Spondylolisthesis

Presented by :
Dr. RATISH MISHRA
Post Graduate, M.S (Orthopedics)

Moderator:

Director. (Prof). Dr. Ramesh Kumar

Director,
Central Institute of Orthopedics
VMMC & Safdarjung Hospital, New Delhi
 definition
• SPONDYLOLISTHESIS is defined as the
translation of one vertebra on its adjacent
caudal segment.
• Anterior translation –ANTEROLISTHESIS
• Posterior translation-POSTEROLISTHESIS
In 1782, Herbiniaux, a Belgian obstetrician,
noted a bone prominence in front of the
sacrum that caused problems in delivery.

In 1854, Kilian coined the term

spondylolisthesis, derived from the Greek
spondylos, meaning “vertebra,” and
olisthenein, meaning “to slip.”
 DEFINITIONS
• Spondylolysis :is a defect in pars
interarticularis

• Spondyloptosis: used to describe as

fall of L5 vertebra into the pelvis and
lie anterior to sacrum.

• Spondylitis :is a term used to describe

several spine conditions that cause
swelling and inflammation in the joints
and vertebrae of the spine.

• Spondylosis is an umbrella term used

to describe pain from degenerative
conditions of the spine.
Relevant anatomical structures
 PARS INTERARTICULARIS
Part of a vertebra located between the inferior and
superior articular processes of the facet joint.

On an anterior oblique radiograph of the lumbar

spine, imaginary Scottie dog SIGN;
NECK-PARS
eye - pedicle,
nose - transverse process,
ear - superior articular facet
forelegs -inferior articular facet.
hindlegs - spinous process,
Hook and catch concept

Hook:
• Pedicle
• Pars inter-articularis
• Inferior process of the cephalad level

Catch:
• Superior process of the caudal level
classification

• Wiltse, Newman and Macnab (Based on location of defect

of posterior element that allows listhesis)

• Meyerding Classification( based on percentage of slip in

lateral radiograph)

• Marchetti and Bartolozzi ( based primarily on etiology-

developmental or acquired)

• Spinal Deformity Study Group/SDSG classification

 Wiltse, Newmann, MacNab
Clin Orthop 1976
Type Name Description
I Congenital Dysplastic abnormalities
II Isthmic
A Lytic (stress fracture)
B Healed fracture (elongated, intact)
C Acute high energy fracture
III Degenerative Segmental instability
IV Traumatic Fracture of hook other than pars
V Pathologic Underlying pathology
VI Iatrogenic Surgical excision of posterior
elements
Wiltse, Newman, and Macnab's classification
Type I, Dysplastic (20%)
• Occurs only at L5-S1 level
• Primary congenital dysplasia of posterior
elements particularly L5-S1 facet joints.
• Typically the inferior facet of L5 is dysplastic
and the sacral facet absent.
• No pars interarticularis defect
• Frequent association with spina bifida occulta of
L5 and sacrum.(70%)
• More common in females.
• Increased incidence in first degree relatives of
patients: genetic
• Even though these anamolies are present at birth ,
spondylolisthesis occur after the child is able to
ambulate..erect posture
DYSPLASTIC PATHWAY
Initiated by the Congenital malformation of posterior
elements (facet joint, pars ,spina bifida occulta) in the
bony hook or its catch.

Inability of L5 vertebra to resist anterior and ventral

forces created by upright posture on lordotic spine

Plastic deformation of soft tissue restrains: IV Disc, Antr

and Postr Ligament complex

Subluxation of vertebra
 DYSPLASTIC PATHWAY

With continuous growth they lost their ability to resist

anteriorly directed forces

Slippage and abnormal growth in the involved vertebral

bodies or sacrum
Changes seen:
-Trapezoid shape of L5 and its anterior translation
- Rounding of supero anterior aspect of sacrum(doming)
- Vertical orientation of the sacrum
- Junctional kyphosis at involved segments
- Compensatory hyperlordosis at the adjacent levels
 Wiltse, Newman, and Macnab's classification

• Type II: Isthmic(50%) Defect in pars

interarticularis(spondylolysis) that allows forward
slippage of L5 over S1
• Three Types:
A. Lytic:- stress fracture of pars interarticularis
B. Healed version of Lytic- pars interarticularis
intact but elongated due to bone remodelling
C. Acute fracture of pars interarticularis due high
energy injury.
Spondylolisthesis most common at L5-S1(87%),
L4-L5(10%), L3-L4(3%)
Often occur in children ,adolescents and young
adults . The incidence tends to stabilize in
adulthood.
 Etiology: isthmic spondylolisthesis :
• Due to upright walking and wt . bearing.
• M=F: 2:1 ( more common in males)
• Risk factors: Gymnastics / Football/wt. lifting, dancing
and others with excessive lordosis or hyperflexion of
the lumbar spine.
• Incidence of spondylolysis is 0% at birth and increase
to 7% by age of 18.
• 80% acquire fracture of pars (spondylolysis) between
age of 5 to 10 year , remaining 20% of fracture before
age of 20 years
• 7%of population has spondylolysis with or without
spondylolisthesis. Most develop only grade 1 anterolisthesis
over time.
• High grade slip (>50%) develop in patient with additional
risk factor like disc degeneration, High slip angle , Increased
pelvic incidence.
• Most are asymptomatic. Patients presents with complain of
low back ache and radicular pain in L5 distribution
• Genetic and familial assosciation: 26% of patients with
isthmic spondylolisthesis had first degree relatives with same
disease.
 Isthmic pathway
In Erect posture-Center of Gravity is anterior to LS joint
Lumbar spine-forward force and rotate anteriorly into flexion about the
sacral dome. Initiated by the repetitive cyclic loading

Sup. and inf. articular process impingement creates a bending

moment that is resisted by the Pars.

Repetitive impingement- fatigue

Stress fracture of Pars and post. neural arc separates from
body

Gap occupied by the fibrous tissue(Pseudoarthrosis)

Non union

Increased shear load to disc though axial load remains

unchanged

Premature disc degeneration ,loss of disc height height,

psudoherniation of disc and psedarthrosis of pars cause
decreased foramen cross-sectional area , nerve compression

Vertebral subluxation
 Wiltse, Newman, and Macnab's classification
• Type III: Degenerative(25%):
• Most common type
• Due to intersegmental instability as a result
of disc degeneration and facet remodeling
and subsequent remodelling of the articilar
process.
• Often accompanied by spinal stenosis
centrally and in lateral recess
• older than 40 years
• Most common at L4-5 (six times more)
• Women ( four to six times )
• They have dynamic component to their
deformity i.e. amount of translation is
affected by body posture.
• slip progression occurred in 34%, and is usually mild and
further disc space narrowing continued in the patients
without further slip.
• Low back pain improved in patients with continued disc
space narrowing: autostabilization.
• Risk factor for progression – presentation before 60,
female sex
facet sgittalization
• Degenerative spondylolisthesis result from degenerative
cascade as described by kirkaldy – willis.
DEGENERATIVE CASCADE BY KIRKALDY -
WILLIS
DEGENERATIVE SPONDYLOLISTHESIS

Sagital facets degeneration

No resistance for anterior translation

force(contraction of posterior erector spinae
muscle and force of gravity acting on lordotic
lumbar spine)

Predilection for slippage

Anterolisthesis
• Boden et al - sagital facet angles of > 45 degree at L4-L5 - 25 times greater
likelihood of degenerative spondylolisthesis.
Degenerative spondylolisthesis

• Disc degeneration

• Disc narrowing and subsequent overloading of facets

• Loss of disc height allow cephalad vertebra to
translate

Accelerated arthritic changes

Secondary remodelling
Anterolisthesis
 Wiltse, Newman, and Macnab's classification
• Type IV :- Traumatic
• fracture in the area of the bony hook other than pars, ie
pedicle, laminas or facets.

• Type V :- Pathological :
• Due to generalized or localized bone disease, eg:
osteogenic imperfecta, multiple myeloma, infection pagets
disease.

• Type VI Post surgical :

Due to loss of posterior elements secondary to surgery.
eg: transection of pars with facetectomy , fusion of
segments
Post surgical

•Laminectomy

•Removal of >1/2 or entire articular process

•Destabilize the spine. Fracture of pars.

•subluxation
Post surgical

Fusion of segments

Resection of capsular, Supraspinous and Interspinous

ligaments

• Increasing motion demand

• subluxation
 Meyerding classification
Based on amount of translation of
superior vertebra over inferior vertebra
Superior end plate of caudal vertebra is
divided into 4 equal portion
Distance between the posterior edges of
Superior and inferior vertebral bodies is
reported as percentage of total length of
superior end plate of inferior vertebra
• grade I: 0-25%
• grade II: 26-50%
• grade III: 51-75%
• grade IV: 76-100%
• grade V (spondyloptosis): >100%
MARCHETTI-BARTOLOZZI CLASSIFICATION
MARCHETTI-BARTOLOZZI CLASSIFICATION

• Based on etiology- developmental ( dysplasia) or acquired( trauma , post

surgery, pathological or degenerative)
• DEVELOPMENTAL SPONDYLOLISTHESIS:
• HIGH DYSPLASTIC- major deficiency of posterior arch, intervertebral disc,
rounded upper end plate of S1, trapezoidal L5 body,
pars lytic or elongated , high risk of progression
• LOW DYSPLASTIC- mild dysplastic changes, flat s1 end plate,
L4 L5 bodies remain rectangular, pars lytic or
elongated, low risk of progression
ETIOLOGY: DEVELOPMENTAL SPONDYLOLISTHESIS
WITH LYSIS

It is due to stress fracture in children with genetic

predisposition for the defect.
• Wiltse et al: normal flexon contracture of the hip in
childhood causes increased lumbar lordosis leading to
increased force at Pars interarticularis.
• Lett et al: shear stress greater at pars when lumbar
spine is extended.
• Cryon and Hutton: Pars is thinner and vertebral disc
is less resistant to shear in children and adolescents
than in adults
SPINAL DEFORMITY STUDY GROUP(SDSG)
CLASSIFICATION

<50%
SLIP

>50% SLIP
SPINAL DEFORMITY STUDY GROUP(SDSG)
CLASSIFICATION
• LOW-GRADE SPONDYLOLISTHESES, (grades 0, 1 and 2, or <50% slip)
Type 1, “nutcracker”, a subgroup with low PI (<45°);
Type 2, a subgroup with normal PI (between 45° and 60°); and
Type 3, a shear type, a subgroup with high PI (>60°).
• HIGH-GRADE SPONDYLOLISTHESIS, (grades 3, 4 and spondyloptosis,
or ≥50% slip)
Each case must first be classified as if presenting a balanced or
unbalanced sacro-pelvic, using values of PI and SS. The spino-
pelvic balance is determined with the use of the plumb line of
C7. If this line falls on or behind the femoral head, the column
will be balanced; if it falls in front of the femoral head, the
column will be unbalanced.
LOW GRADE SPONDYLOLISTHESIS

• TYPE 1:those patients with low PI and SS may present clamping of

the posterior elements of L5 between L4 and S1 during extension,
which eventually causes an effect in “nutcracker” on the pars
articularis of L5
• TYPE 3: patients with high PI and sacral slope (SS) show an increase
in the shear forces incident at the lumbosacral junction, which causes
further tension on the pars articularis of L5: the shear type (Fig. 5).
SACRO-PELVIC ALIGNMENT
• The “balanced” group includes patients
who in the orthostatic position show
high SS and low pelvic tilt (PT).
• Patients in the group “unbalanced”
include those who in the orthostatic
position have retroverted pelvis and
verticalized sacrum, which corresponds
to a low SS and high PT.
• It has been shown that patients with
high degree of vertebral slippage have a
mean PI >60°. Increased PI is associated
with increased lumbar lordosis, which
predisposes to mechanical changes of
the lumbar and lumbosacral junction
and increases the risk of
spondylolisthesis .This contrasts with
those with low-grade spondylolisthesis,
in whom PI values are low, normal or
high.
SPINO-PELVIC ALIGNMENT/
SAGGITAL BALANCE
• The spino-pelvic balance is
determined with the use of the
plumb line of C7.
• If this line falls on or behind the
femoral head, the column will be
balanced;
• if it falls in front of the femoral
head, the column will be
unbalanced.
• sagittal balance is measurement of
the C7 plumb line from upper
posterior border of S1
• This line should pass through the
superior endplate of S1, or more
precisely within 2 cm (some use 1.7
cm) of the posterosuperior corner
of the S1 vertebral body .
 The position of this line is termed
positive, neutral or negative according
to its distance from posterosuperior
corner of S1
 Sagittal balance was significantly
increased (>3 cm) in those with
retroverted posture (unbalanced); this
suggests that the positive sagittal
imbalance may be associated with this
type of spino-pelvic alignment.(type 6)
 Low PT high PT Low SS high PT ,Low SS
nutcracker shear High SS C7PL- C7PL-
BALANCED UNBALANCED
SPINE SPINE
De wald Modified Newman Spondylolisthesis Grading
System

• Better define the amount of anterior roll of L5.

• The dome and the anterior surface of the sacrum is divided
into 10 equal parts.
• The scoring is based on the position of the posterior inferior
corner of the body of the L5 with respect to the dome of the
sacrum.
• The second number indicates the position of the anterior
inferior corner of the body of the L5 vertebra with respect to
the anterior surface of the first sacral segment.
Modified Newman Spondylolisthesis Grading
System.

Modified Newman spondylolisthesis grading system. Degree of slip is measured by two

numbers—one along sacral endplate and second along anterior portion of sacrum:A = 3 +
0; B = 8 + 6; and C = 10 + 10.
NATURAL HISTORY

• Risk factors for the progression :

1)Young age at presentation(
diagnosed before adolescent growth)
2)Female gender
3)A slip angle of > 10 degree,
increased pelvic incidence
4)A high grade slip(greater than 50%)
5)Dome shaped or significantly
inclined sacrum(SDSG INDEX >25%)
Natural History is predominantly determined by

• Developmental or acquired spondylolisthesis

• Low or high dysplasia
• Quality of pedicle , pars and facets
• Age when diagnosis is made
• Degree of lordosis and position of gravity line
• Degree of secondary or remodeled deformity
• Competency, hydration and height of the disc
 NATURAL HISTORY

1)Dysplastic spondylolisthesis :

Early age; usually asymptomatic

Severe slip(9-15,seldom after 20)

Risk of neurological complications

Higher risk of slip progression-cauda equina syndrome as

the neural arc is intact.
NATURAL HISTORY OF ISHTHMIC
SPONDYLOLISTHESIS

:
• No progression of slip
• < 10% displacement
• Asymptomatic
• No progression after
• adulthood
• No backache later in life
Progression of slip
>25% slip
symptomatic
Risk of slip progression
.Backache in later life
Natural history of Degenerative Spondylolisthesis
:

-Rare before 50.

-Matsunaga et al 10 yrs prospective study--34% showed progression
of the slippage-though no significant effect in the clinical outcome
-further disc space narrowing continued in those without slip
-However back pain improved (Autostabilisation)
-83% of the pts with neurological signs and symptoms deteriorated
CLINICAL EVALUATION of SPONDYLOLISTHESIS
-Usually asymptomatic – Incidental finding in X ray.
-Symptoms depend on the severity of slip and is caused by :
1)Chronic muscle spasm : Body limits motion around a painful
pseudo-arthrosis of facet and its Pars .
2) Tears in the Annulus Fibrosus of the degenerated discs.
3) Compression of the nerve roots.
 CLINICAL EVALUATION

When symptomatic :
In Children and Young adults :
• Back fatigue and back pain-on movement (Hyperextension) due to
instability of the affected segment.
• Hamstring fatigue and pain due to irritation of L5 nerve root.
• Sciatica – may occur in one or both legs
CLINICAL EVALUATION

In patients > 50 yrs:

•Backache

•Sciatica

•Pseudoclaudication d/t spinal stenosis when subluxation is

severe.
•
•Other signs of nerve root compression- motor weakness, reflex
changes and sensory deficits.
CLINICAL EVALUATION

Compression of central canal :

Features:
1. Bladder and bowel dysfunction
2. Bilateral leg symptoms
3. +ve SLRT B/L
4. +ve crossed SLRT
 CLINICAL EVALUATION

ON INSPECTION:

• 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 -due to hamstring
tightness and lumbosacral kyphosis.
Inspection findings

Lumbar hyperlordosis Transverse loin crease absence of waist line

 CLINICAL EVALUATION

Scoliosis – esp in children – 3 types:

a) Sciatic : Lumbar curve caused by the muscle spasm
.resolve with symptoms
b) Olisthetic : Due to asymmetrical slipping of
vertebra
c) Idiopathic :
In Olisthetic crisis with total canal occlusion- typical
posture– decrease nerve root tension by supporting
trunk with hands on knee.
In spondyloptosis- shortening of lumbar spine
CLINICAL EVALUATION
CLINICAL EVALUATION

PALPATION :
Palpable step
Tenderness over Pars defect
Hamstring tightness on leg raising.

MOVEMENTS :
Usually normal in young pts.
May be – Hamstring + Paraspinal muscle tightness-
limiting forward bending and hip flexon.
Degenerative type: spine-often stiff.
Positive nerve root tests if root compression.
 The pain generators: Leg pain

• L5 compression / traction

• Abnormal motion

• Facet joint arthrosis

• Pars scar

• The disc above far-lateral

 Imaging

Radiographs:
• AP view
• Standing Lateral view including the hips.(15% of deformities
spontaneously reduce on supine imaging.)
• Oblique view: help in viewing pars interarticularis defect( decapitated
scotty dog)
• Lateral flexion and extension views: determination of translational
instability.
• Flexion-extension lateral views may reveal instability, which is
considered to be present when 4 mm of translation or 10 degrees of
sagittal rotation greater than the adjacent level is identified
• Fegurson view depicts the L5 pedicles, transverse processes and sacral
ala more clearly
Fegurson view(20 degrees caudo cephalic ap view)
radiographs
Flexion Extension X rays
Demonstrates
a bilateral break in the pars interarticularis
or spondylolysis (lucency shown by black
arrow) that allows the L5 vertebral body
(red arrow) to slip orward on the S1
vertebral body (blue arrow).
The normal pars interarticularis is shown by
the white arrow.
Inverted napoleon’s hat
sign

indicates the presence of bilateral

spondylosis and significant
spondylolisthesis. The dome of the
hat is formed by the overlying
body of L5 vertebra and the brim
is formed by transverse processes.
Scotty dog sign on anterior oblique views
Other investigations

CT myelography and MRI are used as indicated for

the evaluation of spinal stenosis and may show facet
overgrowth, hypertrophy of the ligamentum flavum,
and, rarely, disc herniation, tumors, etc.
SPECT: most senstive for impending spondylolysis.,
Can determine the chronicity of lytic defect.
High resolution CT confirms spondylosis…it
differentiate stress reaction from lytic defect.. as
treatment is different
NCV, EMG: to rule out peripheral neuropathy
Arterial doppler/ CT angiography: to rule out
vascular causes of claudication
ROLE OF SPECT

•A Single-photon Emission Computed

Tomography bone scan is necessary to show
whether uptake is increased in the pars. A SPECT
scan is helpful in determining whether the
process is acute or chronic.

• If increased uptake is confirmed, a CT scan can

be obtained to evaluate whether there are
thickened cortices consistent with a stress
reaction or whether there is an acute stress
fracture.
 Magnetic Resonance Imaging

• Allows for additional visualization of soft tissue and neural

structures and is recommended in all cases associated with
neurologic findings.
• In the early course of the disease, MRI helps in identifying the
stress reaction at the pars interarticularis before the end-stage
bony defect.
• MRI may show the degree of impingement of neural elements by
fibrous scar tissue at the spondylolytic defect.
• Status of disc
 Disc degeneration: MRI

Grade I Grade II Grade III Grade IV Grade V

Pfirrmann et al Spine 2001

 Important
Radiological
parameters
• SLIP ANGLE(by Boxall et.al):
• The slip angle is angle formed
between line perpendicular to
posterior aspect of upper sacrum
and line parallel to L5 inferior or
superior end plate.
• Angle greater than 30 degrees
associated with greater risk of slip
progression, instability, and
development of postoperative
pseudarthrosis.
• It is the best predictor of
progression of slip.
• A slip angle greater than 55 degrees
is associated with a high probability
and increased rate of progression
Pelvic incidence (pi)
• Pelvic incidence: A line
perpendicular to the midpoint of
the sacral end plate is drawn. A
second line connecting the same
sacral midpoint and the center of
the femoral heads is drawn. The
angle subtended by these lines is
the pelvic incidence
• Pelvic incidence: Pelvic tilt +
sacral slope
• normal, ≈50 degrees)
• Unaffected by posture
• Increased PI may predispose to
spondylolisthesis. Seen in
degenerative and dysplastic case
• Does not predict progression of
slip
 PELVIC TILT (PT)

• Pelvic tilt:. A line from the

midpoint of the sacral end
plate is drawn to the center
of the femoral heads. The
angle subtended between this
line and the vertical
reference line is the pelvic
tilt.
• Higher pelvic tilt predisposes
to spondylolisthesis.
SACRAL SLOPE(SS)

• Sacral slope: A line parallel to the

sacral end plate is drawn. The
angle subtended between this line
and the horizontal reference line
is the sacral slope.

• Vertical sacrum (SS<100 degrees)

is causes progression in slippage.
 L5 incidence

• Alpha angle L5 incidence: A line

from the midpoint of the upper end
plate of L5 is connected to the center
of the femoral heads. A second line
perpendicular to the upper L5 end
plate is drawn from the midpoint of
the end plate. The angle subtended by
these two lines (α) is the L5
incidence.

• Higher values are associated with

spondylolisthesis/unbalanced pelvis
MEYERDING XRAY GRADING OF
SPONDYLOLISTHESIS
• Percentage of slipping calculated by
measurement of distance from line parallel to
posterior portion of first sacral vertebral body to
line parallel to posterior portion of body of L5;
anteroposterior dimension of L5 inferiorly is used
to calculate percentage of slipping.
• Grade I: displacement of 25% or less;
• Grade II: between 25% and 50%;
• Grade III: between 50% and 75%; and
• Grade IV: more than 75%. A
• Grade V represents the position of L5 completely
below the top of the sacrum -SPONDYLOPTOSIS.
Risk factors for slip progression in
spondyolisthesis
(Hensinger 1989)

Clinical Radiographic
• Growth yrs (9 – 15) • Type 1 (dysplastic)
• Girls > Boys • Vertical sacrum
• symptomatic • >50 % slip
• Postural or gait abnormality • Increasing slip angle
• Instability on flex/ext views
Management of SPONDYLOSIS

Nonoperative Treatment :-
If SPECT scan is positive but HRCT is negative( no pars defect)
suggest stress reaction– treatment is avoidance of sports and
other high intensity exercise for 4-6 week. Rehabilitation with
strengthening of the abdominal and paraspinal musculature,
minimization of pelvic tilt, and antilordotic bracing
If SPECT is positive with pars defect in CT ( spondylosis)–
treatment is rigid orthosis while upright for 6 weeks.
REPAIR OF PARS INTERARTICULARIS

Operative Treatment :-
Indication:- patient remain symptomatic for > 3 month with conservative
treatment
Non union of pars
Prerequisites:-Absence of spondylolisthesis, absent degenerative changes
of disc and facet joint , absence of any dysplastic changes on MRI and CT
SCAN
• Principles:
• Debridement,
• Grafting of the site with autogenous bone graft, and
• Compression across the fracture.
 REPAIR OF SPONDYLOLYTIC DEFECT

• Procedures :
• Buck technique--REAPIR OF PARS INTERARTICULARIS DEFECT IS
DONE BY PEDICLE SCREW INSERTION AND BONE GRAFTING
• Scott wiring and Modified Scott Technique
• Kakiuchi procedure (repair with an ipsilateral pedicle screw and
hook).
 BUCK TECHNIQUE : DIRECT REPAIR OF
PARS INTERARTICULARIS

• Fibrous tissue at the pars defect is identified,

thoroughly débrided, and stabilized with a 4.5-
mm stainless steel cortical screw in compression.
• This technique was indicated only in cases in
which the gap was smaller than 3 to 4 mm.
• The narrowness of the lamina, a minimal
displacement or malposition of the screw can lead
to implant failure or complications Such as nerve
root irritation, injury to the posterior arch Or dura,
or pseudarthrosis.
• Better clinical results have been obtained in
patients younger than age 30 years, possibly
because chronic instability leads to degenerative
disc disease in older patients, which causes
continued symptoms despite fusion of the defect
• (a) Preoperative
lateral radiograph
• (b) axial CT scan
showing unilateral
defect of the pars
interarticularis of
the L4 vertebra.
• (c) Sagittal T2
weighted MRI
demonstrating the
normal L4-L5 disc
without any
degeneration.
• Follow-up lateral
dynamic radiographs
in (d) flexion and (e)
extension, showing
complete healing of
the defect without
signs of instability
• . (f) Postoperative
axial CT scan
demonstrating
complete healing of
the spondylolytic
defect
 Scott Technique

• A stainless steel wire is looped from the transverse processes to

the spinous process of the level involved and tightened, in
conjunction with local iliac crest bone graft.
• This wire creates a tension band construct, placing the pars defect
under compression, and holds the bone graft in place.
• Bradford and Iza reported 80% good to excellent results and 90%
radiographic healing of the defects.
• This technique requires greater surgical exposure, with extensive
stripping of the muscles to expose the transverse process.
• Complications such as wire breakage are common with this
technique.
Scott wiring technique
 Modified scott technique

• Modified SCOTT TECHNIQUE in

which a wire is passed around the
cortical screws introduced into both
pedicles and tightening it beneath
the spinous process.
• Biomechanical tests show that
fixation of the wire to the pedicle
screw does not increase the
stiffness of the system.
• This techniques have defect
healing rates of 86% to 100%.
Modified scott
technique
 Kakiuchi Technique

• Kakiuchi reported successful union

of pars defects with the use of a
pedicle screw, laminar hook, and rod
system.
• A pedicle screw is placed in the
pedicle above the pars defect.
• The pars defect is bone grafted.
• A rod is placed in the pedicle screw
and then into the caudal laminar
hook, and compression is applied.
• This gives a more stable construct
than that afforded by wire
techniques
Comparative studies
Management of isthemic
spondylolisthesis
• NON OPERATIVE:- If patient has spondylolisthesis of more than 1-2
mm– no orthosis is required as healing of pars defect is unlikely
• If no neurologic symptom– brief period of rest , anti inflammatory
medication, muscle relaxant…..f/b low impact aerobic exercise, trunk
stabilisation avoiding extension, and hamstring stretching …full
activity after 8-12 week
 Operative treatment: indications
:
• Persistent symptoms despite 9 months to 1 year of
conservative treatment,
• Persistent tight hamstrings, abnormal gait, and pelvic-trunk
deformity.
• Development of a neurological deficit .
• In a skeletally immature patient with slippage greater than
50% or a mature adolescent with a slip greater than 75%, even
if the patient is asymptomatic.
• Pars defect of more than 1-2 mm—fracture healing is unlikely
• Before surgery –asses patient global balance by standing
lateral and AP radiographs
• Slip angle , sacral end plate morphology, l5 transverse process
should have 2cm2 surface area assessed on CT
• MRI for radicular symptom and disc assesment
Surgical goals

• Address the pars defect & the rattler( Loose

laminar arch)

• Decompress the foraminal stenosis

• Address the degenerate disc/s

• Address the dynamic instability

Operative management
• Isthemic spondylolisthesis without neurological complain with normal l5
tranverse process and good spinal alignment— IN SITU INSTRUMENTED
POSTERO LATERAL FUSION
• If l5 is transverse process is hypolastic(<2 cm2 surface area)- POSTERIOR
LUMBAR INTERBODY FUSION(PLIF)/ TRANSFORAMINAL LUMBAR
INTERBODY FUSION(TLIF) or ANTERIOR LUMBAR INTERBODY FUSION(ALIF)
WITH POSTERIOR SUPPLEMENTAL FIXATION
• With neurological symptom—DIRECT DECOMPRESSION with PLIF WITH
INSTRUMENTED POSTERO LATERAL FUSION
OR
INDIRECT DECOMPRESSION WITH TRANS FORAMINAL LUMBAR INTERBODY
FUSION AND INSTRUMENTED POSTERO LATERAL FUSION
• INDIRECT DECOMPRESSION- is realignment and reestablishment of disc
height using interbody spacer device and bone graft
• INTERBODY SPACER DEVICES include femoral cortical allograft, PEEK
cages(poly-ether-ether-ketone), titanium mesh cages, expandable cages,
carbon fiber devices
IN SITU POSTEROLATERAL
INSTRUMENTS FUSION: WILTSE
SPENCER APPROACH
• midline skin incision and the two
paravertebral fascia incisions.
• create intermuscular plane: the multifidus is
medially located, the longissimus is lateral
• joint facet and the transverse process is
exposed
• All pedicle screws are placed utilizing
fluoroscopic guidance followed by
application of the rods
• Decortication of the transverse processes,
pars, and lateral facets are performed with a
high-speed drill, following which bone graft
is applied
• Wiltse MIS paraspinal approach is muscle-
sparing and has lower infection rates,
Improvement in leg pain even when not
decompressed
In-situ pedicle screw fixation with bone grafting
PLIF( POSTERIOR LUMBAR INTERBODY
FUSION)
• After the levels of interest are exposed, the
posterior spinal elements are removed to
expose the traversing nerve roots and lateral
extent of the disc space. PLIF
• The dorsal third of the interspinous ligament
may be preserved to act as a fulcrum for a
dural retractor and to preserve a tension
band posteriorly. TLIF
• The thecal sac and traversing nerve roots are
mobilized and retracted to the midline, with
care taken to protect the dural and neural
contents with a retractor.
• After exposure of the posterior annulus, a ROUTE OF ACCESS TO
complete discectomy is performed using INTERVETEBRAL BODY SPACE IN
rongeurs, disc shavers, and down biting PLIF AND TLIF
curved curettes.
• Only by completely removing the disc and
denuding the cartilaginous endplates can an
environment conducive to fusion be
provided.
 PLIF
• In addition, disc height may be restored
through the use of distractors with serially
increasing heights.
PLIF
• By increasing the disc height, tension is placed
on the annulus fibrosis, and the bone graft is
placed under a compressive load, which will
help the fusion process. TLIF
• After the interbody graft construct is placed,
pedicle screws are then inserted and attached
to the rods.
• Once in place, the pedicle screws are
compressed along a lordotic rod in an attempt
to reduce any kyphosis caused by interdiscal angle of
distraction. interbody graft
insertion for the
• The transverse processes are then
decorticated, and the bone graft is placed over PLIF procedure
them for a posterolateral fusion. (top, medial) and
TLIF procedure
• A standard closure in layers is then performed. (bottom, lateral)
• DISADVANTAGE: Dural tear and injury to the
nerve roots or conus medullaris
Radiological result(plif with
titanium mesh cage)
 TLIF(TRANSFORAMINAL
INTERBODY FUSION )
• making a vertical incision over the section to be
fused.
• The skin, muscles, and soft tissues are gently TLIF
retracted to expose the lateral aspect of the
spinous process, the lamina, and the facet joint .
• Depending on the clinical presentation, a
laminectomy, facetectomy, or both may be
performed.
• After adequate decompression of the neural
elements has been performed, pedicle screws are
placed in the standard fashion.
• The disc space can be gradually distracted by using
the pedicle screws or an intralaminar spreading
device. The placement of the distractor and screws
TLIF
does not interfere with the dissection and, in fact,
this system allowed for easy visualization of the
nerve roots, thecal sac, and disc space .
 TLIF
• To facilitate complete removal of the cartilaginous endplate and a
more extensive disc excision, the posterior lip of each endplate is
removed with the use of a 1/4-inch osteotome, while carefully
protecting the thecal sac and nerve roots
• An interbody device(s) of appropriate size is then placed while
protecting the dura with a small retractor . The thecal sac may be
minimally retracted (when necessary, the retractor is used to protect
the exiting nerve root) while the mesh construct is put in place .
Originally, the technique was described using two titanium mesh
cylinders. However, single “banana”-shaped or rectangular devices
have been designed to cover the disc space with a single device.
• Once the graft has been placed within the interbody space, pedicle
screws are then attached to lordotic rod and carefully compressed to
restore lumbar lordosis while maintaining the restored disc height.
• The contralateral facet joint may be decorticated, and the bone graft
is placed over them for a posterolateral fusion if there is any
instability.
• A standard closure in layers is performed.
ALIF ( anterior lumbar interbody fusion)

• Indication :- high grade spondylolisthesis

• Salvage procedure who had in situ posterolateral fusion but
developed non union
• Risk of vascular , bladder, bowel injury ,retrograde ejaculation
Inter-body fusions: theoretical considerations

• Anterior column support

• Bio-mecahnically superior:
• Large area for fusion
• Grafts under compressive
loads

• Degenerate disc removed

• consider disc height
• Build in the lordosis
DEGENERATIVE SPONDYLOLISTHESIS
MANAGEMENT
NON OPERATIVE:-
• SYMPTOM LOWBACK ACHE AND LOWER EXTREMITY PAIN AND
WEAKNESS ARE CLAUDICATORY IN NATURE..BECOME STABLE OVER
TIME OR PROGRESS SLOWLY.
• NEUROLOGIC SYMPTOM ARE RELATED TO SPINAL STENOSIS
• LOW BACK ACHE RESPOND TO PHYSIOTHERAPY WITH CORE
STRENGTHENING WITH AVOIDANCE OF EXTENSION EXCERCISES,
AEROBIC CONDITIONING, ANTIINFLAMMATORY DRUGS.
• PATIENT WITH NEUROGICAL SYMPTOM (RADICULOPATHY)—
EPIDURAL STEROID INJECTION
 OPERATIVE:-

• Indication:- progressive spondylolisthesis (occur in 30-34% patient)

• Worsening symptom after 12 week of physical therapy
• Progressive neurologic deficit or no response to epidural injection
• Only 10-15% patient require surgery.
• Planning:- rule out vascular claudication, degenerative hip arthritis,
peripheral neuropathy
• Standing lateral and AP view xray—instability( 4 mm of translation or
10 degree sagittal rotation greater than adjacent level) Disc space
narrowing.
• Upright flexion extension view– translational motion
• Ferguson ap view –degenerative changes in lumbosacral joint, l5
transverse process is observed
• MRI and CT- look for disc herniation, intraforaminal stenosis, facet
joint effusion>2mm suggest instability,
Operative options
• Decompression alone
• Decompression and posterolateral fusion without fixation
• Decompression and fusion with fixation

FUSION can be done by:-

• Posterolateral in situ fixation
• Posterolateral interbody fusion /PLIF
• Trans foraminal interbody fusion/TLIF
• Anterior interbody fusion/ALIF
• Note: -all these procedure found similar fusion rate and
satisfaction rate BUT
• Posterior instrumentation allows Better fusion rate, better
clinical outcomes
• Preffered is B/Ldecompression and fusion with
posterolateral instrumentation
Decompression: absolute indications

• Neurological deficit
• Non relieving Leg pain
• Sphincter dysfunction
• Claudication

• DECOMPRESSION ALONE
DONE IN elderly patient or with
co morbidities who may not
tolerate added morbidity of fusion
and instrumrentation, osteoporotic
bones
 Decompression:

• The Gill procedure: Removal of the loose

laminar arch(laminectomy) and Foraminotomy
+ facetectomy, removal of fibro-
cartilaginous masses at the pars defects,
removal of adhesions of the dura and
ligamentum flavum, and careful dissection
of the nerve root to be freed through the
intervertebral foramen.

• Associated with ↑ pseudarthrosis rate

Carragee JBJS Am 1997

TREATMENT OF SEVERE (HIGH
DYSPLASTIC) SPONDYLOLISTHESIS

• Most authors agree that slippage of more than 50% requires

fusion.
• the reduction of spondylolisthesis with instrumentation
improves the chance of fusion, but these procedures have
many risks and potential complications/neurological injury
• fusion in situ should be considered a method of choice in
severe L5 isthmic spondylolisthesis.
• Remember: in severe spondylolisthesis, the sacral roots are
stretched over the back of the body of S1 and are sensitive to
any movement of L5 on S1
Grob’s technique: Direct pediculo-body fixation

“In situ” fusion in high grade spondylolisthesis

low incidence of neurological complication
GROB TECHNIQUE

• In situ fusion is a relatively safe and reliable procedure

associated with a high rate of arthrodesis and at lower risk of
neurologic injury .

• Fixation of the segment is achieved by two cancellous bone

screws inserted bilaterally through the pedicles of the lower
vertebra into the body of the upper slipped, vertebra

• In advanced intervertebral disc degeneration

INSTRUMENTED REDUCTION AND FIXATION
Reduction And Fusion In High Dysplastic
Spondylolisthesis With Internal Fixation
TREATMENT OF SPONDYLOPTOSIS

• L5 VERTEBRECTOMY

Resection of the L5 vertebra with reduction of L4 onto S1 described by Gaines and

Nichols in 1985
Decompression and interbody fibular graft
fixation for spondyloptosis
Post op complication

• PSEUDOARTHROSIS:- most common complication- more in smoker,

vit d deficiency, pre op large slip angle, high grade translational
deformity, uncorrected segmental kyphosis, hypoplastic L5
treansverse process , inadequate preparation of fusion bed,
inadequate anterior column support.
• NEUROLOGIC DEFECT:- injury during dissection around compromised
nerve root,mal positioned hardware, cauda equina syndrome due to
hematoma
• Vascular complication
• Infection
POST OP CARE:- PATIENT IS MOBILISED
WITHOUT BRACE FIRST POST OP DAY
THANKS FOR YOUR KIND ATTENTION