Table of Contents
- a common incidental finding on the L/S spine Xray in the ED which is usually long standing but may be the result of acute trauma and may be the cause of the back pain and nerve compression.
- spondylolisthesis refers to the forward slippage (anterolisthesis) of one vertebral body with respect to the one beneath it.
- most commonly occurs with L5 slipping over S1, but it can occur at higher levels (particularly degenerative types).
- it may cause any degree of symptoms, from minimal symptoms of occasional low back pain to incapacitating mechanical low back pain, radiculopathy from nerve root compression, and neurogenic claudication.
- 5 types:
- congenital or dysplastic (type 1)
- due to a defect in the upper sacrum or arch of L5.
- 94% are associated spina bifida occulta and high rates of S1 foraminal nerve root compression exists, even with grade 1 slips
- isthmic (type 2) (5% of people)
- These typically present in the teenage or early adulthood years and are most common at L5-S1.
- results from a defect in pars interarticularis, which permits forward slippage of the superior vertebra
- The pars interarticularis, or isthmus, is the bone between the lamina, pedicle, articular facets, and the transverse process
- The pars may be congenitally defective (eg, in spondylolytic subtype of isthmic spondylolisthesis) or undergo repeated stress under hyperflexion and rotation, resulting in microfractures.
- 3 sub-types:
- Lytic (ie, spondylolysis) or stress fracture of the pars
- Elongated yet intact pars
- Acutely fractured pars
- risk factors:
- both lumbar lordosis and rotational forces are also believed to play a role in the development of lytic pars defects and the fatigue of the pars in the young
- an association exists between high levels of activity during childhood and the development of pars defects
- clinical features:
- variable pain
- restricted spinal range of movement
- hamstring tightness - inability to flex hips with fully extended knees
- hyperlordosis of the lumbar and thoracolumbar regions
- hyperkyphosis at lumbosacral junction (as the center of gravity shifts to compensate for slip progression)
- high grade slips may result in palpable step off, gait difficulty and trunk shortening (if spondyloptosis occurs)
- degenerative (type 3)
- ~5% of elderly men and 9% elderly women - mainly L4/L5, and lesser prevalence at L3/4
- The L5 nerve root is usually compressed from lateral recess stenosis as a result of facet and/or ligamentous hypertrophy, and causes weakness of the extensor hallucis longus
- results from chronic disc degeneration and facet incompetence
- spondylosis is a general term reserved for acquired age-related degenerative changes of the spine (ie, discopathy or facet arthropathy) that can lead to this type of spondylolisthesis
- rare, results from fracture of any part of the neural arch or pars that leads to listhesis
- pathologic (type 5)
- results from a generalized bone disease, such as Paget disease or osteogenesis imperfecta
- post-surgical / iatrogenic complications (type 6)
- grade of slippage in the sagiital plane:
- Grade 1 - Less than 25% of vertebral diameter
- Grade 2 - 25-50%
- Grade 3 - 50-75%
- Grade 4 - 75-100%
- Spondyloptosis - > 100% ⇒ trunk shortening
Mx of the young adult with isthmic spondylolisthesis
- surgical fusion MAY be indicated if high grade slip >50%, neurologic involvement, traumatic aetiology, or likely to progress to high grade slip:
- age < 15 years
- ligamentous laxity
- type 1 dysplastic slip
- lumbosacral hypermobility
- most will not have surgery and be advised to modify activities
possible indications for surgery in the older adult
- high grade slip >50%
- neurologic involvement with signs
- traumatic or iatrogenic aetiology
- Type 1 and type 2 slips, with evidence of instability, progression of listhesis, or lack of response to conservative measures
- Type 3 (degenerative) listhesis with gross instability and incapacitating pain
- Postural deformity and gait abnormality1)
spondylolisthesis.txt · Last modified: 2021/11/11 05:07 by gary1