spondylolisthesis

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Published on March 2, 2014

Author: mittal87

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Spondylolisthesis : Spondylolisthesis BY DR. ANKUR MITTAL Spondylolisthesis : Spondylolisthesis DEFINATION: Spondylolisthesis is defined as anterior or posterior slipping of one segment of the spine on the next lower segment. Types Anterolisthesis Retrolisthesis Lateral listhesis Epidemiology : Epidemiology Familial , Mechanical Prevelance of spondylolysis – 3.5% 1 in 3 risk – first degree relatives Isthmic listhesis – 2 times more common in boys and men Progression > women Epidemiology: Epidemiology Fetal – 0% 6 yrs. – 4.4% Adults – 6% to 7% Yukon Eskimos – 50% Common at L5 S1 Classification: Classification Neugebauer 1888 Junghanns 1931 Myerding 1932 Newman and Stone 1963 Wilste , Newman & Macnab 1976, 1989 Marchetti & Bartolozzi 1982 & 1994 Labelle 2006 Herman 2006 Wiltse, Newman, and Macnab's classification of spondylolisthesis : Wiltse , Newman, and Macnab's classification of spondylolisthesis Based on mixture of etiological and topographical Type I, dysplastic Congenital abnormalities of the upper sacral facets or inferior facets of the fifth lumbar vertebra that allow slipping of L5 on S1 . No pars interarticularis defect is present in this type. Dysplastic: Dysplastic PowerPoint Presentation: Type II, isthmic Defect in the pars interarticularis that allows forward slipping of L5 on S1. Three types of isthmic spondylolistheses are recognized: Lytic —a stress fracture of the pars interarticularis An elongated but intact pars interarticularis An acute fracture of the pars interarticularis Type III, degenerative This lesion results from intersegmental instability of a long duration with subsequent remodeling of the articular processes at the level of involvement. Isthmic: Isthmic Isthmic (elongated pars): Isthmic (elongated pars) PowerPoint Presentation: Type IV, traumatic This type results from fractures in the area of the bony hook other than the pars interarticularis , such as the classifipedicle , lamina, or facet. Type V, pathological This type results from generalized or localized bone disease and structural weakness of the bone, such as osteogenesis imperfecta . Pathological: Pathological Osteogenesis imperfecta Paget’s disease Infection Tumors Acute fracture of the pars: Acute fracture of the pars Degenerative: Degenerative PowerPoint Presentation: SHORTCOMES OF THIS CLASSIFICATION difficult to predict progression or response to surgery with this classification difficult to identify the type of spondylolisthesis precisely. Marchetti and Bartolozzi: Marchetti and Bartolozzi Developmental High dysplastic With pars lysis With pars elongation Low dysplastic With pars lysis With pars elongation Acquired Traumatic Acute fracture Stress fracture Postsurgical Direct surgery Indirect surgery Pathologic Local disease Systemic disease Degenerative Primary Secondary In analyzing the spondylolisthesis, first decide if the condition is developmental or acquired. If it is developmental, 1.the degree of dysplasia must be determined as high (severe) or low (mild) by evaluation of the quality of the posterior bony hook : In analyzing the spondylolisthesis , first decide if the condition is developmental or acquired. If it is developmental , 1.the degree of dysplasia must be determined as high (severe) or low (mild) by evaluation of the quality of the posterior bony hook A, Pedicle, pars interarticularis , inferior facets of L5, and sacral facets all form bony hook that prevents L5 vertebra from sliding forward along slope of sacral end plate. B, Figure shows difference between normal bony hook and dysplastic bony hook that is incapable of providing resistance to forward slippage of the L5 vertebra under weight bearing stresses in upright spine. PowerPoint Presentation: 2. The degree of lordosis 3. The position of the gravity line also are important; the farther anterior the gravity line is, the more likely the spondylolisthesis is to increase. 4. The competency of the disc at the level of the spondylolisthesis also is important; MRI may be required to determine this . Indications of an unstable situation include a significant localized kyphosis (high slip angle) of the slip . Bony changes, such as a trapezoid-shaped L5 vertebral body a dome-shaped sacrum Low dysplasia: Low dysplasia Lumbo sacral kyphosis Almost rectangular L5 Sacral doming – min Normal sacrum Posterior elements Normal transverse process High dysplasia: High dysplasia Lumbo sacral kyphosis Trapezoidal L5 Sacral doming Sacral dysplasia and kyphosis Posterior elements dysplasia Small transverse process Labelle’s surgical classification: Labelle’s surgical classification Grade Dysplasia Spinopelvic balance Low - dysplastic Low PI / Low SS Low – grade (< 50 %) High PI / High SS High dysplastic Low PI / Low SS High PI / High SS Labelle’s surgical classification: Labelle’s surgical classification Grade Dysplasia Spinopelvic balance Low - dysplastic High SS / Low PT High – grade (> 50 %) Low SS / High PT High dysplastic High SS / Low PT Low SS / High PT Clinical presentation: Clinical presentation Asymptomatic Low back pain Occasional radicular pain Neurogenic claudication Cauda equina syndrome Clinical features: Clinical features Step Vertical sacrum Flat back, buttock Crouched gait - phalen dickson sign Stooping gait PowerPoint Presentation: Scoliosis is relatively common in younger patients with spondylolisthesis and is of three types : (1) sciatic, ( 2) olisthetic ( 3) idiopathic . 1.Sciatic scoliosis is a lumbar curve caused by muscle spasm. Usually, this is not a structural curve, and it resolves with recumbency or relief of symptoms . 2.Olisthetic scoliosis is a torsional lumbar curve with rotation that blends with the spondylolytic defect and results from asymmetrical slipping of the vertebra. These lumbar curves generally resolve after treatment of the spondylolisthesis . Severe curves, however, may become structural, and treatment is more complicated. 3. When idiopathic scoliosis and spondylolisthesis occur together, they should be treated as separate problems. X ray: X ray Erect AP, LAT Oblique view Flexion , extension Standing lateral 36 inches for C7 plumb line view Scotty dog: Scotty dog 84% sensitivity Myerding radiological grading system: Myerding radiological grading system Grade Percent slip 1 0-25 2 26-50 3 51-75 4 76-100 5 >100 A a Slip = a/A x 100% PowerPoint Presentation: Percentage of slipping calculated by measurement of distance from line parallel to posterior portion of first sacral vertebral body to line parallel to posterior portion of body of L5; anteroposterior dimension of L5 inferiorly is used to calculate percentage of slipping. A grade V represents the position of L5 completely below the top of the sacrum. This also is termed spondyloptosis . PowerPoint Presentation: DeWald recommended a modification of the Newman system to better define the amount of anterior roll of L5 (Fig. 38-173). The dome and the anterior surface of the sacrum are divided into 10 equal parts. The scoring is based on the position of the posterior inferior corner of the body of the fifth lumbar vertebra with respect to the dome of the sacrum . The second number indicates the position of the anterior inferior corner of the body of the L5 vertebra with respect to the anterior surface of the first sacral segment Degree of slip is measured by two numbers—one along sacral end plate and second along anterior portion of sacrum: A = 3 + 0; B = 8 + 6; and C = 10 + 10. PowerPoint Presentation: According to Boxall et al., the angular relationships are the best predictors of instability or progression of the spondylolisthesis deformity . These relationships are expressed as the slip angle, which is formed by the intersection of a line drawn parallel to the inferior or superior aspect of the L5 vertebra and a line drawn perpendicular to the posterior aspect of the body of the S1 vertebra (Fig. 38-174) . The normal slip angle in a patient without spondylolisthesis should be lordotic . With a high-grade spondylolisthesis , the angle is commonly kyphotic . The degree of kyphosis may become large, representing a severe form of segmental kyphosis at L5-S1. A , Standard method of measurement B , Method used when inferior L5 end plate is irregularly shaped. Slip angle: Slip angle Normal – (0 to – 10 deg) High grade - >+10 deg Pelvic incidence: Pelvic incidence Pelvic tilt Sacral slope PI = PT + SS Pelvic incidence: Pelvic incidence Pelvic tilt Sacral slope PI = PT + SS PowerPoint Presentation: CT myelogram MRI Bone scan PowerPoint Presentation: Treatment Factors influencing treatment Natural history Neurologic deficit G rade of slippage S everity of complaints L umbosacral anatomy Duration of symptoms Age C omorbidities PowerPoint Presentation: In general, the vast majority of patients with spondylolisthesis can be treated non-operatively Conservative Treatment Options PowerPoint Presentation: In patients with favorable indications for non-operative treatment, acute pain should be controlled with : activity modification ( bedrest <3 days) pain medication anti-inflammatory drugs muscle relaxing drugs Followed by a therapeutic exercise program with paraspinal and abdominal strengthening to improvemuscle strength, flexibility, endurance and balance If pain does not subside sufficiently, the use of a brace or orthoses may be beneficial . PowerPoint Presentation: Still not relieved then can be supported by spinal injections to reduce inflammation and thus temporarily or even permanently eliminate leg pain : epidural blocks spondylolysis block nerve root blocks PowerPoint Presentation: Children and adolescents with a low-grade spondylolisthesis ( Meyerding I and II) are mostly treated non-operatively; One of the most important measures for dealing with pain is the stretching of the hamstrings. These exercises will improve the clinical condition in the vast majority of the cases. In young patients with an acute pars defect Give a lumbar brace treatment including one thigh because It minimizing flexion- extension movements of the lumbar spine brace will stabilize the acute fracture allowing the lysis to heal by bony bridging Applied for 6–12 weeks, depending on the age and the symptoms of the patient PowerPoint Presentation: Operative Treatment General Principles The choice of surgical treatment greatly depends on the etiology as well as the degree of slippage General objectives of surgical treatment are to: prevent further slip progression stabilize the segment correct lumbosacral kyphosis relieve back and leg pain reverse neurologic deficits PowerPoint Presentation: Both patient age and degree of slippage differentiate absolute and relative indications PowerPoint Presentation: Surgical Techniques Spondylolysis Repair In symptomatic cases with a very slight slippage and a verified fresh pars defect, an osteosynthesis technique should be used Morscher screw and hook direct repair by screw fixation (Buck’s fusion ) figure of eight wiring ( Scott’s technique ) PowerPoint Presentation: Buck’s fusion Isthmic spondylolisthesis at the level of L4/5 Reversed gantry CT demonstrating the bilateral spondylolysis Direct screw fixation and bone grafting of the defect. PowerPoint Presentation: Posterior view of lumbar spine model showing 6.5 × 25-mm cancellous screw placed approximately two thirds into ipsilateral pedicle; 18-gauge wire has been looped around screw head and passed through hole in base of spinous proces Oblique view of lumbar model with wire ends passed through metal button and twisted tightly against metal button. figure of eight wiring Scott’s technique PowerPoint Presentation: Decompression When decompression with laminectomy is performed, fusion is compulsory A symptomatic disc herniation in the segment L4/5 with coexistent slip at L5/S1 can be treated by selective microsurgical decompression at L4/5 alone, discectomy in the olisthetic segment should be avoided due to a high risk of additional destabilization . PowerPoint Presentation: Instrumented Versus Uninstrumented Fusion For many years, uninstrumented fusion in situ has been the gold standard for the treatment of isthmic spondylolisthesis in children and adolescents and still has strong advocates But with the advent of pedicular fixation devices , instrumented fusion is more preferrable because it facilitates aftertreatment The mainstay of surgery in children is spinal realignment in the elderly patient spinal stabilization and decompression PowerPoint Presentation: Slip Reduction The treatment of high-grade spondylolisthesis differs between children and adults, as does that of low- and high-grade slips in adults In high-grade slips in the adult , in situ fixation with or without decompression, depending on the neurologic status, is a proven surgical method , especially when intervertebral body space has markedly diminished The aim is to decompress neural structures, decrease the lumbosacral kyphosis and facilitate fusion In high-grade slips (Grade III–IV) in children , the aim of surgery is to correct sagittal alignment and lumbosacral kyphosis. By improving the biomechanics, the chances of solid fusion are significantly increased PowerPoint Presentation: Interbody Fusion Spondylolisthesis is per se a spinal instability and as with all forms of osteosynthesis good postoperative stability is needed to avoid non-union or implant breakage . Especially when repositioning and/or distraction is performed, an interbody structural support of the anterior column is crucial Fusion techniques can achieve by posterior column stability either by TILF or PLIF anterior column stability both In cases where the spinal canal has to be decompressed and instrumentation is planned, perform either posterior lumbar interbody fusion ( PLIF) or Transforminal interlumbar fusion (TILF) PowerPoint Presentation: Posterior lumbar interbody fusion (PLIF) Technique PowerPoint Presentation: Anterior techniques Advantages complete discectomy precise placement of an interbody implant or graft. No danger of dural sheath damage or nerve root injury. disc height restored and kyphosis diminished, Disadvantages T he anterior technique usually involves a retroperitoneal approach , with complications such as vascular injury damage of the sympathetic plexus with subsequent retrograde ejaculation in males damage to retro- and intraperitoneal structures PowerPoint Presentation: Circumferential stability offers all the advantages of both the techniques , But also incorporates the possible complications. Combined approaches can be either posterior or transforaminal interbody fusion (PLIF or TLIF) or anterior lumbar interbody fusion (ALIF) with posterolateral intertransverse fusion (PLF). Due to the high degree of primary stability achieved with the 360° treatment of the spine, fusion rates are highly reliable an excellent spinal realignment can be achieved. Despite these good results, the technique of 360° instrumentation is technically more demanding than ALIF or PLF alone . PowerPoint Presentation: Fusion to L4 In children with severe developmental spondylolisthesis at L5/S1 ( Meyerding Grades III–V), reduction can be extremely tedious and may be facilitated by instrumentation to L4 This technique allows to distract between L4 and S1, which facilitates the reduction. In selected cases, the L4 screws can be removed at the end of the operation or alternatively 12 weeks later, which leaves the motion segment L4/5 intact However , the lateral process of L5 is often dysplastic in children and does not allow for a reliable fusion. Therefore a fusion to L4 is recommended. PowerPoint Presentation: In adults the L4/5 disc is often degenerated and requires inclusion in the fusion In adults with marked slips of L5/S1, the adjacent L4/5 segment frequently exhibits significant degenerative changes. In these cases, a fusion of L4 to S1 is indicated because the L4/5 segment often rapidly decompensates after the L5/S1 fusion PowerPoint Presentation: Vertebrectomy To achieve good spine realignment, surgical treatment of spondyloptosis is vertebrectomy of L5 (Gaines’ procedure). This is a two-stage procedure first by an anterior approach resection of the entire body of L5 back to the base of the pedicles, as well as the intervertebral discs L4/5 and L5/S1. In a second stage, the posterior approach removeL5 pedicles, facets and laminar arch bilaterally. transpedicular instrumentation from L4 to S1 and sagittal realignment, nerve roots L5 and S1 exit the spinal canal together over a reconstructed intervertebral foramen PowerPoint Presentation: Sacral Dome Osteotomy The main risk of reducing high-grade spondylolisthesis and spondyloptosis is related to the stretching of the L5 nerve roots, which often results in neuropraxia . The sacral dome osteotomy helps to avoid this nerve root injury by shortening of the sacrum. This technique consists of a bilateral osteotomy of the sacral dome, which allows the reduction of the slip without distraction The operation is carried out in a single stage. This demanding procedure should be carried out only with neuromonitoring of the L5 nerve roots PowerPoint Presentation: The pedicles of L4, L5 and S1 are instrumented with pedicle screws The loose posterior arc of L5 is resected and the L5 and S1 nerve root aswell as the intervertebral discs are exposed. The dome of the sacrum is osteotomizedwith a chisel and resected PowerPoint Presentation: A rod is inserted on both sides first connecting the S1 screws with the rods. L4 is then reduced to the rod with a reduction forceps. L4–S1 are slightly distracted L5 is pulled back and connected to the rod with a reduction forceps. An interbody fusion is added to L5/S1 and a posterolateral fusion to L4–S1 PowerPoint Presentation: Complications Neurologic injury (0.3–9.1%) Persistent nerve root deficits (2–3%) Non-unions (0–39 %) Progressive slippage (4–11%) Revision surgery (7.6%)

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