Lumbar Spondylo Listhesis · Spondyloptosis No Surgical Intervention. Bone School @ Bangalore. 16/M...

Lumbar Spondylo ListhesisDilip Gopalakrishnan

Bone School @ Bangalore

Non Physiological Translation

Antero listhesis

Retro listhesis

Lateral listhesis

Spondylo listhesis

Occasional short duration back pain

No neurological deficit

Spondyloptosis

No Surgical Intervention

Disabling back pain

Hamstring tightness

Approaching 50% slip

Dysplastic features

Reduction & inter body fusion

Spondylo Listhesis Varied clinical presentation

ClassificationWiltse , Newman , MacNab

Modified by Wiltse & Rothman

Type 1&2 – Anatomic characteristics of the neural arch

Type 3 to 6 - Acquired pathological conditions

Type-1-Congenital or Dysplastic Spondylolisthesis

Subtype 1A, Horizontal facet joints Spina bifida of L5-S1 Pars intact - Critical narrowing of spinal canal Pars hypoplastic, elongated or broken - No critical

narrowing

Type-1-Congenital or Dysplastic Spondylolisthesis Subtype 1B Sagittal malorientaion of the facet joints Intact neural arch

Type-1-Congenital or Dysplastic Spondylolisthesis Subtype 1C All other congenital malformation of the lumbosacral junction,

including congenital kyphosis

Type-2: Isthmic Spondylolisthesis Subtype 2A Uni or bilateral spondylolysis

Type-2: Isthmic Spondylolisthesis Subtype 2B Elongation of pars interarticularis

Type 3: Degenerative Spondylolisthesis

Type 4: Traumatic SpondylolisthesisBone School @ Bangalore

Type 5: Pathologic Spondylolisthesis

Polymyositis and Osteomalacia

Type 6: Post Surgical Spondylolisthesis Following extensive facet joint removal Stress fracture of weakened inferior articular process

Marchetti & BartolozziDevelopmental

Low Dysplastic

High Dysplastic Lysis or Elongation

Acquired

Exotic

20% -FDR

2:1 F to M

Never seen

Very high incidence

Gymnastics, Throwing sports, Football,Wrestling, Dance, Swimming breast and butterfly strokes

Presentation – Lysis & Low Grade Listhesis

Back pain – commonDullBackButtockPosterior thighGreater trochanter

Pars defectUnstable vertebral segmentDisc degeneration

Radicular lower extremity painLittle or no back pain

L5 or S1 rootParesthesiaweakness(Isthmic)

Physical Signs Back tenderness – not specific Step sign – only in grade 3 or greater Painful limitation of extension Restricted SLR Neurological deficits

Female

Skeletal immaturity

High grade slip

Lumbo sacral kyphosis

Disc degeneration

Associated Conditions Spina bifida occulta

Reactive sclerosis/fracture of contralateral pedicle

Scoliosis

Abnormal disc on MRI

20-70% - Isthmic 40% - Dysplastic

5-7% of all patients Long C shaped Reflex spasm Rarely structural – asymmetric

slippage at LS junction, apex

Meyerding

Slip Angle

Management Spondylolysis

Low grade listhesis

High grade listhesis

Degenerative listhesis

Spondylolysis

Acute Pars Fracture

Bracing

Surgical Treatment

Young individuals (16-30)No evidence of DDDLow back pain onlyLesion at L4 or above

Direct pars repair

Conservative treatment in Young Patients for LGSL

25 % slip – asymptomatic Radiographic evaluation Activity modification

Surgical indication in young patients Failure of conservative treatment – 1yr Tight hamstring with abnormal gait Sciatic scoliosis Progressive neurologic deficit Progressive slipping beyond 25-50% even when

asymptomatic

Conservative treatment - adultsDo not automatically assume that the patients

symptoms are due to the spondylo listhesislook for other causes Short period of rest with rapid return to activities Pain medications No scientific evidence for bracing Exercise – Flexion,Stabilization,Stretching

Surgical TreatmentSix months of conservative treatment fails to improve symptomsMRIDynamic LS spine filmsDiscographySelective nerve root blockFacet/Pars block

Degenerative SL Neurogenic claudication Canal stenosis Back pain Decompression IT or IB fusion

High Grade Spondylolisthesis

Meyerding345Optosis

High Dysplastic Lumbo Sacral Kyphosis

Trapezoidal L5

Dome shaped S1 UEP

Pelvic retroversion Hyper lordosis Dysplastic posterior elements High risk of slip

progression

Lumbo Pelvic Parameters

Pelvic IncidencePI=PT+SS

High SS/Low PTBalanced Pelvis

Low SS/High PTRetroverted Pelvis

Hresko, Labelle, Rousoully - 2005

Pediatric – Growing Years Adult

Symptomatic HGSBone School @ Bangalore

Symptomatic HGS – Growing Years Back pain Sagittal plane imbalance Phalen dixon sign Radicular pain

Cauda equina

Surgical Intervention

High Dysplastic HGS – Growing Years 50% or greater slip Dysplastic features Lumbo sacral kyphosisWith minimal or no symptoms

Still an indication for fusion

High Grade Spondylo listhesis

No one right way of management

Surgical Management In situ fusion

Reduction and fusion

Resection

Posterior approach Combined

Complete Partial

In Situ Fusion Un instrumented

Instrumented

Postero lateral 360 o

Trans vertebral

In Situ – Trans Vertebral - Bohlman

Auto ,Allo – FibulaHollow Modular ScrewCage

Pedicle screw instrumentation

24/25 extremely satisfied patients in SRS questionnaire, Rick. C.Sasso 2007

Reduction Correction of

Pelvic retroversion

Lumbosacral kyphosis (slip angle)

Partial reduction

Complete correction of translation not required

Improving the biomechanical milieu for fusion

Reduction Inter body & Postero lateral

fusion

Anterior column support –Cage

Pedicle screw instrumentation

Extension to L4

Extension to S2

Iliac screws

L 5 Root

Successful Outcome Solid Fusion

L5 VertebrectomyGaines & Nichols SpondyloptosisWith severe symptomatic sagittal imbalance

Spinal shortening surgery

Asymptomatic HGS In Adults Good sagittal balance Distorted posture Bony stabilization – spontaneous fusion

Back pain or radicular pain – Proximal lumbar pathology

Symptomatic HGS in Adults Acceptable sagittal balance

with 3,4, 5

Sagittal imbalance symptomatic

Spondyloptosis

In situ instrumented fusion –PL + Gill laminectomy

Partial reduction and instrumented fusion – 360o, Gill + Sacral dome resection

Bohlman transvertebralfusion, sacral dome resection + Gill & instrumentation

Do not be obsessed with radiological correction

Good decompression & Solid fusion

Summary - LGS Low dysplastic features Back pain , radicular pain Conservative or surgical In situ fusion , Reduction with Instrumented –IT or IB

Stenotic symptoms in DSLDecompression and fusion

Summary - HGS High dysplastic features Symptomatic in growing years – risk of progression Need surgical intervention Reduction and inter body fusion with instrumentation Correction of lumbosacral kyphosis & pelvic retroversion L5 root injury Full reduction of anterior slip not required In situ trans vertebral fusion Gaines procedure In adults cause of pain may be elsewhere

Lumbar Spondylo Listhesis · Spondyloptosis No Surgical Intervention. Bone School @ Bangalore. 16/M...

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