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Spondylolisthesis

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Other Names

  • Degenerative Spondylolisthesis (DS)
  • Spondylolytic Spondylolisthesis
  • Adult Isthmic Spondylolisthesis
  • Pediatric Spondylolisthesis

Background

  • Spondylolisthesis is defined as a displacement of one Vertebral Body relative to adjacent vertebrae
    • This most commonly occurs due to degenerative changes
    • Typically this occurs anteriorly, but can happen in any plane

History

  • First documented case was by the Belgian obstetrician Herbinau in 1782[1]
  • Junghanns (1931) first recognized degenerative lumbar spondylolisthesis as a clinical entity[2]

Epidemiology

  • Most commonly L4/L5, less commonly L3/L4 or L5/S1
  • Frequently detected as an incidental finding on plain radiographs
  • Female >> Men (need citation)

Pathophysiology

  • Progression of displacement
    • There is no correlation between progression of clinical symptoms and progression of radiographic spondylolisthesis
    • In most patients, low grade spondylolisthesis rarely progresses and has a benign clinical course[3]
    • Slip progression only occurs in about 30% of patients[4]
  • Direction of slipping depends on several factors
    • Symmetry of facet joint lesions
      • If facets are symmetrical, than slippage occurs in the sagittal plane
      • If facet joints are asymmetrical, then there is typically a rotary component[5]
    • Distribution of weightbearing forces

Degenerative Spondylolisthesis

  • Defined as spondylolisthesis without a defect in the pars
    • By far the most common form
  • Cause
    • Likely begins with incompetent degenerative disc
    • Anterior-posterior sheer forces on facet joints eventually lead to some degree of failure
    • This leads to spondylolisthesis and spinal stenosis
  • Contributors to degenerative spondylolisthesis include
    • Arthritis of the facet joints and subsequent loss of their normal structural support
    • Dysfunction of the ligamentous stabilizing component, possibly due to hyperlaxity
    • Ineffectual or weak core muscular stabilization
    • Disc degeneration
  • Some degenerative changes may be protective against disease progression including
    • Spur formation
    • Sclerosis
    • Ossification of ligaments

Isthmic Spondylolisthesis

  • Defined as spondylolisthesis with radiographic evidence of Spondylolysis
  • Most patients with spondylolysis will develop spondylolisthesis

Pediatric Spondylolisthesis

  • Common cause of lower back pain in children
  • Often co-occuring with Spondylolysis

Pathoanatomy

Associated Injuries


Risk Factors

  • Non-modifiable
    • African American
  • 8 Age > 40
  • Systemic
  • Anatomic
    • Sacrilization of L5
    • Sagitally oriented facet joints

Differential Diagnosis


Clinical Features

  • History
    • Patients most often endorse insidious onset of symptoms
    • Complain of mechanical back pain relieved by rest, sitting
    • Some get neurogenic claudication which is worse with upright walking
    • Radicular symptoms can be unilateral or bilateral
  • Physical Exam: Physical Exam Back
    • Hamstring tightness is common in these patients
    • L4 root compression: weakness in quadriceps, ankle dorsiflexion, diminished patellar DTR
    • L5 root compression: weakness in ankle dorsiflexion, EHL, hip abduction
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Lumbar Spine are first line imaging in all patients with suspected spondylolisthesis or undifferentiated back pain
    • Typically includes AP, lateral neutral, lateral flexion and lateral extension
    • Lateral views helpful to assess degree of sslippage
  • Assessment of stability with Flexion Extension Lumbar Spine films
    • Used by some surgeons in decision making
    • Instability can roughly be defined as radiographically demonstrated motion of the spondylolisthesis beyond expected normal values of the lumbar spine
    • No clear agreement on definition of ‘motion segment instability' among neurosurgeons
    • Some cite 4 mm of translation or >10° angulation with motion

MRI

  • Useful to evaluate soft tissues
  • Usually reserved for patients who fail to improve with conservative measures

CT

  • Useful to evaluate bony pathology
  • Myelogram represents alternative for patients who can not obtain MRI

Classification

Wiltse-Newman Classification

  • I. Dysplastic[6]
  • II. Isthmic
    • IIA. Disruption of pars as a result of stress fracture
    • IIB. Elongation of pars without disruption related to repeated, healed microfractures
    • IIC. Acute fracture through pars
  • III. Degenerative
  • IV. Traumatic
  • V. Pathologic

Marchetti-Bartolozzi Classification

  • Developmental: Includes Wiltse I and II
  • Acquired: Traumatic, postsurgical, pathologic, degenerative

Myerding Classification

  • Characterized by degree of slippage
    • Grade I: < 25%
    • Grade II: 25 to 50%
    • Grade III: 50 to 75% (Grade III and greater are rare in degenerative spondylolithesis)
    • Grade IV: 75 to 100%
    • Grade V: Spondyloptosis (all the way off)

Management

Prognosis

  • In the majority of patients with low-grade spondylolisthesis with mild symptoms, the disease is static and does not progress[7]
    • Same study showed that in individuals with spinal stenosis or radicular features, 83% were found to clinically deteriorate over 10 years
  • Wessberg et al: patients rarely show clinical deterioration, continued to manage symptoms at 3.3 years[8]

Nonoperative

  • Indications
    • Most cases which are uncomplicated without intractable pain or myelopathy
  • Medications
  • Activity restriction
    • Goal is to decrease provocative activities, within reason
  • Physical Therapy
  • Corticosteroid Injections
    • When combined wiht physical therapy, improved lower back and leg pain for up to 2 years[9]
    • Typically second line therapy

Operative

  • Indications
    • Challenging for surgeons to determine which patients would benefit from surgical intervention due to high false positive rate
    • Patients who are refractory to conservative management
    • Intractable pain
    • Progressive neurological defecits
  • Technique
    • Spinal fusion
    • Laminectomy
    • Decompression
  • Poor prognostic indicators postoperatively (need citation)
    • Older age
    • Intraoperative blood loss
    • Longer operative time
    • Number of levels fused

Rehab and Return to Play

Rehabilitation

Return to Play

  • Patients with spondylolisthesis (grade 1) should rest 4 to 6 weeks and then demonstrate full range of motion and pain-free extension before RTP[10]

Complications

  • Cauda Equina Syndrome
  • Pseudoarthrosis is common (need citation)
  • Adjacent disc disease
  • Dural tear
  • Neuropathy

See Also


References


  1. Newman, P. H. "Spondylolisthesis, its cause and effect: Hunterian Lecture delivered at the Royal College of Surgeons of England on 10th February 1955." Annals of the Royal College of Surgeons of England 16.5 (1955): 305.
  2. Junghanns H . Spondylolisthesen ohne spalt im Zwishengelenkstuck. Arch Orthop Unfallchir 1931;29:118–127.
  3. Frennered AK, Danielson BI, Nachemson AL. Natural history of symptomatic isthmic low-grade spondylolisthesis in children and adolescents: A seven-year follow-up study. J Pediatr Orthop 1991;11:209e13.
  4. Matsunaga S , Sakou T , Morizono Yet al. . Natural history of degenerative spondylolisthesis: pathogenesis and natural course of the slippage. Spine 1990;15:1204–1210.
  5. Farfan HF. The pathological anatomy of degenerative spondylolisthesis. A cadaver study. Spine (Phila Pa 1976) 1980; 5(5):412e8.
  6. Wiltse LL, Newman PH, Macnab I. Classification of spondylolisis and spondylolisthesis. Clin Orthop Relat Res 1976;117:23e9.
  7. Matsunaga S , Sakou T , Morizono Yet al. . Natural history of degenerative spondylolisthesis: pathogenesis and natural course of the slippage. Spine 1990;15:1204–1210
  8. Wessberg P , Frennered K . Central lumbar spinal stenosis: natural history of non-surgical patients. Eur Spine J 2017;26:2536–2542.
  9. Weinstein JN , Lurie JD , Tosteson TDet al. . Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257–2270
  10. Eck JC, Riley LH., III Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004;23:367-379
Created by:
John Kiel on 17 June 2019 16:45:10
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Last edited:
19 August 2021 14:38:50
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