Approach to Backache
Definition
Incidence
Classification
Symptoms
Examination
Radiological studies
Non-operative treatment
Surgical treatment
Goals
Pars defect repair
Decompression
In situ fusion
Reduction & fixation
spondylolysis in children
spondylolysis in adults
spondylolisthesis in children
spondylolisthesis in adults
Definition
- an anterior or posterior slipping or displacement of one vertebra on another
- a unilateral or bilateral defect of the pars inter-articularis w/out displacement of the vertebra known as spondylolysis or spondyloschisis.
- from the Greek "spondylo" meaning vertebra and "olisthesis" meaning slip
Incidence
- ~4% at age of 6 yr
- 6% in adults
- 6% of these becomes symptomatic
Classification
- Wiltse
- based on the cause of the defect
- Dysplastic(congenital)
- congenital abnormalities of the upper sacrum or the arch of L5 cause slipping
- abN or insufficient facet joint & disc complex
- rare
- more common in girls
- high familial tendency
- high incidence of neurology even w/ minor slips - intact lamina of L5 pulling on dura
- Isthmic
- hereditary dysplasia of the pars + stresses from upright posture → bilateral defect in pars interarticularis
- most common form
- 2:1 male - female ratio, more common in whites
- not present at birth
- 5% at age 6-8 yr, 7-6% by the age of 18 yr
- especially important in repetitive hyperextension sports ( fast bowlers, gymnasts )
- three types can be recognised.
- Lytic
- fatigue fracture of the pars interarticularis
- strong hereditary tendency
- Elongated pars
- micro fractures that heal w/ elongated pars
- Acute fracture of the pars interarticularis
- from significant trauma
- most frequently with spondylolysis, slippage is rare
- Lytic
- Degenerative
- due to disc & facet joint degeneration & segmental instability
- 5x more in females, 3x more in black women
- usually at L4-L5 level
- transitional vertebra - sacralised L5 common
- older than 40 yr
- Traumatic
- results from fractures in areas of facet
- Pathologic
- generalised or localised bone disease present
- in Albers-Schonberg dx(osteopetrosis), arthrogryposis, Paget's disease & syphilitic bone dx.
- extremely rare
- Post surgical(iatrogenic)
- surgical disruption of ligamentous, discal or bony structures
Symptoms
Pain
- most common
- it typically begins with the adolescent growth spurt
- two types:
- back ache - dull, aching pain in the back, buttocks & posterior thigh (pars non-union, ligamentous stretch may be source)
- nerve root irritation usually at L5-S1(sciatica) - radiating pain into the lower extremities
- Neurologic signs
- paraesthesias, weakness & incontinence
- claudication symptoms
Examination
- gait abnormalities
- waddle w/ limited hip flexion, shortened stride length & a wide base of support
- results from hamstring tightness, vertical tilting of the pelvis (lumbosacral kyphosis), compensatory lumbar hyperlordosis & FFD of the hips and knees
- change in normal posture
- lumbosacral kyphosis & compensatory lumbar hyperlordosis
- palpable step-off & trunk shortening with significant slip (Gr III-IV)
- local tenderness, muscle spasm
- hamstring tightness → limited trunk flexion, decreased straight leg raising
Associated conditions
- spina bifida occulta 30-70% with isthmic, 40% with dysplastic ~
- scoliosis 5-7% in spondylolisthesis - usually corrects with treatment of the slip
- lumbarisation or sacralisation 7-9%
Radiological studies
X-rays
- AP & lateral lumbo-sacral views + coned LS junction
- standing
- disruption of pars, degree of slippage on lateral
- reversed Napoleon hat sign on AP (spondyloptosis)
- oblique views
- "Scottie dog's neck" observed for unilateral defects
Radiographic measurements
- Meyerding grading - % slip
- grade 1 - < 25% anterior slip
- grade 2 - 25 – 50% slip
- grade 3 - 50 – 75% slip
- grade 4 - > 75% slip
- spondyloptosis = complete slip off
- slip angle
- measures lumbosacral kyphosis
- Meyerding grading - % slip
- Bone scan
- in acute injury positive before pars defect visible on X-ray
- may benefit from POP immobilisation
- Myelography
- rarely shows nerve root lesion or herniated disc
- block always due to the tenting of the dura over the body at the level of the slip
- CT or MRI
- to evaluate nerve root compression
- associated disc degeneration → fusion level above
- Treatment
- treatment in children is different to that in adults
Non-operative treatment
- Clinical follow up
- Wiltse's guidelines:
- Pars defect discovered very early (less than ten years):
- radiographs every four month initially; later, semiannually to 15 years of age
- then at one- to two-year intervals until completion of growth.
- Up to 25 percent isthmic spondylolisthesis in an asymptomatic child:
- no limitation of activity
- recommend an occupation avoiding heavy labour
- Up to 50 percent slip in an asymptomatic child
- radiographs semiannually until skeletal maturity
- recommend activity modification and refraining from contact sports
- advise an occupation avoiding heavy labour
- Up to 50 percent slip in a symptomatic patient:
- initiate conservative therapy (exercises, corset, brace, limitation of activities)
- recommend semiannual radiographs until 15 years of age and annually thereafter until age 17 or 18
- advise avoiding heavy labour
- Greater than 50 per cent slip
- consider surgical treatment
Physiotherapy
- hamstring stretching, lumbodorsal fascial stretching, and abdominal strengthening
Immobilisation
- bedrest, corset, brace or plaster jacket
- in patients with symptoms , but < 50% slippage
- in acute pars # -s – if bone scan hot
Surgical treatment
Indications
- Persistence symptoms for at least one year despite adequate conservative rx.
- Persistently abnormal gait, tight hamstrings
- Postural deformities eg.sciatic scoliosis
- Progressive neurologic deficit
- Progressive slipping (> 25 to 50%) even when asymptomatic
- Slip angle > 40-50° in a growing child
- likely to be associated with further progression and deformity
Goals
- reduction of back & leg pain
- prevention of further slip
- stabilisation of the unstable L5-S1 segment
- reversal of neurologic deficit
- restoration of more normal spine mechanics, posture and gait
- improved appearance
Pars defect repair
- in <25% slip
- motion is preserved in the segment
- evaluate disc as it can cause pain (MRI or discogram)
Decompression
- if radicular pain
- Gill's laminectomy → residual back pain & increased slippage
- not recommended without fusion
In situ fusion
- usually if <50% slip & no neurology
- posterolateral more effective than posterior
- post operative immobilisation in brace or jacket for 3/12
- instrumentation may be used
- disadvantage:
- pseudoarthrosis rate higher than in other fusions
- further slippage
- neurological risk if > 50% slip
- residual deformity
Reduction & fixation
- advantage:
- stops progression of deformity
- promotes union
- limits fusion length
- restores body posture & mechanics
- indications:
- cauda equina sy.
- progressive slip >50%
- major deformity with decompensation, distress
- traction-cast reduction
- posterior distraction instrumentation
- anterior interbody fusion
- advantage:
spondylolysis in children
- no slip & asymptomatic - no treatment
- no slip but symptomatic - brace for 6 to 8 months
- painful spondylolysis not responding to bracing - L5-S1 arthrodesis
- painful spondylolysis not responding to bracing at L4 - repair of lesion
- Scott technique - wire TP to SP
spondylolysis in adults
- if slip is < 25% - pars repair
spondylolisthesis in children
- grade 1 slips
- fusion if pain despite conservative treatment
- grade 2 slips
- if between 6 & 12 years - fusion even if asymptomatic because of risk of progression
- if mature adolescent & symptomatic - fusion; if asymptomatic observation
- grade 3 & 4
- all should be fused because of likelihood to progress
- usually need L4 to S1 fusion w/ rigid fixation - high rate of pseudo-arthrosis
- reduction probably not necessary
spondylolisthesis in adults
- symptomatic grade 1 & 2
- fusion (posterolateral) in situ + fixation
- symptomatic grade 3 or 4
- controversial
- ? reduce deformity or fusion in situ with fixation
spondylolisthesis with neurology in children
- nerve root decompression + fusion (ALWAYS)
- usually L5 nerve root that is compressed (between pars & disc or vertebra below)
- sometimes the S1(remove part of body of S1)
spondylolisthesis with neurology in adults
- decompression only (Gills) - will have residual backache
- probably should also do a fusion with or without internal fixation
severe spondylolisthesis (spondyloptosis) with lumbar sacral kyphosis
- options: anterior fusion, posterior fusion with or without reduction, combined anterior & posterior fusion, vertebrectomy
- may or may not be combined with internal fixation
- treatment of spondylolisthesis is associated with a higher incidence of pseudo-arthrosis than other fusions