Jwalant S. MehtaMS(Orth), D (Orth), MCh (Orth), FRCS (Tr &
Orth)
Consultant Spine Surgeon, ABMU Health Board
SPONDYLOLISTHESIS
OUTLINE OF THE TALK
¤ Classification
¤ Natural history
¤ Patho-physiology
¤ Treatment rationale
¤ Cases
SPONDYL OLISTHESIS
1741 Nicholas Andry: hollow back
1782 Herbiniaux Belgian obstetrician
1854 Kilian slow displacement ‘Spondylolisthesis’
1855 Roberts: No slip if arch intact
CLASSIFICATIONS
Newman & Stone JBJS Br 1963; 45: 39 - 59
Type Name Description
I Congenital Dysplastic abnormalities
II Isthmic
A Lytic (stress fracture)
B Healed fracture (elongated, intact)
C Acute high energy fracture
III Degenerative Segmental instability
IV Traumatic Fracture of hook other than pars
V Pathologic Underlying pathology
VI Iatrogenic Surgical excision of posterior elements
Wiltse, Newmann, MacNab Clin Orthop 1976
MEYERDINGS GRADES
Low Grade
High GradeIII
IIIIVV
SLIP ANGLE
Important in grades III – V
SPINO-PELVIC MEASURES
PELVIC INCIDENCE
Pelvic tilt Sacral slope
PI = PT + SS
High PT Low SSLow PT High SS
RELEVANCE OF PELVIC MEASURES
¤ PI quantifies the pelvic shape
¤ Pelvic morphology and spino-pelvic balance are abnormal in spondylolisthesis
PATHO-PHYSIOLOGY
HOOK AND CATCH
Hook:¤ Pedicle
¤ Pars inter-articularis
¤ Inferior process of the cephalad level
Catch:¤ Superior process of the caudal
level
PATHOPHYSIOLOGY
¤ Dysplastic pathway
¤ Traumatic pathway
Dysplastic pathway Traumatic pathway
Weakness in the hook & catch mechanism
Body weight transmitted through weak zone
Soft tissue restraints: plastic deformation
Growth plate overloaded
Repetitive cyclic loads (sports)
Stress fracture of a Normal pars
Hard cortical pars pre-disposes to fatigue
fracture and non-union
Predisposes to a vertical subluxation
DYSPLASTIC CHANGES¤ Proximal sacral rounding
¤ Trapezoidal L5
¤ Vertical sacrum
¤ Junctional kyphosis
¤ Compensatory hyper-lordosis
Contributes to the mechanics of progression, but not causation
PROXIMAL SACRAL ROUNDING
Yue Spine 2005
PROXIMAL SACRAL ROUNDING
DISCAL OVER-LOADING
¤ Both the pathways lead to ↑ shear loads, axial loads remaining constant
¤ Premature disc degeneration
Alternative loading pathwayHaher Spine 1994
¤ Chronic muscle spasm (protective): ‘painful’ pars Annular tears Root compression / traction
Leg pain is the most common symptomMoller Spine 2000
The pain generators: Back pain
THE PAIN GENERATORS: LEG PAIN
¤ L5 compression / traction
¤ Abnormal motion
¤ Facet joint arthrosis
¤ Pars scar
¤ The disc above far-lateral
CLINICAL EVALUATION: HISTORY
¤ Symptoms: Back painLeg painNeurology
¤ Severity
¤ Activities of daily living
CLINICAL EVALUATION: EXAMINATION
¤ Range and rhythm of trunk motion
¤ Neurology
¤ Sagittal alignment & gait
SAGITTAL ALIGNMENT
¤ Stance
¤ Gait
¤ Head over pelvis
¤ Hips and knees
IMAGING
¤ Erect radiographs:APLateral (to include the hips)
¤ MRI; CT
¤ Occasionally:
SPECT; Dynamic radiographs; Discography
PURPOSE OF IMAGING
¤ Disc degeneration (MRI / CT)
¤ Facet joint orientation, tropism, degeneration (MRI / CT)
¤ Pelvic and spinal measures (Erect xrays)
DISC DEGENERATION
DISC DEGENERATION: MRI
Pfirrmann et al Spine 2001
Grade I Grade II Grade III Grade IV Grade V
FACET JOINTS
FACET JOINTS: ORIENTATION & TROPISM
¤ Mean facet joint angle:
Sagittal: anterior forces
¤ Tropism
R –L: asymmetric loads
Mild < 5°Moderate 7° – 15°Severe > 15°
Vanharanta Spine 1993
Don JSDT 2008 Wang Spine 2009Boden JBJS Am 1996
FACET DEGENERATION: CARTILAGE
1. Uniformly thick layer
2. Focal erosions
3. Areas of deficiency with exposed bone
4. Cartilage absent except traces
Grogan et al AJNR 1997
FACET DEGENERATION: SUB-CHONDRAL SCLEROSIS
1. Thin layer of cortical bone
2. Focal thickening
3. Thick < ½ of the surface
4. Dense cortical bone > ½ of the surface
Grogan et al AJNR 1997
FACET DEGENERATION: OSTEOPHYTES
1. No osteophyte
2. Small
3. Moderate
4. Large
Grogan et al AJNR 1997
Severe Spinal Stenosis
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
WILTSE CLASSIFICATION:III. DEGENERATIVE
Instability phase: Kirkaldy Willis
Posterior elements are intact
L45; F >M
Disc:
¤ degeneration,
¤ ↓ height
Facets:
¤ Tropism
¤ Abnormal sagittal orientation
¤ Facetal arthritis; subluxation
NATURAL HISTORY
NATURAL HISTORY: GENETICS
¤ 15 – 70% 1st degree relatives
¤ Lysis commoner in boys
¤ Slips commoner in girls
¤ Eskimos 25% (arch defects)
Albanese JPO 1982Wynne-Davies JBJS Br 1979
Roche JBJS Am 1952
Stewart JBJS Am 1953
NATURAL HISTORY: ‘THE SLIP’
¤ 15% of persons with a pars lesion
¤ During the growth spurt
¤ Minimal change after 16 y
¤ No pain during progression
Bentley Spine 2003
EXTENT OF THE PROBLEM
¤ Most are asymptomatic
¤ 90% slips at initial presentation do not progress
Seitsalo JBJS Br 1990Danielson Spine 1991Frennerd JPO 1991
Seitsalo Spine 1991
PROGRESSION
PROGRESSION RISK
¤ > 20 y: more stable, less symptomatic, less likely to progress
¤ High level of athletic activity, no effect on progression
¤ Association with back pain ‘weak’
Ohmori JBJS Br 1995
Muschik JPO 1996
RISK OF PROGRESSION: HIGHER LEVELS
THE RISK OF PROGRESSION IN THE YOUNG ADULT: DISC DEGENERATION
RISK FACTORS FOR SLIP PROGRESSION IN SPONDYOLISTHESIS(HENSINGER 1989)
Clinical
¤ Growth yrs (9 – 15)
¤ Girls > Boys
¤ Back pain
¤ Postural or gait abn
Radiographic
¤ Type 1 (dysplastic)
¤ Vertical sacrum
¤ >50 % slip
¤ Increasing slip angle
¤ Instability on flex/ext views
RISK OF PROGRESSION: PROXIMAL SACRAL ROUNDING
TREATMENT RATIONALE
NATURAL HISTORY OF PROGRESSION
¤ Adolescents III+: likely to progress
¤ I, II after mid-adolescence: unlikely to progress
NON-OPERATIVE TREATMENT
¤ Always consider first……………….everytime!
¤ Improvement likely if back > leg pain
¤ Isthmic / degnerative with leg pain: improvement less likely
¤ Investigate / treat osteopaenia
NON-OPERATIVE TREATMENT: PAEDIATRIC
¤ Stop aggravating activities
¤ Gradual mobilisation
¤ Trunk strengthening
¤ Period of bracing
NON-OPERATIVE TREATMENT: ADULTS
¤ Exercises
¤ Aerobics
¤ NSAID’S
¤ Epidural steroids
MANAGEMENT DECISION
¤ Individualized for each patient
¤ Think of the natural history
¤ Severity and duration of symptoms
¤ Co-morbidities
SURGICAL INDICATIONS
¤ Severe back and leg pain
¤ Failed conservative trial
¤ Abnormal neurology
¤ +ve diagnostic injections
SURGICAL GOALS
¤ Address the pars defect & the rattler
¤ Decompress the foraminal stenosis
¤ Address the degenerate disc/s
¤ Address the dynamic instability
SURGICAL OPTIONS
1. In-situ postero-lateral fusion
2. Decompression + In-situ postero-lateral fusion
3. Additional inter-body fusion options
DECOMPRESSION: ABSOLUTE INDICATIONS
¤ Neurology
¤ Leg pain
¤ Sphincter dysfunction
¤ Claudication
DECOMPRESSION: EXTENT¤ The Gill procedure: Removal of the loose
laminar arch
¤ Foraminotomy + facetectomy
¤ Never in isolation
¤ Associated with ↑ pseudarthrosis rateCarragee JBJS Am 1997
IN-SITU POSTERO-LATERAL FUSION
¤ L5 S1 only adequate
¤ Improvement in leg pain even when not decompressed
Burkus JBJS Am 1992Frennerd Spine 1991Ishikawa Spine 1994
deLobrresse Clin Orthop 1996
POSTERIOR INSTRUMENTATION
¤ Better fusion rate, better clinical outcomes
¤ Un-instrumented better for osteoporortic bones
Moller Spine 2000
Zdeblick Spine 1993Yuan Spine 1994Bjarke Spine 2002Deguchi J Spinal Dis 1998Ricciardi Spine 1995
LEVELS TO INSTRUMENT
¤ Look at the changes at the levels above
¤ Higher slip angle: retro-listhesis above the slip
INTER-BODY FUSIONS: THEORETICAL CONSIDERATIONS
¤ Anterior column support
¤ Bio-mecahnically superior: Large area for fusion Grafts under compressive loads
¤ Degenerate disc removed
consider disc height
¤ Build in the lordosis
¤ Indirect reduction
INTER-BODY FUSIONS ( …… IF)
P LIF T LIF
A LIF
INDICATIONS FOR SURGERY:CHILDREN
¤ Low grade slip / ‘lysis…..non op measures effective
¤ Progression beyond Gr II
¤ At presentation, > Gr III
¤ Persisting pain; neurologic deficit
¤ Progressive postural deformity / gait abnoralities
SURGERY:PAEDIATRIC / ADOLESCENT
¤ ‘ Lysis Intact disc on MR (Gr I slip)
Direct repair of defect
¤ Grade I Asymptomatic….no surgery
¤ Grade II, III 1 level bilateral lateral fusion
Rarely decompression
Documented progression; back pain
SURGERY:PAEDIATRIC / ADOLESCENT
¤ Grade III+ Asymptomatic: 2 level in situ….L4 – S1
Slip angle < 55° good fusion rate
Post op: Hyper-extension cast + thigh extension
Slip angle > 55° add anterior fusion
Post-op: recumbent during healing
¤ Severe slips Excise body ( Gaines procedure) L4 – S1 fusion
INDICATIONS FOR SURGERY:ADULTS
¤ Non responsive to conservative measures
¤ Results better for leg than for back pain
¤ Isthmic / degenerative………persistent neurology; radicular symptoms
¤ Back pain alone…….decompress & stabilise (↓ symptoms)
DEGENERATIVE SLIP
¤ Caudal + facet injections
¤ Decompress stenosis
¤ Non-instrumented or instrumented fusion
¤ Think of the natural history
¤ Look at each patient and analyse the problems
¤ Individualize the treatment plan
¤ If surgery is the last resort ………….
RECOMMENDATIONS
RECOMMENDATIONS
¤ Choose surgical targets carefully
¤ Ensure patient expectations match with your goals
¤ In-situ PL fusion + decompression
¤ Add inter-body in ‘high risk’ situations
CASES
PROGRESSION ON WAITING LIST
FLEXION EXTENSION X RAYS
R L
POST OP
CASE
CASE
CASE
RADIOLOGICAL RESULT
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
CLINICAL RESULT
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
CASE
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
RADIOLOGICAL RESULT
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
CLINICAL RESULT