Pediatric Spondylolisthesis (Developmental)

Author: Derek Moore

Topic updated on 04/23/13 7:11pm

Introduction

Common cause of low back pain in children and adolescents.
Conditions represent a continuum of disease including
- pars stress reaction
- spondylolysis
- spondylolithesis
Pars Stress Reaction
- sclerosis with incomplete bone disruption of pars
Spondylolysis
- term used to describe anatomic defect (radiolucent gap) in pars interarticularis with adjacent bone sclerosis
- epidemiology
  - one of most common causes of back pain in children and adolescents
  - defects are not present at birth and develop over time (seen in 4-6% if population)
- mechanism
  - usually activity related and occurs from repetitive hyperextension
    - prevalence as high as 47% in certain athletes (gymnasts, weightlifters, football linemen)
Spondylolithesis
- defined as forward translation of one vertebral segment over the one beneath it
- epidemiology
  - approximately 15% of individuals with a pars interarticularis lesion have progression to spondylolisthesis
  - most common at L5-S1 (90%) in pediatric population (L4-5 most common in adult population)
- risks of progression
  - the larger the slip the more likely it is to progress
  - dysplasic slips (Wiltse Type I) are more likely to progress

Spondylolithesis Classification

Wiltse-Newman Classification
Type I	• Dysplastic • Secondary to congenital abnormalities of lumbosacral articulation including maloriented or hypoplastic facets, sacral deficiency, poorly developed pars • Posterior elements are intact (no spondylolysis) • More significant neurologic symptoms
Type II-A	• Isthmic - Pars Fatigue Fx
Type II-B	• Isthmic - Pars Elongation due to healed stress fx
Type II-C	• Isthmic - Pars Acute Fx
Type III	• Degenerative
Type IV	• Traumatic
Type V	• Neoplastic

Marchetti-Bartolozzi classification
Developmental	• Includes Wiltse I and II
Acquired	• Traumatic, postsurgical, pathologic, degenerative

Myerding Classification
Grade I	• < 25%
Grade II	• 25-50%
Grade III	• 50-75%
Grade IV	• 75-100%
Grade V	• Spondyloptosis

Presentation

Symptoms
- most cases of spondylolysis are asymptomatic
- symptoms include insidious onset of activity related low back pain and/or buttock pain
- neurologic symptoms include
  - hamstring tightness (most common) and knee contracture
  - radicular pain (L5 nerve root)
  - bowel and bladder symptoms
  - cauda equina syndrome (rare)
- listhetic crisis
  - severe back pain aggravated by extension and relieved by rest
  - neurologic deficit
  - hamstring spasm - walk with a crouched gait
Physical exam
- palpation and motion
  - flattened lumbar lordosis
  - palpable step off of spinous process
  - limitation of lumbar flexion and extension
    - pain with single-limb standing lumbar extension
  - measure popliteal angle to evaluate for hamstring tightness
- neurologic exam
  - straight leg raise may be positive
  - rectal exam if bowel and bladder symptoms present

Imaging

Pars Stress Reaction & Spondylolysis
- radiographs
  - lateral radiograph
    - may show defect in pars in 80%
  - oblique radiograph
    - views may show sclerosis and elongation in pars interarticularis (scotty dog sign)
  - AP
    - may see sclerosis of the stress reaction
- bone scan
  - most sensitive (however lesion may be cold)
  - excellent screening tool for low back pain in children or adolescents
- CT
  - best study to diagnose and delineate anatomy of lesion
  - pars stress reaction will show up as sclerosis on xrays and CT scan
- Single photon emission computer tomography (SPECT)
  - best diagnostic adjunct when plain radiographs are negative
Spondylolisthesis
- radiograph
  - views
    - lateral xray used to measure slip angle and grade.
    - flexion and extension radiographs used to evaluate instability
  - measurements
    - slip grade
      - measure angle between superior endplate of L5 and a line perpendicular to the posterior border of the sacrum
      - a slip angle of > 50 degrees is associated with greater risk of progression
    - slip angles
      - methodology to determine slip angle
    - pelvic incidence
      - pelvic incidence = pelvic tilt + sacral slope
      - a line is drawn from the center of the S1 endplate to the center of the femoral head
      - a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting the point in the center of the S1 endplate
      - the angle between these two lines is the pelvic incidence (see angle X in figure above)
      - correlates with severity of disease
      - pelvic incidence has direct correlation with the Meyerding–Newman grade
    - pelvic tilt
      - sacral slope = pelvic incidence - pelvic tilt
      - a line is drawn from the center of the S1 endplate to the center of the femoral head
      - a second vertical line (parallel with side margin of radiograph) line is drawn intersecting the center of the femoral head
      - the angle between these two lines is the pelvic tilt (see angle Z in figure above)
    - sacral slope
      - pelvic tilt = pelvic incidence - sacral slope
      - a line is drawn parallel to the S1 enplate
      - a second horizontal line (parallel to the inferior margin of the radiograph) is drawn
      - the angle between these two lines is the sacral slope (see angle Y in the figure above)
- CT
  - best study to diagnose and delineate anatomy of pars defect
- MRI
  - indicated if neurologic symptoms present
  - useful to diagnose associated stenosis central and foraminal

NonOperative Treatment

Nonoperative
- observation with no activity limitations
  - indications
    - asymptomatic patients with low-grade spondylolithesis or spondylolysis
  - may participate in contact sports
- physical therapy and activity restriction
  - indications
    - symptomatic isthmic spondylolysis
    - symptomatic low grade spondylolithesis
  - technique
    - physical therapy should be done for 6 months and include
      - hamstring stretching
      - pelvic tilts
      - abdominal strengthening
    - watch low grade dysplastic carefully as there is a higher chance of progression
- TLSO bracing for 6 to 12 weeks
  - indications
    - acute pars stress reaction spondylolysis
    - isthmic spondylolysis that has failed to improve with physical therapy
    - low grade spondylolithesis that has failed to improve with physical therapy
  - outcomes
    - brace immobilization is superior to activity restriction alone for acute stress reaction spondylolysis
Operative
- par interarticularis repair
  - indications
    - L1 to L4 isthmic defect that has failed nonoperative management
    - multiple pars defects
- L5-S1 in-situ posterolateral fusion with bone grafting
  - indications
    - L5 spondylolysis that has failed nonoperative treatment
    - low grade spondylolithesis (Myerding Grade I and II) that
      - has failed nonoperative treatment
      - is progressive
      - has neurologic deficits
      - is dysplastic due to high propensity for progression
- L4-S1 posterolateral fusion, +/- reduction, (+/- ALIF)
  - indications
    - high grade isthmic spondlylithesis (Meyerding Grade III, IV, V)
    - reduction is extremely controversial with no accepted guidelines

Surgical Technique

Par interarticularis repair
- approach
  - posterior midline approach to lumbar spine
- technique
  - repair pars defect with screw fixation, tension wiring, or screw and sublaminar hook technique
  - decompression indicated if clinical symptoms of stenosis
L5-S1 in-situ posterolateral fusion with bone grafting
- approach
  - posterior midline approach to lumbar spine
- reduction
- technique
  - in-situ fusion with bone grafting / without instrumentation preferred method
  - postoperative immobilization in a TLSO
  - decompression only indicated if clinical symptoms of stenosis or radiculopathy
L4-S1 posterolateral fusion +/- reduction
- approach
  - posterior midline approach to lumbar spine
- reduction
  - reduction may be done with instrumentation or positioning
  - pros of reduction
    - can restore sagittal alignment and reduce lumbosacral kyphosis
  - cons
    - risk of significant complications (8-30%) including
      - L5 and S1 nerve root injuries
      - sexual dysfunction
      - catastrophic neurologic injury
- fusion
  - usually instrumented

Complications

Neurologic deficits
Pseudoarthrosis
Progression of slippage
Hardware failure

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Qbank (8 Questions)

TAG

(OBQ11.61) 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? Topic

Review Topic

FIGURES: A

1. Decreased patellar reflexes
2. Weakness to hip flexion
3. Weakness to great toe extension
4. Weakness to knee extension
5. Weakness to ankle plantar flexion

PREFERRED RESPONSE ▶

DISCUSSION: 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 stidu 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.

Incorrect Answers:
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.

REFERENCES:

1. Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. J Am Acad Orthop Surg. 2006 Aug;14(8):488-98. PMID:16885480 (Link to Abstract)

2. Lonner BS, Song EW, Scharf CL, Yao J. Reduction of high-grade isthmic and dysplastic spondylolisthesis in 5 adolescents. Am J Orthop (Belle Mead NJ). 2007 Jul;36(7):367-73. PMID:17694184 (Link to Abstract)

3. Petraco DM, Spivak JM, Cappadona JG, Kummer FJ, Neuwirth MG. An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction. Spine (Phila Pa 1976). 1996 May 15;21(10):1133-8; discussion 1139. PMID: 8727186 (Link to Abstract)

Question Authors:

Terrill Julien MD, AFSHIN RAZI MD, Ben Taylor MD, William Lauerman M.D.,

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TAG

(OBQ09.15) 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? Topic

Review Topic

FIGURES: A

1. Pars interarticularis repair is indicated
2. Lumbosacral fusion is indicated
3. Gill procedure is indicated
4. Combined anterior interbody fusion and posterior decompression is indicated
5. Iliac crest bone grafting is indicated

PREFERRED RESPONSE ▶

DISCUSSION: 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. 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 at L4 and above treatment includes pars interarticularis repair whereas at L5-S1 treatment is in-situ fusion with bone grafting. A Gill procedure is a wide, bilateral decompression of the neural elements with removal of the loose lamina and is only indicated when the patient has signs of the neural compromise. Combined anterior/posterior fusion approaches are only a reasonable option in patients with spondylolisthesis.

Illustrations: A

REFERENCES:

1. Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. Instr Course Lect. 2008;57:431-45. Review. PMID:18399601 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ08.55) 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? Topic

Review Topic

FIGURES: A

1. a thoracolumbar orthosis
2. in situ L5-S1 bilateral posterolateral fusion
3. repair of pars defect wih screw fixation
4. limitation of athletic activity
5. observation with no restriction of physical activity

PREFERRED RESPONSE ▶

DISCUSSION: 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."

REFERENCES:

1. Jackson DW, Wiltse LL, Cirincoine RJ. Spondylolysis in the female gymnast.Clin Orthop Relat Res. 1976 Jun;(117):68-73. PMID:132328 (Link to Abstract)

2. Wiltse LL, Jackson DW. Treatment of spondylolisthesis and spondylolysis in children. Clin Orthop Relat Res. 1976 Jun;(117):92-100. PMID:1277690 (Link to Abstract)

Question Authors:

Derek Moore, John Badylak MD,

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(OBQ07.71) What additional diagnostic test is most sensitive to diagnose pediatric spondylolysis when AP and lateral radiographs are normal. Topic

Review Topic

1. Flexion-extension lateral radiographs
2. Oblique radiographs of the of the lumbosacral spine
3. Single photon emission computed tomography (SPECT)
4. Indium-labeled bone scan
5. Ultrasound

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Gregory PL, Batt ME, Kerslake RW, Webb JK. Single photon emission computerized tomography and reverse gantry computerized tomography findings in patients with back pain investigated for spondylolysis. Clin J Sport Med. 2005 Mar;15(2):79-86. PMID:15782051 (Link to Abstract)

Question Authors:

Derek Moore, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ06.10) 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? Topic

Review Topic

FIGURES: A

1. Bracing with a molded lumbosacral orthosis
2. Aggressive physical therapy
3. CT guided biopsy
4. In-situ posterolateral fusion of L5-S1
5. Epidural steroid injection

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Cohen E, Stuecker RD. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects. J Pediatr Orthop B. 2005 Mar;14(2):63-7. PMID:15703512 (Link to Abstract)

2. Hammerberg KW: Sponddylolysis and spondylolithesis, in DeWalk RL (ed): Spinal Deformities: The comprehensiveText. New York, NY, Thieme, 2003, pp 787-800

Question Authors:

Derek Moore, Patrick McCulloch MD, Eric Shirley MD,

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Videos

	Pelvic Incidence Animation Spine - Educational Presentation - Pediatric Spondylolisthesis (Developmental) This video animation demonstrates a low, medium, and high pelvic incidence. It s...	10/13/2012 394 views 2
	Spondylolysis & Spondylolisthesis in the Adolescent Athlete - Dr. Scott Simon Spine - Educational Presentation - Pediatric Spondylolisthesis (Developmental) This is a powerpoint presentation reviewing spondylolysis & spondylolisthesis in...	9/18/2012 197 views 0

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ABOS II: Pediatric Spondylolisthesis (Developmental)

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. J Am Acad Orthop Surg. 2006 Aug;14(8):488-98. PMID:16885480 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Hammerberg KW: Sponddylolysis and spondylolithesis, in DeWalk RL (ed): Spinal Deformities: The comprehensiveText. New York, NY, Thieme, 2003, pp 787-800
Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008

Undefined

Lonner BS, Song EW, Scharf CL, Yao J. Reduction of high-grade isthmic and dysplastic spondylolisthesis in 5 adolescents. Am J Orthop (Belle Mead NJ). 2007 Jul;36(7):367-73. PMID:17694184 (Link to Abstract)
Petraco DM, Spivak JM, Cappadona JG, Kummer FJ, Neuwirth MG. An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction. Spine (Phila Pa 1976). 1996 May 15;21(10):1133-8; discussion 1139. PMID: 8727186 (Link to Abstract)
Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. Instr Course Lect. 2008;57:431-45. Review. PMID:18399601 (Link to Abstract)
Jackson DW, Wiltse LL, Cirincoine RJ. Spondylolysis in the female gymnast.Clin Orthop Relat Res. 1976 Jun;(117):68-73. PMID:132328 (Link to Abstract)
Wiltse LL, Jackson DW. Treatment of spondylolisthesis and spondylolysis in children. Clin Orthop Relat Res. 1976 Jun;(117):92-100. PMID:1277690 (Link to Abstract)
Gregory PL, Batt ME, Kerslake RW, Webb JK. Single photon emission computerized tomography and reverse gantry computerized tomography findings in patients with back pain investigated for spondylolysis. Clin J Sport Med. 2005 Mar;15(2):79-86. PMID:15782051 (Link to Abstract)
Lenke LG, Bridwell KH. Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis. Instr Course Lect. 2003;52:525-32. Review. PMID:12690878 (Link to Abstract)
Boxall D, Bradford DS, Winter RB, Moe JH. Management of severe spondylolisthesis in children and adolescents. J Bone Joint Surg Am. 1979 Jun;61(4):479-95. PMID:438234 (Link to Abstract)
Cohen E, Stuecker RD. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects. J Pediatr Orthop B. 2005 Mar;14(2):63-7. PMID:15703512 (Link to Abstract)
Jenis LG, An HS. Lumbar spondylolisthesis. Orthopedics 2002, pp1138-1146
Hu SS, Bradford DS. Spondylolysis and spondylolisthesis, in Weinstein SL (ed): The Pediatric Spine, 2001, pp 433-451

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Pediatric Spondylolisthesis (Developmental)

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