1. Dr. M. M. Prabhakar
Medical Superintendent
Director Govt. Spine Institute
Prof. & Head Department of
Orthopaedics
B. J. Medical college
Ahmedabad

2. Spondylolisthesis
 Definition: Ant. or post. translational displacement
of one vertebral body over another.
 Due to:
1. Trauma
2. Degenerative changes
3. Defects in the bony architecture
congenital or pathological

3. Spondylolisthesis
Type I
 Dysplastic Spondylolisthesis: secondary to a congenital
defect of either the superior sacral or inferior L5 facets
or both with gradual slipping of the L5 vertebra

4. Type II
Isthmic or spondylolytic:
the lesion is in the
isthmus or pars interarticularis,
If a defect in: the pars interarticularis & no slipping
spondylolysis.
If one vertebra has slipped forward: Spondylolisthesis.
Type II A: Lytic or stress spondylolisthesis and is
most likely caused by recurrent micro-fractures
caused by hyperextension. It is also called a "stress
fracture" of the pars interarticularii and is much more
common in males

5. Type II B probably also occurs from micro-fractures
in the pars. However, in contrast to Type II A, the
pars interarticularii remain intact but stretched out as
the fracture fill in with new bone
Type II C is very rare in occurrence and is caused by
an acute fracture of the pars. Nuclear imaging may be
needed to establish diagnosis

6. Type III is a degenerative
spondylolisthesis, and
occurs as a result of the
degeneration of the lumbar
facet joints. The alteration
in these joints can allow
forward or backward
vertebral displacement.
Most often seen in older
patients.
There is no pars defect and
the vertebral slippage is
never greater than 30%

7. Type IV, traumatic spondylolisthesis, is associated
with acute fracture of a posterior element (pedicle,
lamina or facets) other than the pars interarticularis

8. Type V, pathologic spondylolisthesis, occurs because
of a structural weakness of the bone secondary to a
disease process such as a tumor or other bone
diseases

9. Traumatic Listhesis
Traumatic listhesis is rare condition.
Results from Acute fracture of the posterior element
other then pars…
It is fracture dislocation of the spine…involving all
three columns…
It is the shear forces which cause break in the
posterior stabilizers and the force is transmitted at
the level of Intervertebral disc resulting in anterior or
posterior displacement of the vertebral body.

10. Commonly occurs at cervical spine with axis
fractures…resulting in displacement at c2 c3 level
(Hangman’s fracture)
Rare in lumbar spine usually associated with high
velocity trauma.
Above L2 level it is fracture dislocation of the spine
involving all three columns.

11. Pathophysiology

12. Clinical presentation
Severe back pain or neck pain
Leg pain or arm pain dermatomal with associated
neurological deficit
Or combination of both
Restriction of the spine movement

13. Physical exam
Palpation:
 Spasms Paraspinous muscle limiting flex/ext
 Step-off
Tight Hamstrings
Compensatory Hyperlordosis
Waddling gait
Neurological deficits:
 Motor/sensory
 Nerve compression in lat. recesses
 Cauda equina syndrome (rare)

14. Imaging
 X-rays:
1. A/P
2. Lat flex./ext.
–
1.
Supine and standing
Oblique
–
Integrity of the pars “Scotty Dog”

16. Imaging
NORMAL

17. Imaging
 Grading:
1.
2.
3.
4.
5.
6.
0 = no slip
1 = 0 – ¼ (25%)
2 = ¼ - ½ (50%)
3 = ½ - ¾ (75%)
4 = ¾ - 1 (100%)
5=dislocation

19. Imaging
CT scan: evaluate boney pathology
MRI: evaluate soft tissue pathology
Nerve compression
Spinal compression
Disc disruption
SPECT:
(Single photon emission Computer
tomography)
Inconclusive x-rays despite high clinical suspicion
- Acute vs chronic for differential diagnosis

20. CT Image

22. Conservative Treatment
1.
2.
3.
NSAIDS
Bed rest
Steroid injections
Acute phase with neurological involvement.
 Not for long term use

1.
Bracing

23. Conservative Treatment
 Physical therapy:
1.
2.
3.
Physiotherapy
Tilt table mobilization
Muscle strengthening exercise
Only after the acute inflammatory pain subside and
spasm relives…usually after 6 wks.

24. Conservative treatment

25. CT Image Post treatment

26. Surgical Intervention
 GOALS:
1.
2.
Stabilization
Decompression of neural elements

27. Surgical Intervention
 Indications:
 High Grade Slip :
1.
2.
Cosmetic
Gait abnormalities
 Failure of conservative management:
1.
2.
3.
4.
Severe pain
Radiological evidence of instability
Documented progression of slip
Progression of neurologic signs

28. Surgical Intervention
 Contradictions:
1.
2.
3.
4.
Smoking
Disability/compensation claims, litigation
Previous fusions, pseudoarthrosis repairs
Predictors Poor Outcome:
–
–
–
–
–
Male
Middle age
Cigarettes
Multiple surgeries
Compensation/ litigation

29. Surgical Intervention
 Complications:
1. Bone graft, chronic pain 5% pts.
2. Fusion, pseudoarthrosis, bleeding, infection
3. Instrumentation, loss of fixation, loosening and
bone screw interface, implant breakage
4. Decompression (neural elements), nerve damage,
dural tears, arachnoiditis, surgical scars

30. Surgical Intervention
Decompression with Posterior Lateral Fusion:

1.
2.
3.
Younger pts (30 y.o.)
Intact vertebral disk
Fusion:
–
–
1.
In situ
Pedicle screws
McGuire and Anderson:
–
–
–
–
–
27 pts, military recruits
Stable, low grade slips
No difference in fusion rate with in situ vs pedicle screws
Smokers less effective outcomes (40% nonunion)
Fusion did not determine success 67% went back to military
service, decrease leg and back pain

31. Surgical Intervention
Ant. Column support and Posterior Stabilization:
Interbody Graft techniques:
Mini-laportomy retroperitoneal
 Requires separate incision
 Post. Trans-foraminal approach

Post lateral fusion with pedicle screws
Post. Trans-foraminal approach:
Decompression and stabilization 1 approach
 Decreased risk of neural compromise


32. Surgical Intervention
Ant. Column support and Posterior Stabilization:
Spruit et alt.
21% pre-op slips 7 % post op
100% fusion rates
75% returned to pre injury activity

33. Surgical Intervention

34. Surgical Intervention
Reduction of High Grade
Spondylolisthesis/Spondyloptosis
Advocated by some authors
Improve cosmesis
 Correct slip angle
 Improve kyphosis

No need to perform in adults
HIGH rate of neural compromise
Don’t do it!!!!!

35. Hangman’s Fracture
Younger age group (Avg 38 yrs)
Usually due to hyperextension-axial compression
forces (windshield strike)
Neurologic injury seen in only 5-10 %
(acutely decompresses canal)
Traditional treatment has been Halo-vest
Collar adequate if < 6 mm displaced
Coric et al JNS 1996

36. Hangman’s Fracture
 Traumatic spondylolisthesis of
C2.
 The fracture line passes through
the neural arch.
 It may or may not result in ant.
displacement of C2 on C3.
 Most commonly caused by a
Motor Vehicle accident and a
fall.
 Current classification (Levine &
Edwards) is based on
radiological findings: 4 types are
described and each category has
different mechanism of trauma.

37. Type I
Mechanism: hyperextension – axial loading
Integrity of ALL, PLL, and Disc
No angulation.
Displacement < 3 mm
Stable fracture: Collar.

38. Type II
Significant angulation and translation.
Extension – axial loading followed by flexion.
Most common type
Unstable: halo vest.

39. Type IIA
Significant angulation
No translation
Flexion – distraction
Unstable: Halo vest

40. Type III
Severe angulation and translation + unilateral or bilateral C2-3 facet dislocations.
Flexion – compression.
Unstable fractures: Surgical reduction and fixation.

41. Treatment
Low grades like type I and Type II are treated
conservatively
Skull traction (contra indicated in IIA causing
distraction and further damage)
Cervical collar/ SOMI brace
Halo traction device
High grade type II facture require surgical
intervention
Open reduction, fixation and fusion
Trans pedicular screw fixation for motion preservation
in type II fracture

42. Direct pars screw:
the C2 pedicle should be
palpated using a fine
dissector after removal of
soft tissues.

43. Key points
Conservative treatment is mainstay
Progression of slip rarely occurs
Decompression and fusion give excellent results
for radiculopathy and back pain
4. Fusion 360 degrees increases fusion rates but
does not correlate with better outcomes
5. Poor outcomes in high grade of cervical
listhesis.
1.
2.
3.

44. THANK YOU