Dr. M. M. PrabhakarMedical Superintendent

Director Govt. Spine InstituteProf. & Head Department of

OrthopaedicsB. J. Medical college

Ahmedabad

Spondylolisthesis Definition: Ant. or post. translational

displacement of one vertebral body over another.

Due to:1. Trauma2. Degenerative changes3. Defects in the bony architecture

congenital or pathological

SpondylolisthesisType I

Dysplastic Spondylolisthesis: secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra

Type IIIsthmic or spondylolytic: the lesion is in

the isthmus or pars interarticularis, If a defect in: the pars interarticularis & no

slipping spondylolysis. If one vertebra has slipped forward:

Spondylolisthesis.Type II A: Lytic or stress spondylolisthesis

and is most likely caused by recurrent micro-fractures caused by hyperextension. It is also called a "stress fracture" of the pars interarticularii and is much more common in males

Type II B probably also occurs from micro-fractures in the pars. However, in contrast to Type II A, the pars interarticularii remain intact but stretched out as the fracture fill in with new bone

Type II C is very rare in occurrence and is caused by an acute fracture of the pars. Nuclear imaging may be needed to establish diagnosis

Type III is a degenerative spondylolisthesis, and occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement.

Most often seen in older patients.

There is no pars defect and the vertebral slippage is never greater than 30%

Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis

Type V, pathologic spondylolisthesis, occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases

Traumatic ListhesisTraumatic listhesis is rare condition.Results from Acute fracture of the posterior

element other then pars…It is fracture dislocation of the spine…

involving all three columns…It is the shear forces which cause break in

the posterior stabilizers and the force is transmitted at the level of Intervertebral disc resulting in anterior or posterior displacement of the vertebral body.

Commonly occurs at cervical spine with axis fractures…resulting in displacement at c2 c3 level(Hangman’s fracture)

Rare in lumbar spine usually associated with high velocity trauma.

Above L2 level it is fracture dislocation of the spine involving all three columns.

Pathophysiology

Clinical presentationSevere back pain or neck painLeg pain or arm pain dermatomal with

associated neurological deficitOr combination of bothRestriction of the spine movement

Physical exam Palpation:

Spasms Paraspinous muscle limiting flex/ext Step-off

Tight HamstringsCompensatory HyperlordosisWaddling gaitNeurological deficits:

Motor/sensoryNerve compression in lat. recessesCauda equina syndrome (rare)

Imaging X-rays:

1. A/P2. Lat flex./ext.

– Supine and standing

3. Oblique– Integrity of the pars “Scotty Dog”

ImagingNORMAL

Imaging Grading:1. 0 = no slip2. 1 = 0 – ¼ (25%)3. 2 = ¼ - ½ (50%)4. 3 = ½ - ¾ (75%)5. 4 = ¾ - 1 (100%)6. 5=dislocation

ImagingCT scan: evaluate boney pathologyMRI: evaluate soft tissue pathology

Nerve compressionSpinal compressionDisc disruption

SPECT: (Single photon emission Computer tomography)Inconclusive x-rays despite high clinical

suspicion- Acute vs chronic for differential diagnosis

CT Image

Conservative Treatment1. NSAIDS2. Bed rest3. Steroid injections

Acute phase with neurological involvement. Not for long term use

4. Bracing

Conservative Treatment Physical therapy:1. Physiotherapy2. Tilt table mobilization3. Muscle strengthening exercise

Only after the acute inflammatory pain subside and spasm relives…usually after 6 wks.

Conservative treatment

CT Image Post treatment

Surgical Intervention GOALS:1. Stabilization2. Decompression of neural elements

Surgical Intervention Indications: High Grade Slip :

1. Cosmetic2. Gait abnormalities

Failure of conservative management:1. Severe pain2. Radiological evidence of instability3. Documented progression of slip4. Progression of neurologic signs

Surgical Intervention Contradictions:

1. Smoking2. Disability/compensation claims, litigation3. Previous fusions, pseudoarthrosis repairs4. Predictors Poor Outcome:

– Male– Middle age – Cigarettes– Multiple surgeries– Compensation/ litigation

Surgical Intervention Complications:

1. Bone graft, chronic pain 5% pts.2. Fusion, pseudoarthrosis, bleeding, infection3. Instrumentation, loss of fixation, loosening

and bone screw interface, implant breakage4. Decompression (neural elements), nerve

damage, dural tears, arachnoiditis, surgical scars

Surgical Intervention Decompression with Posterior Lateral Fusion:

1. Younger pts (30 y.o.)2. Intact vertebral disk3. Fusion:

– In situ– Pedicle screws

4. McGuire and Anderson: – 27 pts, military recruits– Stable, low grade slips– No difference in fusion rate with in situ vs pedicle

screws– Smokers less effective outcomes (40% nonunion)– Fusion did not determine success 67% went back to

military service, decrease leg and back pain

Surgical InterventionAnt. Column support and Posterior

Stabilization:Interbody Graft techniques:

Mini-laportomy retroperitoneal Requires separate incision

Post. Trans-foraminal approachPost lateral fusion with pedicle screwsPost. Trans-foraminal approach:

Decompression and stabilization 1 approach Decreased risk of neural compromise

Surgical InterventionAnt. Column support and Posterior

Stabilization:

Spruit et alt.21% pre-op slips 7 % post op100% fusion rates75% returned to pre injury activity

Surgical Intervention

Surgical InterventionReduction of High Grade

Spondylolisthesis/SpondyloptosisAdvocated by some authors

Improve cosmesis Correct slip angle Improve kyphosis

No need to perform in adultsHIGH rate of neural compromise

Don’t do it!!!!!

Hangman’s FractureYounger age group (Avg 38 yrs)

Usually due to hyperextension-axial compression forces (windshield strike)

Neurologic injury seen in only 5-10 % (acutely decompresses canal)

Traditional treatment has been Halo-vest

Collar adequate if < 6 mm displacedCoric et al JNS 1996

Hangman’s FractureTraumatic spondylolisthesis

of C2.The fracture line passes

through the neural arch. It may or may not result in

ant. displacement of C2 on C3.

Most commonly caused by a Motor Vehicle accident and a fall.

Current classification (Levine & Edwards) is based on radiological findings: 4 types are described and each category has different mechanism of trauma.

Type I

Mechanism: hyperextension – axial loadingIntegrity of ALL, PLL, and DiscNo angulation.Displacement < 3 mmStable fracture: Collar.

Type II

Significant angulation and translation.Extension – axial loading followed by flexion.Most common typeUnstable: halo vest.

Type IIA

Significant angulationNo translationFlexion – distractionUnstable: Halo vest

Type III

Severe angulation and translation + unilateral or bilateral C2-3 facet dislocations.Flexion – compression.Unstable fractures: Surgical reduction and fixation.

TreatmentLow grades like type I and Type II are treated

conservativelySkull traction (contra indicated in IIA causing

distraction and further damage)Cervical collar/ SOMI braceHalo traction device

High grade type II facture require surgical intervention Open reduction, fixation and fusionTrans pedicular screw fixation for motion

preservation in type II fracture

Direct pars screw:the C2 pedicle should

be palpated using a fine dissector after removal of soft tissues.

Key points

1. Conservative treatment is mainstay2. Progression of slip rarely occurs3. Decompression and fusion give excellent

results for radiculopathy and back pain4. Fusion 360 degrees increases fusion

rates but does not correlate with better outcomes

5. Poor outcomes in high grade of cervical listhesis.

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