spondylolisthesis upload
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Spondylolisthesis
Herbinaux 1782
Greek: Spondylo + olisthesis
DefinitionsSpondylolisthesis-Anterior or posterior
slipping or displacement of one vertebra on another.
Spondylolysis- dissolution of, or a defect in, the pars interarticularis of a vertebra.
Spondyloptosis-vertebra that is completely or essentially completely dislocated.
EtiologyHereditary – DysplasticFailure of union of separate ossification
centres Birth fracturesStress fracturesDegenerative changes
Classification
Wiltse McNab and Newman
Marchetti and Bartolozzi
PathophysiologyDysplastic
Congenital defect in Hook or catchSecondary deformity
Traumatic
Extension of Lumbar spinePars impactionRepetitive loading – pars fails
Degenerative
Intersegmental instability and remodelling
Iatrogenic
Incidence : 6%
Racial : EskimosSpondylolysis 15-70 % 1st Deg relatives
Dysplastic more in FemalesLysis 2-3 times more in Males
Slip occur during growth spurt
Clinical features
Children: asymptomaticPostural/gait abn : Pelvic Waddle
Adolescents: Activity related painTraumatic History in 40 %
LBA
Thigh/Leg - pain/Weakness
Bowel/Bladder symptoms
Scoliosis- sciatic/olisthetic/idiopathic
Lumbar spine – foreshortening.
Buttocks- heart shaped
Phalen- Dickson sign
Step off sign
Hamstring tightness.
Tenderness over pars defect
Reduced lumbar movements.
Nerve root compression
Central canal compressionB/B symptomsB/L Leg symptomsB/L SLR +Crossed SLR +
Investigations
Pelvic Incidence
Sacral Slope
Pelvic tilt
Ullman sign
High dysplasticL5 - body TrapezoidS1 - Dome shaped
Sweet heart PelvisSacral verticalisation
Lumbosacral kyphosisCompensatory hyperlordosis
Bone Scan
CT
SPECT
MRI
Treatment
Conservative
Surgical
Factors affecting Progression
Congenital alterationsSeverity of anatomic deficitsGrowthWeightbearingAge and Gender
Max slip- Spurt- 9-15 yrs
< 10 yrs- monitor every 6 months till 15yrsthen every Yr till compl of
growth
Asymptomatic upto 25 %
No Treatment
SymptomaticRestActivity ModificationNSAIDSExercisesSteroid injectionsTLSO Brace
Surgical IndicationsProgression >25%
High grade slip >50 %
Intractable pain or Neuro deficits
Progressive postural/gait abn
Insitu fusionWith Autogenous graft
Repair of Pars defect Pedicle screwBone graftingSublaminar hook
DecompressionLaminectomyRemove loose posterior element (Gill’s)
With instrumentationTLIF
PLIF
ALIF
Combined anterior and posterior
ComplicationsProgression of deformityIncreased slip anglePseudoarthrosisNeurologic injuriesA/c and delayed Cauda equinaBack pain and gait disturbances
Reduction: Indications
Slip angle > 45 degLumbosacral kyphosisPostural imbalanceRequiring decompressionSlip progression after fusionUnacceptable appearance
Spondyloptosis
Vertebrectomy
Reduce L4 onto sacrum
Ant + Post (Gaines)