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Updated: May 10 2022

Degenerative Spondylolisthesis

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  • summary
    • Degenerative Spondylolisthesis is a common degenerative condition characterized by subluxation of one vertebral body anterior to the adjacent inferior vertebral body with intact pars.
    • The condition is most common in females over 40 years of age, at the L4-5 level.
    • Diagnosis is made with lateral radiographs. Flexion and extension lateral lumbar radiographs can identify the degree of instability. MRI studies can be helpful for central or foraminal stenosis.
    • Treatment is a trial of nonoperative management with NSAIDs and physical therapy.  Surgical management is indicated for progressive disabling pain that has failed nonoperative management, and/or progressive neurological deficits.
  • Epidemiology
    • Prevalence
      • ~5% in men
      • ~9% in woman
    • Demographics
      • more common in African Americans, diabetics, and woman over 40 years of age
      • ~8 times more common in woman than men
        • increase in prevalence in women postulated to be due to increased ligamentous laxity related to hormonal changes
    • Anatomic location
      • degenerative spondylolisthesis is 5-fold more common at L4/5 than other levels
        • this is different that isthmic spondylolisthesis which is most commonly seen at L5/S1
    • Risk factors
      • sacralization of L5 (transitional L5 vertebrae)
      • sagittally oriented facet joints
  • Etiology
    • Pathoanatomy
      • forward subluxation (intersegmental instability) of vertebral body is allowed by
        • facet joint degeneration
        • facet joint sagittal orientation
        • intervertebral disc degeneration
        • ligamentous laxity (possibly from hormonal changes)
      • degenerative cascade involves
        • disc degeneration leads to facet capsule degeneration and instability
        • microinstability which leads to further degeneration and eventual macroinstability and anterolithesis
        • instability is worsening with sagittally oriented facets (congenital) that allow forward subluxation
      • neurologic symptoms caused by
        • central and lateral recess stenosis
          • a degenerative slip at L4/5 will affect the descending L5 nerve root in the lateral recess
            • caused by slippage, hypertrophy of ligamentum flavum, and encroachment into the spinal canal of osteophytes from facet arthrosis
        • foraminal stenosis
          • a degenerative slip at L4/5 will affect the L4 nerve root as it is compressed in the foramen
          • vertical foraminal stenosis (loss of height of foramen) caused by
            • loss of disk height
            • osteophytes from posterolateral corner of vertebral body pushing the nerve root up against the inferior surface of the pedicle
          • anteroposterior foraminal stenosis (loss of anterior to posterior area) caused by
            • degenerative changes of the superior articular facet and posterior vertebral body
  • Classification
      • Myerding Classification
      • Grade I
      • < 25%
      • Grade II
      • 25 to 50%
      • Grade III
      • 50 to 75% (Grade III and greater are rare in degenerative spondylolisthesis)
      • Grade IV
      • 75 to 100%
      • Grade V
      • Spondyloptosis (all the way off)
  • Presentation
    • Symptoms
      • mechanical/ back pain
        • most common presenting symptom
        • usually relieved with rest and sitting
      • neurogenic claudication & leg pain
        • second most common symptoms
        • defined as buttock and leg pain/discomfort caused by upright walking
          • relieved by sitting
          • not relieved by standing in one place (as is vascular claudication)
          • may be unilateral or bilateral
        • same symptoms found with spinal stenosis
      • cauda equina syndrome (very rare)
    • Physical exam
      • L4 nerve root involvement (compressed in foramen with L4/5 DS)
        • weakness to quadriceps
          • best seen with sit to stand exam maneuver
        • weakness to ankle dorsiflexion (cross over with L5)
          • best seen with heel-walk exam maneuver
        • decreased patellar reflex
      • L5 nerve root involvement
        • weakness to ankle dorsiflexion (cross over with L4)
          • best seen with heel-walk exam maneuver
        • weakness to EHL (great toe extension)
        • weakness to gluteus medius (hip abduction)
      • provocative walking test
        • have patient walk prolonged distance until onset of buttock and leg pain
          • have patient stop but remain standing upright
            • if pain resolves this is consistent with vascular claudication
          • have patient sit
            • if pain resolves this is consistent with neurogenic claudication (DS)
      • hamstring tightness
        • commonly found in this patients, and must differentiate this from neurogenic leg pain
  • Imaging
    • Radiographs
      • recommended views
        • weight bearing lumbar AP, lateral neutral, lateral flexion, lateral extension
      • findings
        • slip is evident on lateral x-ray
        • flexion-extension studies
          • instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment
    • MRI
      • indications
        • persistent leg pain that has failed nonoperative modalities
        • best study to evaluate impingement of neural elements
      • views
        • T2 weighted sagittal and axial images best to look for compression of neurologic elements
    • CT
      • useful to identify bony pathology
    • CT myelogram
      • helpful in patients in which a MRI is contraindicated (pacemaker)
  • Treatment
    • Nonoperative
      • physical therapy and NSAIDS
        • indications
          • most patients can be treated nonoperatively
        • modalities include
          • activity restriction
          • NSAIDS
          • PT
      • epidural steroid injections
        • indications
          • second line of treatment if non-invasive methods fail
    • Operative
      • lumbar decompression with instrumented fusion, +/- interbody fusion
        • indications
          • most common is persistent and incapacitating pain that has failed 6 mos. of nonoperative management and epidural steroid injections
          • progressive motor deficit
          • cauda equina syndrome
        • technique
          • often combined with a posterior lumbar interbody fusion or transforaminal interbody fusion
          • new data shows equivalent outcomes using cortical screw fixation verses pedicle screw fixation
          • decompression often performed with a PLC perserving unilateral (undercutting) approach
          • navigation and MIS techniques are widely used
        • outcomes
          • ~79% have satisfactory outcomes
          • improved fusion rates shown with pedicle screws
          • improved outcomes with successful arthrodesis
          • worse outcomes found in smokers
            • smokers should undergo smoking cessation prior to surgery
      • posterior lumbar decompression alone
        • indications
          • usually not indicated due to instability associated with spondylolithesis
          • only indicated in medically frail patients who cannot tolerate the increased surgical time of performing a fusion
        • outcomes
          • ~69% treated with decompression alone are satisfied
          • ~ 31% have progressive instability
      • anterior lumbar interbody fusion (ALIF)
        • indications
          • reserved for revision cases with pseudoarthrosis
        • outcomes
          • injury to superior hypogastric plexus can cause retrograde ejaculation
  • Techniques
    • Posterior decompression and posterolateral fusion (+/- instrumentation)
      • approach
        • posterior midline approach
        • multiple parasagittal incisions for minimally invasive approaches
      • decompression
        • usually done with laminectomy, wide decompression, and foraminotomy
      • fusion
        • posterolateral fusion with instrumentation most common
        • TLIF/PLIF growing in popularity and may increase fusion rates and decrease risk of postoperative slip progression
      • reduction of listhesis
        • limited role in adults
      • cost
        • in degenerative spondylolisthesis adding an interbody cage increases hospital costs without increasing fusion rates
    • Cortical bone trajectory screw
      • designed to decrease the amount of lateral exposure for obtaining screw starting points
        • lower intraoperative blood loss, smaller skin incision, and decreased pain scores at 1-week post-op
        • fusion rates and functional outcomes similar to conventional pedicle screw fixation
        • some studies suggest conventional pedicle screw fixation may be more stable
          • other studies have demonstrated greater screw pullout strength given cortical contact of screw
        • mostly described in combination with interbody fusion (PLIF or TLIF)
      • starting point is more medial and caudal than traditional pedicle screws
        • trajectory is more cephalad and lateral than traditional screw
        • cortical trajectory screws are generally smaller than traditional pedicle screws
  • Complications
    • Pseudoarthrosis (5-30%)
      • CT scan is more reliable than MRI for identifying failed arthrodesis
    • Adjacent segment disease (2-3%)
      • risk of adjacent segment degeneration requiring surgery is about 20-29% at 10 years
    • Surgical site infection (0.1-2%)
      • treat with irrigation and debridement (usually hardware can be retained)
    • Dural tear
    • Positioning neuropathy
      • LFCN
        • seen with prone positioning due to iliac bolster
      • ulnar nerve or brachial plexopathy
        • from prone positioning with inappropriate position
    • Complication rates increase with
      • older age
      • increased intraoperative blood loss
      • longer operative time
      • number of levels fused
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