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Spondylolisthesis

Spondylistheses

Spondylolisthesis is an anterior displacement of a (usually lumbar) vertebra in relation to the vertebrae below, due to congenital anomaly, degenerative change or trauma.


Presentation

Spondylolisthesis most commonly involves lumbar vertebrae at the level of L4-5 and less commonly, at L3-4. Unilateral or bilateral stress fracture of the pars interarticularis is common. Clinical features include:

  • Lower back pain, that worsens after exercise and on coughing and sneezing
  • Radiation of pain to the legs along the course of sciatic nerve
  • Tingling sensation or numbness in the legs
  • Tightness of the hamstring muscles
  • Slipping sensation while moving upright
  • Muscle spasms
  • Reduction in the range of motion of lower back
  • Kyphosis
  • Abnormal gait (waddling gait)

In severe cases, the patient may develop cauda equina syndrome which is characterized by loss of bladder and bowel tone and their dysfunction.

Wound Infection
  • COMPLICATIONS: A: 7 unintended durotomies and 3 wound infections. B: 1 unintended durotomy, 1 pseudarthrosis, 2 wound infections, and 1 implant failure. There were no neurologic complications in any of the groups.[ncbi.nlm.nih.gov]
Back Pain
  • RESULTS: There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S-BP).[ncbi.nlm.nih.gov]
  • The VAS for back pain and reported satisfaction with treatment showed similar patterns (p 0.003 and p 0.017, respectively), whereas other outcomes did not differ among the treatment groups at 1 year.[ncbi.nlm.nih.gov]
  • His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.[ncbi.nlm.nih.gov]
  • The patients presented with intractable chronic low-back pain. Plain radiographs and 2D CT scanning revealed the presence of the aforementioned anomalies.[ncbi.nlm.nih.gov]
  • METHODS: A 30-year-old female was diagnosed with spondylolisthesis at age 12, has chronic mild to moderate back pain during prolonged walking/standing, hyperlordosis and anterior rotation of the pelvis.[ncbi.nlm.nih.gov]
Low Back Pain
  • The patients presented with intractable chronic low-back pain. Plain radiographs and 2D CT scanning revealed the presence of the aforementioned anomalies.[ncbi.nlm.nih.gov]
  • RESULTS: The onset of low back pain was delayed during walking/standing over the course of treatment, hyperlordosis decreased, and hypertonicity of iliopsoas and quadrates lumborum muscles decreased.[ncbi.nlm.nih.gov]
  • This young lady also had relief of her low back pain and leg pain following the surgery.[ncbi.nlm.nih.gov]
  • The primary outcome measure is Visual Analogue Scale of self-reported low back pain.[ncbi.nlm.nih.gov]
  • Abstract 57-year-old woman was recruited for a research study of muscle activation in persons with low back pain.[ncbi.nlm.nih.gov]
Spine Pain
  • You may notice: Pain in the spine Pain, pins and needles, numbness or weakness due to pressure on nerve roots (running down the legs or arms) Difficult walking due to pain or a feeling of clumsiness A change in the shape of your back with flattening of[britscoliosissoc.org.uk]
  • Severe trauma to the thoracic spine means a major, high impact, direct injury to the thoracic spine which produces immediate thoracic spine pain and precludes unaided ambulation for a period of at least 2 weeks, and is associated with other fractures[veterans.gc.ca]
Personality Change
  • Aging is the main cause Heredity—sometimes the spinal canal is too small from birth, and symptoms may show up in a relatively young person.[dartmouth-hitchcock.org]

Workup

Diagnosis is made on the basis of the following.

  • History
  • Myelography with injection of radiopaque dye
  • X-ray of lumbar spine
  • Computerized tomography imaging
  • Magnetic resonance imaging

Treatment

Conservative treatment is done with the following agents [3] [4]:

  • Non-steroidal anti inflammatory drugs (NSAIDs) are given to reduce inflammation and alleviate the pain. Other potent analgesics may also be given.
  • Oral steroids (such as prednisone or methylprednisolone) can be given in severe cases. Epidural steroid injections may also be given.
  • Physiotherapy, lumbar traction, thermal treatment, electrical stimulation and lumbosacral orthoses are other treatment options for the management of spondylolisthesis.
  • Braces are recommended for spinal support.
  • Chiropractic therapy can also help in reducing the severity of symptoms.

Surgical treatment includes:

  • Spinal fusion. The three most common methods are postero-lateral (intertransverse) fusion, lumbar interbody fusion and pars repair [5] [6]. Antiplatelet and anti-inflammatory therapies are the contraindications of fusion.
  • In situ anterior fusion (ALIF), for high grade spondylolisthesis [7]
  • Fixation
  • Decompression [8] [9]
  • Reduction [10]

Rehabilitation therapy should also be included in the treatment.

Prognosis

The prognosis of the disease is usually good, with a large majority of patients responding to conservative therapeutic measures. Rarely, involvement of nerve roots can lead to concomitant morbidities like cauda equina syndrome.

Surgical treatment may take up to 3 months to heal but the patients usually recover with excellent prognosis [1] [2]. Degenerative spondylolisthesis is associated with worsening of symptoms with time and poor prognosis.

Etiology

Based on etiology, spondylolisthesis is divided into five major categories:

  • Isthmic spondylolisthesis: This is the most common form of spondylolisthesis. A defect in pars interarticularis leads to this form. Hyperextended posture is the common cause.
  • Dysplastic spondylolisthesis: This develops due to defect in the development of vertebral facets. It is a congenital disorder.
  • Pathologic spondylolisthesis: This develops as a result of bone disorders. 
  • Traumatic spondylolisthesis: This results due to direct trauma to the spine. Fractures of pedicle, lamina or facet joints are commonly associated with this form.
  • Degenerative spondylolisthesis: Arthritic changes in the joints contribute to the development of this form of spondylolisthesis. It is the common in old age.

Epidemiology

A prevalence rate of 5-7% has been found in the United States population. Spondylolisthesis is common in athletes and gymnasts as a result of hyperextended postures. Patients with family history of bone defects are more prone to develop spondylolisthesis. It is also common in old age.

Sex distribution
Age distribution

Pathophysiology

Pars interarticularis or isthmus is present in the posterior part of the vertebra. It may be congenitally absent (dysplastic), or may sustain damage as a result of repeated strain (isthmic) or direct trauma (traumatic). The posterior support of vertebrae is lost (intersegmental instability) and the vertebra slips on the underlying vertebra. Defective bone mineralization (pathologic) and degenerative changes can also lead to spondylolisthesis. The spinal canal may undergo narrowing and stenosis. Nerve roots may also be crushed leading to pain along the course of the involved nerve.

Meyerding’s classification system divides spondylolisthesis into 4 grades depending upon the degree of slippage of the involved vertebra:

  • Grade 1: Less than or equal to 25% anterior displacement as compared to the underlying vertebra.
  • Grade 2: 26% to 50% anterior displacement.
  • Grade 3: 51% to 75% anterior displacement.
  • Grade 4: More than 75% anterior displacement.

Prevention

  • Avoiding undue pressure on the vertebrae while exercising can help prevent spondylolisthesis.
  • Mild exercises that strengthen the back muscles should be done according to the advice of physiotherapist.
  • Smoking has been found to contribute to failure of fusion procedure so, it should be avoided. Similarly, alcohol should be avoided.
  • Complete rest should be observed by such patients.
  • Posture should be maintained to avoid stress on the spinal column. Back should be kept straight and the shoulders, square, without hunching over.
  • Healthy, low-fat and low-sodium diet should be consumed.
  • In obese people, weight loss can help reduce the severity of symptoms by decreasing the strain on the spinal column.
  • Lifting heavy weights should be avoided during post-operative period to prevent recurrence.

Summary

Spondylolisthesis is the condition in which a vertebra slips forward in position relative to the adjacent vertebra. The forward sipping is also known as anterolisthesis, whereas, the backward displacement of a disc is known as retrolisthesis. A number of causes contribute to the development of this disease.

The patient may remain asymptomatic or have varying degrees of symptoms depending upon the degree of slippage. Spinal deformities and nerve abnormalities constitute the complications of spondylolisthesis.

Patient Information

Spondylolisthesis is the disease in which one of the vertebrae of the spinal column slips forward on the one lying beneath it. The causes of the disease may include trauma, bone erosion or degenerative changes occurring in the bones with age.

The common presentations of this disorder are pain in the lower back region that might spread to the buttocks and the back of legs. Muscle cramps are common. The person may develop abnormal posture and gait due to severity of the symptoms.

The patient is treated with anti-inflammatory drugs. Physiotherapy is the first line of treatment. Complicated cases are surgically treated. The patient usually recovers and the risk of morbidity is low.

References

Article

  1. Luczkiewicz P, Smoczynski A, Smoczynski M, Lorczynski A, Piotrowski M. [The long-term results of decompression and anterior lumbar interbody fusion for the treatment of degenerative lumbar spondylolisthesis].
  2. Chirurgia narzadow ruchu i ortopedia polska. 2004;69(3):173-177.
    Levenets VN. [Long-term results of surgical treatment of spondylolisthesis]. Ortopediia travmatologiia i protezirovanie. Oct 1977(10):52-53.
  3. Delpierre J. [Conservative treatment of spondylolysis and spondylolisthesis]. Acta orthopaedica Belgica. Jul-Oct 1981;47(4-5):464-467.
  4. Magora A. Conservative treatment in spondylolisthesis. Clinical orthopaedics and related research. Jun 1976(117):74-79.
  5. Lubbers T, Bentlage C, Sandvoss G. [Anterior lumbar interbody fusion as a treatment for chronic refractory lower back pain in disc degeneration and spondylolisthesis using carbon cages - stand alone]. Zentralblatt fur Neurochirurgie. 2002;63(1):12-17.
  6. Yuan JD, Wang J, Zhou HB, Fu Q, Chen ZM, Zhao J. [Analysis of results on minimum 4-year follow-up of modified posterior lumbar interbody fusion for the treatment of isthmic spondylolisthesis]. Zhongguo gu shang = China journal of orthopaedics and traumatology. Jul 2010;23(7):519-522.
  7. Pankowski R, Smoczynski A, Roclawski M, et al. Operative treatment of isthmic spondylolisthesis with posterior stabilization and ALIF. Cages versus autogenous bone grafts. Studies in health technology and informatics. 2012;176:311-314.
  8. Hrabalek L, Wanek T, Adamus M. [Treatment of degenerative spondylolisthesis of the lumbosacral spine by decompression and dynamic transpedicular stabilisation]. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 2011;78(5):431-436.
  9. Luczkiewicz P, Smoczynski A, Smoczynski M, Pankowski R, Piotrowski M. [The results of decompression and anterior lumbar interbody fusion with the use of interbody cages for the treatment of degenerative lumbar spondylolisthesis]. Chirurgia narzadow ruchu i ortopedia polska. 2006;71(3):173-175.
  10. Gong K, Wang Z, Luo Z. Reduction and transforaminal lumbar interbody fusion with posterior fixation versus transsacral cage fusion in situ with posterior fixation in the treatment of Grade 2 adult isthmic spondylolisthesis in the lumbosacral spine. Journal of neurosurgery. Spine. Sep 2010;13(3):394-400.

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Last updated: 2018-06-22 07:26