Download - Traumatic Spondylolisthesis
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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