293

Instability

in Lumbar

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Spondylolisthesis:
Study

L. Penning1

J R

of Several

A Radiologic

Concepts

An attempt
was made to define
more precisely
the notion
of spine instability
in
axes of spondylolisthesis.
lumbar
movement
and theBydegree
means ofof mobility
lateral radiographs
at the L3-L4, in flexion
L4-L5, and
and extension,
L5-S1
levels
the

Blickman1

were determined
in 24 cases of true (spondylolytic)
spondylolisthesis.
Axes of movement at the spondylolisthetic
levels showed
a somewhat
larger spread
in and around
the discs than at the normal levels, but instability
in the form of parallel displacement
of vertebral
endplates
was not observed.
Hypermobility
at the spondylolisthetic
level
proved to be a regular finding. The still current concept
of instability
as presented
by Knutsson
in 1944 was critically
reviewed
and denied as valid. Imprecision
in the
literature
regarding
instability
may partly
be attributed
to insufficient
discrimination
between
vertebral
displacement
as anatomic
relationship
and as abnormal
type of
movement.
By designing
a two-dimensional
model
other
movements
than flexionextension
could be studied;
a special form of instability
at the spondylolisthetic
level
was shown to appear
during forward
and backward
movement
of the lumbar spine
above it. This detailed
analysis
facilitates
understanding
of the effect of different
surgical procedures
on vertebral
movement
and instability
in lumbar spondylolisthesis.
A major
lumbar

indication

spine.
Some

instability.

bodies

during

view,

motion

of

instability
only

abnormal

forward

to

is only

visually
our

1 979:

accepted

after

(defined
dylolysis]

AJR

requests

134:293-301

to L. Penning.

February

0361-803X/80/0134-0293

American

Roentgen

Ray

by

according

$00.00

placed,

Society

study.

place

between

lesion

also

In their
a sign
differ;

measured
only

parallel

[4].

Exces-

considered

a sign

in many

reliably

the

of instability.

of

the

as
of

Opinions

instances

evaluated

with

movement

if the

and

angle

of lumbar

such
presence

in detail.

in spondylolisthesis
of

films

relationship,

opinion,

or analyzed

be

both

L5-S1

vertebrae

In their
as

anatomic

abnormal

measurements

and

such

of

vertebral

also

movements

can

the

of instability.

is

the

is the gradual
progression
of
[6]. Other
authors
[4, 7] relate

to instability.

not

of

of movement

the

is already

on lateral

series

Newman

of the

1980

characteristic
type

of

to criteria

in alignment

take

of

instability

of

spines

axes

of

at normal

movement

in flexion

this

levels.
between

and

extension,

interspaces.

and Methods
.

dress

slip

and

and

L4-L5,

tests

regard

of instability
over the years

determined,

made

In a consecutive

sits; DepartmentofDgnosbcRadiokgyUniver:
reprint

were

Subjects

but

movement

determinations

L3-L4,

type

with

changes

not
site

abnormal

exactly

are

at the

Received
February
9,
revision
August 22, 1979.

and
assessed

opinion,

vertebrae

the

radiographs

static

normal

movement
Such

or

on

regard

does
at

movement,

displacement

malalignment

In

normally

5]. A special
in spondylolisthesis

displacement

consider

or loading

is

imprecise

is an abnormal

movement

[4,

in spondylolisthesis

is rather

[1 -3]

studies

which

range

fusion

literature

essentially

displacement,

not

the
authors

instability

sive

for surgical

Yet

[8]

as caused

interarticular

parts

to a modification
tilting

For

table

the flexion

of 38 patients

x-ray

study,

with

the

by a congenital
of the

neural

of the method
unit,

a radiologic

patient

the patient

bends

of true

or nonacutely

arch),

of Meschan

bends

diagnosis

acquired

flexion-extension
backward

forward

defect

studies

[9]. Standing

maximally

maximally

spondylolisthesis

against
for

with knees

were

[sponmade

the vertically
the

extension

extended

and

PENNING

294

TABLE

1 : Exposition

of Material

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L3,

0,

(1

Movement

(mm)

of Arch

with

L3-L4

L4-L5

L5-51

Body

underiying

22

10

11

12(c)

21

?(?)

14
14

L4:
0, 2

1980

Re-

ver-

15
10
10

20
15
2

21
25
12

6(v)
4(c)
4(v)

6
7

20
10

20
13

17
19

4(c)

16

18

12

25

17

12

18

28

5(v)

18

10

19

17

25

6(v)

15

11

17

12

18

3(v)

15

12
13
14

14
11
13

20
15
12

14
19
15

5(v)
4(c)
7(v)

10
5
7

15

10

15

21

10(v)

17

16
17
18
19
20
21

12
12
11
15
10
7

18
8
7
10
12
15

19
21
7
15
13
13

II, 22
III,23
lV,24

10
19
10

7
20

21
10

6(v)
5(c)
5(c)
4(v)
4(c)
4(v)
10(c)

14
16
9
14
10
15
12

4
II, 5
L5:

134, February,

spec to.

-- .

-.

Movement

..

of Lysis.
Case No

AJR:

BLICKMAN

of Measurements

_________

Flexion-Extension
vertebra
Grade.

and Results

AND

17
5

0:
8

3(c)

I:

caudally;

11

4(v)

10

4(v)

Fig.

leaning

adjusted

were

cases

the

reliable

vertebrae

omitted

aged
was

cases.
51

and

to this

height

of the

feet

table.

Three

x-ray

surgical

intervention.

pictures

cases

vertebra

did

was

nounced

5.

discs

is

system,

case,

grade

slip,

flexion

not

horizontal

but

move
51

older

upper

the

allow

only

with

and

bilateral

cases

(cases

respect
4.

and

movement

between

lumbar

vertebrae

way.

upper

outlines

of the

film

L5 vertebral

The process
the successive

drawn.

between

to the

7, and

Disc

narrowing

disc

had
of the

Disc

in
was

of

(I-IV)

at each

place

arch

IV.

at the

transitional
this

vertebra

narrowing

1 9 cases,
at L3-L4
slightly

below

most
prowas noted
narrowed.

All

the vertebral

of the

upper

superimposition

(method

of movement
of Begg

films
box.

when

superimposed

in the
Cranial

the
lines

same

to the

of

film.

and

way

between

as for

First

are
the

and
placed
outlines

at segments
Falconer
on
of

L3-L4,

[1 1])

(fig.

top

of each

other

the

body

the

of

1).

L4-

vertebra

The

perior
part
millimeters

on
sacrum

a second

vertebral

body are seen.

and

moving

identical

their

and

of the

landmarks

bisecting

The

vertebra

perpendiculars

site of the axis of movement.

In practice
this
consuming.
Instead
the site of the axis is
imaginary
construction
of the lines indicated
is then pierced
through
the upper film into
upper film rotated until the shadows of the
are superimposed.
If exact superimposition

correct

body

is correctly
position

shadows

of

given
2 mm

or

by
more

do not superimpose

the

needle.

is identified

on rotation

film.

of the

shadows

(or the vertebra

the radiologic

the

Next,

measure-

superimposed

vertebral

superimposed

constructing

of movement
the

one

lower

Movement
of the arch of the spondylolisthetic
vertebra
respect
to its body, and with respect
to the vertebra
below.
range

extension

axis

from

along

on the

of Euler [1 2] (fig. 2). The flexion

of a moving

by drawing

the

are

superimposed

and

drawn

of motion.

(principle

which intersect
at the
method
is rather time
visually estimated
by
above. A sharp needle
the lower film, and the
cranial vertebral
body
deviation

bodies

between

vertebra

is

a baseline

is repeated
with L4 and L3. The angles
lines indicate
the amount
of movement

of movement.

of movement

occurs,

normal.

are

line

to form

segment

the two shadows

moving

I slip;

grade

of range

body,
axis

films

is determined

vertebra

a grade

case,

sacrum;

1 9).

patients.

L4-L5

parts
L5

one

ment

body

a pencil

of the

extension

at L5 in

of the

a lumbosacral

noted

the

and

equal

lysis

had

was

1 3,

four

1 6 cases
Ill;

and

Made

viewing

in same

superimposed

taking

1 ). The spondylolin four,

surface

into

female

spondylolisthetic

vertebra

appeared

L5-S1
and

of

Three

Flexion-extension
and

measured

margins
line

In 1 1

did not
were

(table
at L4

to ventral,

By this

In case

Determinations

the

scale.

Called

in the

33)

slip

no

seven

case,

divided

dorsal

portions.
that

case

in one

forward

spondylolisthetic

other

(average,

at L3

II; one

had

cases,

years
[10]

grade

invariably

L5.

The
of the

of previous

(accepted)

from

the

interarticular

in

1 3-63

vertebra,

cases,

Four

24

Meyerding

according

are

Axes of movement

localized

graded

the

floor.

of the flexion-extension

remaining

1 7 male,

two

on the

the foot-rest

because

quality

the

isthesis
the

stool

or raising

evaluation.

Of

20

on a small

by lowering

cases

of angular

ventrally.

are
hands

1 -Determination

by superimposition
of radiographs
in flexion and extension.
Images of L5 are
superimposed,
and line is drawn along edge of upper film on lower film.
Similar line drawn after superimposition
of images
of Si . Angle between
lines
is angular
excursion
between
L5-S1 . Angular
excursions
between
other

of the arch
(at
and its direction

magnification

of the

below)

the

the site
determined

factor

body

of the

movement
of

the
(no

of about

spondylolisthetic

of the anterosu-

lysis)
is measured
correction
is made

1.35).

with

After

in
for

AJR: 134, February

INSTABILITY

1980

IN LUMBAR

SPONDYLOLISTHESIS

295

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13#{176}(6-20)

14#{176}(7-20)

16#{176}(8-21)
Fig. 2.-Determination
of axis of movement
by Euler principle.
Movement
diagram.
Lower
vertebra
(51)
presumed
to be fixed;
upper
vertebra
(L5)
depicted
in position
of flexion
and extension
with respect
to lower
vertebra.
Identical
points
of upper
vertebra
(a and a, b and b, c and c, etc.)
are
connected
and perpendiculars
erected
at midpoints
aa, bb , and cc , intersection
of perpendiculars
being
axis of movement.

Fig.
Average

4.-Site
mobitity

of axis of movement
and its spread
given

Fig.
vertebral

5.-Movement
body
(A)

in
for

normal
discs
each segment.

in

same

subtects.

22#{176}

15T2-#{176})

17#{176}(6-28)

A
Fig.

3.-Site

L3-L4,

of axis

of movement

one case; L4-L5,

at disc

below

four cases, and L5-S1,

spondylolytic

vertebra.

19 cases. A, Axes with

Spondylolisthesis
itself,
in illustration.
B, Same
below spondylolisthesis.

respect
to caudal
endplates
of slipped
vertebra.
varying
in grade from case to case, is not indicated
axes with respect
to cranial
endplates
of vertebra
Average
mobility
and its spread given for each segment.

direction

Results
The average
of movement

range of movement
for flexion-extension

spondylolisthetic

presents

the

material

(L3-L4,

vertebrae

same

data

L4-L5,

are

and location
of the axes
in the discs below the
given

for the normal

and

L5-S1).

in figure

discs
All discs

3. Figure

in the

same

of undimin-

ished

and

of movement.

height

vertebra
measured
5 at L5-Si.

not

have
normal

of separated
arch
with
body
of vertebra
below
Dotted

outline:

located
been
discs

extension

directly

listed
were

as

respect
to
(B). Arrows
(1);

below

normal.

22 at L3-L4,

solid

corresponding
indicate
main

outline:

flexion

(2)

a spondylolisthetic

The

number

20 at L4-L5,

of
and

PENNING

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296

AND

AJR: 134, February,

BLICKMAN

1980

Fig. 6.-Spondylolisthetic
lumbosacral spine in flexion
(A) and extension
(B).
1 = axis of movement
L4-L5;
2 = axis
of movement
L5-S1
: 3 = projection
of
joint space
of intervertebral
joint L4-L5;
4 = projection
of joint space
of intervertebral joint L5-S1 : 5 = defect
at interarticular
part; 6 = flaval ligament
L4-L5;
7 = flaval ligament
L5-S1.

Movement

between

vertebra
(fig.
case it could
was

absent

took

place

arch

with

body

and arch

5) averaged
not reliably
(table

1 ). Movement

in caudal

respect

(from

or ventral

3-12
mm).
in another
extension

In one
case it

to flexion)

direction.

Movement

below

was always

to the vertebra

and

of the spondylolisthetic

6 mm (range,
be determined;

of the

present

and averaged
12 mm (range,
2-18
mm). It invariably
place
(from extension
to flexion)
in the cranial
direction.

L5 is less

ensure

arches

stability

of L4 and

lntra-

51 . Our

and

Intervertebral

Stability
of the lumbar
spine as a whole
is maintained
by
the cooperation
of discs,
joints,
and ligaments.
According
to Spalteholz
and Spanner
[1 3], the intervertebral
discs
determine
vertebrae,

the extent
of possible
movements
between
the
the intervertebral
joints
the direction
of these

movements.

The

slipping
The

flaval

tebrae

force
together

Stability

ample

of

the

of

arch,

articular

element.
with

of L5,

has

become

L5-S1

(fig.

of

vertebral
them

processes

as one
and

arches

pressing

between

ligaments

between

shown

arch

with

narrowing

may

be regarded

as the

and

in turn

of the

lumbar

interarticular
on

the
the

will
spine

portions
bodies

vertebral

bodies

L4-

of L5.

vertebral

body

respect

and

L5-S1

often

plane,
and averages
flaval
ligaments
on

as their

joints

movement

combined

bone

, its move-

intervertebral

this

to the

as a linking

L5-

is always
with

some

in
rota-

1 2 mm (fig. 5). The

the spondylolisthetic

lateral

(capsular)

portions

stability

of the

spondylolisthetic

stressed

in the

specimens,
parts
of

of cases
is

of the

worth

disc

of patients

common

in

body

It has

model

been

of template

mentioning

that Jonck

noted
complete
disappearance
the flaval
ligaments
in a large

in which

in our series

vertebral
literature.

narrowing

and

clinically

was

found.

As

the literature

[3],

disc

manifest

spondolylis-

thesis.

Axes

of Movement

at Normal

and

Spondylolisthetic

Levels

as a
of the

L5 and

intervertebral

L4-L5

show

insufficiently

percentage

as the
1 , movements
of

joints

the body

of L5 with

functions

by the (normal)

is minimal

[1 5], in autopsy
of the capsular

and

process

arch

accounted
for in the construction
Al . In this context
it is perhaps

body
and

body

been

between
element,

the vertebral

dependent

in the ex-

instability

stability

of the

ver-

with

have only insignificant

attachments,
via the capsular
ligaments
L4-L5,
to the laterally
situated
superior
articular
processes
of L5. The defective
role of the flaval
ligaments

interarticular

(table

body)

intravertebral

(L5

vertebral

has
a

of the arch

direction,

tion in the sagittal

influence
of the

in ensuring

exert
the

or caudal

in the

spinous

movements

Stability

elasticity,

vertebra

processes

mainly

high

by the lysis

to vertebral

anterior
neighbour.

aligned.

movement

stability
6).

their

allowing

affect
the intervertebral
whole.
Due to the separation
arch

to

keeping

These

respect

manifestation

due

in preventing
to its caudal

spondylolisthetic

articular

inferior

respect

6) is diminished

its

superior

essential

with

on the
and

of fig.

part

arch

are

ligaments,

contracting

other

joints

of a vertebra

intervertebral

of a spondylolytic

measurements

cranial

Instability

the

relationship

Si . The

between
the flaval
ment being directed

Discussion

because

only
occurs
with
regard
to the caudal
vertebra
(in our
example
Si ), and not with regard
to the cranial
vertebra.
The flaval ligaments
[1 4], especially
their medial
(laminar)

parts,

took

affected

normal
bony
why slipping

L5 maintain
This explains

Si
disc
L4

In the normal stable

brae occurs
according
location

of axes

acterized

by abnormal

by local

and

spine, movement
between
to a fixed pattern,
best
degree

deviation

location

of mobility.
from

or behavior

this

Instability
pattern,

of axes

the vertedefined
by
is char-

as evidenced

and/or

excessive

AJR:

134.

mobility.

February

1980

Normal

movement

has been

INSTABILITY

IN LUMBAR

comprehensively

stud-

297

SPONDYLOLISTHESIS

ied by anatomists
flexion-extension

[1 3, 1 6, 1 7]. They located

the axes of
movement
between
the lumbar vertebrae
the centres
of the intervertebral
discs. Our radio-

in or near

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logic

determinations

in normal

discs

of axes
(fig.

4) are

of flexion-ftxtension
in agreement

movement

with

the findings

of

these anatomists.
The number
of measured
normal discs
L5-Si
is small; however,
there is no reason to assume that
this disc should behave differently.
Whereas
instability
in spondylolisthesis
could reveal itself
by abnormal
location
of axes of movement,
our measurements demonstrate
only that the axes of movement
in the
discs below a spondylolisthetic
vertebra
show a somewhat
larger
spread
than normal
(fig. 3). Regarding
the significance of this larger spread,
the work of Rolander
[1 8] is
important.
In comparing
the axes of movement
C centers
of

motion

of normal

specimens,
the

and degenerated

he found

latter.

In his

interpreted

as

placement

lumbar

a significantly

opinion,

this

indicating

larger
larger

instability

in any of the stages

of movement

an abnormal

ment

without

such.
The

larger

comparable
explained

dylolytic
that

shift

spread

deformation

and

stability

It may
directing

of the

found

effect
has

accordance

in the

that,

of the intervertebral

below

movement

finding.

a shift

surprising
the

largely

the

Obviously
is not to guide

joints

may be
a spon-

of

disc

the

location

The

axis.

absence

of a

on the movements
vertebra,

unchanged.

the
This

Rolander

type

with

disc

around
the intervertebral
discs,
with a distribution
comparable to that found
by us in spondylolisthesis.
From a representative

of

also

is in

endplates
pearance

[1 8],

who

result

joints did not appreof movement

in his

the main function

of the intervertebral
the movement,
but to prevent
forward

Instability

by Knutsson

(c).

disc

instability

[4] in a paper

degeneration.

dealing

was

introduced

with instability

In flexion-extension

mal vertebral
movements
were noted and
results
of loss of stability.
The abnormal

in 1944

associated

studies,
interpreted

abnoras the

movements
conof vertebrae
as evidenced

sisted of parallel
displacement
from backward
displacement
( retroposition
) in extension,
disappearing
partially
or entirely
in flexion.
Backward
displacement
thus constituted
a temporary
position
and consequently
was considered
a manifestation
of instability.
On reconstruction
of the axes of movement
in the illustrations
of the paper [4], they were found to be located
in or

case

(fig.

7),

change
their
of backward
of

abnormal

movement

axis.

suIts

were

with

instability

it is evident

angle
during
displacement

parallel

which,

excentric

[1, 3,
The
ment

designation

(A) has
determiassesswere at

slipping.

Disc

Fig. 7.-Ostensible
parallel
movement
from extension
to flexion
normal
placement
of axis of movement
(1 in B). This illustrates
that
nation
of axis is more reliable
method
to judge
movement
than visual
ment.
Parallel
displacement
would
occur
only if axis of movement
(2)
infinity

below

of the

the

joints

of

by compensatory
of movement
and

despite

experiments

is

This
below

be speculated

that excision
of the intervertebral
change
the location
of axes

specimens.

as

It could

spondylolisthetic

remained

with

of move-

stability

in spondylolisthesis

degeneration

despite

dis-

exceeded

axis

and

vertebra
is accompanied
ensure
a normal
type

seem

disc

noted
ciably

location

of axes

\,,

be

2 mm) as was found

obviously
may bring

of movement

is a regular

spondylolisthetic
alterations
that

of the

type

never

in

not

parallel

to that found
in disc degeneration.
by the fact that disc degeneration

vertebra

lasting

in the

affecting

of axes

could

because

small

about

in autopsy

spread

spread

range of 1 mm (exceptionally
in normal
discs.
Disc degeneration

the

discs

gliding,

however,
Similar

made

but

takes

in disc

with

illustrations

in other

degeneration

and

imprecision
subluxation

comparable
papers

redealing

spondylolysthesis

in literature
regarding
vertebral
) and instability,
in our opinion,
discrimination
relationship,

and forward
displacement
essarily
imply abnormal
investigations

indicate

has

been

type

of movement
6)

determination
judgement
sequently

preserved.

easily

type

gives
of the

normal
visual

, the changes

(e.g.

whether
instability,

that

rise
axis

to erroneous
of

movement

or not abnormal
is present.

as

anatomic
relationin disc degeneration

in spondylolisthesis,
of movement.

However,

displaceis partly

between
displacement
and displacement

abnormal
type of movement.
Abnormal
ships such as backward
displacement

fig.

vertebral
The disapis not the

71.

related
to insufficient
as abnormal
anatomic

our

the

a normal
type of
around
a slightly

of

place

reconstructions

from

that

movement.
in flexion

do not necOn the contrary,

movement

as a rule

assessment
in alignment

of

interpretation.
will
movement,

allow

the

L5-Sl

in
Only

reliable
and

con-

298

PENNING

AND

BLICKMAN

AJR:

Fig. 8.-Same
in fig.

6, not

February,

1980

lumbosacral

spine

in flexion-extension,

back-and-forth

Downloaded from www.ajronline.org by 114.125.60.251 on 06/20/15 from IP address 114.125.60.251. Copyright ARRS. For personal use only; all rights reserved

134,

movement
Numbers

as

but

in

of L4 with reindicate
same

spect
to Si .
structures
as in fig. 6. Despite
absence
of much
movement
of arches
and flaval
ligaments,
marked
wobbling
of body
of L5 is evident.
Relationships
in intervertebral
joints
L4-L5
(3) and L5-S1
(4)
remain
normal.
Arch
of L5 positioned
about

51

may
from

Several
authors
[2, 7] discussing
instability
report
on
positive
correlation
with complaints
of low back pain. In our
opinion,
the abnormal
vertebral
relationship
itself,
being
more pronounced
in certain
extreme
positions
of the spine,
with

bony

intervertebral

Myelography

as

before

[5,

phlebography

surgery

It may

[201

be argued

that

not determined
by repeating

patient,

but

is a good
limited

believe

extension

22]

have

in

axis
whole.
motion,

into

than

are

metry,

enough
[4] and

the

more

from

midposition

cineradiography,

exposures
reliable.
Perhaps
grammetry

is that
make

smaller

determination

A satisfactory
solution
the best perspectives
[24],

but

this

method

to

and

the

more

by one fixed

anas

center

its place

of
from

type of movement.
stereophotogram-

of

movement

of

axes

insertion

positions

or

does

not

[24]

described

motion

in daily

under
that for certain

et al. [22] observed

the vertebrae
did

clockwise
sense,
but wobbled
[1 8] noted
flexion
of the upper
lumbar
spine
during
longitudinal
Selvik

are chosen,

flexion-extension

rich variety
of movements
made
noted paradoxical
movements
Hoag
motion

It
if

not

move

back

and

in

extension
loading
of

of the

and forth.

spine

of
his

as that

positions.

the supine
instability

Back-and-Forth

and
merit

erect
standing
consideration.

These

Instability

As our studies
idea was
the basis

two
less

of tan-

had been

limited

to flexion-extension,

the

developed
to use a schematic
drawing
(fig. 6) as
for a model
for additional
motion
studies
in the

sagittal
plane.
The model (fig. Al is a template
for construction of such a model)
allows
all kind of movements
around
the axes of movement
as determined
by us. Figure
8 shows
one of the possible
movements
of the model
in which
L4 is
the discs

for this problem

is difficult.
are opened
by stereophotorequires

of flexion-extentest of instability.
will occur
only

example,
types of

displaced

of movement

conditions.
of spinal

other

Simple

only

mobile
segments
extension
in, for

with

between

method

can

of an unstable
pile of blocks,
the different
showing
different
modes
of flexion
and

abnormal
of the latter

studies
such

the

[25],

made.

of L4 and

consequently

applied

loads are
movements

arches

flexion
to a more
anterior
shift seems
to be made
by
Instability
might
consist
of

flexion-extension

ranges

flexion

disc,

to extension

shifting

more complex
methods,
like
or

from

in the

flexion

of movement

aberrations
of this
by sophisticated

[1 8, 21,

to extension

from

thus is not directed

by an axis

flexion

authors

of movement
posteriorly

and

extra
other

continuous
Rolander
the lower

reliability

between

in the vertebrae

used here is a suitable

that abnormal
movement

specimen.

within

However,

positions

out
We

between

sion radiography
is conceivable

special
cases

there

axes

indicators

be used postoperatively.
Another
question
is whether

fully represent
the
life. Several
authors

our measurein the same

of

Several

the axis

to rule
others.

because

discs.

other

consideration.

that

of
studies

many
positions
in-between
the extremes,
movements
could
be detected.
A disadvantage
method

methods
pathology

representative

a more
posterior
position
in
position
in extension.
A similar
the nucleus
pulposus
[4, 23J.
discrete
Perhaps

and
this

of flexion-extension

in location

in movement

Movement

method

around

is located

but

contrast

is not sensitive
by Knutsson

by taking

of movement

teriorly,

demonstrate

the

they

and

shown

midposition

should

agreement

be enhanced

and

other

the reproducibility
flexion-extension

overall

area

could

1 9] and

canal
for

is undertaken.

radiography
that we used
disc instability
as defined
have
ments

contents
of spinal
very
well account

on

foramina,

correlation.
such

the
could

impingement

talum

halfway

This, and other types of movements,

be reproduced
with model made
template
in fig. Al.

located
respect
L4-L5
by flexion
movement,
resisting

parallel
L4-L5
axes

to Si
and

. In this

L5-Si

of movement.

takes

displacement,
place around

Forward

displacement

movement
in
the normally
of L4 with

to Si in the way shown

is attended
by extension
at
and flexion
at L5-Si
, backward
displacement
of L4
at L4-L5

and

extension

although
possible,
elasticity
of the flaval

at L5-Si
is very
ligaments.

. Normally

limited
For

due to
instance,

such
the
as

AJR: 134, February

INSTABILITY

IN

LUMBAR

of angles

very

be related

unequal

tensions

mobility

vertebral

in the flaval

of the

body

in

ligaments.

posterior

arch

However,

with

spondylolisthesis,

respect

tensions

in

due

ligaments
are more equally
distributed
with the spinous
process
remaining
about halfway between the spinous processes of L4 and Si , both in forward
and backward
movement of L4 with respect to Si . The normal faculty
of parallel
displacement
of vertebrae
situated
two or more segments
apart (clearly
to be differentiated
from parallel displacement
between

bordering

vertebrae,

which

is definitely

to

Larger
of the

1 .

level

flaval

of movement,

determination

and construction
of a theoretical
movement
in the saggital
plane

to the
the

299

SPONDYLOLISTHESIS

soon as L4 moves forward

with respect
to Si , the spinous
process
of L5 approaches
that of L4; but the distance
with
respect
to the spinous
process
Si is increased,
leading
to
to the

Downloaded from www.ajronline.org by 114.125.60.251 on 06/20/15 from IP address 114.125.60.251. Copyright ARRS. For personal use only; all rights reserved

1980

resent

instability of the

than normal
spondylolisthesis

a special

form

spread
of

axes in spondylolisthesis
disc

of axes

spine.

of axes of movement
occurs,
but is unlikely

instability.

The

is probably

related

Parallel

parallel

movement

of adjoining

ment
3.

displacement

is only

ostensible;

thesis

logic

studies

this

type

will

intervertebral

be necessary

of instability

and

joints.

Further

to determine

to assess

radio-

the extent

its clinical

by Excessive

Another

4.

significance.

hypermobility

of the disc

In our

material,

thesis

of

L5

was

discs L5-Si
, it
too small to have
of large individual
normal
range
definitely
called

below

average

of L5-Si

vertebra.

In the

five

normal

difficulty
(below

we compared
a spondylolisthetic

the

mobility

of at least

affected
six

10

more.

segment

cases,

less.

cases

Local

cases;

was

average

less
mobility

hypermobility

mobility

in

one-third

exceeded
average
mobility
cases
mobility
was
less.

hypermobility
spondylolisthetic

the

affected

segment

In 1 2 cases
than

1 0#{176}
more.

in the
thus
of

In the

affected

was
these

by at least
These
data

had

the mobility

Hadley

found
(25%

of

the

disc

below

Jackson

AM, Kirwan
the

finding
of the

in spondylolisslipped

disc.

studies

of the

spine.

RJ, Luekens CA. Standing

Clin Orthop 1 976;1 1 7:

subluxation.

6.

Dandy

DJ,

9.
1 0.

a
11.

1 2.

the
1 3.

MJ.

PH.

Joint

severe

:472(group

53 : 578-595

of lumbar

J Bone

pain.

lum-

1965;47

subluxation

instability

back

with

(Br]

Surg (Br] 1971

The

etiology

vertebrae

as

Surg

(Br]

Joint

J Bone

of spondylolisthesis.

Joint

: 39-59

I. An atlas of anatomy
1975: 552

basic

to radiology.

Philadel-

HW.
Spondylolisthesis.
Surg
Gynecol
Obstet
1932;54 :371-377
Begg AC, Falconer
MA. Plain radiography
in intraspinal
protrusion of lumbar intervertebral
discs: a correlation
with operative
findings.
BrJSurg
1949;36:225-239
Olsson TH, Selvik G, Willner S. Vertebral
motion in spondylolisthesis.
Acta Radio! [Diagn](Stockh)
1976;i 7 : 861 -868
Spalteholz
W, Spanner
R. Handatlas
und Lehrbuch
der AnaMeyerding

des

Menschen,

1 5th

Nachemson

A, Evans

third

lumbar

human

Jonck
disc

ed.

Amsterdam:

Scheltema

& Hol-

1953:70

1967;1

JBiomech

Conclusions

Lumbosacral

Primary
low

Surg

Saunders,

tomie

1 5.

TH.
of

(Br] 1963;45

kema,
14.

King

associated

Joint

:6-22

Meschan
phia:

syndrome

J Bone

cause

Spine

J Bone

Shannon

FP,

Newman
Surg

the

A clinical

spondylolisthesis).
Morgan

MF. Lytic spondylolisthesis

1978;3 : 260-266
associated
with disk degeneration
Radio! (Stockh)
1944;25
: 593-609

level.

PH.

1957;39

total)

EO, Sullivan

lumbosacral

bosacral
481

1 0#{176}.
In only 25% of
indicate
that
local

of the lumbar
spine at the
vertebra
is common.

as demform
of

1964:416-417

Newman

8.

was
of

Thomas,

5.

remaining

in 75%

of move-

vertebra,
a special

LA. Anatomico-roentgenographic

common

in the

segment

universal

Knutsson
F. The instability
in the lumbar spine. Acta

0;

in six

not

by hypermobility

4.

7,

vertebra)
segments
in the same lumbar spine. The average
mobility
in discs below a spondylolisthetic
vertebra
is larger
than in the other two discs measured
(table 1 ). In normal
discs,
mobility
never exceeded
21
in spondylolisthetic
segments,
mobility
between
21 #{176}and 28#{176}
was found in eight
cases. If the mobility of the abnormal
disc is compared
with
the average
mobility
of the two other normal discs in each
case,

above

0)

this
abnormal

axes

the

80-84

3.

1 5#{176}
(range,
8#{176}-2i
This number
is
statistical
significance.
Moreover,
because
variations,
Tanz [26] failed to obtain a
of mobility
from which deviations
could be
abnormal.
was

individual

but

is instability

2. Lowe RW, Hayes TD, Kaye J, Bagg

roentgenograms
in spondylolisthesis.

in spondylolis-

60_300).

could
opinion,

REFERENCES

is local

a spondylolisthetic

mobility

1 8#{176}
(range,

In order
to overcome
mobility
of normal
and

A common

Springfield:

that must be considered

considered

instability,
In our

of

Mobility

form of instability

of

instability.

Instability

spread

are situated
in or around
their normal
sites.
The increased
faculty
for back and forth
movements

normal

of the

at the
to rep-

to the attendant

vertebrae,

of the spine
above
the spondylolisthetic
onstrated
in the model,
is considered

function

larger

by Knutsson
[4] as the primary
sign of disc
not be demonstrated
in spondylolisthesis.

thus may be greatly increased

in the spondylolisthetic
spine
due to the intravertebral
instability
at the interarticular
portions.
Although
not an instability
in the usual sense, it
may be considered
as a form of abnormal
mobility
putting
extra stresses
on the discs, especially
the disc below the
spondylolisthetic
vertebra,
which
is not protected
by the

all types
of
that may

degeneration.

2.

abnormal)

of movement,

model
allowing
offers observations

LM.
space

The

JH.

Some

interlaminar

mechanical

properties

ligament

of the

(ligamentum

flavum).

:211-220

mechanical

narrowing.

disturbances
J Bone

Joint

resulting
Surg

(Br]

from

1961

lumbar

43 : 362-

375

Radiologic
lumbar spine

assessment
of flexion-extension
in spondylolisthesis
by means

studies of the
of measurement

1 6.

Fick
lenke.

R.

Handbuch

Jena:

Gustav

der

Anatomie

Fischer,

1904

und

der

Mechanik

der

Ge-

300

1 7.
1 8.

PENNING

Strasser

H. Lehrbuch

Springer,

1913

Rolander

SC.

der

Muske!

und

Ge!enkmechanik.

Downloaded from www.ajronline.org by 114.125.60.251 on 06/20/15 from IP address 114.125.60.251. Copyright ARRS. For personal use only; all rights reserved

20.
21.

Laasonen

Berlin:

BLICKMAN

22.

Hoag
fication

Motion

of the lumbar

spine

with

special

to the stabilizing
effect of posterior
fusion.
study
on autopsy
specimens.
Acta
Orthop
1966;90 :1-127
19.

AND

EM,

EhrstrOm

J. Myelography

reference

An experimental
Scand

in lumbar

23.

(suppl]

vertebrae

back

pain. AJR

in normal

1944;52

individuals

:261-268

and

in patients

surface

JM, Kosek

with

low

25.
26.

M, Moser

of vertebral

JS,

Hampson

strain

(Br] 1978;6O

24.

spondylo-

listhesis.
Acta Radio!
(Diagn]
(Stockh)
1 978; 1 9 : 889-896
Th#{233}ronJ, Moret J. Spinal phlebography.
Lumbar
and cervical
techniques.
Berlin: Springer,
1978:81
-91
Gianturco
C. A roentgen
analysis
of the motion
of the lower
lumbar

986
Shah

AJR:

in the

motion.

WGJ,
cadaveric

134,

February,

1980

JR. Kinematic
analysis
and classiJAQA 1960;59
: 899-908,
982Jayson
lumbar

MIV.
spine.

The distribution
of
J Bone Joint Surg

:246-251
Selvik G. A roentgen
stereophotogrammetric
method for the
study of the kinematics
of the skeletal
system (thesis).
Lund:
AV-centralen,
1974
Wiltse LL, Hutchinson
RH. Surgical
treatment
of spondylolisthesis. Clin Orthop 1964;35:
116-135
Tanz SS. Motion of the lumbar spine. A roentgenologic study.
AJR 1953;69
:399-412

134,

February

Downloaded from www.ajronline.org by 114.125.60.251 on 06/20/15 from IP address 114.125.60.251. Copyright ARRS. For personal use only; all rights reserved

AJR:

INSTABILITY

1980

IN LUMBAR

SPONDYLOLISTHESIS

301

#{149}1

/
/
/
/
I

I
/
I
/
/
/
/
I

.rt/

S.

S.

.,
.0

Fig.

51

Al

After

of axes
insertion

-Template

template

for

movable

has been affixed

spondylolisthetic

to cardboard

(indicated
by numbers
1 for L4-L5
and
of elastic
bands
representing
flaval

lumbosacral

or transparent

spine:

plastic,

lateral

vertebrae

projections

of

L4,

L5

are cut out and made

2 for L5-Sl),
perforating
them,
and inserting
pin.
ligaments
(3-3
for L4-L5
and 4-4
for L5-Sl).

(body

and

to articulate

separated

arch),

and

by superimposition

Perforation
of holes in arches
allows
By inserting
pin through
holes
5,

intravertebral
instability
of L5 due to separated
arch is abolished;
parallel movements
between
L4 and 51 (fig. 8) then meet with much
greater resistance.
Insertion
of pin through
holes 6 imitates spondylodesis
anterior
L5-Sl
; movements
between
bodies
of L5 and 51
are abolished,
but movements
between
arches L5 and 51 are still possible.
Figure
6 may help in the construction.
An imperfection
in the model is that. for reasons of construction,
axis of movement
L5-S1
has been taken as axis of movement
for
arch of L5. Movement
of arch in spondylolisthesis
is determined
by flaval ligaments
and intervertebral
joints
L5-S1
. but not by disc
L5-S1 . In practice,
no circumscribed
location
of axis for movement
of arch, with respect to body of L5 or Si . could be found.