jwalant s. mehta ms(orth), d (orth), mch (orth), frcs (tr & orth) consultant spine surgeon, abmu...
TRANSCRIPT
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Jwalant S. MehtaMS(Orth), D (Orth), MCh (Orth), FRCS (Tr &
Orth)
Consultant Spine Surgeon, ABMU Health Board
SPONDYLOLISTHESIS
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OUTLINE OF THE TALK
¤ Classification
¤ Natural history
¤ Patho-physiology
¤ Treatment rationale
¤ Cases
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SPONDYL OLISTHESIS
1741 Nicholas Andry: hollow back
1782 Herbiniaux Belgian obstetrician
1854 Kilian slow displacement ‘Spondylolisthesis’
1855 Roberts: No slip if arch intact
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CLASSIFICATIONS
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Newman & Stone JBJS Br 1963; 45: 39 - 59
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Type Name Description
I Congenital Dysplastic abnormalities
II Isthmic
A Lytic (stress fracture)
B Healed fracture (elongated, intact)
C Acute high energy fracture
III Degenerative Segmental instability
IV Traumatic Fracture of hook other than pars
V Pathologic Underlying pathology
VI Iatrogenic Surgical excision of posterior elements
Wiltse, Newmann, MacNab Clin Orthop 1976
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MEYERDINGS GRADES
Low Grade
High GradeIII
IIIIVV
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SLIP ANGLE
Important in grades III – V
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SPINO-PELVIC MEASURES
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PELVIC INCIDENCE
Pelvic tilt Sacral slope
PI = PT + SS
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High PT Low SSLow PT High SS
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RELEVANCE OF PELVIC MEASURES
¤ PI quantifies the pelvic shape
¤ Pelvic morphology and spino-pelvic balance are abnormal in spondylolisthesis
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PATHO-PHYSIOLOGY
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HOOK AND CATCH
Hook:¤ Pedicle
¤ Pars inter-articularis
¤ Inferior process of the cephalad level
Catch:¤ Superior process of the caudal
level
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PATHOPHYSIOLOGY
¤ Dysplastic pathway
¤ Traumatic pathway
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Dysplastic pathway Traumatic pathway
Weakness in the hook & catch mechanism
Body weight transmitted through weak zone
Soft tissue restraints: plastic deformation
Growth plate overloaded
Repetitive cyclic loads (sports)
Stress fracture of a Normal pars
Hard cortical pars pre-disposes to fatigue
fracture and non-union
Predisposes to a vertical subluxation
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DYSPLASTIC CHANGES¤ Proximal sacral rounding
¤ Trapezoidal L5
¤ Vertical sacrum
¤ Junctional kyphosis
¤ Compensatory hyper-lordosis
Contributes to the mechanics of progression, but not causation
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PROXIMAL SACRAL ROUNDING
Yue Spine 2005
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PROXIMAL SACRAL ROUNDING
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DISCAL OVER-LOADING
¤ Both the pathways lead to ↑ shear loads, axial loads remaining constant
¤ Premature disc degeneration
Alternative loading pathwayHaher Spine 1994
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¤ Chronic muscle spasm (protective): ‘painful’ pars Annular tears Root compression / traction
Leg pain is the most common symptomMoller Spine 2000
The pain generators: Back pain
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THE PAIN GENERATORS: LEG PAIN
¤ L5 compression / traction
¤ Abnormal motion
¤ Facet joint arthrosis
¤ Pars scar
¤ The disc above far-lateral
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CLINICAL EVALUATION: HISTORY
¤ Symptoms: Back painLeg painNeurology
¤ Severity
¤ Activities of daily living
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CLINICAL EVALUATION: EXAMINATION
¤ Range and rhythm of trunk motion
¤ Neurology
¤ Sagittal alignment & gait
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SAGITTAL ALIGNMENT
¤ Stance
¤ Gait
¤ Head over pelvis
¤ Hips and knees
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IMAGING
¤ Erect radiographs:APLateral (to include the hips)
¤ MRI; CT
¤ Occasionally:
SPECT; Dynamic radiographs; Discography
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PURPOSE OF IMAGING
¤ Disc degeneration (MRI / CT)
¤ Facet joint orientation, tropism, degeneration (MRI / CT)
¤ Pelvic and spinal measures (Erect xrays)
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DISC DEGENERATION
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DISC DEGENERATION: MRI
Pfirrmann et al Spine 2001
Grade I Grade II Grade III Grade IV Grade V
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FACET JOINTS
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FACET JOINTS: ORIENTATION & TROPISM
¤ Mean facet joint angle:
Sagittal: anterior forces
¤ Tropism
R –L: asymmetric loads
Mild < 5°Moderate 7° – 15°Severe > 15°
Vanharanta Spine 1993
Don JSDT 2008 Wang Spine 2009Boden JBJS Am 1996
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FACET DEGENERATION: CARTILAGE
1. Uniformly thick layer
2. Focal erosions
3. Areas of deficiency with exposed bone
4. Cartilage absent except traces
Grogan et al AJNR 1997
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FACET DEGENERATION: SUB-CHONDRAL SCLEROSIS
1. Thin layer of cortical bone
2. Focal thickening
3. Thick < ½ of the surface
4. Dense cortical bone > ½ of the surface
Grogan et al AJNR 1997
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FACET DEGENERATION: OSTEOPHYTES
1. No osteophyte
2. Small
3. Moderate
4. Large
Grogan et al AJNR 1997
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Severe Spinal Stenosis
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
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WILTSE CLASSIFICATION:III. DEGENERATIVE
Instability phase: Kirkaldy Willis
Posterior elements are intact
L45; F >M
Disc:
¤ degeneration,
¤ ↓ height
Facets:
¤ Tropism
¤ Abnormal sagittal orientation
¤ Facetal arthritis; subluxation
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NATURAL HISTORY
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NATURAL HISTORY: GENETICS
¤ 15 – 70% 1st degree relatives
¤ Lysis commoner in boys
¤ Slips commoner in girls
¤ Eskimos 25% (arch defects)
Albanese JPO 1982Wynne-Davies JBJS Br 1979
Roche JBJS Am 1952
Stewart JBJS Am 1953
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NATURAL HISTORY: ‘THE SLIP’
¤ 15% of persons with a pars lesion
¤ During the growth spurt
¤ Minimal change after 16 y
¤ No pain during progression
Bentley Spine 2003
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EXTENT OF THE PROBLEM
¤ Most are asymptomatic
¤ 90% slips at initial presentation do not progress
Seitsalo JBJS Br 1990Danielson Spine 1991Frennerd JPO 1991
Seitsalo Spine 1991
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PROGRESSION
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PROGRESSION RISK
¤ > 20 y: more stable, less symptomatic, less likely to progress
¤ High level of athletic activity, no effect on progression
¤ Association with back pain ‘weak’
Ohmori JBJS Br 1995
Muschik JPO 1996
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RISK OF PROGRESSION: HIGHER LEVELS
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THE RISK OF PROGRESSION IN THE YOUNG ADULT: DISC DEGENERATION
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RISK FACTORS FOR SLIP PROGRESSION IN SPONDYOLISTHESIS(HENSINGER 1989)
Clinical
¤ Growth yrs (9 – 15)
¤ Girls > Boys
¤ Back pain
¤ Postural or gait abn
Radiographic
¤ Type 1 (dysplastic)
¤ Vertical sacrum
¤ >50 % slip
¤ Increasing slip angle
¤ Instability on flex/ext views
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RISK OF PROGRESSION: PROXIMAL SACRAL ROUNDING
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TREATMENT RATIONALE
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NATURAL HISTORY OF PROGRESSION
¤ Adolescents III+: likely to progress
¤ I, II after mid-adolescence: unlikely to progress
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NON-OPERATIVE TREATMENT
¤ Always consider first……………….everytime!
¤ Improvement likely if back > leg pain
¤ Isthmic / degnerative with leg pain: improvement less likely
¤ Investigate / treat osteopaenia
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NON-OPERATIVE TREATMENT: PAEDIATRIC
¤ Stop aggravating activities
¤ Gradual mobilisation
¤ Trunk strengthening
¤ Period of bracing
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NON-OPERATIVE TREATMENT: ADULTS
¤ Exercises
¤ Aerobics
¤ NSAID’S
¤ Epidural steroids
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MANAGEMENT DECISION
¤ Individualized for each patient
¤ Think of the natural history
¤ Severity and duration of symptoms
¤ Co-morbidities
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SURGICAL INDICATIONS
¤ Severe back and leg pain
¤ Failed conservative trial
¤ Abnormal neurology
¤ +ve diagnostic injections
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SURGICAL GOALS
¤ Address the pars defect & the rattler
¤ Decompress the foraminal stenosis
¤ Address the degenerate disc/s
¤ Address the dynamic instability
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SURGICAL OPTIONS
1. In-situ postero-lateral fusion
2. Decompression + In-situ postero-lateral fusion
3. Additional inter-body fusion options
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DECOMPRESSION: ABSOLUTE INDICATIONS
¤ Neurology
¤ Leg pain
¤ Sphincter dysfunction
¤ Claudication
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DECOMPRESSION: EXTENT¤ The Gill procedure: Removal of the loose
laminar arch
¤ Foraminotomy + facetectomy
¤ Never in isolation
¤ Associated with ↑ pseudarthrosis rateCarragee JBJS Am 1997
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IN-SITU POSTERO-LATERAL FUSION
¤ L5 S1 only adequate
¤ Improvement in leg pain even when not decompressed
Burkus JBJS Am 1992Frennerd Spine 1991Ishikawa Spine 1994
deLobrresse Clin Orthop 1996
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POSTERIOR INSTRUMENTATION
¤ Better fusion rate, better clinical outcomes
¤ Un-instrumented better for osteoporortic bones
Moller Spine 2000
Zdeblick Spine 1993Yuan Spine 1994Bjarke Spine 2002Deguchi J Spinal Dis 1998Ricciardi Spine 1995
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LEVELS TO INSTRUMENT
¤ Look at the changes at the levels above
¤ Higher slip angle: retro-listhesis above the slip
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INTER-BODY FUSIONS: THEORETICAL CONSIDERATIONS
¤ Anterior column support
¤ Bio-mecahnically superior: Large area for fusion Grafts under compressive loads
¤ Degenerate disc removed
consider disc height
¤ Build in the lordosis
¤ Indirect reduction
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INTER-BODY FUSIONS ( …… IF)
P LIF T LIF
A LIF
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INDICATIONS FOR SURGERY:CHILDREN
¤ Low grade slip / ‘lysis…..non op measures effective
¤ Progression beyond Gr II
¤ At presentation, > Gr III
¤ Persisting pain; neurologic deficit
¤ Progressive postural deformity / gait abnoralities
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SURGERY:PAEDIATRIC / ADOLESCENT
¤ ‘ Lysis Intact disc on MR (Gr I slip)
Direct repair of defect
¤ Grade I Asymptomatic….no surgery
¤ Grade II, III 1 level bilateral lateral fusion
Rarely decompression
Documented progression; back pain
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SURGERY:PAEDIATRIC / ADOLESCENT
¤ Grade III+ Asymptomatic: 2 level in situ….L4 – S1
Slip angle < 55° good fusion rate
Post op: Hyper-extension cast + thigh extension
Slip angle > 55° add anterior fusion
Post-op: recumbent during healing
¤ Severe slips Excise body ( Gaines procedure) L4 – S1 fusion
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INDICATIONS FOR SURGERY:ADULTS
¤ Non responsive to conservative measures
¤ Results better for leg than for back pain
¤ Isthmic / degenerative………persistent neurology; radicular symptoms
¤ Back pain alone…….decompress & stabilise (↓ symptoms)
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DEGENERATIVE SLIP
¤ Caudal + facet injections
¤ Decompress stenosis
¤ Non-instrumented or instrumented fusion
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¤ Think of the natural history
¤ Look at each patient and analyse the problems
¤ Individualize the treatment plan
¤ If surgery is the last resort ………….
RECOMMENDATIONS
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RECOMMENDATIONS
¤ Choose surgical targets carefully
¤ Ensure patient expectations match with your goals
¤ In-situ PL fusion + decompression
¤ Add inter-body in ‘high risk’ situations
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CASES
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PROGRESSION ON WAITING LIST
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FLEXION EXTENSION X RAYS
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R L
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POST OP
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CASE
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CASE
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CASE
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RADIOLOGICAL RESULT
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
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CLINICAL RESULT
Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
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CASE
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Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
RADIOLOGICAL RESULT
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Centre for Spinal Studies and Surgery NottinghamCentre for Spinal Studies and Surgery Nottingham
CLINICAL RESULT