acute symptoms. (Adaptation). 3. Pathological – Generalized or localized bone disease. 4. Traumatic – violent trauma (Young-Adult)

18. Clinical Presentation Majority of cases may remain asymptomatic initially. Commonest initial complaint is Back pain with or without radiation. Pain aggravated by Standing and walking. (extension- shear forces) Flexion Bias. Pain reduces with flexion, sitting, rest. Increased lumbar lordosis, with a +ve Step sign - Palpable Step of forward displacement of vertebrae. Degenerative changes in other articular structures over a period of time. Depending upon the severity of displacement & the level of displacement, the neurological symptoms may appear, like lateral foramen stenosis, central canal stenosis or even Spinal cord compression.

19. Radiological Findings Lateral view LS spine Grading system. (AP width of Vertebral body) 2. Oblique view LS spine (Bw lateral & posterior view) shows the defect in pars-inter-articularis Scotty Dog appearance of normal PIA. Scotty Dog wearing a collar in case of # or defect of PIA (A defect in PIA without slipping of vertebrae) - Spondylolysis Scotty dog head separated from the neck (A defect in PIA with slipping of vertebrae) - Spondylolisthesis

20. Spondylolysis Scotty Dog wearing a collar

21. MRI FINDING

22. Grades of Listhesis Using the lateral view X-ray, the listhesis can be graded according to the degree of severity. The Myerding grading system measures the percentage of vertebral slip forward over the body beneath. The grades are as follows: Grade 1: 25 % Mild to moderate central canal stenosis Grade 2: 25 % to 50 % Severe stenosis, Grade 3: 50 % to 75 % Grade 4: 75 % to 100 %

23. Physiotherapy a) Pain relief (Levels of pain modulation) b) Back care Ergonomic advises such as – Keeping a Bolster under the knee in supine position,avoid prolonged standing or walking, Weight reduction. Activity restrictions (no heavy lifting, excessive bending/twisting/stooping etc that causes stress to lumbar spine). Postural education. Spinal Braces - LS belt/ corset/ frame

24. Surgery Aim 1. Pars interarticularis repair 2. Reduction of the listhetic deformity 3. Decompression +/- fusion Options 1. Inter body fusion 2. Inter-transverse fusion with or without internal fixations Post operative PT & Bracing

25. Surgery Severe cases not responding to conservative management & showing symptoms of neurological compromise such as Spinal cord compression requires Operative management

26. Reference M Sinaki, BA Mikkelsen - Archives of physical medicine and …, 1984 - melioguide.c https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-100 Peter B O'Sullivan Scholarly articles for agabegi et al (The spinal journal 2010) Google scholar

27. Thank you