The lecture has been given on May 18th, 2011 by Dr. Hamid.

1. Spodylolysthes
is

6. Introduction
 Spondylolisthesis is a common cause for lower-
back pain, radiculopathy, and neurogenic
claudication among the adult population.
 Definition: ant. slipping of the spine.
 Site
 Normal locking mechanism

9. Classification (Wiltse et al 1976)
 congenital,dysplastic
 isthmic,* 5%,7year,gymnastic,wt,lifters,
 degenerative,*L4-L5
 pathologic,
 iatrogenic,
 traumatic.

10. Epidemiology
 level L4-L5.&L5-S1
 F:M = 6:1
 Black : White = 6:1
pathology

11. Clinical Presentation
 Hx acording to age of presentation
 lower-back pain,
 neurogenic claudication,
 Vesicorectal disorder,
 radiculopathy is present, the L5 nerve root
most often is affected.L4 second most
common


12. Physical Examination
 loss of lumbar lordosis,flat
buttock,sacrum,scoliosis
 Transverse loin crese
 Hip flexion contractures
 Muscle atrophy
 Fell- step-off at the listhetic level.
 range of motion (ROM) usually is normal and
occasionally hypermobility may exist.
 Hamstring tightness
 Neurological examination

14. Imaging Studies
 lumbar AP, lateral, and oblique views.
 lateral flexion and extension,MRI
 Meyerding’s system for grading:
Grade 1 is 25%,
Grade 2 is 50%,
Grade 3 is 75%,
Grade 4 is 100% displacement ,
GradeV --spondyloptosis

15. Risk factors for progression
 Clinical ,gender,age,symptome,gaite
 Radilogical,angle,typ sarcum,l5

17. Prognosis
Dysplastic
Lytic
Degenerative

18. Non-operative treatment
 1-day to 2-day period rest-
 short course of anti-inflammatory
medications
 Physiotherapy
 Spinal support
 Modification of activity
 Psychological support
 Epidural injection

19. Surgical treatment
------Surgical goals
 pain reduction,
 improvement of neurologic symptoms,
 improvement in the quality of life.
If attainment of these goals is unlikely,
conservative treatment should be continued.

20. Indications
 indications :
--progressive neurologic deficit
--cauda equina syndrome.
--slip >50% and progressive
- persistent radiculopathy
-persistent and unremitting lower-back
-pain for more than 6 months,
-disabling symptom-affect work,sport

21. Decompression Alone
Laminectomy and Posterior Spinal Fusion (without
Interpedicled Instrumentation(
Decompression with Anterior and Posterior
Spinal Fusion

23. SPONDYLOLYSTHESIS

26. Post traumatic
spondylolethesis

28. Spinal stenosis

30. Lumbar Spinal Stenosis
 Normal canal
 “Narrowing of osteoligamentous vertebral canal
and/or the intervertebral foramina causing
compression of the thecal sac and/or the caudal
nerve roots”
 Classification
 ----congenital
 -----aquired

31. Lumbar Spinal Stenosis
 Developmental & Congenital
----Idiopathic narrowing
-Short pedicles
-Reduced interpedicular dist.
--Bone dysplasias
---Achondroplasia

32. Acquired or Degenerative
 Spondylosis
 Facet lig flavum
 Chronic PID
 Post-traumatic
 Tumor
 Infection
 Spondylolisthesis
 pagets

33. Pathoanatomy
 Adult degenerative lumbar spinal stenosis (ie
Acquired stenosis)
 Facet hypertrophy
 Vertebral osteophytes
 thickened ligamentum flavum
 Disc protrusions
 Overall decreased volume of spinal canal

35. Stenotic
 Vertebrae provide body support
 Discs act as “shock absorbers”
 Vertebra protects spinal cord and nerves
 Nerves have space and are not pinched
 As we age, ligaments and bone can
thicken
 Narrowing is called “stenosis”
 Narrowing squeezes nerves in spinal
canal and nerve roots exiting spine
to legs
 Result - pain & numbness in back
and legs
Nerve Root
Spinal
Canal
Lumbar Vertebra
Bone (Facet
Joint)
Healthy
Intervertebral Disc
Thickened
Ligament
Flavum
Pinched
Nerve Root
Narrowed
Spinal Canal

36. Clinical Presentation
 Hx-age- ach-heaviness,n,symptoms
 neurogenic claudication with intermittent pain
radiating to the thighs or legs.

37. Claudication,ppppsn
 Neurogenic
 Pain proxdist
 Relief w/ flexion
sitting,squating
 Extension worsens pain
 Better w/ stairs
 Pulses wnl
 Skin wnl
 +/- Neuro deficits
 Vascular
 Pain dist prox
 Relief w/ standing
 Pain not positional
 Pulses diminished
 Mottled skin
 Neuro exam wnl

38. EMG-NCS
 Differentiation between neuropathy and
radiculopathy

39. Evaluation
 AP & Lat radiographs 20-16
 Flex/ext films to reval stability
 CT 16-11
 MRI
 Lumbar myelography + CT
 Evaluation of extent of neural element compression

40. Treatment
 Non-Operative
 NSAIDs
 Physical therapy
Stretching, strengthening,
 heat, electrical stimulation,Activity modification
 Bracing- especially w/ spondylolisthesis
 Steroid injection-

41. Non-Operative Treatment
 Good for non-progressive minimally debilitating
conditions
 Pt getting better  non op
 Pt getting worse  Surgery

42. Surgery?
 Indications
 Worsening neuro sx, bowel bladder dysfunction, cauda
equina syn, debilitating pain
 Best candidate
 Predominantly leg pain
 Clinical exam ∝ Imaging studies
 Mild to moderate neuro deficit
 No back pain (excluding spondylolisthesis)

43. Operative Treatment
 Laminectomy
Bilateral laminectomies for all affected levels
 If discectomy performed, consider arthrodesis
 Hemilaminectomy
 Pts w/ unilateral symp
 Better preserves post op stability
 Difficulty in accessing
Contralateral side
Neural foramen
 Risk for dural tear

44. Operative Treatment
 Laminoplasty
 Hinging open the lamina on one side, interpositioning
the resected spinous process
 Increased size of spinal canal
 X-Stop
 Device designed to selectively impart relative flexion at
one symptomatic motion segment of the spine

45. The X-STOP®
Spacer
Supraspinous
ligament
Spinous
process
 Spacer only limits extension
 Wings prevent side-to-side and
upward migration
 Preserves your supraspinous
ligament, which prevents
backward migration
 Preserves anatomy
 Treats LSS symptoms, not
“anatomy”

46. Compared to traditional LSS surgery,
X-STOP benefits include:
 Can be done under local anesthesia
 Can be done as an outpatient procedure
 No removal of the lamina (vertebral bone) or
ligaments that protect and stabilize the spine
 Potential of a shorter recovery
The X-STOP Spacer

47. STENOSIS

48. STENOSIS

49.  Compresses the
exiting nerve root
FORAMINAL STENOSIS

50. CANAL SHAPE
 Round
 Triangular
 Trefoiled
(15%)
 Trefoiled &
asymmetric

51. POSTURE

52.  Root symptoms
 Unilateral
 No claudication
 Acute or chronic
FORAMINAL STENOSIS

53.  Claudication
 Radicular pain
 Weakness is rare
 Acute or chronic
LATERAL RECESS STENOSISLATERAL RECESS STENOSIS

54. CENTRAL STENOSIS
 Varied presentation
 Classically with
neurogenic
claudication
 Some may only have
back pain
 Rarely painless
progressive weakness

55. X-RAY

56. SPINAL STENOSIS

57. MRI
 Non-invasive
 Soft tissue
visualization
 Gold standard

58. MRI
 Sagittal images
 Visualization of
foramen

59.  Excellent for intra-canal
pathology
 Poor for foraminal
pathology
 Replaced by MRI
MYELOGRAPHYMYELOGRAPHY

60.  Excellent visualization
of spinal canal
CT-MYELOGRAPHY

61. EPIDURAL STEROID
 Commonly prescribed
 50% short-term efficacy
 Not as selective
 May not require
fluroscope

62. Facet joint
injection or RF
Medial branch block
or RF
Transforaminal epidural
injection
Intradiscal
procedure:
Discography
Provacation test
Ozone discectomy
Laser discectomy
Percutanous disc
Epiduroscopy and adhesolysis
Epidural injection

63. d

66. TRANSFORAMINAL ROOT
BLOCK
 Highly selective
 Diagnostic as well as
therapeutic
 Delivers medicine to
the floor of spinal
canal

67. FACET INJECTION
 Facet for back pain
 Not for radicular pain
 May act as epidural in
40% of cases

68. OPERATIVE TREATMENT
 Decompression of neural
element
 Stabilization of unstable
segment

69. FUSION
 Sagittal instability
 Scoliosis
 Iatrogenic pars defect
 Greater than 50% facet
joint resection

70. INSTRUMENTATION