spondylolisthesis upload
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Spondylolisthesis
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Herbinaux 1782
Greek: Spondylo + olisthesis
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DefinitionsSpondylolisthesis-Anterior or posterior
slipping or displacement of one vertebra on another.
Spondylolysis- dissolution of, or a defect in, the pars interarticularis of a vertebra.
Spondyloptosis-vertebra that is completely or essentially completely dislocated.
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EtiologyHereditary – DysplasticFailure of union of separate ossification
centres Birth fracturesStress fracturesDegenerative changes
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Classification
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Wiltse McNab and Newman
Marchetti and Bartolozzi
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PathophysiologyDysplastic
Congenital defect in Hook or catchSecondary deformity
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Traumatic
Extension of Lumbar spinePars impactionRepetitive loading – pars fails
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Degenerative
Intersegmental instability and remodelling
Iatrogenic
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Incidence : 6%
Racial : EskimosSpondylolysis 15-70 % 1st Deg relatives
Dysplastic more in FemalesLysis 2-3 times more in Males
Slip occur during growth spurt
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Clinical features
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Children: asymptomaticPostural/gait abn : Pelvic Waddle
Adolescents: Activity related painTraumatic History in 40 %
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LBA
Thigh/Leg - pain/Weakness
Bowel/Bladder symptoms
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Scoliosis- sciatic/olisthetic/idiopathic
Lumbar spine – foreshortening.
Buttocks- heart shaped
Phalen- Dickson sign
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Step off sign
Hamstring tightness.
Tenderness over pars defect
Reduced lumbar movements.
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Nerve root compression
Central canal compressionB/B symptomsB/L Leg symptomsB/L SLR +Crossed SLR +
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Investigations
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Pelvic Incidence
Sacral Slope
Pelvic tilt
Ullman sign
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High dysplasticL5 - body TrapezoidS1 - Dome shaped
Sweet heart PelvisSacral verticalisation
Lumbosacral kyphosisCompensatory hyperlordosis
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Bone Scan
CT
SPECT
MRI
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Treatment
Conservative
Surgical
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Factors affecting Progression
Congenital alterationsSeverity of anatomic deficitsGrowthWeightbearingAge and Gender
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Max slip- Spurt- 9-15 yrs
< 10 yrs- monitor every 6 months till 15yrsthen every Yr till compl of
growth
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Asymptomatic upto 25 %
No Treatment
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SymptomaticRestActivity ModificationNSAIDSExercisesSteroid injectionsTLSO Brace
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Surgical IndicationsProgression >25%
High grade slip >50 %
Intractable pain or Neuro deficits
Progressive postural/gait abn
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Insitu fusionWith Autogenous graft
Repair of Pars defect Pedicle screwBone graftingSublaminar hook
DecompressionLaminectomyRemove loose posterior element (Gill’s)
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With instrumentationTLIF
PLIF
ALIF
Combined anterior and posterior
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ComplicationsProgression of deformityIncreased slip anglePseudoarthrosisNeurologic injuriesA/c and delayed Cauda equinaBack pain and gait disturbances
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Reduction: Indications
Slip angle > 45 degLumbosacral kyphosisPostural imbalanceRequiring decompressionSlip progression after fusionUnacceptable appearance
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Spondyloptosis
Vertebrectomy
Reduce L4 onto sacrum
Ant + Post (Gaines)