Spondylolisthesis

Spondylolisthesis
Definition
The term "Spondylolisthesis" refers to a condition where one of the vertebrae (usually L5) becomes misaligned anteriorly (slips forward) in relation to the vertebra below. This forward slippage is caused by a problem or defect within the pars interarticularis. Occasionally, facet joint and/or posterior neural arch defects may also cause this syndrome as well. The forward slippage does NOT always occur. This nonslipped pars defect is called a "Spondylolysis" and is almost always a precursor to the actual forward slippage.

Spondylolisthesis

Spondylolisthesis

Developmental anatomy
 The first theory proposed a failure of ossification during embryonic development, leading to a pars interarticularis defect at birth  The second theory demonstrated that the pars defect began to appear around age six and became progressively more common till age 16. After age 16, the incidence fell and rarely developed after adolescence  It is currently thought that the defect develops from small stress fractures that fail to heal and form a chronic nonunion.

Classification
Dysplastic spondylolisthesis  Isthmic spondylolisthesis
DEGENERATIVE SPONDYLOLISTHESIS TRAUMATIC SPONDYLOLISTHESIS PATHOLOGICAL SPONDYLOLISTHESIS  IATROGENIC SPONDYLOLISTHESIS

Dysplastic spondylolisthesis
 Is a true congenital spondylolisthesis that occurs because of malformation of the lumbosacral junction with small, incompetent facet joints.  Very rare, but tends to progress rapidly  Often associated with more severe neurological deficits.

Isthmic spondylolisthesis
SUB-TYPE A:

Is the most commonly found type of spondylolisthesis in people under 50 years of age. It is believed that "biomechanical stress," such as repetitive mechanical strain from heavy work or sports, causes a fatigue fracture within the pars interarticularis.

Isthmic spondylolisthesis
SUB-TYPE B:
This type of Isthmic spondylolisthesis is characterized by a elongated pars without separation. It is believed that the elongation occurs secondary to "repeated, minor trabecular stress fractures of the pars." Each time these possible sub-acute stress fractures occur and heal, the vertebral body is displaced farther and farther forward. Eventually, the pars may fail to heal and result as a full pars defect.

SUB-TYPE C:
These types of spondylolisthesis' are extremely rare and result from an acute pars fracture, often as result of traumatic lumbar hyperextension injury

DEGENERATIVE SPONDYLOLISTHESIS
o This is the most common form of spondylolisthesis in patients over 50 years of age and rarely occurs in those under 50 o There is no fracture or elongation of the pars interarticularis and the neural arch is intact. In contrast, patients with isthmic spondyolisthesis almost universally have widening of the central spinal canal at the level of the slip. This narrowing of the canal in degenerative spondylolisthesis has been termed the "napkin ring effect.

DEGENERATIVE SPONDYLOLISTHESIS
The classic symptomology of patients with symptomatic degenerative spondylolisthesis are similar to those with symptomatic lumbar spinal stenosis; which can be either neurogenic claudication or radiculopathy (either unilateral or bilateral radiculopathy) with or without low back pain. Neurogenic claudication is thought to result from central canal narrowing that is exacerbated by the listhesis (forward slip). The classic symptoms of neurogenic claudication are bilateral (both legs) posterior leg pain that worsens with activity, but is relieved by sitting or forward bending.

TRAUMATIC SPONDYLOLISTHESIS  This type of spondylolisthesis, which is extremely rare, results from a traumatically-induced fracture to the neural arch other than the pars region.  One of the examples is The "Hangman's Fracture" in the cervical spine's second vertebra (Axis) is a common and often deadly example of such a traumatically induced phenomenon. This type of fracture is extremely rare in the lumbar spine.

PATHOLOGICAL SPONDYLOLISTHESIS

Generalized or systemic disorders of bone may affect the neural arch of the spine and allow spondylolysis or spondylolisthesis to occur.
Osteoperosis Paget's disease Metastatic carcinoma

IATROGENIC SPONDYLOLISTHESIS
:  Is a complication of lumbar anterior interbody fusion (LAIF. Either the vertebrae above o below develops a pars fracture.  Laminectomy procedures will result in an overload of weight-bearing stress on the contralateral pars and, in some patients, result in a pars fracture.

symptoms
 Spondylolysis commonly is asymptomatic.  Symptomatic patients often have pain with extension and/or rotation of the lumbar spine.  Common nerve symptoms

symptoms
Leg pain Electric shock-like symptoms traveling down the leg Numbness or tingling in the legs and feet Muscle weakness of the legs Other symptoms can occur. bowel or bladder dysfunction, or any numbness around the genitals, These symptoms may be a sign of cauda equina syndrome.

Limitations of Techniques
Radiography of the lumbar spine is limited by its inability to detect stress reactions in the pars interarticularis that have not progressed to complete fracture. CT of the lumbar spine is not sensitive for detecting early acute stress reactions in the pars interarticularis where there is only marrow edema and microtrabecular fracture. MRI of the lumbar spine can easily identify acute stress reactions in the pars interarticularis. However, direct identification of pars defects (old stress) may be slightly more difficult with MRI than with CT. BONE SCAN : easily identifies acute stress reaction in the pars interarticularis, but cannot identify old pars defect.

Treatment
o If the slip is small and the symptoms are manageable, then treatment is most often with observation. In children, this may include activity restrictions, such as withholding the child from participation in some sports. o When the slip is more significant, there may be a higher risk of the problem progressing, and surgery may be favored. In addition, patients who have symptoms of nerve compression are more likely to have surgery recommended.

Classification of slip
Slip in Spondylolisthesis is measured by measuring the anterior slip of vertebral body. Meyerding classified the slip into 4 grades: Grade 1- slip from 0-25% upto 1/4 length Grade 2- slip from 25-50% upto 1/2 length Grade 3- slip from 50-75% upto 3/4 length Grade 4- slip more than 75%

 Percent slip= The displacement of L5 over S1/Width of S1

Spondylolisthesis Treatment
Treatment is given according to the grades of the slip. Grade 1 and 2 can be managed conservatively, while grade 3 and 4 require surgical intervention. Spondylolisthesis Treatment is given with the aim to achieve maximum correction of the exaggerated lordosis and then maintain the correction.

Exercises to correct the deformity Exercises to induce relaxation are given Strong abdominal exercises are given for abdominal muscles Flexion exercises for the spine, for example: sitting on a chair with back resting, then gradually bending the trunk forward from the lumbar region

 Active posterior tilting is taught to the patient to compensate the exaggerated lumbar lordosis. 3.The patient is given guidelines for correction of posture and its maintenance. 4.Stretching of hamstrings is done at regular intervals.

 5.Patient is adviced to lie prone to control the advancement of lordosis. 6.A thoraco-lumbar-sacral orthoses is given to prevent the lordosis. The brace has to be worn continuously.

 spondylolisthesis surgery is indicated when there are neurological symptoms, slip is progressing or if the pain is very intense. Spinal fusion is done with or without the reduction of slip, postero-lateral fusion is very common. Spinal fusion prevents further progression of the slip. The spine may be internally stabilized with the help of rods and plates.

Physiotherapy Management after Surgery

During Immobilization Deep breathing exercises Early ankle, foot and arm movements are also encouraged Assisted movements to knee joints are given Isometric exercises of gluteal muscles Gradually hip flexion is encouraged, but it should not exceed 60 degrees.

Spondylolisthesis

Spondylolisthesis

Spondylolisthesis