Spondylolisthesis

• Spondylolisthesis is an abnormal AP translation of 2 vertebral bodies relative to each other.
  • This translation is secondary to a defect in the pars interarticularis (spondylolysis) or the posterior ligamentous-bony restraints.
• Spondylolisthesis is classified by type (Table 1) and by the severity of the slip (Table 2).

• No preventive measures except long-term brace wear have been found to be effective in decreasing the progression of spondylolisthesis.
• Because major progression is rare, brace treatment commonly is not recommended.

• Isthmic spondylolisthesis usually begins in childhood, but a slight increase in incidence occurs in adolescence, up to 6% in males.
• Degenerative spondylolisthesis occurs mainly in older adults.
• Compared with males, females develop spondylolisthesis more often and develop more pronounced slips at a younger age.

• A family history of spondylolisthesis
• Particular physical activities in adolescence that involve hyperextension of the spine, such as playing the lineman position in football and participating in gymnastics, have been associated with a high incidence of isthmic spondylolisthesis .

• The cause of isthmic spondylolisthesis is a stress fracture through a thin portion of the posterior elements (pars interarticularis).
• The causes of degenerative spondylolisthesis are degeneration and instability of the disc.

• Most people with the condition are otherwise physically normal.
• However, an increased risk is present if one has a connective-tissue disorder, such as Marfan syndrome, or neuromuscular conditions, such as athetoid cerebral palsy.

• Symptoms often can be insidious, but they may follow a relatively minor injury.
• Pain localized to the low back and thigh area may be seen in association with sciatica from an L5 radiculopathy.
• Back or leg pain
• Gait abnormality
• Abnormal posture (hyperlordotic)
• History of trauma: Acute or mild repetitive, often sports-related

Tests

• The differential diagnosis of spondylolisthesis is extremely important because the presence of a spondylitic defect is not necessarily the source of a patient’s pain.
• A common cause of pain in a patient with a spondylolisthesis is an L4-L5 disc herniation.
  • The differential diagnosis of back pain should include tumor, infection, facet arthropathy, stenosis, or degenerative disc disease.

• Children and adolescents:
  • Lumbar bracing in lordosis may be used for up to 6 months to relieve pain.
  • Nonoperative treatment: Good to excellent results in up to 91% of patients
  • Once the patient is asymptomatic without the brace, serial radiographs may be evaluated every 1-2 years until skeletal maturity.
  • Patients for whom a 12-month regimen of nonsurgical treatment fails or who have symptomatic high-grade slips may require posterolateral fusions.
• Adults:
  • Patients with grade 0 and grade I slips can be treated as for simple mechanical back pain.
  • Patients with more severe slips (grade II or higher) require posterior spine fusion and possible nerve root decompression.
  • Reduction of high-grade slips, the need for anterior spinal fusion, and the levels to be fused are all controversial topics.

• For high-grade slips and patients in whom nonoperative therapy fails, posterior spinal fusion is indicated.
• The most common procedure is a posterolateral 1-level L5-S1 fusion .
• If reduction of the spondylolisthesis is attempted or an L5 radiculopathy is present, the L5 nerve root should be widely decompressed.
• The addition of anterior spinal surgery:
  • Is reserved for the more severe grades
  • May increase the chance of fusion
  • May prevent postsurgical progression of the spondylolisthesis

• Spondylolisthesis slightly predisposes an individual to problems with chronic back pain.
• Most symptomatic low-grade slips in children and adolescents can be treated nonsurgically and lead to no long-term disability.

• Greatly variable
• If the slip progresses to a high grade, compression of the cauda equina with loss of bowel and bladder function may occur occasionally.
• Many different reduction techniques have been described, including halo-femoral traction, cast reduction, and open reduction and internal fixation.
  • After reduction, radiculopathy secondary to L5 nerve root dysfunction can occur .

• Educate patients with a high-grade slip about looking for progressive bladder dysfunction.
• After recovery from a symptomatic episode, new onset of bowel or bladder symptoms may indicate slip progression.

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