CLINICAL ORTHOPAEDICS NOTES FOR BPT 3RD YR

BY MEP
SPONDYLOLISTHESIS
Definition
Incidence &prevalence
Classification
Etiopathology
Clinical Features(Signs &symptoms)
Investigations
Management
DEFINITION
Spondylolisthesis is forward displacement of vertebra over
the one below it .
lt commonly occurs between L5-S1,and between L3-L5.
Occasionally, the displacement is
backward(Retrolisthesis).
INCIDENCE & PREVALENCE
Approximately 5 to 6% of males, and 2 to 3% of females
have a spondylolisthesis. It becomes apparent more often
in people who are involved with very physical
activities such as weightifting, gymnastics, or footbal.
Males are more likely than females to develop symptoms
from the disorder, primarily due to their engaging in
more physical activities. Although some children under
the age ot five may be predisposed towards having a
spondylolisthesis, or may indeed already have an
undetected spondylolisthesis, it is rare that such young
children are diagnosed with spondylolisthesis.
Spondylolisthesis becomes more common among 7 to 10
year olds. The increased physical activities of adolescence
and adulthood, along with the wear and tear of daily
life, result in spondylolisthesis being most common
among adolescents and adults.
ETIOPATHOLOGY &CLASSIFICATION
Anatomical classification
Etiological classification.
Anatomical Classification
1. Congenital
A. This type has dysplastic articular process at the level
of olisthesis. They are axially oriented and are frequently
associated with dysplasia of of the superior vertebral end
plate as well as with spina bifida. This unstable condition
permits the slippage to occur.
B. This type seen in adult results from either sagittal
(parellel) orientation of the articular processes that
dislocate in adult life.
C. Other congenital anomalies of the lumber spine
permit spondylolisthesis to occur. Congenital kyphosis is
the principal one.
2. Isthmic
The lesion is located in pars interarticularis. Three types
are recognised:
A. In the lytic type, there is a stress fracture of the pars.
B. An elongated but intact pars is present secondary to
healed stress fractures.
C. Acute fractures of the pars which results from major
fracture
3. Degenerative
This type results from long standing inter segmental
instability.
4. Post-surgical
A. A partial or complete loss of posterior bony and
discogenic support occurs secondary to extensive
decompressive facetectomy, often in patients with
sagittaly oriented facets.
B. Postoperative stress fractures of the articular process
at their junction with laminae produce these lesions.
5. Post-traumatic
This type always due to severe trauma, results from acute
fractures in areas of the bony hook other than the pars
6. Pathological
This lesion results from generalised or localised bone
disease. Destruction of the posterior elements allows the
cephalic vertebrae to slip forward onto the one below it.
A. Generalised.
B. Localised.
Etiological Classification
Marchetti and Bartolozzi in 1986 published a classification
based exclusively on etiology.They divided all lesions
into:
A. Developmental:
Due to Lysis
-Elongation
B. Acquired:
Traumatic due to
-Acute fracture
-Stress fracture
-latrogenic
-Pathologic
-Degenerative.
CLINICAL FEATURES
Symptoms
1. Asymptomatic: Many people are asymptomatic and get
aware of the problem only when a X-ray is taken for some
other problem.
2.Pain in the lower back, which aggravates after exercise
and decreases on rest.
3. Increasing lordosis (swayback).
4. Pain and/or weakness in one or both thighs/legs.
5. Decreasing ability to control bowel or bladder
function.
6. Tight hamstrings
7. In case of advanced spondylolisthesis, change may
occur in the way people stand or walk, e.g.
Development of waddling style of walking. This
causes the abdomen to protrude further, due to low
back curving more further. The torso (chest, etc) may
seem shorter and muscle spasms in low back may occur.
Signs
1. Step off sign: On inspection at lumbosacral junction
(seen in grade 2 or more).
2. Movements of the lumbar spine are restricted.
3. Hamstring tightness as revealed by SLR.
Hamstring tightness was originally believed to be due
to traction on cauda equina. However, it occurs in all
grades of spondylolisthesis and is rarely associated
with neurological signs. It may be that hamstring
tightness represents either an attempt of the body to
stabilise the LS level or an attempt to rotate pelvis to
more vertical position to re-establish patients center
of gravity. Eighty percent of asypmtomatic patients
have hamstring tightness.
4. Deep palpation of spinous process above slip will
5. Lumbosacral kyphosis
6. Lordotic pasture: Above the slip to compensate for the
7. Sacrum becomes vertical and buttocks become heart
produce local and sometimes radicular pain.
As deformity increases, displacement. shaped.More
severe,
8. Trunk gets shortened and absence of waistline.
9.In children with no deficit unlike adults, one may get
a peculiar spastic gait called as Waddle due to:
-Tight hamstring
- Lumbosacral kyphosis.
10. Neurological deficits
Motor
Sensory
Reflexes
Bowel/bladder involvement.
11. Scoliosis: 3 causes:
a. Sciatic: Lumbar curve caused by muscle spasm.
Curve is not structural but resolves with recumbence.
b.Olisthethc: Torsional lumbar curve that results from
asymmetrical slipping of vertebrae.
c. ldiopathic: Listhesis and scoliosis should then be
tackled separately.
Associated Conditions
Spina bifida occulta: Accompanies isthmic defects with
a reported incidence of 24 to 74% and dysplastic of 40%
Scoliosis: Occurred in 30% of patients requiring surgery
for spondylolisthesis
Abnormal discs on MRI: 10 to 39%. This was rarely
associated posterior disc protrusion at level of slip.
Lumbarisation and sacralisation reported in 7 to 9%
of spondylolysis.
INVESTIGATIONS
Radiological Findings
Bone scan
Myelography.
X-rays
MRI
X-rays
.A-Pview
Lateral view (standing)
Oblique view: For viewing spondylolysis
a. Meyerding slip grading: The ratio between A-P diameter
of top of first sacral vertebrae and the distance L5 has
slipped anteriorly determine percentage of slip.
Grade 1: Displacement up to 25%
Grade 2: 25 to 50%
Grade 3: 50 to 75%
Grade 4: More than 75%
Complete slippage of L5 over s1 is called as
spondyloptosis
b. Dewald modification of Newman: Better defines the
amount of anterior roll of L5
Bone Scan
Indicated in acutely symptomatic patients particularly
young athletes to determine whether acute injury or
repair process has begun.
Also helpful in distinguishing between an acute
fracture and pre-existing spondylolysis in victims of
multiple trauma. Besides bone scan is required to
determine whether a spondylolytic lesion is acute enough
to merit immobilisation with cast.
Positive bone scan & a negative X-ray-Recent injury
that may benefit from immobilisation.
Negative bone scan and a positive X-ray-Old lesion
that will not heal.
Asymptomatic patients.
SPECT (single photon emission CT bone scanning) is
a very sensitive method of confirming diagnosis when
stress reaction is suspected.
A primary limitation of bone scan has been inability
to clearly resolve the bony architecture of vertebral bodies
due to superimposition of individual structures of
vertebrae over each other. SPECT has overcome this
problem
MRI
Indicated to see
Extent of disk injury
Nerve root compression.
Myelogram
Reveals partial or complete block at the level of neural
arch of L5.
Largely replaced by MRI
Treatment
The grade of slip (grades 1 to 5) and the symptoms will
help determine the type of treatment that will be suitable.
One should consider the following options:
1.No treatment
Approximately 5% of the population has a
spondylolisthesis, most of whom will never need any
treatment as their spondylolisthesis is stable, and non
progressive. For adults, treatment is only recommended
for those patients who have symptoms of pain and
disability. For children, treatment is necessary if they have
pain, and when the forward vertebral slip is progressing
Observation is adequate for the adult who has no
symptoms or the child who has a minimal spondylolisthesis
and no symptoms.
Most patients with spondylolisthesis should avoid
activities that might cause more stress to the lumbar spine
such as heavy lifting and sports activities like gymnastics,
football, competitive swimming, and diving. Patients, or
their parents, must discuss their daily activities and
hobbies with their physician to see if they are all right to
continue,
2. Bed Rest/activity Restrictions
Bed rest following an injury to the back is used less and
less because of the risk of deconditioning (e-g, loss of
muscle tone which delays recovery). Ten years ago, if
one had a similar back problem he would be placed on
bed rest for at least ten days. We now know that a shorter
period of time, such as two to three days followed by a
guided physical therapy program is a better solution to
back pain
Once the spondylolisthesis has been recognized,
treatment often consists of a short rest period (two to thre
days) followed by a physical therapy program by a
registered physical therapist that has an understanding
of spondylolisthesis.
There should be restriction of heavy lifting, excessive
bending, twisting or stooping and avoidance ot any work
or recreational activities that causes stress to the lumbar
spine. The physician should outline a rehabilitation
program to return the patients activities as soon as
possible.
It is in our best interest to closely follow the activity
program as outlined by the physician, nurse, or therapist
to restore best level of functioning as soon as possible. If
the work requires heavy lifting, bending, or stooping, he
should not be allowed to return to that type of work
immediately. Specific work restrictions should be
discussed so that a less demanding job may be found.
Remember, participating in daily activities is
important to both long-term physical and emotional well
being.
3.Medication
Many medications are available to help reduce pain. Your
physician may prescribe their use, generally to reduce:
i Inflammation
ii. Muscle spasms
iii.Pain.
4.Corset/Brace
In certain situations a corset or brace is useful to provide
additional support to the spine. This support may
decrease muscle spasm and pain.
Corsets consist of soft fabric, and may include rigid
supports. Corsets can be obtained either through your
physician, orthotist (i.e. a person trained to make
orthopedic braces), medical supply company, or
pharmacy. Normally a corset is worn when one is up
and about, but is often not necessary when lying in bed.
Braces are made of plastic and can be readymade or
custom fit. Readymade braces are appropriate in those
patients whose lumbar spine has a near normal contour.
If there is a marked forward slip of vertebra, readymade
braces are often difficult to fit and wear. Some physicians
opt for custom made lumbar braces (orthoses) for all of
their patients with spondylolisthesis,
If custom-molded orthoses is required, an orthotist is
sought. The orthotist will take measurements and apply
a cast to make a mold of the body. A custom brace wil
then be made
When first giving a brace, advise on:
How to get in and out of brace?
Increasing the amount of time spent in brace each day urti
brace schedule is achieved
Watching out for skin irritation (some redness is expected
onder the brace). If Any sores on the skin are noted,
removal of brace and report to physician, nurse, orthotist
inmediately for further skin-care instructions.
5. Surgery
The indications for surgery in spondylolisthesis and
spondylolysis include the following (primarily for
adolescents and young adults):
1. Persistence or recurrence of major symptoms for at
least one year despite activity modification and
physical therapy.
2. Tight hamstrings, persistence of abnormal gait or
postural abnormalities unrelieved by physical
therapy.
3. Sciatic scoliosis.
4. Progressive neurological deficit.
5. Progessive slippage beyond 25 to 50%, even when
asypmtomatic.
6. A high slip angle (40 to 50) in a growing child, since
it is associated with further progression and
deformity.
7. Psychological problems attributed to shortness of
trunk, abnormal gait, and postural deformities
characteristic of more severe slips.
REFERENCES
ESSENTIALS OF ORTHOPAEDICS BY E MAHESHWARI
TEXTBOOK OF ORTHOPAEDICS &TRAUMA BY
KULKARNI
TEXTBOOK OF ORTHOPAEDICS BY NATARAJAN & BY
JOHN EBNEZAR