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Average 4.3 of 44 Ratings
A 12-year-old gymnast has had progressive low back and buttock pain refractory to conservative management for two years. A sagittal MRI is shown in Figure A. Surgical management with reduction of L5 on S1 would most likely lead to which of the following neurologic complications?
Decreased patellar reflexes
Weakness to hip flexion
Weakness to great toe extension
Weakness to knee extension
Weakness to ankle plantar flexion
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The patient described in the clinical scenario has a high-grade L5/S1 spondylolisthesis. Surgical reduction of this condition places the L5 nerve root at risk. Injury to the L5 nerve root can manifest as weakness to hip abduction, EHL, and tibialis anterior (dual innervation with L4). Sensory manifestations would include pain or paresthesia over the lateral calf and dorsal foot.
Cheung et al reviewed spondylolysis and spondylolisthesis in adolescents. They recommended in-situ L5 to S1 posterolateral fusion for low-grade (<50%) slips that have failed non-surgical management. Although still controversial, they recommend in-situ L4-S1 fusion for high-grade slips.
Lonner et al addressed the pros and cons of surgical reduction for high-grade pediatric spondylolisthesis. In their review of five patients who underwent decompression and reduction, two had L5 nerve root deficits which resolved within three months. Benefits of reductions included decrease in slip progression, restoration of sagittal balance, regional balance and improved clinical outcomes.
Petraco et al performed a cadaveric study to quantify the change in length of the L5 nerve root associated with reduction of spondylolisthesis. They found that the risk of stretch 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 infer that partial reduction may be a significantly safer treatment approach for high-grade spondylolisthesis than complete reduction.
1. Decreased patellar reflexes would be caused by an L4 nerve injury.
2. Weakness to hip flexion would be caused by injury to L1-3.
4. Weakness to knee extension would be caused by an L4 nerve injury.
5. Weakness to ankle plantar flexion would be caused by an S1 nerve injury.
Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD.
J Am Acad Orthop Surg. 2006 Aug;14(8):488-98. PMID: 16885480 (Link to Abstract)
Cheung, JAAOS 2006
Lonner BS, Song EW, Scharf CL, Yao J
Am J. Orthop.. 2007 Jul;36(7):367-73. PMID: 17694184 (Link to Abstract)
Lonner, AJO 2007
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
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Average 4.0 of 23 Ratings
A 17-year-old high school football lineman was diagnosed with the condition shown in the Figure A radiograph. He continues to have pain despite 6 months of wearing a custom lumbar spine orthotic (LSO) and avoiding all sports activities. His physical exam is notable for pain with single-limb standing lumbar extension and a normal neurologic exam. How would the surgical management differ if this condition occurred at L3 instead of L5?
Pars interarticularis repair is indicated
Lumbosacral fusion is indicated
Gill procedure is indicated
Combined anterior interbody fusion and posterior decompression is indicated
Iliac crest bone grafting is indicated
This clinical presentation is consistent with a symptomatic spondylolysis, without listhesis or neurologic deficits, that has failed nonoperative management. Pain with single-limb standing lumbar extension is a characteristic physical finding with this condition. The oblique radiograph demonstrates a defect in the pars interarticularis.
For comparison a radiograph of a normal lumbar spine is shown in Illustration A below. Illustration B shows that the oblique radiograph is often likened to a "Scotty dog". The parts of the dog are as follows: the transverse process-the nose; the pedicle-the eye; the pars interarticularis-the neck; the superior articular facet-the ear; the inferior articular facet-the front leg.
The review article by Hu et al discusses surgical management of this condition. They argue that pars repair is feasible at L4 and above while at L5-S1 fusion with bone grafting is required. The Gill procedure, a wide and bilateral decompression of the neural elements with removal of the loose lamina, is only indicated when the patient has signs of the neural compromise. Combined anterior/posterior fusion approaches are only considered in patients with spondylolisthesis rather than those with spondylolysis alone. While some surgeons may prefer an initial attempt at pars repair for L5, the more established indication is at L4 and above.
Hu SS, Tribus CB, Diab M, Ghanayem AJ.
Instr Course Lect. 2008;57:431-45. PMID: 18399601 (Link to Abstract)
Average 3.0 of 43 Ratings
A 14-year-old soccer player has a history of intermittent low back pain. He reports for the last 4 months he has had no symptoms or limitations in his athletic activity. Treatment should include?
a thoracolumbar orthosis
in situ L5-S1 bilateral posterolateral fusion
repair of pars defect wih screw fixation
limitation of athletic activity
observation with no restriction of physical activity
The patient has a Low Grade L5-S1 isthmic spondylolisthesis with minimal symptoms. The most appropriate treatment is observation with no restriction of physical activity.
Isthmic spondylolithesis is classically seen in gymnasts, football offensive lineman and other athletes who do a lot of repetitive hyperextension activities. It can be classified as Low Grade or High Grade. Most patients with Low Grade spondylithesis can be treated with non-operative treatment that involves PT and activity modification.
Jackson et al performed a Level 4 study of 100 female gymnasts and found a pars defect in 11% and associated listhesis in 6% of patients, which is a much higher incidence than in non-athletic females.
Wiltse et al reports "there are 2 fairly common types of spondylolisthesis in children - dysplastic and isthmic. The dysplastic type is secondary to congenital defects at the lumbosacral joint. The isthmic is usually due to a fatigue fracture of the pars interarticularis but there is also an hereditary element in this type. Most children with spondylolisthesis never develop significant symptoms and even of those who do, the vast majority can be treated without surgery."
Jackson DW, Wiltse LL, Cirincoine RJ.
Clin Orthop Relat Res. 1976 Jun;(117):68-73. PMID: 132328 (Link to Abstract)
Jackson, CORR 1976
Wiltse LL, Jackson DW.
Clin Orthop Relat Res. 1976 Jun;(117):92-100. PMID: 1277690 (Link to Abstract)
Wiltse, CORR 1976
Average 3.0 of 29 Ratings
What additional diagnostic test is most sensitive to diagnose pediatric spondylolysis when AP and lateral radiographs are normal.
Flexion-extension lateral radiographs
Oblique radiographs of the of the lumbosacral spine
Single photon emission computed tomography (SPECT)
Indium-labeled bone scan
Of the listed answers, single photon emission computed tomography (SPECT) is the most sensitive imaging modality to diagnose spondylolysis when AP and lateral radiographs are normal. Initial imaging studies should first include AP and lateral radiographs, which demonstrate 80% of defects, and oblique radiographs which demonstrate an additional 15% of defects. If no lesion is seen on plain radiogaphs, SPECT can be considered as a diagnostic study. Conventional lumbar spine MRI techniques are valuable for demonstrating normality of the pars, but may be associated with a high false positive rate for the diagnosis of pars defects.
The cited reference by Gregory et al. showed that single photon emission computerized tomography can be an effective tool to diagnosis spondylolysis in young patients with back pain.
Illustration A, B, and C demonstrate single photon emission computed tomography images in a patient with spondylolysis.
Gregory PL, Batt ME, Kerslake RW, Webb JK
Clin J Sport Med. 2005 Mar;15(2):79-86. PMID: 15782051 (Link to Abstract)
Average 2.0 of 53 Ratings
A 13-year-old gymnast reports the acute onset of low back pain that began four weeks ago. Radiographs are unremarkable. A single-photon-emission-computer-tomography (SPECT) is shown in Figure A. Initial treatment should consist of?
Bracing with a molded lumbosacral orthosis
Aggressive physical therapy
CT guided biopsy
In-situ posterolateral fusion of L5-S1
Epidural steroid injection
The question presents a 13-year-old gymnast with the acute onset of low back pain that is activity related. Her radiographs are normal, but a SPECT scan shows increased signal of the L5 pars, indicative of impending or acute stress reaction spondylolysis. The reference by Cohen & Stuecker demonstrated that bracing and avoiding strenuous activities prevented the formation of pars defects in patients with impending spondylolysis. Early diagnosis was made with MRI. Patients should wear a lumbosacral orthosis full time for 6 to 12 weeks.
Cohen E, Stuecker RD
J Pediatr Orthop B. 2005 Mar;14(2):63-7. PMID: 15703512 (Link to Abstract)
Cohen, JPO 2005
Average 2.0 of 44 Ratings
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