SPONDYLOLISTHESIS

ANUJ SHRESTHA
PG2, RESIDENT
NMCTH
OBJECTIVES:

❑INTRODUCTION
❑PATHOANATOMY
❑CLASSIFICATION
❑CLINICAL FEATURES
❑RADIOGRAPHIC EVALUATION
❑TREATMENT OPTIONS
❑SUMMARY
INTRODUCTION:

• Greek Spondylos (vertebra) &

olisthenin(to slip)

• Herbinaux (1782) : L5
slippage over S1

• Killian (1854): Coined the

term Spondylolisthesis
Terms:
• Spondylolisthesis:Anterior
translation of the cephalad vertebra
relative to the adjacent caudal
vertebra
• Spondylolysis: Defect in pars
interarticularis
• Spondylosis: Degenetarive changes
of spine
• Spondyloptosis: Complete fall of
L5 vertebra into the pelvis
• Spondylitis: Inflammation of spine
Biomechanics:
Anteriorly directed vector

Contraction of Erector Spinae

muscle

Coupled with the force of

gravity

Act on upper body mass

through lordotic spine
Anatomic structures that resist
anteriorly directed force are:

• Facets
• Annulus fibrosis
• Posterior bony arch
• Pedicles
Hook & catch concept:
• Hook:
➢Pedicles
➢Pars-interarticularis
➢Inferior process of cephalad level

• Catch:
➢Superior process of caudal level
EPIDEMOLOGY :
• Incidence : 7 % by age of 18 years

• L5/S1- 82% , L4/L5-11%

• Degenerative spondylolisthesis: Common in women

> 50 years

• Isthmic spondylolisthesis- Familial association:

26% in first degree relatives

Source:https://pubmed.ncbi.nlm.nih.gov/31078236/
Classifications:

❑Wiltse, Newmann, Macnab classification

(Aetiological & topographical)

❑Meyerding classification(% of slip in lateral

radiograph)

❑Marchetti-bartolozzi classification(based on
developmental & acqired)
I) Wiltse Classification:
• Type –I : Dysplastic 20 %(congenital abnormalities
of upper sacral facet or inferior facet of L5)

• Type-II : Isthmic 50% (defect in pars

interarticularis)

• Type III :Degenerative25 %(intersegmental

instability)
• Type IV : Traumatic(# in bony hook)
• Type V :Pathologic (eg: osteogenesis imperfect)
• Type VI : Iatrogenic (added later)
II) Meyerding Classification:
Meyerding Classification :Divides superior endplate of
caudal vertebra into 4 equal portion, allow 5 possible
grades,based on position of posterior inferior corner of
cephalad vertebra
III)Marchetti – Bartolozzi classification:
1) Developmental 2) Acquired
A) Traumatic:
➢Acute fracture
A) High dysplastic: ➢Stress fracture
➢With lysis
➢With elongation B) Post surgical
➢Direct surgery
A) Low dysplastic:
➢Indirect surgery
➢With lysis
➢With elongation C) Pathological
➢Lytic pathology
➢Systemic pathology
D) Degenerative
➢Primary
➢secondary
DYSPLASTIC SPONDYLOLISTHESIS
➢Malformation of posterior elements
(inferior facet of cephalad vertebra & superior
facet of caudal vertebra)
➢Sacrum dome shaped or hypoplastic

➢Loss of buttressing effect to resist anterior and

caudally directed forces

➢M/C occur in lumbopelvic junction

➢A/W anamolies :spina bifida occulta
ISTHEMIC SPONDYLOLISTHESIS
Hallmark : defect in pars interarticularis
Defect : lytic(stress fracture) or microfracture
Most common type with Common : L5-S1
Age: 5- 50 years
First occur during or just before adolescence
May progress until skeletal maturity
IIA : disruption of pars due to stress #
IIB : Elongation of pars without disruption due
to healed micrfractures
IIC: Acute # through pars
DEGENERATIVE
SPONDYLOLISTHESIS
2nd most common type
Common : L4- L5 level
Results from segmental instability as a result
of disc degeneration & facet remodeling
Female =5 times Male
Age > 50 yrs
Risk factors for the progression:
1) Young age at presentation
2) Female gender
3) Slip angle > 30 degree
4) High grade slip
5) Dome shaped or significantly inclined sacrum
6) Increased pelvic incidence
7) Disc degeneration
CLINICAL FEATURES :
➢ Usually asymptomatic : Incidental finding in X ray
➢Symptoms depend on the severity of slip
➢Due to :
1) Chronic muscle spasm

2) Tears in the Annulus Fibrosus

3) Compression of the nerve roots

C/F (according to age):
In Children
➢Asymptomatic usually
➢Parent noticed unduly protruding abdomen
➢Pecular stance
In Young adults :

➢Low back pain- on movement (Hyperextension),

Intermittent

➢Hamstring pain due to irritation of L5 nerve root

➢Radiculopathy – may occur in one or both legs.

C/F :

In patients > 50 yrs:

• Backache – episodes of backache

• Sciatica
• Pseudoclaudication d/t spinal stenosis
• Other signs of nerve root compression- motor
weakness, reflex changes and sensory deficits.
ON EXAMINATION:
A) LOOK:
➢ Buttocks – Flat
- Heart shaped in high grade slip
- d/t sacral prominence
➢ Sacrum – more vertical
- appears to extend to the waist
➢Lumbar hyperlordosis above the level of the slip to
compensate for the displacement
➢Transverse loin crease
➢With severity- absence of waist line
➢Peculiar spastic gait -d/t hamstring tightness and
lumbosacral kyphosis (late stage)
Inspection:

Incresed
Heart shaped Abdominal Absence of
lumber
crease waist line
lordosis
O/E:
B) FEEL :
 Palpable step
 Tenderness over Pars defect
 Hamstring tightness on leg raising

C) MOVE :
 Hamstring + Paraspinal muscle tightness limiting
forward bending and hip flexon.
 Degenerative type: spine stiff.
 SLRT +ve( lower lumber nerve root compression)
Radiographic assessment ( X-ray)
• AP View:
➢Inverted Napoleon’s hat sign
(in severe Spondylolisthesis)

➢ Standing lateral view: Vertebral

subluxation and pars defect
(15% deformities reduce on supine
imaging)
Ferguson coronal view:

➢By angling
(30°cephalad tilt & the x-
ray beam parallel to L5-
S1disc)

L5 pedicles, transverse
process and sacral ala is
more visible
X-RAY (upright lateral Flexion and
extension views):
 Show excessive
movement across the
site of pseudoarthrosis
in pars
 Subluxation of vertebral
body as patient moves
from extension to
flexion
 For operative decision
 X-RAY Oblique view:SCOTTY DOG SIGN:
“SCOTTY DOG SIGN” (decapitated dog )
Pars area is in relief apart from underlying bony
elements
Bone scintography/ SPECT:
• Detects stress reaction
before fracture

• Uses: Symptomatic
patient without
radiological cahnges

• Findings: Increase bone

metabolic activity in
acutely injured pars
interarticularis
CT myelography:
• Indication:
• Radicular complaints and
multiple foci of pathology
on MRI

• Continued radiculopathy in
absence of MRI finding

• Radiculopathy & significant

spinal deformity that
precludes the use of MRI
MRI:
• Very useful in pre-op
evaluation
• Non- invasive
• Indication:
• Detection of compression
on neural elements
• Early detection of disc
dessication
Treatment options:
1) Non- operative:

A) Activity modification
B) NSAIDs
C) Physiotherapy
D) Steroid injection
E) Spinal orthosis

2) Operative Treatment:
Physiotherapy :
➢Restriction of
vigorous activities
➢Abdominal &
paraspinal core
muscles
sstrengthening
exercises
➢Avoid extension
exercise
➢Hamstring
stretching
➢UST for short time
OPERATIVE TREATMENT:
Indications :

➢Persitent symptoms despite 6 months of

conservative treatment

➢Persistent abnormal gait with pelvic-trunk

deformity

➢Progressive Neurological deficit

➢Asymptomatic patient with slippage > 50 %

(skeletally imature) & > 75 % in adult
Surgical goals:
➢Adress pars defect & rattler

➢Decompress foraminal stenosis

➢Adress degenerate disc

➢Adress dynamic instability

Operative options:
• Direct repair of pars defect
• Decompression & fusion without fixation
• Decompression & fusion with pedicle screw
fixation
• Posterolateral insitu fixation
• PLIF (Posterolateral Interbody Fusion &
Fixation)
• TLIF (Trans Foraminal Interbody Fusion)
• ALIF(Anterior interbody fusion)
Direct repair of pars interaticulais:

• Radiographic Criteria for direct

repair:
➢Absence of spondylolisthesis
➢Absence of degenerative change at involved
disc level
➢Absence of degenerative facet changes
➢Absence of dysplastic changes such as spina
bibida
 Direct repair of pars interaticulais:
• TECHNIQUE:
➢Buck technique:
➢Indicated : gap < 3 mm
▪ Fibrous tissue at pars defect
debrided
▪ Stabilized with 4.5 mm cortical
screw
 Direct repair of pars interaticulais:

• Other techniques are:

➢Scott wiring & modified scott
technique

➢Kakiuchi procedure( repair with

ipsilateral pedicle screw & hook
Repair of pars defect V-rod technique:
In situ posterolateral instrumented fusion

• Debride lytic defect

Exposure & bone harvest

• Pedicle screw
fixation(polyaxial pedicle)

• Approach: Wiltse & Spencer

Interbody fusion
• Interbody fusion promote fusion between the
vertebral bodies by
a) Device( with instrumentation)
b) Bone graft
GOAL : Elimination of pathological segemnt

• Acc to Surgical approach used during device:

➢ Anterior lumbar interbody fusion (ALIF)

➢Transforaminal lumbar interbody fusion (TLIF)
➢Posterior lumbar interbody fusion (PLIF)
 Transforaminal lumbar interbody
fusion (TLIF):
• Ideal for grade I or II
spondylolisthesis with
unilateral symptoms

• Improved fusion rates d/t

circumferential support
• Single bone graft between
vertebra from side
Posterior lumbar interbody fusion
(PLIF)
3 surgical steps:

➢Laminectomy or laminotomy
with partial or complete
facetectomy
➢Removal of intervertebral disc
➢Fusion
Decompression
Absoulte Indications:

• Neurological deficit

• Sphincter dysfunction

• Claudication
Decompression (in degenerative
type)
• Gill procedure= removal of loose laminar
arch
• Foraminotomy
• Faectectomy
• Common : Decompression & fusion with or
without instrumentation
Studied from NewYork USA by Andre M Samuel published in 2017
Conclusion:Current evidence supports surgical treatment of degenerative
spondylolisthesis. Posterolateral spinal fusion remains the treatment of choice, the
use of interbodies and decompressions without fusion may be efficacious in
certain populations. However, additional high-quality evidence is needed,
especially in newer areas of practice such as minimally invasive techniques and
sagittal balance correction.
• Published in 2021
• Result:This research found that both surgical techniques, TLIF
and PLIF, are suitable for DLS treatment. The two methods
differed in postoperative complications which were less frequent
in TLIF. There were no significant differences in the
postoperative quality of life
• Long-Term Results of Surgery Compared with Nonoperative Treatment for
Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes
Research Trial (SPORT) from Lebanon in 2018
• For patients with symptomatic DS, patients who received surgery had
significantly greater improvements in pain and function compared to
nonoperative treatment through eight years of follow-up. Fusion technique did
not affect outcomes.
• Studied from Mubai India by Kulkarni et. al published in 2020
• In recent years, there is increasing trend towards minimal access surgery in spine,
which is associated with improvement in implants, navigation technology and use of
newer imaging modality. Although MIS techniques have historically been commonly
implemented for limited indications in spine with technological advancement and
increased surgeon experience, can adopt MISS for wide range of surgeries including
high grade spondyloisthesis and spondyloptosis.
Take Home Messages:
✓Isthimic type is m/c type of spondylolisthesis with
hallmarks of pars defect
✓Risk factors for progression are early age of
presentation with female gender
✓Transverse loin crease, absence waist line with
palpable step in spine is key to clinical diagnosis
✓AP view along with Ferguson coronal view, upright
lateral Flexion and extension views and oblique
views X-ray are needed
✓Recent advance in treatment for high grade
spondyloisthesis and spondyloptosis is MIS
Thank You