spondylolisthesis and ddx

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SpondylolisthesisSpondylolisthesis

Mohammed Nabil Al Ali, Majid AL-DanDan , Hassan Mohammed Al Awadh, Ahmed Faisal Alkhazal ,

Mohammed Saleh Al Saeed, Mohammed Faisal Alkhazal

5th Year Medical Students , At King Faisal University , AlHassa


- OVERVIEW

- PATHOPHYSIOLOGY and TYPES

- EPIDEMIOLOGY

- CLINICAL PRESENTATION

- PHYSICAL EXAMINATION

- DIAGNOSIS

- DIAGNOSTEC TESTS

- DIFFERENTIAL DIAGNOSIS

- TREATMENT

- SUMMARY

Outlines Outlines ::


• It is a descriptive term referring to slippage (usually forward) of a vertebra and the spine above it relative to the vertebra below it

The word spondylolisthesis is derived from the Greek words spondylo , meaning spine, and listhesis , meaning to slip or slide.

OVERVIEW (definition)

• It lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis).


Pars interarticulars

Spinous process

OVERVIEW ( Anatomy )

Articular process (inferior)


OVERVIEW ( Anatomy )


ANATOMY

OVERVIEW (Dermatomes)


OVERVIEW (Dermatomes)


PATHOPHYSIOLOGYPATHOPHYSIOLOGY

and

TYPESTYPES


• Spondylolisthesis occurs when there’s bilateral defects in the vertebral pars intrarticulariss which permit the vertebral body to slip anteriorly. Usually occurs at level (L5,S1)

• Spondylolysis is the most common cause for spondylolisthesis. It’s a unilateral or bilateral defect in the vertebral pars interarticularis result from stress fracture.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY


• spondylolysis typically is acquired as the bone "fatigues" from recurrent microtrauma during excessive lumbar hyperextension or repeated lumbar flexion and extension.

• rebeated Hyperflextion and extension of the joints are more common in athletes.

• (diving, weight lifting, wrestling and football)


• Spondylolysis progresses to spondylolisthesis in approximately 15% of cases. Progression to spondylolisthesis is correlated with persistent pain and lack of healing.


It can be classified into 6 distinct categories as the following ( developed by Wiltse, Macnab, and Newman ):

Type I: Congenital spondylolisthesis

Type II: Isthmic spondylolisthesis

Type III: Degenerative spondylolisthesis

Type IV: Traumatic spondylolisthesis

Type V: Pathologic spondylolisthesis

Type VI : Postsurgical

TYPES TYPES ( ( according to etiology according to etiology ))


• characterized by presence of dysplastic sacral facet joints allowing forward translation of one vertebra relative to another.

Type I: Congenital spondylolisthesis

• Caused by the development of a stress fracture of the pars interarticularis.

• It is also further divided into 3 subtypes :

Type IIA , type IIB and type IIC .

Type III: Degenerative spondylolisthesis

It is commonly caused by intersegmental instability produced by facet arthropathy.

Type II: Isthmic spondylolisthesis


Type IV: Traumatic spondylolisthesis

Caused by fracture or dislocation of the lumbar spine, not involving the pars

Type VI : Postsurgical (iatrogenic)

Type V: Pathologic spondylolisthesis.Caused by malignancy, infection, or other types of abnormal bone


EPIDEMIOLOGY - Generally - Mortality/Morbidity - Race - Sex - Age


• Heavy Athletic activities requiring predispose some athletes to developing pars defects.

Generally

•Approximately 82% of cases of isthmic spondylolisthesis occur at L5-S1.

Another 11.3% occur at L4-L5.

• Degenerative spondylolisthesis occurs more frequently with increasing age.

• The L4-L5 interspace is affected 6-10 more times than any other level.

• Sacralization of L5 is frequently seen with L4-5 degenerative spondylolisthesis .


• Increased mortality is not associated with spondylolisthesis.

• The most common morbidity is persistent low back pain or nerve impingement.

• Degenerative spondylolisthesis produces characteristic arthritic symptoms that may worsen with age.

Mortality/Morbidity


Isthmic spondylolytic defects affect roughly 1.1% of black females.

• The most commonly affected group is the white male with an incidence of 6.4%.

• Arkara Plains Indians and Aleut people groups have a very high incidence of spondylolytic defects, due to a combination of genetic and environmental factors.

Degenerative spondylolisthesis affects black females more commonly than white females( females more affected than males).

Race


• Congenital spondylolisthesis (dysplastic type)

• Degenerative spondylolisthesis

occurs more commonly in females with a 5:1 female to male ratio. The incidence increases after age 40 years.

occurs with a 2:1 female to male ratio with symptoms beginning around the adolescent growth spurt. These comprise about 14-21% of all cases of spondylolisthesis

Sex


•Acute isthmic spondylolysis often occurs during the first and second decades of life. Most cases occur before the patient reaches age 15 years.

• Younger patients are at higher risk than older patients for developing progressive spondylolisthesis.

•But the risk for progression in adults is rare when the lesion is at L5..

Age


•Congenital/dysplastic spondylolisthesis has been documented in children as young as 3.5 months. More commonly, congenital spondylolistheses go undiagnosed until later in life after an individual has been ambulating for quite some time.

•Degenerative spondylolisthesis occurs most commonly after age 40 years.

• In contrast, lesions at L4-5 may progress into adulthood because of increased sagittal rotation, shear translation, and axial rotation at this segment


CLINICAL PRESENTATION

- Symptoms . - Signs .


1-The patient is usually asymptomatic.

2- unlikely cause back pain in adults (especially

after age 40 y) with no history of symptoms before age 30 years

3-Low back pain is the most common symptom , and it is often exacerbated by motion, The patient may report relief of pain with extended periods of rest.

4- it is associated with numbness and tingling in the legs (L5 or S1 distribution) and leg pain.

Symptoms


1-Tenderness to deep palpation of the spinous process above the slip (typically L4) & causes radicular pain due to palpation.

2- muscle tightness (Tight hamstrings muscle) that is associated with all grades of spondylolisthesis occurs at a rate of 80%.

It commonly results in an abnormal gait & inability of the patient to flex the hip with the knees extended.

Signs


3- Paraspinal muscle spasm and tenderness are usually present.

4- Limited forward flexion of the trunk is common with reduced straight-leg raising, which may cause pain

5- Postural deformity and a transverse abdominal crease are seen as a result of the pelvis being thrust forward.


6- Patients with degenerative spondylolisthesis (DSPL) are characterized by an increased pelvic tilt (PT) and decreased sacral slope (SS) than the control population, suggesting the presence of a pelvic compensation


1-Phalen-Dickson sign:

bent-knee, hip-flexed posture with high-grade spondylolisthesis

2-One-legged hyperextension test (stork test):

Use To differenation between spondylolysis (+) and spondylolisthesis(-)

PHYSICAL EXAMINATION


With increasing slippage, the sacrum becomes relatively more vertical, impairing hip extension and compelling the patient to walk with a knee-flexed, hip-flexed gait

1-Phalen-Dickson sign:


A positive one-legged hyperextension test while standing on one leg and bending backward, pain is experienced in the ipsilateral back.

2-One-legged hyperextension test (stork test):


In most cases it is not possible to see visible signs of spondylolisthesis by examining a patient.

Patients typically have complaints of pain in the back with intermittent pain to the legs. Spondylolisthesis can often cause muscle spasms, or tightness in the hamstrings.

Spondylolisthesis is easily identified using plain radiographs.

DIAGNOSIS


Grades ( Myerding Classification)


1- Radiography: lateral view of lumbar spine is especially useful in detection Spondylolisthesis.

2- Computed Tomography: CT SCANNING axial or sagittal image of the lumbar spine can be performed with or without contrast enhancment.

3- Magnetic Resonance Imaging(MRI): has the distinct advantage of imaging of the spine in any plane. Typically, the axial and sagittal planes are used.

DIAGNOSTEC TESTS


Spondylolisthesis. Oblique projection radiograph shows the presence of bilateral pars defects (arrows), with an appearance resembling a

Scottie dog with a collar. (The collar is the pars defect.)


A) -Lateral lumbar spine. Note the pars defects (arrow) and anterior displacement of the L5 vertebra.

B) -Oblique lumbar spine. Observe the clearly visible lucent collar (arrow).


Sagittal CT reconstruction image shows the pars

defect along with grade 1 spondylolisthesis.

Spondylolisthesis. Axial CT image shows bilateral spondylolysis

(arrows). Note elongation of the spinal canal at this level


DIFFERENTIAL DIAGNOSES

• Lumber facet-arthropathy .• Coccyx pain.• Mechanical low back pain .• Overuse Injury.• Lumber compression Fracture.• Lumber canal stenosis .• Lumbar disk herniation .


• is degenerative arthritis affecting the facet joints in the spine

• Low back pain can radiate to gluteal, back of the thigh and rarely below the knee.

• was no numbness, no muscle weakness and the reflexes were normal.

• Stiffness • Poor posture• Radiography: CT and X-ray

Lumber facet-arthropathy


Axial CT

marked osteophytosis and joint space narrowing severe osteoarthritis


X-ray

A mild scoliosis was clearly present.

marked fixation in the opposite (right) sacroiliac joint, and at the L5-S1 joint (the lumbo-sacral joint). L4 was tender on palpation.

Forward bending caused moderate pain in her back and gluteal.


• Coccydynia is inflammation localized to the tailbone pain and tenderness at coccyx.

• The pain is often worsened by sitting. • Patient leaning against the buttocks

• Radiography: CT and X-ray

Coccyx pain


Lateral radiograph (a) and sagittal CT reconstruction (b) demonstrating a fractured coccyx in a patient who was diagnosed with coccydynia following a ground-level fall 6 months earlier


• fracture of lumber spine due to trauma or pathological fracture in osteomyelitis.

• Common in woman who is near or over age 50 .

• Sudden back pain radiate to lower limb. numbness and motor weakness in lower limb if nerve roots is affected

• Radiography: CT and X-ray

Lumber compression Fracture


• congenital narrowing of the lumbar spinal canal.

• low back pain,• weakness, numbness, pain, and loss of

sensation in the legs.• worse pain in standing or walking and

backward. It is relieved by sitting and forward.• sphincteric function impairment.• Negative straight leg raising test • Radiography: X-ray, CT and MRI

Lumber canal stenosis


X-ray

• loss of the normal intervertebral disc height

• the presence of bone spurs (osteophytes)

• spinal instability (abnormal motion between the vertebrae).


CT and MRI


• Herniation of the nucleus pulposus (HNP) through an anular defect due to wear and tear or a sudden injury

I. Low back pain.

II. Leg pain– Coughing and sneezing aggravates the

leg pain.– aggravated by sitting, prolonged

standing.– relieved by walking, lying down

Disk Herniation


IV. Nerve-related symptoms:-Numbness and weakness in the area which the nerve supply-in the lower part of lumbar spine: sciatica .-in the upper part of the lumbar spine: pain in the front of the thigh-loss of bladder and/or bowel control, which are symptoms of a specific and severe type of nerve root compression called cauda equina syndrome.


• In Lateral disc herniation:In L5 root affection: pain radiates on the dorsum and the base of the big toe.

in S 1 root affection: pain radiate to the sole of the foot.

• In central disc herniation:• hyposthesia bilaterally • ankle reflex is lost bilaterally and also may be

the knee reflex.• a foot drop with bilateral dorsi flexor weakness

In Physical Examination:• Straight leg raise (SLR) test. +ve• Femoral stretch test +ve• Difficult tip toe walking and heel walking

Radiography: MRI and CT


MRI

HNPs appear as focal, asymmetric protrusions of disk material beyond

the confines of the annulus

high signal intensity in the posterior anulus is often seen on sagittal T2-

weighted


CT


TREATMENTTREATMENT 1. Conservative .

2. Surgery and Complications 3. Complications


Treatment for spondylolisthesis depends on several factors, including the age and overall health of the person, the extent of the slip, and the severity of the symptoms.

Treatment most often is conservative and more severe spondylolisthesis might require surgery.


o Bed rest.

o Avoidance of activities if there is >25% slippage.

o Non-steroidal anti-inflammatory drug (NSAID).

o Epidural steroid injections(ESI)

Generally, an ESI is given only when other treatments aren't working.

1.Conservative treatment

o A brace or back support might be used to help stabilize the lower back and reduce pain.


o Physical therapy:

Stabilization exercises are the mainstay of treatment. These exercises strengthen the abdominal and/or back muscles, minimizing bony movement of the spine.

These measures only provide temporary relief.


Surgery might be necessary if the vertebra continues to slip or if the pain is not relieved by conservative treatment and begins to interfere with daily activities.

The main goals of surgery for spondylolisthesis are:

1) to relieve the pain associated with an irritated nerve,

2) to stabilize the spine where the vertebra has slipped out of place,

3) and to increase the person’s ability to function.

2. Surgical treatment


The main types of surgical treatmen for spondylolisthesis include:

1) laminectomy (decompression)

2) Fusion


1. LaminectomyWhen the vertebra slips forward, the

nearby nerves that exit the spine can become pinched or irritated.

In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal.

The goal is remove the lamina and release pressure on the nerves .


B.METRx Minimally Invasive Hemilaminectomy:

It involves removing part of one of the two laiminae on a vertebra to relieve excess pressure on the spinal nerve(s) in the lumbar spine.

A. traditional open lumbar laminectomy :

the two laminae and spinous process of a vertebra are removed to relieve excess pressure on the spinal nerves in the spine.

Types of laminectomy :


2. Fusion A spinal fusion is normally done

immediately after laminectomy for spondylolisthesis.

It is designed to fuse the two vertebrae into one bone and stop the slippage from worsening.

The fusion is used to lock the vertebrae in place and stop movement between the vertebrae.

• Types :

A. Traditional FusionB. Minimally invasive surgical spine fusion


A. Traditional Fusion

The vertebrae are affixed to one another using surgical instrumentation.

Bone graft is then placed between the vertebrae allowing them to "fuse" together over time.

This stabilizes the painful joint segment and relieves pressure from the painful spinal nerves

Examples :

1. Postero-lateral fusion (PLF)

2. Posterior Lumbar Interbody Fusion(PLIF)


1. posterolateral fusion (PLF) posterolateral fusion is the grandfather of fusion technique as

it was developed just over 100 years ago. In a posterior approach to lumbar fusion, the surgeon makes

an incision down the middle of the lower back. One of the criticisms of PLF is that it involves an extensive

dissection (the stripping of muscle and fascia off of bone) of the adjacent transverse processes, facet(s) and sometimes lamina.

After the decompression, the surgeon will place graft material along the sides of the vertebrae to stimulate bone growth.

Titanium screws and rods are often used to provide immediate stability to the spine until a solid fusion has been achieved.


2. Posterior Lumbar Interbody Fusion(PLIF):

In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back).

The surgeon works from the back of the spine and removes the disc between the problem vertebrae.

Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space)

Transpedicular instrumentation is attached to stabilize the motion segment while fusion occurs.


B. Minimally invasive surgical spine fusion

It allows the surgeon to make smaller incisions in the skin and avoid large muscle retraction.

o It is arguably an important improvement on traditional PLIF, because it minimizes nerve root and thecal sac retraction/damage and necessitates less osseous and soft tissue dissection.

o This technique approaches the epidural space from a more posterolateral direction, taking out the facets on one side and only part of the lamina.

o The bony endplates are scraped until rough and the space is filled with a plastic or metal cage and bone chipes to achieve a fusion between the vertebral bodies.

• Transforaminal Lumbar Interbody Fuision (TLIF):


o Implant failure.o Pseudoarthrosis.o Nonunion.o Foot drop.o Spinal compression.o Acute bowel ischaemia

Complications of surgical repair


- Spondylolisthesis is a forward or backward slippage of one vertebra on an adjacent vertebra.

- Causes of spondylolisthesis include trauma, degenerative, tumor, and birth defects.

- Symptoms of spondylolisthesis include lower back or leg pain, hamstring tightness, and numbness and tingling in the legs.

- diagnosis is mainly based on imaging .

- Most people with spondylolisthesis can be treated conservatively, without the need for surgery.

- Patients who fail to improve with conservative treatment may be a candidate for surgery.

SUMMARY


REFERENCES

- Emedicine

- Uptodate

- http://www.mdguidelines.com/spondylolisthesis[

- medicinenet

All refrences are written under each sidebut mostly we depended on :



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