Spondylolisthesis

Outline of the talk

Classification
Natural history
Patho-physiology
Treatment rationale
Cases
 Spondyl Olisthesis
1741 Nicholas Andry: hollow back

1782 Herbiniaux Belgian obstetrician

1854 Kilian slow displacement

Spondylolisthesis

1855 Roberts: No slip if arch intact

Classifications
Newman & Stone
JBJS Br 1963; 45: 39 - 59
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
Meyerdings
grades
Low
Grade

High
Grade
I
II

III
IV
V
Slip angle
Important in grades III V
Spino-pelvic measures
Pelvic Sacral
Pelvic tilt
incidence slope

PI = PT + SS
Low PT High SS High PT Low SS
Relevance of pelvic measures

PI quantifies the pelvic shape

Pelvic morphology and spino-pelvic balance are

abnormal in spondylolisthesis
Patho-physiology
Hook and catch
Hook:
Pedicle
Pars inter-articularis
Inferior process of the cephalad level

Catch:
Superior process of the caudal level
Pathophysiology

Dysplastic pathway

Traumatic pathway
Dysplastic pathway Traumatic pathway

Weakness in the hook & Repetitive cyclic loads

catch mechanism (sports)

Body weight transmitted Stress fracture of a

through weak zone Normal pars

Hard cortical pars pre-

Soft tissue restraints: disposes to fatigue
plastic deformation fracture and non-union

Growth plate Predisposes to a vertical

overloaded subluxation
Dysplastic changes
Proximal sacral rounding

Trapezoidal L5

Vertical sacrum

Junctional kyphosis

Compensatory hyper-lordosis

Contributes to the mechanics of

progression, but not causation
proximal sacral rounding

Yue Spine 2005

proximal sacral rounding
Discal over-loading

Both the pathways lead to shear

loads, axial loads remaining constant

Premature disc degeneration

Alternative loading pathway

Haher Spine 1994
 The pain generators: Back pain

Chronic muscle spasm (protective):

painful pars
Annular tears
Root compression / traction

Leg pain is the most common symptom

Moller Spine 2000
 The pain generators: Leg pain

L5 compression / traction

Abnormal motion

Facet joint arthrosis

Pars scar

The disc above far-lateral

Clinical evaluation: history
Symptoms:
Back pain
Leg pain
Neurology

Severity

Activities of daily living

Clinical evaluation:
examination
Range and rhythm of trunk motion

Neurology

Sagittal alignment & gait

Sagittal alignment
Stance

Gait

Head over pelvis

Hips and knees

Imaging
Erect radiographs:
AP
Lateral (to include the hips)

MRI; CT

Occasionally:
SPECT; Dynamic radiographs; Discography
Purpose of imaging
Disc degeneration (MRI / CT)

Facet joint orientation, tropism, degeneration (MRI / CT)

Pelvic and spinal measures (Erect xrays)

Disc degeneration
 Disc degeneration: MRI

Grade I Grade II Grade III Grade IV Grade V

Pfirrmann et al Spine 2001

Facet joints
 Facet joints: orientation & tropism

Mean facet joint angle:

Sagittal: anterior forces
Don JSDT 2008
Wang Spine 2009
Boden JBJS Am 1996

Tropism
R L: asymmetric loads
Mild < 5
Moderate 7 15
Severe > 15
Vanharanta Spine 1993
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
 Facet degeneration: sub-chondral sclerosis

1. Thin layer of cortical

bone

2. Focal thickening

3. Thick < of the surface

4. Dense cortical bone >

of the surface
Grogan et al AJNR 1997
Facet degeneration:
osteophytes

1. No osteophyte

2. Small

3. Moderate

4. Large
Grogan et al AJNR 1997
Severe Spinal Stenosis

Centre
Centrefor
forSpinal
SpinalStudies
Studiesand
andSurgery
Surgery Nottingham
Nottingham
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
Natural history
Natural history: genetics
15 70% 1st degree relatives
Albanese JPO 1982
Wynne-Davies JBJS Br 1979

Lysis commoner in boys

Roche JBJS Am 1952
Slips commoner in girls

Eskimos 25% (arch defects) Stewart JBJS Am 1953

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

Extent of the problem
Most are asymptomatic

Seitsalo JBJS Br 1990

Danielson Spine 1991
Frennerd JPO 1991

90% slips at initial presentation do not progress

Seitsalo Spine 1991