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Average 4.0 of 41 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 64-year old female presents with severe low back pain and bilateral leg pain, worse on the right. An AP and lateral radiograph in extension are shown in Figures A and B respectively. After extensive nonoperative management fails to provide any significant pain relief, surgical intervention is performed. A laminectomy and instrumented fusion is performed and shown in Figure C. What would be the most likely neurologic deficit found in the postoperative period?
Weakness to ankle plantar flexion.
Weakness to great toe extension
Weakness to Hip Flexion
Loss of the patellar reflex
Bowel and bladder dysfunction saddle anesthesia
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The clinical scenario is consistent with a Grade 2 adult isthmic spondylolisthesis that was treated with reduction and fusion. The L5 nerve root is at greatest risk of injury, and would present with weakness to great toe extension.
Adult isthmic spondylolisthesis at L5/S1 often leads to radicular symptoms caused by compression of the exiting L5 nerve root in the L5-S1 foramen. Compression can be caused by hypertrophic fibrous repair tissue of the pars defect, uncinate spur formation of the posterior L5 body, or bulging of the L5/S1 disc.
Petraco et al. performed a cadaver study looking at the effects of reduction of an adult isthmic spondylolisthesis on the L5 nerve root. They found that injury to the L5 nerve with reduction of a high-grade spondylolisthesis is not linear; with 71% of the total L5 nerve strain occurring during the second half of reduction. They suggest partial reduction may be a significantly safer treatment approach for high-grade spondylolisthesis than complete reduction.
Jones et al. review adult isthmic spondylolisthesis. They report most symptomatic cases are successfully managed nonsurgically, but patients with intractable pain or neurologic symptoms may benefit from surgical decompression and stabilization. Surgical intervention has shown >80% success in appropriately selected patients, with a low incidence of complications.
Figure A and B show radiographs of Grade 2 Adult isthmic spondylolisthesis. Figure C shows reduction of the Grade 2 slip with placement of pedicle screws and an interbody device.
Answer 1: Weakness to ankle plantar flexion would be caused by injury to the S1 nerve root.
Answer 3: Weakness to Hip Flexion would be caused by injury to the L2 and L3 nerve root.
Answer 4: Loss of the patellar reflex would be caused by an injury to the L4 nerve root.
Answer 5: Bowel and bladder dysfunction saddle anesthesia is characteristic of a cauda equina syndrome.
Petraco DM, Spivak JM, Cappadona JG, Kummer FJ, Neuwirth MG
Spine. 1996 May;21(10):1133-8; discussion 1139. PMID: 8727186 (Link to Abstract)
Petraco, SPINE 1996
Jones TR, Rao RD.
J Am Acad Orthop Surg. 2009 Oct;17(10):609-17. PMID: 19794218 (Link to Abstract)
Jones, JAAOS 2009
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Average 4.0 of 12 Ratings
A correlation has been found between Pelvic Incidence (PI) and spondylolisthesis. Based on the angles X,Y, and Z shown in Figure A, B, and C, which of the following most accurately determines the Pelvic Incidence (PI) in this patient?
Angle Z + Angle Y
Angle X - Angle Y
Angle X - Angle Z
Pelvic Incidence (Angle X) = Pelvic Tilt (Angle Z) + Sacral Slope (Angle Y) as shown in Answer 1.
Of the spinopelvic radiographic measurement, Pelvic Incidence (PI) correlates strongest with isthmic spondylolisthesis grade. PI is the angle subtended by an initial line from the center of the femoral head to the midpoint of the sacral endplate and a second line perpendicular to the center of the sacral endplate. PI is relatively constant during childhood (~47 degrees), increases during adolescence, and remains constant in adulthood (~57 degrees). Unlike many other parameters of pelvic morphology, PI is not affected by changes in posture. A low PI indicates low shear forces at the lumbosacral junction and less lumbar lordosis.
Hanson et al reviewed 40 patients with spondylolisthesis, comparing sagittal alignment, sacral inclination, slip angle and Pelvic Incidence. They concluded that PI was significantly higher in patents with spondylolisthesis and correlated significantly with Meyerding grade.
Labelle et al reviewed the radiographic measurements in L5/S1 spondylolisthesis. They determined that pelvic shape, best defined by PI, determines the position of the sacral endplate which in turn is increased in patients with spondylolisthesis.
Illustration A shows the Pelvic Incidence on an illustration.
Answer 2: Angle X - Angle Y = Pelvic Tilt (Angle Z)
Answer 3: Angle X - Angle Z = Sacral Slope (Angle Y)
Answer 4: Angle Z = Pelvic Tilt
Answer 5: Angle Y = Sacral Slope
Labelle H, Roussouly P, Berthonnaud E, Dimnet J, O'Brien M
Spine. 2005 Mar;30(6 Suppl):S27-34. PMID: 15767882 (Link to Abstract)
Labelle, SPINE 2005
Hanson DS, Bridwell KH, Rhee JM, Lenke LG
Spine. 2002 Sep;27(18):2026-9. PMID: 12634563 (Link to Abstract)
Hanson, SPINE 2002
Average 2.0 of 72 Ratings
Studies have shown a direct relationship between pelvic incidence and isthmic spondylolisthesis, suggesting that pelvic anatomy has a direct influence on the development of this condition. Which angle in Figure A-E best illustrates the measurement of pelvic incidence.
Angle E (Figure A)
Angle X (Figure B)
Angle Z (Figure C)
Angle Y (Figure D)
Angle V (Figure E)
Angle X (Figure B) demonstrates the measurement of pelvic incidence.
Recent studies have shown a direct linear relationship between pelvic incidence and the severity of the spondylolisthesis, suggesting that pelvic anatomy may have a direct influence on the development of an isthmic spondylolisthesis.
Hanson et al. found pelvic incidence was significantly higher in patients with low- and high-grade isthmic spondylolisthesis as compared with controls and had significant correlation with the Meyerding–Newman grades.
Labelle et al. reviewed the clinical significance of pelvic incidence, and described how pelvic incidence (PI) can be calculated as the sum of Pelvic Tilt (PT) and Sacral Slope (SS).
Illustration A illustrates the relationship between these angles.
Answer 3: Angle Z (Figure C) shows the measurement of pelvic tilt.
Answer 4: Angle Y (Figure D) shows the measurement of sacral slope.
Answer 5: Angle V (Figure E) shows the measurement of the slip angle.
Average 3.0 of 29 Ratings
You are seeing a 28-year-old female for lower back pain after she fell off a horse 2 days ago. She has no neurologic deficits. A lateral radiograph and axial CT scan are shown in Figures A and B, respectively. What is the most appropriate first line of treatment?
Observation, mobilization, and further treatment based on symptoms
Spinal casting and bed rest for 6 weeks
Thoracolumbosacral orthosis for 6-8 weeks
Open reduction and internal fixation
L5 to S1 posterior spinal fusion with instrumentation
Lumbar spondylolysis or spondylolisthesis is present in up to 5% of the population. It is thought to "occur" in the first or second decade and remain asymptomatic in many people until some later event. The first line treatment for adults with spondylolysis or spondylolisthesis is observation, mobilization, and further treatment based on symptoms.
Virta et al. report on a cohort of 20 women and 26 men with spondylolisthesis derived from a population of 1147 45 to 64-year-old subjects. Their data suggest that mild-moderate spondylolisthesis detected by chance in a middle-aged population does not predispose to more disabling back pain than controls without spondylolisthesis. They did find however that women with spondylolisthesis had mild back symptoms more often than controls.
O'Brien reviews the diagnosis, pathophysiology, progression, and treatment of both isthmic and lytic spondylolisthesis in his 2003 instructional course lecture.
Instr Course Lect. 2003;52:511-24. PMID: 12690877 (Link to Abstract)
Virta L, Rönnemaa T.
Spine (Phila Pa 1976). 1993 Sep 1;18(11):1496-503. PMID: 8235822 (Link to Abstract)
Virta, SPINE 1993
A 26-year-old male presents with chronic back and bilateral leg pain that has not improved with extensive nonoperative management including physical therapy, oral medications, and corticosteroid injections. Radiographs are shown in Figure A. What is the most appropriate next step in treatment?
Placement of epidural spinal stimulator
Lumbar decompression alone
Lumbar decompression with L5 to S1 posterior lumbar fusion
Lumbar decompression, L4 to S1 posterior lumbar fusion, and anterior column support
Minimally invasive direct lateral interbody fusion with percutaneous pedicle screw placement
The clinical presentation and imaging studies are diagnostic of a high grade spondylolisthesis that has failed nonoperative management. Surgery is indicated, and the procedure of choice is a posterior lumbar decompression with an instrumented fusion from L4 to S1 with anterior column support.
The Meyerding classification, shown in Illustration A, is used to determine the Grade. Grade I and Grade II are considered Low Grade. Grade III, IV, and V are considered High Grade. Surgical treatment differs between Low Grade and High Grade.
DeWald et al performed a retrospective study of 21 patients with high grade spondylolisthesis. They recommend in situ posterior instrumentation from L4 to S1 with anterior column support. Anterior column support can be performed, anteriorly or posteriorly, either by using intervertebral body structural strut support or with a trans-sacral fibular dowel to improve stability and success of arthrodesis.
Reduction of the slipped vertebrae remains controversial for all grades of spondylolisthesis. Lenke and Bridwell argue that partial reduction aiming to improve the slip angle (lumbosacral kyphosis) is more beneficial and provides less risk to the L5 nerve roots than complete reduction. They also recommend anterior and posterior spinal fusion at L5-S1.
Lenke LG, Bridwell KH.
Instr Course Lect. 2003;52:525-32. PMID: 12690878 (Link to Abstract)
DeWald CJ, Vartabedian JE, Rodts MF, Hammerberg KW.
Spine (Phila Pa 1976). 2005 Mar 15;30(6 Suppl):S49-59. PMID: 15767887 (Link to Abstract)
DeWald, SPINE 2005
Average 4.0 of 28 Ratings
HPI - fell from a height years ago, neglected till pain became worse ,morning stiffness started one year ago ,pain now is uncontrollable with NSAID. also she took lots of muscle relaxants but, improvement was temporary and very little
patient own words"while walking", i feel a click on my lower back, like friction of 2 objects".
-pain has been felt for one year now
-she is a house wife with 3kids, she has a lot of work to do every day with no help.
How would you treat this Grade 1 adult isthmic spondylolithesis with back pain only, and a negative neurologic exam.
HPI - The patient presents with severe bilateral buttock pain that makes it difficult for her to walk. She is comfortable when sitting, but can not stand upright due to the pain radiating into her buttocks and posterior thighs.