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Spondylolisthesis
From WikiSM
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
- 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
- Symmetry of facet joint lesions
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
- Vertebral Body
- Stabilized by
- Degeneration of Intervertebral Disc, Facet Joints can contribute to instability
Associated Injuries
Risk Factors
- Non-modifiable
- African American
- 8 Age > 40
- Systemic
- Anatomic
- Sacrilization of L5
- Sagitally oriented facet joints
Differential Diagnosis
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
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
- One Legged Hyperextension: Patient stands on one leg, leans back
- Provocative Walking Test: Walk patient to help distinguish neurogenic vs vascular cause of claudication
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
- Internal
- External
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ 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.
- ↑ Junghanns H . Spondylolisthesen ohne spalt im Zwishengelenkstuck. Arch Orthop Unfallchir 1931;29:118–127.
- ↑ 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.
- ↑ Matsunaga S , Sakou T , Morizono Yet al. . Natural history of degenerative spondylolisthesis: pathogenesis and natural course of the slippage. Spine 1990;15:1204–1210.
- ↑ Farfan HF. The pathological anatomy of degenerative spondylolisthesis. A cadaver study. Spine (Phila Pa 1976) 1980; 5(5):412e8.
- ↑ Wiltse LL, Newman PH, Macnab I. Classification of spondylolisis and spondylolisthesis. Clin Orthop Relat Res 1976;117:23e9.
- ↑ Matsunaga S , Sakou T , Morizono Yet al. . Natural history of degenerative spondylolisthesis: pathogenesis and natural course of the slippage. Spine 1990;15:1204–1210
- ↑ Wessberg P , Frennered K . Central lumbar spinal stenosis: natural history of non-surgical patients. Eur Spine J 2017;26:2536–2542.
- ↑ Weinstein JN , Lurie JD , Tosteson TDet al. . Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257–2270
- ↑ 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:
6 October 2022 00:00:13
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