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Thursday, January 7, 2016

Spondylolisthesis surgery management

Asalamualaikum, For entry today i would like to share some info reagarding one of the common problem that always happen on human , its call spondylolisthesis

Spondylitis: Inflammation of the spine. ie Ankylosing spondylitis.

Spondylosis: Degenerative changes in spine leading to osteophyte formation and disc space narrowing.  Most people over 40 have a degree of spondylosis but are symptom free.

Spondylolysis: “Broken vertebra”.  Fracture often occurs at the pars interarticularis  

Subluxation (dislocation) of one of the vertebral bodies with respect to the vertebral body above or below it. 
·         Frequently associated with a break in the pars interarticularis.
·         Most commonly L5-S1.
·         Graded according to the amount of dislocation on scale from 1 to 4.
·         Symptoms: Pain, loss of sensation, weakness in the legs due to narrowing of the vertebral foramen and nerve root compression

·         Lateral x-rays are taken in standing to accentuate slippage.
·         If defect is large, it is seen on nearly all x-rays of lumbar spine.
·         Diagnosis will be missed in 20 % of young symptomatic patients if oblique radiographs are not made.

·         Scotty-dog sign of Lachapele, with defect appearing as a collar around the dog's neck is seen.
·         Acute injury: Gap is narrow with irregular edges.
·         Chronic lesion: Edges are smooth & rounded, suggesting a pseudarthrosis. 

Slip angle
·         Slip angle is measured by drawing a line perpendicular to line drawn along posterior aspect of S1 and a line parallel to inferior end plate of L5.
·         As slip progresses, leads to ‘Sagittal rotation’.
·         Common in pts who have a 50% slip.
·         Always present in pts with a 75% slip.

Congenital insufficiency of facet joints (of S1 or L5).
Gradual attenuation of the pars interarticularis.
L5 facets appear to subluxate ventrally on the sacral facets.
Pts more prone to recurrent symptoms and clinical deformity

Most common type seen in children & young adults.
Occurs in about 5% of the population.
Results from shear stress at pars intra-articularis, and is more common in repetitive hyperextension activities.
Often occurs as a result of degenerative disc disease and facet deficiency.
Often associated with intersegmental instability and central stenosis.
Involves L4-L5 level more often than the L5/S1 level.

Unusual but can be due to an acute traumatic fracture.  Mostly seen in high impact RTAs.

Tumors and osteoporosis can weaken the pars interarticularis enough to cause slippage.


Grade I/Spondylolysis.
·         < 25% slip.
·         Rarely symptomatic.
·         Neurologic lesions are uncommon.
·         Usually no pain on flexion.
·         Hamstrings minimally tight.
·         Pain usually quite localized unilaterally & exacerbated by hyperextension.

Grade II
·         25-50% slip.
·         Significant in younger children (ages 6 to 12), as it is highly likely to progress during the remaining growth years.
·         In a mature adolescent the risk of progression is far less.

Grade III + IV
·         High degree of lumbosacral kyphosis.
·         Prophylactic fusion in children & adolescents with slippage > 50% is recommended.
·         With spondylolisthesis, treatment consists of bilateral arthrodesis from L4 to S1 including transverse processes of L4.

·         The most common surgical procedure, if conservative treatment is ineffective, is spinal fusion combined with decompression of the neural elements.
·         All fusion surgeries involve the use of bone graft and can include instrumentation (medical devices to fix adjacent vertebrae) such as pedicle screws and interbody cages.
·         Most common surgeries used are:
·         Anterior Lumbar Interbody Fusion (ALIF)
·         Transforiminal Interbody Fusion (TLIF)
·         Posterolateral Fusion (PLF)
·         Posterior Lumbar Interbody Fusion (PLIF)

·         Extraperitoneal approach through an oblique abdominal skin incision.
·         Total discectomy, complete removal of the cartilaginous plates, and bone grafts impacted as firmly as possible after the intervertebral disk spaces were spread open.
·         Supraspinous ligament removed, followed by minimal resurfacing of adjacent margins of the spinous processes and a ceramic interspinous block (CISB) is firmly inserted into the interspinous space using an impactor.

·         Decompression performed, pedicle screws placed, and discectomy carried out.
·         Cartilaginous endplates removed. IVD space is distracted and packed with bone graft. Interbody fusion cages are then positioned.
·         The pedicle screws are attached to the rod and the construct is compressed, restoring lumbar lordosis.
·         22 pts with Grade I or II spondylolisthesis underwent transforaminal lumbar interbody fusion.  19 pts had LBP and associated radiculopathy, 3 had LBP only. Follow up 1 to 12 months post surgery (mean, 5.3 months).
·         LBP completely resolved in 16 patients, moderate relief achieved in 5 patients, and the pain was unchanged in one patient.

                PLF / PLIF
·         PLIF most often performed in combination with PLF with or without instrumentation.
·         PLF involves midline subperiosteal approach with laminectomy, medial facetectomy, foraminotomy and removal of loose fragments.
·         Decompression performed and endplates removed then the iliac crest autograft is inserted after stabilization with pedicle screws and Isola rods.
·         In PLIF the above procedure in performed with the addition of the insertion of carbon fiber ramps next to the bone graft. 

Clinical Signs
Clinical findings:
·         back pain, spinal deformity, gait abnormalities, and tight hamstrings.
·         Characteristic gait pattern: "pelvic waddle“.
·         Widely based stance with stiff lumbar spine and hips, increased lumbar lordosis, a retroverted      pelvis, excessive knee flexion, and slight plantar flexion of the feet.

·         Core stability for grade I and low grade II slips and post-operatively.
·         Sinaki et al. (1999). Patients treated with flexion vs those treated with extension exercises.
·         Short-term results and 3 year outcomes were significantly better in flexion exercise program. 62%       of the group improved significantly.
·         Bracing.

This is more related in a medical line , but it will give us some idea what is the medical management of this problem ..wallahuaklam.
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