Isthmic Spondylolisthesis

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Isthmic Spondylolisthesis

• George Sutherland M.D.
• PGY-2
• LSU-HSC 06/27/06

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Outline

• Case report
• Definition
• Epidemiology
• Injury Mechanism
• Pathophysiology
• Hx
• PE
• Imaging
• Radiograph
• CT
• MRI
• SPECT
• Conservative Treatment
• PT
• Injections
• bracing
• Surgical Intervention

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Case report

• HPI 31 yo male, h/o progressive back
  pain/numbness radiating down bilateral thighs and
  to top of feet for 1 year. Exacerbated by
  activity and relieve by sitting down.

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Case Report

• Lat. view

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MRI
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Spondylolisthesis

• Definition Ant. or post. translational
  displacement of one vertebral body over another.
• Due to
• Trauma
• Degenerative changes
• Defects in the boney architecture

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Anatomy
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Spondylolisthesis

• 2 patterns of Adult Spondylolisthesis
• Isthmic
• Abnormality in par interarticularis
• Degenerative
• Result of lumbar spondylosis, disk degeneration,
  and instability

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Epidemiology
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Epidemiology

• Incidence 4-6 pop.
• Males
• Female higher slip rate
• L5-S1
• Genetic predisposition

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Other facts

• 50 spondylolysis have no slip
• 70 Spina bifida occulta
• Defect in pars occurs 5-7 y.o. with progression
  of slip occurring in adolescence
• 50 Eskimos

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Injury Mechanism

• Wiltse
• Subtype A fatigue and failure of pars w/
  complete separation of bone
• Subtype B elongated pars due to recurrent fx and
  healing
• Subtype C acute fx of pars

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Pathophysiology
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Pathophysiology

• Physiologic response
• Facet hypertrophy
• Healing around pars
• Cartilage
• Fibrous tissue
• Neural foramen
• Narrowing canal
• COMPRESSION!!

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History

• Most people asymptomatic
• c/o
• LBP
• Leg pain, dermatomal
• Numbness / parasthesia
• Combo
• Sclerodermal broad region over buttock post.
  thigh referred
• Deg. disk
• Pars defect

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Physical exam

• Palpation
• Spasms Paraspinous muscle limiting flex/ext
• TTP around slip
• Step-off
• Tight Hamstrings
• Compensatory Hyperlordosis
• Waddling gait
• Neurological deficits
• Motor/sensory
• Nerve compression in lat. recesses
• Gill lesion fibrocartilaginous mass
• Cauda equina syndrome (rare)

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Imaging

• X-rays
• A/P
• Lat flex./ext.
• Supine and standing
• Oblique
• Integrity of the pars Scotty Dog

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Imaging
NORMAL
PARS DEFECT
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Imaging

• Grading
• 0  no slip
• 1 0 ¼
• 2 ¼ - ½
• 3 ½ - ¾
• 4 ¾ - 1
• 5dislocation

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Imaging

• CT scan evaluate boney pathology
• SPECT
• Inconclusive x-rays despite high clinical
  suspicion
• - Acute vs chronic
• MRI evaluate soft tissue pathology
• Nerve compression
• Spinal compression

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DDX

• Spondylosis
• Acute disk herniation
• Spondyloarthropathy
• -seropositive and negative

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Conservative Treatment

• NSAIDS
• Weight loss
• Steroid injections
• Acute phase
• Not for long term use
• Bracing

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Conservative Treatment

• Physical therapy
• Physiotherapy
• Aerobic conditioning

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Conservative Treatment
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Conservative Treatment

• Narcotics contraindicated
• Increase recovery
• Prolong disability
• Most people will recover in 3 months and go on to
  full activity.

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Surgical Intervention

• GOALS
• Stabilization
• Decompression of neural elements

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Surgical Intervention

• Indications
• High Grade Slip
• Cosmetic
• Gait abnormalities
• Failure of conservative management
• Severe pain
• Radiological evidence of instability
• Documented progression of slip
• Progression of neurologic signs

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Surgical Intervention

• Contradictions
• Smoking
• Disability/compensation claims, litigation
• Previous fusions, pseudoarthrosis repairs
• Predictors Poor Outcome
• Male
• Middle age
• Cigarettes
• Multiple surgeries
• Compensation/ litigation

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Surgical Intervention

• Complications
• Bone graft, chronic pain 5 pts.
• Fusion, pseudoarthrosis, bleeding, infection
• Instrumentation, loss of fixation, loosening and
  bone screw interface, implant breakage
• Decompression (neural elements), nerve damage,
  dural tears, arachnoiditis, surgical scars

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Surgical Intervention

• Direct repair of pars interarticularis
• Wire loops
• Screws with bone graft
• Moreles and Pozzo
• 32 pts 18-54 yo
• 3.2 year f/u
• Resection of Gill lesion, decompression of nerve
  and internal fixation
• Good radiologic healing with improvement of
  clinical symptoms

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Surgical Intervention

• Direct repair of pars interarticularis
• 4. Schlenzka showed no difference in outcome or
  adjacent segment degeneration vs posterior
  lateral fusion

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Surgical Intervention

• Decompression alone
• Older pts (gt55yo) with leg pain, complete disk
  collapse, and stable lesion
• Remove facets, loose lamina, fibrocartilage and
  pars
• Gill lesion

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Surgical Intervention

• Decompression with Posterior Lateral Fusion
• Younger pts (30 y.o.)
• Intact vertebral disk
• Fusion
• In situ
• Pedicle screws
• 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

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Surgical Intervention

• Ant. Column support and Posterior Stabilization
• Interbody Graft techniques
• Mini-laportomy retroperitoneal
• Requires separate incision
• Post. Trans-foraminal approach
• Post lateral fusion with pedicle screws
• Post. Trans-foraminal approach
• Decompression and stabilization 1 approach
• Decreased risk of neural compromise

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Surgical Intervention

• Ant. Column support and Posterior Stabilization
• Spruit et alt.
• 21 pre-op slips 7 post op
• 100 fusion rates
• 75 returned to pre injury activity
• Kawakami
• L5 over S1 axis of alignment lt35mm
• Increased axis poorer outcomes

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Surgical Intervention
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Surgical Intervention

• Reduction of High Grade Spondylolisthesis/Spondylo
  ptosis
• Advocated by some authors
• Improve cosmesis
• Correct slip angle
• Improve kyphosis
• No need to perform in adults
• HIGH rate of neural compromise
• Dont do it!!!!!

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Key points

• Isthmic spondylolisthesis is acquired and
  manifests itself in early adult hood.
• Conservative treatment is mainstay
• Progression of slip rarely occurs
• Decompression and fusion give excellent results
  for radiculopathy and back pain
• Fusion 360 degrees increases fusion rates but
  does not correlate with better outcomes
• Poor outcomes

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Bibliography

• Sclenzka D, Seitsalo S, Poussa M, et al
  Operative treatment of spondylolysis... Eur Spine
  J 2104-112, 1993.
• Gill, GG Long-term follow-up evaluation of a few
  patients with spondylolithesis treated by
  excision of Clin Orthop 182215-219, 1984.
• Spruit M, Pavlov PW, Leitao J, et al Posterior
  reduction and anterior lumbar interbody fusion
  Eur Spine J 11428-433 discussion 434, 2002
  Epub May 14, 2002

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Bibliography

• Kawakami M, Tamaki T, Ando M, et al Lumbar
  sagittal balance influences the clinical outcome
  after decompression Spine 2759-64, 2002.
• McGuire RA, Haley T Outcome of low-grade
  spondylolisthesis treated with decompression,
  reduction, and posterolateral spinal fusion
  Submitted for publication.
• Rothman-Simeone, The Spine Vol II, 2006.

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