2. SPONDYLOLISTHESIS
Forward translation of one
vertebra on another in the
sagittal plane of the spine
Spondylolysis
defect in the pars interarticularis
of lumbar vertebra
most commonly due to repeated
and increased stress on the pars
interarticularis
3. ANATOMY
Pars
region between the superior and inferior articulating
facet of the vertebra
weakest area in the neural arch
susceptible to stress fracture
4. Pars defects
not observed in newborns or nonambulatory
patients
lysis or elongation does not occur in primates
that do not have an upright bipedal gait
presence of lumbar lordosis (unique in humans)
is necessary for spondylolisthesis to occur
5. EMBRYOLOGY AND OSSIFICATION CENTRES
SAGI ET AL SPINE 1998
pars ossify at 12-13 weeks gestation
via endochondral ossification
Lumbar Vertebrae
ossification centre in the region of
the pars
uneven trabeculation and cortication
ossification centre that arises at the
upper end of pedicle
uniform trabeculation throughout the
pars
potential stress riser which could be
susceptible to fatigue fracture
7. CLASSIFICATION
WILTSE, NEWMAN AND MACNAB 1976
Type I: Dysplastic (child)
Type II: Isthmic (5-50 yrs)
Type III: Degenerative (older)
Type IV: Traumatic
Type V: Pathologic
8. DYSPLASTIC SPONDYLOLISTHESIS
dysplasia/aplasia of posterior facet joints of
the L5/S1 levels
constant spina bifida occulta at the L5 level
– congenital nature
concomitant elongation of the pars
interarticularis --- frank lysis
condition is strongly familial, with as many
as a third of first-degree relatives affected
with the dysplastic form (Wynne-Davis et al)
9. Lateral radiograph
• rounding of the top of the sacrum as
L5 has rolled round anteriorly due to
poorly formed posterior facet joints
AP view
• 'Napoleon's hat' appearance of L5
superimposed through the sacrum
10. ISTHMIC SPONDYLOLISTHESIS
repetitive cyclical extension/torsion of the spine
repetitive infraction fatigue failure of the pars
high prevalence rate
highest biomechanical forces on the pars at
L5/S1 level
commonest site of a lytic spondylolysis
11. Lateral radiograph of a lytic
spondylolisthesis
Oblique radiograph of a lytic
spondylolisthesis
12. DEGENERATIVE SPONDYLOLISTHESIS
incompetence of the posterior facet joints
10x more common at the L4/5 than the L5/S1
not encountered in the under 50-year-old
the degree of slippage in the sagittal plane is
no good guide to the amount of neural
compression
fourth dimension, time, is important
degenerative process going on for years and years
patients are much more readily able to adapt to neural
compression than for example with a rapidly growing tumour
13. CT scan
• level of a degenerative
spondylolisthesis
• facets have come forward to
contact the back of the
vertebral body and completely
close off the epidural space
DEGENERATIVE SPONDYLOLISTHESIS
14. Traumatic spondylolisthesis
acute vertebral fractures do not occur through the
pars, but through pedicles, bodies, discs
so-called 'traumatic spondylolistheses' are not
discrete entities
should not be part of the generic spondylolisthesis
classification
Pathological spondylolisthesis
metastasis and rheumatoid disease are the more
common causes
disease of the whole motion segment rather than
the pars in particular
15. CLASSIFICATION
MARCHETTI AND BARTOLOZZI 1997
etiology-based system
importance of high and low grade developmental spondylolisthesis
permitting early recognition and treatment
16. LOW GRADE SPONDYLOLISTHESIS
low grade variety present in young adults
frequently associated with spina bifida
slip is characterized by translation without any angulatory or
kyphotic component
17. HIGH GRADE SPONDYLOLISTHESIS
Usually at L5-S1 and become symptomatic in adolescents
wedge shaped L5 and a domed vertical sacrum
anterior translation of L5 associated with angulation --true
lumbosacral kyphosis
potential to develop into spondyloptosis if untreated or
mismanaged
18. CLASSIFICATION BY MARCHETTI AND
BARTOLOZZI
SPINE/SRS SPONDYLOLISTHESIS SUMMARY STATEMENT 2005
based on etiology
clearly distinguishes between developmental and
acquired forms of this deformity
highlights the pathogenesis of the different types of
spondylolisthesis
potentially has the most relevance to natural
history, risk of progression, and implications for
treatment
19. NATURAL HISTORY
wide spectrum of clinical presentation
dysplastic and isthmic spondylolisthesis present during
childhood and adolescence
dysplastic variety usually at a younger age than
isthmic
early stages - low back pain is the only consistent clinical
feature
immature patient - high index of suspicion should be
raised about the possibility of an underlying
spondylolisthesis
20. NATURAL HISTORY
hamstring tightness, spinal deformity, gait
abnormality
frank neurology
severe degrees of spondylolisthesis
usually dysplastic variety - lower lumbosacral nerve
roots can be compressed behind the upper back of the
sacrum
isthmic spondylolisthesis
some degree of L5 radicular pain is not uncommon
hypertrophic callus around the lysis
degenerative spondylolisthesis
spinal claudication in association with low back pain
21. PHALEN-DIXON SIGN
sciatic crisis typically seen in high
grade adolescent
spondylolisthesis
sign includes
sciatic pain
vertical sacrum and pelvis
lumbosacral kyphosis
tight hamstrings
hyperlordotic lumbar spine
waddling gait
22. BACK PAIN AND SPONDYLOLISTHESIS
The cause of back pain is unclear and is
multifactorial
The pain may be due to
disc degeneration
facet degeneration
chronic nerve root irritation from compression or
traction
patient may have accompanying spinal stenosis
24. Defect in the pars interarticularis –
‘collar’ around the ‘neck’ of an illusory
‘dog’- oblique xray
25. THE BENDING FILMS
demonstrate persistent
motion and instability
especially in the presence of
degenerated disc disease at
the level of spondylisthesis
disc degeneration and
collapse of the disc space is
an attempt to stabilize the
motion segment
26. RADIOLOGICAL EXAMINATION
large number of suggested and preferred radiological parameters to
assess spondylolisthesis
Only 2 are of any great importance (Wiltse LL et al )
1. The amount of displacement
2. The slip angle (the angular relationship between L5 and S1 in the
dysplastic form of spondylolisthesis)
Percentage slip (x/y(x 100)
slip angle or angle of sagittal rotation
27. RADIOGRAPHIC INDEX
Slip angle of Boxall
superior border is chosen
more constant
not affected by adaptive changes
commonly occur in the inferior end
plate
represent local kyphosis across
the L5-S1 motion segment
30. RADIOLOGICAL EXAMINATION
CT scan
helpful in preoperative planning especially in cases with
severe dysplasia
MRI
assess neural foramen on the sagittal views
determine extent of associated disc disease
disc herniation is common
25% cases occur at the level above the slip
15% occur at the level of the slip itself
rule out tumor or infection
32. PREDICTORS OF SLIP PROGRESSION
female gender
prepubescence
trapezoidal L5
domed and vertical sacrum and
sagital rotation
slip angle > -10o
high grade slip (>50% slip
progression)
inclined sacrum (>30o beyond
vertical)
33. INDICATIONS FOR SURGERY
AGABEGI ET AL (THE SPINE JOURNAL 2010)
Slip progression
more common in skeletally immature patients who have
not reached the adolescent growth spurt
the higher the grade of slip, the more likely it is to
progress
slip progression rarely occurs in adults
High-grade slip with significant lumbosacral
kyphotic deformity causing sagittal imbalance
34. INDICATIONS FOR SURGERY
AGABEGI ET AL (THE SPINE JOURNAL 2010)
Neurological deficit
In most cases, the L5 nerve root is involved
Low back pain unresponsive to a prolonged course
of conservative treatment
Radicular pain with associated nerve root
compression on imaging studies that is not
responsive to conservative treatment
35. CONSERVATIVE TREATMENT
Directed at symptomatic relief
Rest
anti-inflammatory agents
lumbar corset
Physical therapy
abdominal strengthening exercises
hamstring stretching
avoidance of extension exercises which will
exacerbate the symptoms
Sinaki et al showed 3-year outcomes were significantly better in
patients who followed the flexion exercise program compared to
extension exercise
36. SURGICAL TREATMENT
directed towards symptoms and etiology
radiculopathy
neurologic deficit from spinal stenosis
instability pain
discogenic pain
the mainstay of treatment is
Decompression
Fusion
Instrumented
Non instrumented
37. ISTHMIC SPONDYLOLISTHESIS
TREATMENT
VACCARO ET AL
Findings Treatmennt
Grade I observation
Grade II Asymptomatic: Observe
Symptomatic: Activity modification
Failed: Surgery
Grade III-IV Surgery
38. ISTHMIC SPONDYLOLISTHESIS
OPERATIVE TREATMENT
procedure advantage/disadvantage results
Defect repairs Preserve motion
Technically difficult
Variable
60-90%
Laminectomy (Gills) Increase instability Poor long term outcome
abandoned
Posterolateral fusion (in
situ)
Improved symptoms Children
Adult: variable
Reduction and fusion Allow correction
Add stability
Slippage >60%
Slip angle >50 degree
Age 12 to 30
(Bradford 1988)
Anterior and posterior
fusion
Additional stability
360 degree fusion
Difficult surgery
39. ROLE OF REDUCTION
( AGABEGI ET AL, 2010 )
high-grade spondylolisthesis causes lumbosacral
kyphosis --- sagittal imbalance
reduction procedure controversial
literature support both sides of the argument
high rate of neurologic complications
reserved for patients with loss of global sagittal
balance because of significant lumbosacral
kyphosis
circumferential fusion and stable fixation with iliac
screws are strongly recommended to prevent slip
progression and pseudarthrosis
40. DEGENERATIVE SPONDYLOLISTHESIS
OPERATIVE TREATMENT OPTIONS
Decompressive laminectomy
Decompression with posterolateral fusion
Decompression with instrumented fusion
Long-term follow-up in patients with
degenerative spondylolisthesis reveals a
positive correlation between fusion and
improved clinical outcome
41. THE FUSION OPTIONS
achieve posterior column stability
posterolateral intertransverse fusion (PLF)
achieve anterior column stability
anterior lumbar interbody fusion (ALIF)
achieving a circumferential fusion
posterior lumbar interbody fusion (PLIF)
transforaminal interbody fusion (TLIF)
no consensus of what constitutes optimal
surgical treatment
surgical option must be individualized
42. POSTERIOR INTERTRANSVERSE FUSION
historically most popular
way of performing fusion
direct decompression of the
neural elements
deformity correction
stability with pedicle screw
instrumentation
the disadvantages are
less optimal fusion rate: graft
under tension
as it does not address the
anterior column: persistent
discogenic low back pain is
common
43. ANTERIOR LUMBAR INTERBODY FUSION
allows for complete discectomy
permits placement of a large
interbody graft
facilitate slip angle correction
reconstructs the disc space height
anterior graft
biomechanically compressive
environment
allowing optimal fusion
44. ANTERIOR LUMBAR INTERBODY FUSION
The disadvantages
related to the approach
risk of injury to major vessels,
retroperitoneal and intraperitoneal
structures
in males, the sympathetic plexus can
be damaged and cause retrograde
ejaculation
does not allow direct nerve roots
decompression
Suk et al.
anterior support would be helpful for
preventing reduction loss in cases of
spondylolytic spondy- lolisthesis of
the lumbar spine
45. CIRCUMFERENTIAL FUSION
the benefits of anterior and posterior
surgery ( TLIF/PLIF)
circumferential stability obviously
promotes high fusion rate
Open or MIS
46. SPONDYLOPTOSIS
severe symptoms of low back pain,
deformity, and neurologic symptoms or
deficits
Surgical options
in situ circumferential fusion technique described
by Smith and Bohlman
Gaines procedure (resection of L5 and reduction of
L4 onto the sacrum through a combined anterior
and posterior approach)
Gaines technique is associated with a
high rate of postoperative neurologic
deficits and is generally reserved for the
most severe deformities
47. Gaines Procedure
• resection of L5 and
reduction of L4
onto the sacrum
• combined anterior
and posterior
approach
50. multicenter, prospective study
highest level of evidence
guide decision-making on operative vs nonoperative
care for the specific disorder of degenerative
spondylolisthesis
treatments compared were lumbar laminectomy
with a single level fusion vs nonoperative treatment
treating surgeon determined type of fusion
(uninstrumented posterolateral fusion, instrumented
posterolateral fusion, circumferential fusion)
51. Conclusion
patients with degenerative spondylolisthesis and
spinal stenosis treated surgically showed
substantially greater improvement in pain and
function during a period of 2 years than patients
treated nonsurgically
52. DEGENERATIVE SPONDYLOLISTHESIS
OPERATIVE TREATMENT OPTIONS
Decompression alone or decompression with
segmental arthrodesis ?
higher proportion of patients with good or excellent
outcomes among patients who underwent
decompression and arthrodesis compared with
those underwent decompression alone (Herkowitz
et al)
53. DEGENERATIVE SPONDYLOLISTHESIS
OPERATIVE TREATMENT OPTIONS
Instrumentation or non-instrumented fusion in
degenerative spondylolisthesis
Martin et al ( systematic review )
significantly higher rate of achieving a solid
fusion in patients treated with instrumentation
compared with those treated without
instrumentation
Kornblum et al
solid arthrodesis is associated with less
segmental instability and better outcomes than
pseudarthrosis
supports the use of instrumentation for fusion
rates
Notas del editor
The term “isthmic” should be avoided because it is a
nonspecific anatomic reference and does not differentiate
between developmental and acquired forms of spondylolisthesis. Both types may have defects of the pars
interarticularis, but they represent significantly different
pathologic processes.
Gill laminectomy—a procedure for spondylolisthesis, which consists of removing the involved loose lamina and decompressing the exiting nerve roots by removing hypertrophic fibrocartilage in the pars defect
Because of the risk of slip progression, a concurrent fusion
procedure in adults to prevent late
symptomatic instability, especially
in the setting of degenerative disk
disease has been recommended
All patients had neurogenic claudication or radic- ular leg pain with associated neurologic signs, spi- nal stenosis shown on cross-sectional imaging, and degenerative spondylolisthesis shown on lat- eral radiographs obtained with the patient in a standing position.