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Spondylolisthesis and DDx
1. Spondylolisthesis
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Mohammed Nabil Al Ali, Majid AL-DanDan ,
Hassan Mohammed Al Awadh, Ahmed Faisal Alkhazal ,
Mohammed Saleh Al Saeed, Mohammed Faisal Alkhazal
Free Powerpoint King Faisal University , AlHassa
5th Year Medical Students , AtTemplates
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3. OVERVIEW (definition)
The word spondylolisthesis is derived from
the Greek words spondylo , meaning spine,
.and listhesis , meaning to slip or slide
⢠It is a descriptive term referring to slippage
(usually forward) of a vertebra and the spine
above it relative to the vertebra below it
⢠It lead to a deformity of the spine as well as a
narrowing of the spinal canal (central spinal
stenosis) or compression of the exiting nerve
roots (foraminal stenosis).
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4. OVERVIEW ( Anatomy )
Spinous
process
Articular process
(inferior)
Pars
interarticulars
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9. PATHOPHYSIOLOGY
⢠Spondylolisthesis occurs
when thereâs bilateral
defects in the vertebral
pars intrarticulariss which
permit the vertebral body to
slip anteriorly. Usually
occurs at level (L5,S1)
⢠Spondylolysis is the
most common cause for
spondylolisthesis. Itâs a
unilateral or bilateral defect
in the vertebral pars
interarticularis result from
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stress fracture.
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10. ⢠spondylolysis typically is acquired as the
bone "fatigues" from recurrent
microtrauma during excessive lumbar
hyperextension or repeated lumbar
flexion and extension.
⢠rebeated Hyperflextion and extension of
the joints are more common in athletes.
⢠(diving, weight lifting, wrestling and
football) Free Powerpoint Templates
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11. ⢠Spondylolysis progresses to
spondylolisthesis in approximately
15% of cases. Progression to
spondylolisthesis is correlated with
persistent pain and lack of healing.
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12. TYPES ( according to etiology )
It can be classified into 6 distinct
categories as the following
( developed by Wiltse, Macnab, and Newman ):
ďąType I: Congenital spondylolisthesis
ďąType II: Isthmic spondylolisthesis
ďąType III: Degenerative spondylolisthesis
ďąType IV: Traumatic spondylolisthesis
ďąType V: Pathologic spondylolisthesis
ďąType VI Free Powerpoint Templates
: Postsurgical
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13. Type I: Congenital spondylolisthesis
⢠characterized by presence of dysplastic
sacral facet joints allowing forward
translation of one vertebra relative to
another.
Type II: Isthmic spondylolisthesis
⢠Caused by the development of a stress
fracture of the pars interarticularis.
⢠It is also further divided into 3 subtypes :
Type IIA , type IIB and type IIC .
Type III: Degenerative spondylolisthesis
It is commonly caused by intersegmental
instability producedTemplates arthropathy.
by facet
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14. Type IV: Traumatic spondylolisthesis
Caused by fracture or dislocation of the
lumbar spine, not involving the pars
Type V: Pathologic spondylolisthesis.
Caused by malignancy, infection, or other
types of abnormal bone
Type VI : Postsurgical (iatrogenic)
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16. Generally
â˘Approximately 82% of cases of isthmic
spondylolisthesis occur at L5-S1.
Another 11.3% occur at L4-L5.
⢠Heavy Athletic activities requiring predispose
some athletes to developing pars defects.
⢠Degenerative spondylolisthesis occurs more frequently
with increasing age.
⢠The L4-L5 interspace is affected 6-10 more times than
any other level.
⢠Sacralization of L5 is frequently seen with L4-5
degenerative spondylolisthesis .
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17. Mortality/Morbidity
⢠Increased mortality is not associated with
spondylolisthesis.
⢠The most common morbidity is persistent
low back pain or nerve impingement.
⢠Degenerative spondylolisthesis produces
characteristic arthritic symptoms that may
worsen with age.
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18. Race
Isthmic spondylolytic defects
affect roughly 1.1% of black females.
⢠The most commonly affected group is the white
male with an incidence of 6.4%.
⢠Arkara Plains Indians and Aleut people groups
have a very high incidence of spondylolytic defects,
due to a combination of genetic and environmental
factors.
Degenerative spondylolisthesis
affects black females more
commonly than white females( females more
affectedFree Powerpoint Templates
than males).
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19. Sex
⢠Congenital spondylolisthesis (dysplastic type)
occurs with a 2:1 female to male ratio with
symptoms beginning around the adolescent
growth spurt. These comprise about 14-21%
of all cases of spondylolisthesis
⢠Degenerative spondylolisthesis
occurs more commonly in females with a 5:1
female to male ratio. The incidence increases
after age 40 years.
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20. Age
â˘Acute isthmic spondylolysis often occurs
during the first and second decades of life.
Most cases occur before the patient reaches
age 15 years.
⢠Younger patients are at higher risk than
older patients for developing progressive
spondylolisthesis.
â˘But the risk for progression in adults is rare
when the lesion is at L5..
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21. ⢠In contrast, lesions at L4-5 may progress
into adulthood because of increased sagittal
rotation, shear translation, and axial
rotation at this segment
â˘Congenital/dysplastic spondylolisthesis has
been documented in children as young as 3.5
months. More commonly, congenital
spondylolistheses go undiagnosed until later
in life after an individual has been ambulating
for quite some time.
â˘Degenerative spondylolisthesis occurs most
commonly after age 40 years.
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23. Symptoms
1-The patient is usually asymptomatic.
2- unlikely cause back pain in adults (especially
after age 40 y) with no history of symptoms before
age 30 years
3-Low back pain is the most common
symptom , and it is often exacerbated by
motion, The patient may report relief of pain
with extended periods of rest.
4- it is associated with numbness and tingling
in the legs (L5 or S1 distribution) and leg pain.
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24. Signs
1-Tenderness to deep palpation of the
spinous process above the slip (typically L4)
& causes radicular pain due to palpation.
2- muscle tightness (Tight hamstrings muscle)
that is associated with all grades of
spondylolisthesis occurs at a rate of 80%.
It commonly results in an abnormal gait
& inability of the patient to flex the hip
with the knees extended.
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25. 3- Paraspinal muscle spasm and tenderness
are usually present.
4- Limited forward flexion of the trunk is
common with reduced straight-leg raising,
which may cause pain
5- Postural deformity and a transverse
abdominal crease are seen as a result of the
pelvis being thrust forward.
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26. 6- Patients with degenerative spondylolisthesis
(DSPL) are characterized by an increased
pelvic tilt (PT) and decreased sacral slope
(SS) than the control population, suggesting
the presence of a pelvic compensation
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27. PHYSICAL EXAMINATION
1-Phalen-Dickson sign:
bent-knee, hip-flexed posture with high-grade
spondylolisthesis
2-One-legged hyperextension test (stork test):
Use To differenation between
spondylolysis (+) and spondylolisthesis(-)
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28. 1-Phalen-Dickson sign:
With increasing slippage, the sacrum
becomes relatively more vertical, impairing
hip extension and compelling the patient to
walk with a knee-flexed, hip-flexed gait
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29. 2-One-legged hyperextension test (stork test):
A positive one-legged hyperextension test
while standing on one leg and bending
backward, pain is experienced in the
ipsilateral back.
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30. DIAGNOSIS
In most cases it is not possible to see visible
signs of spondylolisthesis by examining a
patient.
Patients typically have complaints of pain in
the back with intermittent pain to the legs.
Spondylolisthesis can often cause muscle
spasms, or tightness in the hamstrings.
Spondylolisthesis is easily identified
using plain radiographs.
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32. DIAGNOSTEC TESTS
1- Radiography:
lateral view of lumbar spine is especially useful
in detection Spondylolisthesis.
2- Computed Tomography:
CT SCANNING axial or sagittal image of the
lumbar spine can be performed with or without
contrast enhancment.
3- Magnetic Resonance Imaging(MRI):
has the distinct advantage of imaging of the
spine in any plane. Typically, the axial and
sagittal planes are used.
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34. Spondylolisthesis. Oblique projection radiograph shows the presence of
bilateral pars defects (arrows), with an appearance resembling a Scottie
dog with a collar. (The collar is the pars defect.)
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35. A) -Lateral lumbar spine. Note the pars defects (arrow)
and anterior displacement of the L5 vertebra.
B) -Oblique lumbar spine. Observe the clearly visible
lucent collar (arrow). Templates
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36. Sagittal CT reconstruction
image shows the pars
defect along with grade 1
spondylolisthesis.
Spondylolisthesis. Axial CT image
shows bilateral spondylolysis
(arrows). Note elongation of the
spinal canal at this level
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38. Lumber facet-arthropathy
⢠is degenerative arthritis affecting the
facet joints in the spine
⢠Low back pain can radiate to gluteal,
back of the thigh and rarely below the
knee.
⢠was no numbness, no muscle
weakness and the reflexes were
normal.
⢠Stiffness
⢠Poor posture
⢠Radiography: CT and X-ray
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39. Axial CT
ďź marked osteophytosis and joint space narrowing
ďź severe osteoarthritis
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40. X-ray
ďź A mild scoliosis was
clearly present.
ďź marked fixation in the
opposite (right) sacroiliac
joint, and at the L5-S1
joint (the lumbo-sacral
joint). L4 was tender on
palpation.
ďź Forward bending caused
moderate pain in her
back and gluteal.
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41. Coccyx pain
⢠Coccydynia is inflammation localized
to the tailbone pain and tenderness
at coccyx.
⢠The pain is often worsened by sitting.
⢠Patient leaning against the buttocks
⢠Radiography: CT and X-ray
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42. Lateral radiograph (a) and sagittal CT reconstruction (b)
demonstrating a fractured coccyx in a patient who was
diagnosed with coccydynia following a ground-level fall
6 months earlier
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43. Lumber compression Fracture
⢠fracture of lumber spine due to
trauma or pathological fracture in
osteomyelitis.
⢠Common in woman who is near
or over age 50 .
⢠Sudden back pain radiate to
lower limb. numbness and motor
weakness in lower limb if nerve
roots is affected
⢠Radiography: CT and X-ray
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44. Lumber canal stenosis
⢠congenital narrowing of the lumbar
spinal canal.
⢠low back pain,
⢠weakness, numbness, pain, and loss of
sensation in the legs.
⢠worse pain in standing or walking and
backward. It is relieved by sitting and
forward.
⢠sphincteric function impairment.
⢠Negative straight leg raising test
⢠Radiography: X-ray, CT and MRI
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45. X-ray
⢠loss of the normal
intervertebral disc height
⢠the presence of bone
spurs (osteophytes)
⢠spinal instability
(abnormal motion
between the vertebrae).
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47. Disk Herniation
⢠Herniation of the nucleus pulposus
(HNP) through an anular defect due to
wear and tear or a sudden injury
I. Low back pain.
II. Leg pain
â Coughing and sneezing aggravates the
leg pain.
â aggravated by sitting, prolonged
standing.
â relieved by walking, lying down
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48. IV. Nerve-related symptoms:
-Numbness and weakness in the area which
the nerve supply
-in the lower part of lumbar spine: sciatica .
-in the upper part of the lumbar spine: pain in
the front of the thigh
-loss of bladder and/or bowel control, which
are symptoms of a specific and severe type
of nerve root compression called cauda
equina syndrome.
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49. ⢠In Lateral disc herniation:
In L5 root affection: pain radiates on the dorsum and
the base of the big toe.
in S 1 root affection: pain radiate to the sole of the foot.
⢠In central disc herniation:
⢠hyposthesia bilaterally
⢠ankle reflex is lost bilaterally and also may be
the knee reflex.
⢠a foot drop with bilateral dorsi flexor weakness
ďś In Physical Examination:
⢠Straight leg raise (SLR) test. +ve
⢠Femoral stretch test +ve
⢠Difficult tip toe walking and heel walking
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ďś Radiography: MRI and CT
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50. MRI
HNPs appear as focal, asymmetric
high signal intensity in the posterior
protrusions of disk material beyond
anulus is often seen on sagittal T2the confines of the annulus
weighted
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53. ď Treatment for spondylolisthesis
depends on several factors,
including the age and overall health
of the person, the extent of the slip,
and the severity of the symptoms.
ď Treatment most often is conservative
and more severe spondylolisthesis
might require surgery.
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54. 1.Conservative treatment
o Bed rest.
o Avoidance of activities if there is >25% slippage.
o Non-steroidal anti-inflammatory drug (NSAID).
o Epidural steroid injections(ESI)
ďźGenerally, an ESI is given only when other
treatments aren't working.
o A brace or back support might be used to
help stabilize the lower back and reduce pain.
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55. o Physical therapy:
Stabilization exercises are the
mainstay of treatment. These exercises
strengthen the abdominal and/or back
muscles, minimizing bony movement of
the spine.
ďźThese measures only provide
temporary relief.
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56. 2. Surgical treatment
ď Surgery might be necessary if the
vertebra continues to slip or if the pain is
not relieved by conservative treatment
and begins to interfere with daily
activities.
ď The main goals of surgery for
spondylolisthesis are:
1) to relieve the pain associated with an irritated
nerve,
2) to stabilize the spine where the vertebra has
slipped out of place,
3) and toFree Powerpoint Templates ability to function.
increase the personâs
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57. ďThe main types of surgical
treatmen for spondylolisthesis
include:
1) laminectomy (decompression)
2) Fusion
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58. 1. Laminectomy
ď When the vertebra slips forward, the
nearby nerves that exit the spine can
become pinched or irritated.
ď In addition, the size of the spinal
canal in the problem area shrinks,
placing pressure on the nerves
inside the canal.
The goal is remove the lamina and
release pressure on the nerves .
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59. Types of laminectomy :
A. traditional open lumbar
laminectomy :
ďź the two laminae and spinous process
of a vertebra are removed to relieve
excess pressure on the spinal nerves
in the spine.
B.METRx Minimally Invasive
Hemilaminectomy:
ďź It involves removing part of one of the
two laiminae on a vertebra to relieve
excess pressure on the spinal nerve(s) in
the lumbar spine.
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60. 2. Fusion
ď A spinal fusion is normally done
immediately after laminectomy for
spondylolisthesis.
ď It is designed to fuse the two vertebrae
into one bone and stop the slippage from
worsening.
ď The fusion is used to lock the vertebrae
in place and stop movement between
the vertebrae.
⢠Types :
A.
Traditional Fusion
B. Minimally invasive surgical spine fusion
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61. A. Traditional Fusion
ďź The vertebrae are affixed to one another
using surgical instrumentation.
ďź Bone graft is then placed between the
vertebrae allowing them to "fuse" together
over time.
ďź This stabilizes the painful joint segment
and relieves pressure from the painful
spinal nerves
Examples :
1. Postero-lateral fusion (PLF)
2. Posterior Lumbar Interbody Fusion(PLIF)
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62. 1. posterolateral fusion (PLF)
ď posterolateral fusion is the grandfather of fusion
technique as it was developed just over 100
years ago.
ď In a posterior approach to lumbar fusion, the
surgeon makes an incision down the middle of
the lower back.
ď One of the criticisms of PLF is that it involves an
extensive dissection (the stripping of muscle and
fascia off of bone) of the adjacent transverse
processes, facet(s) and sometimes lamina.
ď After the decompression, the surgeon will place
graft material along the sides of the vertebrae to
stimulate bone growth.
ď Titanium screws and rods are often used to
provide immediate stability to the spine until a
Free has been achieved
solid fusionPowerpoint Templates .
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63. 2. Posterior Lumbar Interbody
Fusion(PLIF):
ď In this procedure, the problem vertebrae are
fused from the anterior (front) and posterior
(back).
ď The surgeon works from the back of the spine
and removes the disc between the problem
vertebrae.
ď Bone graft material is inserted from the back
of the spine into the space between the two
vertebrae where the disc was removed (the
interbody space)
ď Transpedicular instrumentation is attached to
stabilize the motion segment while fusion
occurs.
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64. B. Minimally invasive surgical
spine fusion
It allows the surgeon to make smaller
incisions in the skin and avoid large
muscle retraction.
⢠Transforaminal Lumbar Interbody Fuision (TLIF):
o It is arguably an important improvement on
traditional PLIF, because it minimizes nerve root
and thecal sac retraction/damage and necessitates
less osseous and soft tissue dissection.
o This technique approaches the epidural space from a more
posterolateral direction, taking out the facets on one side and
only part of the lamina.
o The bony endplates are scraped until rough and the space
is filled with a plastic or metal cage and bone chipes to
achieve a fusion between the vertebral bodies.
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65. Complications of surgical repair
o Implant failure.
o Pseudoarthrosis.
o Nonunion.
o Foot drop.
o Spinal compression.
o Acute bowel ischaemia
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66. SUMMARY
- Spondylolisthesis is a forward or backward
slippage of one vertebra on an adjacent vertebra.
- Causes of spondylolisthesis include trauma,
degenerative, tumor, and birth defects.
- Symptoms of spondylolisthesis include lower
back or leg pain, hamstring tightness, and
numbness and tingling in the legs.
- diagnosis is mainly based on imaging .
- Most people with spondylolisthesis can be treated
conservatively, without the need for surgery.
- Patients who fail to improve with conservative
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treatment may be a candidate for surgery. Page 66
67. REFERENCES
All refrences are written under each side
but mostly we depended on :
- Emedicine
- Uptodate
- http://www.mdguidelines.com/spondylolisthesis
- medicinenet
[
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Bilateral pars defects at the L4 vertebra allow anterior displacement of the body and pedicles. The intact upper lumbar segments (L1-L3) move in unison with the displaced L4 body and pedicles, leaving the rest of the L4 neural arch behind, which will be palpated as the prominent spinous process
Phalen-Dickson sign demonstrating bent-knee, hip-flexed posture with high-grade spondylolisthesis.