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Introduction
  • Defined as spondylolisthesis in an adult caused by a defect in the pars interarticularis (spondylolysis)
    • pars defects usually acquired and caused by microtrauma 
  • Epidemiology
    • incidence
      • spondylolysis is seen in 4-6% of population
      •  increased prevalence in sports that involve repetitive hyperextension (gymnasts, weightlifters, football linemen)
    • location
      • 82% occur at L5/S1
      • 11% occurs  L4/5 (11%)
      • due to forces in the lumbar spine being greatest at these levels and the facet being more coronal
  • Pathophysiology
    • foraminal stenosis
      • 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
        • bulging of the L5/S1 disc
      • lateral recess stenosis
        • caused by facet arthrosis and hypertrophic ligamentum flavum
      • central stenosis
        • rare due to fact that these slips are usually only Grade I or II
  • Prognosis
    • relatively few patients (5%) with spondylolysis with develop spondylolisthesis
    • slip progression more common in females
    • slip progression usually occurs in adolescence and rare after skeletal maturity
Classification
 
Wiltse-Newman Classification
 Type I  • Dysplastic: a congenital defect in pars  
 Type II-A  • Isthmic - pars fatigue fx
 
 Type II-B  • Isthmic - pars elongation due to multiple healed stress fx
 
 Type II-C  • Isthmic - pars acute fx   
 Type III  • Degenerative: facet instability without a pars fx  
 Type IV  • Traumatic: acute posterior arch fx other than pars  
 Type V  • Neoplastic: pathologic destruction of pars  
 
Myerding Classification
 Grade I  • < 25%
 
 Grade II  • 25-50%
 
 Grade III  • 50-75%  
 Grade IV  • 75-100%  
 Grade V  • spondyloptosis  
 
Physical Exam
  • Symptoms
    • axial back pain
      • most common presentation
      • pain usually has a long history with periodic episodes that vary in intensity and duration
    • leg pain
      • usually a L5 radiculopathy usually caused by foraminal stenosis at the L5-S1 level
    • neurogenic claudication
      • caused by spinal stenosis
      • characterized by buttock and leg pain worse with walking
      • symptoms of neurogenic claudication rare because these slips rarely progress beyond Grade II
    • cauda equina syndrome
      • rare because these slips rarely progress beyond Grade II
  • Physical exam
    • L5 radiculopathy
      • ankle dorsiflexion and EHL weakness
Imaging
  • Radiographs
    • recommended views
      • obtain AP, lateral, obliques, and flexion-extension views
    • findings
      • AP
        • deformity in coronal plane
      • lateral
        • will see spondylolisthesis and pars defect
      • flexion-extension
        • instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment
    • measurements
      • 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 endplate
        • 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)
  • MRI
    • views
      • T2 parasagittal images are best study to evaluate for foraminal stenosis and compression of neural elements
Treatment
  • Nonoperative
    • oral medications, lifestyle modifications, therapy 
      • indications
        • most patients can be treated nonoperatively
      • techniques
        • activity restriction
        • NSAID
        • role of injections unclear
        • bracing may be beneficial especially in the acute phase
  • Operative
    • L5-S1 decompression and instrumented fusion +/- reduction
      • indications
        • L5-S1 low-grade spondylolisthesis with persistent and incapacitating pain that has failed 6 months of nonoperative management (most common)
        • progressive neurologic deficit
        • slip progression
        • cauda equina syndrome
      • reduction
        • improved sagittal balance with reduction
        • risk of stretch injury to L5 nerve root with reduction 
    • L4-S1 decompression and instrumented fusion +/- reduction 
      • indications
        • L5-S1 high-grade spondylolithesis with persistent and incapacitating pain that has failed 6 months of nonoperative management
    • ALIF
      • indications
        • can be used successfully to treat low-grade isthmic spondylolisthesis even when radicular symptoms are present
        • cannot be used to treat high grade isthmic spondylolisthesis due to translational and angular deformity
      • outcomes
        • studies have shown good to excellent results in 87-94% at 2 years
Surgical Techniques
  • L5/S1 wide decompression and instrumented fusion
    • approach
      • posterior midline 
    • decompression
      • indicated in adult with leg pain below knee
      • usually involves Gill laminectomy and foraminal decompression
        • removal of loose lamina and scared pars defect allows decompression of nerve root
        • a Gill decompression is destabilizing and should be combined with fusion
    • fusion
      • posterolateral fusion is standard
      • interbody fusion (PLIF/TLIF) commonly performed
        • posterior lumbar interbody fusion (PLIF) involves insertion of device medial to facets
        • transforaminal lumbar interbody fusion (TLIF) requires facetectomy and more lateralized and transforaminal approach to the disc space
    • cons
      • interbody fusion has increased operative time with greater blood loss and longer hospitalizations
  • Anterior Lumbar Interbody Fusion (ALIF)
    • approach
      • usually done through trans-retroperitoneal approach 
    • decompression
      • decompression of nerve root done indirectly by foraminal distraction via restoration of disc height
    • fusion
      • grafts used include autologous iliac crest, structural allograft, and cages of various materials
    • pros
      • may increase chance of union by more complete discectomy and endplate preparation
      • allows improved restoration of disc height
    • cons
      • retrograde ejaculation and sexual dysfunction
      • persistent radiculopathy due to inadequate indirect foraminal decompression
      • persistent low back pain may be caused by nociceptive pain fibers in pars defect that are not removed in an anterior procedure alone
Complications
  • Psuedoarthrosis
  • Dural Tear
 

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Technique Guides (2)
Questions (11)

(OBQ09.124) 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? Review Topic

QID: 2937
FIGURES:
1

Observation, mobilization, and further treatment based on symptoms

67%

(1438/2147)

2

Spinal casting and bed rest for 6 weeks

0%

(7/2147)

3

Thoracolumbosacral orthosis for 6-8 weeks

27%

(578/2147)

4

Open reduction and internal fixation

1%

(31/2147)

5

L5 to S1 posterior spinal fusion with instrumentation

4%

(80/2147)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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(OBQ10.8) 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. Review Topic

QID: 3096
FIGURES:
1

Angle E (Figure A)

3%

(58/2174)

2

Angle X (Figure B)

74%

(1599/2174)

3

Angle Z (Figure C)

15%

(317/2174)

4

Angle Y (Figure D)

5%

(108/2174)

5

Angle V (Figure E)

4%

(81/2174)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(SBQ12SP.3) 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? Review Topic

QID: 3701
FIGURES:
1

Weakness to ankle plantar flexion.

14%

(619/4290)

2

Weakness to great toe extension

81%

(3476/4290)

3

Weakness to Hip Flexion

1%

(30/4290)

4

Loss of the patellar reflex

1%

(27/4290)

5

Bowel and bladder dysfunction saddle anesthesia

3%

(118/4290)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ11.169) 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? Review Topic

QID: 3592
FIGURES:
1

Angle Z + Angle Y

63%

(1453/2312)

2

Angle X - Angle Y

7%

(171/2312)

3

Angle X - Angle Z

13%

(311/2312)

4

Angle Z

12%

(285/2312)

5

Angle Y

3%

(66/2312)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ06.106) 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? Review Topic

QID: 292
FIGURES:
1

Placement of epidural spinal stimulator

1%

(11/2133)

2

Lumbar decompression alone

0%

(5/2133)

3

Lumbar decompression with L5 to S1 posterior lumbar fusion

32%

(683/2133)

4

Lumbar decompression, L4 to S1 posterior lumbar fusion, and anterior column support

66%

(1409/2133)

5

Minimally invasive direct lateral interbody fusion with percutaneous pedicle screw placement

1%

(20/2133)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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