Spondylolisthesis

 Spondylolisthesis

Descriptive term derived from

Greek spondylo (spine) and olisthesis (slip)

Forward displacement of a lumbar vertebra on the one level below


Spondylolisthesis - Classification

Type I - Dysplastic

Congenital abnormalities of the facet joint

No pars interarticularis defect is present in this type.


Type II - Isthmic

Defect in pars interarticularis


Type III - Degenerative

Intersegmental instability of long duration

subsequent remodeling of the articular processes at the level of involvement

Spondylolisthesis - Classification

Type IV - Traumatic

Fractures in bony hook other than the pars interarticularis

pedicle, lamina, or facet


Type V - Pathologic

Generalized or localized bone disease and structural weakness of the bone

osteogenesis imperfecta

Adult Isthmic Spondylolisthesis

Second largest group of patients with spondylolisthesis

degenerative spondylolisthesis is more common


Level of involvement

L5/S1 90% to 95%

L4/5 5% to 8%

very few at the more cephalad levels


Typical presentation

axial lower back pain – mechanical

Radiating pain – foraminal stenosis

Adult Isthmic Spondylolisthesis

Severity range from spondylolysis (no slip) spondyloptosis (grade V) 

Meyerding grading 

Low-grade slips more than 90%

High-grade slips <10%

Radiography

30˚ oblique x-ray

Scotty dog sign

Slip angle

Local kyphosis at the level of spondylolisthesis


Angle formed between:

line perpendicular to the posterior margin of lower VB

line parallel to the upper VB inferior endplate


Sensitive value for instability


Predictive value for slip progression

larger than 30 degrees

Slip angle

Spondylolytic spondylolisthesis


Highly predictive of progression

Slip percentage, slip angle, high-grade spondylolisthesis


Not predictive

Pelvic incidence, sacral inclination


Slip angle

63 spondylolisthesis patients 

preoperative prone traction radiographs


Slip distance, slip angle, and disc height restoration

Highly predictive on prone traction radiographs

Treatment

Operation

Decompression

Indication : No segmental instability, multiple stenotic patient in younger age


Posterolateral fusion

Indication : No sagittal angular alignment, slippage ≤ grade I, acceptable area of sacral ala and transverse process for bone graft


Interbody fusion

Indication : Segmental instability, loss of lordosis, severe degenerative change of disc, inappropriate alignment


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