This document discusses spondylolisthesis, defined as the anterior or posterior displacement of one vertebra on another. It describes classifications based on anatomy and etiology, radiological grading scales, clinical presentation, diagnostic imaging including X-rays, CT, MRI, and myelography. Treatment options are discussed including non-operative care with bracing and exercise, as well as surgical techniques such as decompression with or without fusion, interbody fusion approaches, reduction methods, instrumentation, and complications. Surgical treatment aims to prevent slip progression, stabilize the segment, correct deformity, relieve pain and reverse neurological deficits.

1. SPONDYLOLITHESIS
Presented by
Mohamed Adel Abdelrazek M Sc
Assistant lecturer of Orthopaedic Surgery
Zagazig faculty of medicine
2016

2. DEFINITION
 Spondylolisthesis by definition is an anterior or posterior
translational displacement of one vertebra on another.
 Due to the body’s center of gravity being anterior to the
lumbosacral joint, slippage occurs as the lumbar spine
rotates around the sacral dome.
 The age of the patient when these defects occur and the
individual’s sagittal alignment of the spine determine to
what degree the deformity progresses.

3. CLASSIFICATIONS
Anatomic classification (according to Wiltse and Rothman

5. CLASSIFICATIONS
Etiology-based classification (according to Marchetti and
Bartolozzi)

6. MEYERDING RADIOLOGICL GRADING
The anteroposterior diameter of the sacrum is separated into quartiles.
Slippage within the first quartile is graded as Grade I, etc., up to the fourth quartile, where
it is Grade IV.
Spondyloptosis is classified as Grade V.

7. CLINICAL PICTURE
Patients with spondylolysis or
spondylolisthesis may be asymptomatic and
never present for medical evaluation.
The severity of the deformity does not always
correlate with the magnitude of pain.
The cardinal symptoms are :
 mechanical low back pain (worse on
motion, better on rest)
 leg pain (sciatica)

8. SYMPTOMS
 Additional but less frequent symptoms are:
 discogenic back pain (worse on sitting and forward
bending)
 facet joint pain (worse on standing and backward
bending)
 numbness and tingling
 motor weakness
 claudication symptoms:

9. SYMPTOMS
 Neurogenic claudication is produced by spinal
stenosis secondary to:
• slippage and
• hypertrophy of the ligamentum flavum and
• facet joints encroaching into the spinal canal.
 Adolescents with symptomatic high-grade
spondylolisthesis often have sciatic pain that can
develop into a sciatic crisis known as:Phalen-
Dixon sign which also includes vertical sacrum
and pelvis, lumbosacral kyphosis, tight hamstrings,
and an unusual pelvic waddling gait

10. SIGNS
 In adults and elderly patients, physical examination may
even be unremarkable and rather depend on secondary
segmental degeneration.
 However, frequent findings are:
 ) tight hamstrings
 ) sensorimotor deficits
 ) pain on backward bending and rotation (often facet joint
pain)
 ) pain on forward bending (often discogenic pain)
 ) pain on extension from the forward bent position
 ) limitation of walking distance
 Pain provocation on specific movements can indicate the
source of the pain although not completely reliable.
 These signs provide a hint as to which structures should be
further explored with spinal injections

11. DEFERENTIAL DIAGNOSIS
 Similar symptoms can also be Induced by spinal
stenosis, central disc herniations or scoliotic
deformities.
 Osteoarthritis of the hip is found in about 15% of
patients with degenerative spondylolisthesis.
 Peripheral vascular disease is common in the
elderly and may cause very similar symptoms to
spinal claudication.
 Diabetic neuropathy can usually be clinically
differentiated from a painful radiculopathy.
 As with all spinal pathologies, radiographs should
be searched for signs of spondylodiscitis or
primary/metastatic tumor disease.

12. RADIOLOGY
Standard Radiographs
 Conventional anteroposterior and lateral radiographs
should be performed as an initial assessment.
 In high-grade spondylolisthesis, the slipped vertebra
contours a shape on the anteroposterior radiograph
similar to an “inverted Napoleon’s hat”.
 Very often the pars defect is already visible on the
lateral view
 If a slippage or pars defect is not clearly visible, oblique
(45° angled) radiographs are helpful. In case of a pars
defect, the “Scottie dog” wears a collar .

14. RADIOLOGY
 Functional radiographs (Dynamic) may give valuable
information concerning spontaneous repositioning of a
slip, which may be useful in planning surgery.
 However, functional views may fail to reliably
demonstrate an instability and the motion within an
olisthetic segment can even be less than in a normal
segment.

15. Conclusion:
Erect flexion and prone traction radiographs represent the extremes of sublu
xation and reduction of the olisthesis, respectively, and the change in olisthe
sis seen between these extremes is correlated with the change in disc area
and the intervertebral slip angle.
Application of the traction radiographic technique in planning for spondylolist
hesis reduction is discussed along with the technique of stabilization.

16. RADIOLOGICAL MEASURMENTS
 Various measurements have been advocated to
closely describe the normal anatomy of the
lumbosacral junction.
 The most important measurements are:
 ) Lumbar Lordosis-Pelvic Incidence Mismatch
 ) Slip angle according to Boxall et al.
 ) Percent of rounding of top of sacrum

19. RADIOLOGY
 Bone scan:in children and adolescents
as they allow the differentiation
between acute (fresh fracture) and
chronic pars defects.
 CT : can demonstrate a pars defect as
well as facet hypertrophy and the
pedicle anatomy (size, trajectory),
which is of importance if surgery is
planned.
Multislice CT with image reformation or
reversed gantry CT techniques are
used.

20. RADIOLOGY
MRI

21. RADIOLOGY
 Functional Myelography:
 It has the advantage of
visualizing the effect of lumber
motion on spinal canal.
 CT myelography has been
surpassed by MRI for the vast
majority of indications.
However, it is helpful in cases
with:
 ) contraindications for MRI
(e.g. pacemaker)
 ) functional stenosis
 ) postoperative (iatrogenic)
spondylolisthesis

22. MANAGEMENT PLANNING
 Risk factors for slip progression and need of
surgical intervention:
 Young age
 High grade slip
 Lumbosacral deformity ( dome)
 30% only of degenerative , post surgical , post
traumatic spondylolithesis progress

23. MANAGEMENT PLANNING
 About 75% of the patients who are initially
neurologically intact do not deteriorate over time.
These are the patients who will respond to a
conservative treatment.
 Conversely, most patients (about 80%) with a
history of neurogenic claudication or vesicorectal
symptoms deteriorate with poor final outcome .
 In view of this, treatment is dependent on the
presence of a neurologic deficit either caused by a
foraminal or a central stenosis.

24. NON-OPERATIVE TREATMENT
 Favorable indications for non-operative treatment
) no neurologic deficit
) high patient comorbidity
) tolerable pain threshold
) improvement by exercise program
) short duration of symptoms
) improvement by brace treatment

25. NON-OPERATIVE TREATMENT
 Acute pain should be controlled with:
) activity modification (bedrest <3 days)
) pain medication
) anti-inflammatory drugs
) muscle relaxing drugs
 This is followed by a therapeutic exercise program with paraspinal
and abdominal strengthening to improve muscle strength, flexibility,
endurance and balance
 The non-operative treatment can be supported by spinal injections
to reduce inflammation and thus temporarily or even permanently
eliminate leg pain:
) epidural blocks
) spondylolysis block
) nerve root blocks
 Bracing should be tried in acute pars fracture
 If there is no neurologic deficit, intensive conservative management
should be tried over a period of at least 3–6 months.

26. SURGICAL TREATMENT
 General objectives of surgical treatment are to:
 Prevent further slip progression
 Stabilize the segment
 Correct lumbosacral kyphosis and restoring spinopelvic parameters
 Relieve back and leg pain
 Reverse neurologic deficits

27. SURGICAL TECHNIQUES
 Spondylolysis Repair
In symptomatic cases with a very slight slippage and a
verified fresh pars defect, an osteosynthesis using the
Morscher screw and hook or direct repair by screw
fixation (Buck’s fusion) or figure of eight wiring (Scott’s
technique) may be justified.
 Decompression without fusion:
Symptomatic disc herniation in the segment L4/5 with
coexistent slip at L5/S1 can be treated by selective
microsurgical decompression at L4/5 alone,
Discectomy in the olisthetic segment should be avoided
due to a high risk of additional destabilization
Foraminal stenosis cannot be addressed selectively
without causing added instability.
If neurologic symptoms necessitate decompression and a
complete laminectomy (Gill’s procedure) is done,
fusion is mandatory because of the destabilization.

28. SURGICAL TECHNIQUES-FUSION
 Slip reduction:
 In low-grade slips it remains uncertain whether an attempt to
reduce the anterior slip is actually necessary or desirable
(Often some degree of reduction is already achieved
spontanoiusly).
 In high-grade slips in the adult:
Partial reduction of the slip angle should be attempted if
significant malalignment and foraminal stenosis is present.
 High-grade slips (Grade III–IV) in children:
The aim of surgery is to correct sagittal alignment and
lumbosacral kyphosis.
By improving the biomechanics, the chances of solid fusion are
significantly increased (being difficult technique with high
complication rate some surgeons favor in situ fusion with
acceptable results)

29. SURGICAL TECHNIQUES
Interbody fusion?
 Especially when repositioning and/or distraction is
performed, an interbody structural support of the
anterior column is crucial
 In cases where the anterior column has not been
addressed biomechanically, fusion rates for
posterolateral fusions vary from 100% to as low as 33%
.
 Even in cases where fusion has been verified, patients
continue to suffer from what is presumed to be
“discogenic back pain”
 Spinal canal decompression adds to the preexisting
instability

30. SURGICAL TECHNIQUES
Interbody fusion?
 Combined approaches can be either posterior or
transforaminal interbody fusion (PLIF or TLIF) or
anterior lumbar interbody fusion (ALIF) along with
posterolateral intertransverse fusion .
 Due to the high degree of primary stability achieved
with the 360° treatment of the spine, fusion rates
are highly reliable with numerous reports claiming
rates of 100%

31. SURGICAL TECHNIQUES
Fusion to L4 ?
 In children with severe developmental
spondylolisthesis at L5/S1 (Meyerding Grades III–V),
reduction can be extremely tedious and may be
facilitated by instrumentation to L4.
This technique allows to distract between L4 and S1,
which facilitates the reduction.
 In adults with marked slips of L5/S1, the adjacent
L4/5 segment frequently exhibits significant
degenerative changes. In these cases, a fusion of L4 to
S1 is indicated because the L4/5 segment often rapidly
decompensates after the L5/S1 fusion.

32. SURGICAL TECHNIQUES
Trans-sacral L5 screw or fibular graft
In cases where L5 pedicle is inaccessable
,L5-S1 can be curetted and fused using
fibular strut graft or 7mm screw through
S1

34. SURGICAL TECHNIQUES
L5 vertebrectomy
 To achieve good spine realignment, surgical treatment
of spondyloptosis, which almost only affects L5/S1, may
necessitate vertebrectomy of L5 (Gaines’ procedure)
 This is a two-stage procedure, first incorporating an
anterior approach with resection of the entire body of L5
back to the base of the pedicles, as well as the
intervertebral discs L4/5 and L5/S1.
 In a second stage, the posterior approach allows
realignment of the spine after L5 pedicles, facets and
laminar arch have been removed bilaterally.
 After transpedicular instrumentation from L4 to S1 and
sagittal realignment, nerve roots L5 and S1 exit the
spinal canal together over a reconstructed intervertebral
foramen.

35. SURGICAL TECHNIQUES
Sacral Dome Osteotomy
 The main risk of reducing high-grade spondylolisthesis
and spondyloptosis is related to the stretching of the L5
nerve roots, which often results in neuropraxia.
 The sacral dome osteotomy helps to avoid this
nerve root injury by shortening of the sacrum.
 This technique consists of a bilateral osteotomy of the
sacral dome, which allows the reduction of the slip
without distraction.
 The operation is carried out in a single stage.
 It is recommended to reduce the slip only far enough to
allow for a good sagittal realignment and an interbody
buttressing by a graft or cage to avoid L5 root palsy

37. SURGICAL TECHNIQUES
Extension to pelvis:
 Indicated in high grade spondylolisthesis.
 Historically , many constructs were described but
modern techniques included : pelvic screws and
more recently S2-alar-iliac screws

39. Conclusion:
Modern iliac screw anchors have low rates of pseudarthrosis but have b
een associated with high rates of implant prominence.
The S2-alar-iliac screw may allow for decreased implant prominence
and inline placement of anchors with proximal spinal instrumentation, red
ucing the need for additional dissection. The rates of pseudarthrosis at the
lumbosacral junction with the S2-alar-iliac technique have been low. It is a
powerful method for obtaining control of the pelvis and achieving lum
bosacral fusion, while minimizing implant and wound problems. Spine sur
geons should be familiar with the indications and techniques of spinopelvi
c fixation to achieve optimal outcomes.

40. COMPLICATIONS
 Common complications after spondylolisthesis
surgery are:
 ) neurologic injury (0.3–9.1%)
 ) persistent nerve root deficits (2–3%)
 ) non-unions (0–39%)
 ) progressive slippage (4–11%)
 ) revision surgery (7.6%)

41. COMPLICATIONS
 If there is obvious compression of neural structures,
from hematoma or misplacement of spinal
instrumentation, immediate revision surgery should be
the consequence.
 Adjacent segment instability after instrumentation
may be due to excessive iatrogenic destabilization of the
overlying facet joint and capsule, due to excessive
thinning or complete removal of the overlying lamina or
due to degenerative changes to the adjacent motion
segment
 Data concerning adjacent segment degeneration are
inconsistent. Incidences are reported to range between
less than 3% and 35%. The discussion remains open as
to whether these observed degenerative changes reflect
the natural history of disc disease or stand in context to
the adjacent fusion