orthopedics 5th year, 5th lecture (dr. hamid)

Spodylolysthesis

Introduction

Spondylolisthesis is a common cause for lower-back pain, radiculopathy, and neurogenic claudication among the adult population.

Definition: ant. slipping of the spine. Site Normal locking mechanism

Classification (Wiltse et al 1976)

congenital,dysplastic isthmic,* 5%,7year,gymnastic,wt,lifters, degenerative,*L4-L5 pathologic, iatrogenic, traumatic.

Epidemiology

level L4-L5.&L5-S1

F:M = 6:1

Black : White = 6:1

pathology

Clinical Presentation Hx acording to age of presentation lower-back pain, neurogenic claudication, Vesicorectal disorder, radiculopathy is present, the L5 nerve root

most often is affected.L4 second most common

Physical Examination loss of lumbar lordosis,flat buttock,sacrum,scoliosis Transverse loin crese Hip flexion contractures Muscle atrophy Fell- step-off at the listhetic level. range of motion (ROM) usually is normal and

occasionally hypermobility may exist. Hamstring tightness Neurological examination

Imaging Studies lumbar AP, lateral, and oblique views. lateral flexion and extension,MRI Meyerding’s system for grading:

Grade 1 is 25%,

Grade 2 is 50%,

Grade 3 is 75%,

Grade 4 is 100% displacement ,

GradeV --spondyloptosis

Risk factors for progression

Clinical ,gender,age,symptome,gaite Radilogical,angle,typ sarcum,l5

PrognosisDysplastic

Lytic

Degenerative

Non-operative treatment 1-day to 2-day period rest- short course of anti-inflammatory

medications Physiotherapy Spinal support Modification of activity Psychological support Epidural injection

Surgical treatment

------Surgical goals pain reduction, improvement of neurologic symptoms, improvement in the quality of life.

If attainment of these goals is unlikely, conservative treatment should be continued.

Indications indications :

--progressive neurologic deficit

--cauda equina syndrome.

--slip >50% and progressive

- persistent radiculopathy

-persistent and unremitting lower-back -pain for more than 6 months,

-disabling symptom-affect work,sport

Decompression Alone

Laminectomy and Posterior Spinal Fusion (without Interpedicled Instrumentation(

Decompression with Anterior and Posterior Spinal Fusion

SPONDYLOLYSTHESIS

Post traumatic spondylolethesis

Spinal stenosis

Lumbar Spinal Stenosis

Normal canal “Narrowing of osteoligamentous vertebral canal

and/or the intervertebral foramina causing compression of the thecal sac and/or the caudal nerve roots”

Classification ----congenital -----aquired

Lumbar Spinal Stenosis Developmental & Congenital

----Idiopathic narrowing-Short pedicles

-Reduced interpedicular dist.

--Bone dysplasias

---Achondroplasia

Acquired or Degenerative Spondylosis Facet lig flavum Chronic PID Post-traumatic Tumor Infection Spondylolisthesis pagets

Pathoanatomy

Adult degenerative lumbar spinal stenosis (ie Acquired stenosis)Facet hypertrophyVertebral osteophytes thickened ligamentum flavumDisc protrusionsOverall decreased volume of spinal canal

Stenotic

Vertebrae provide body support Discs act as “shock absorbers” Vertebra protects spinal cord and nerves Nerves have space and are not pinched

As we age, ligaments and bone can thicken

Narrowing is called “stenosis” Narrowing squeezes nerves in spinal

canal and nerve roots exiting spine to legs

Result - pain & numbness in back and legs

Nerve Root

Spinal Canal

Lumbar Vertebra

Bone (Facet Joint)

Healthy

Intervertebral Disc

Thickened Ligament Flavum

Pinched Nerve Root

Narrowed Spinal Canal

Clinical Presentation

Hx-age- ach-heaviness,n,symptoms neurogenic claudication with intermittent pain

radiating to the thighs or legs.

Claudication,ppppsn Neurogenic

Pain proxdist Relief w/ flexion

sitting,squating Extension worsens pain Better w/ stairs Pulses wnl Skin wnl +/- Neuro deficits

Vascular Pain dist prox Relief w/ standing

Pain not positional

Pulses diminished Mottled skin Neuro exam wnl

EMG-NCS

Differentiation between neuropathy and radiculopathy

Evaluation

AP & Lat radiographs 20-16Flex/ext films to reval stability

CT 16-11 MRI Lumbar myelography + CT

Evaluation of extent of neural element compression

Treatment Non-Operative

NSAIDsPhysical therapy

Stretching, strengthening,

heat, electrical stimulation,Activity modificationBracing- especially w/ spondylolisthesisSteroid injection-

Non-Operative Treatment

Good for non-progressive minimally debilitating conditions

Pt getting better non opPt getting worse Surgery

Surgery? Indications

Worsening neuro sx, bowel bladder dysfunction, cauda equina syn, debilitating pain

Best candidatePredominantly leg painClinical exam Imaging studiesMild to moderate neuro deficitNo back pain (excluding spondylolisthesis)

Operative Treatment Laminectomy

Bilateral laminectomies for all affected levels If discectomy performed, consider arthrodesis

HemilaminectomyPts w/ unilateral sympBetter preserves post op stabilityDifficulty in accessing

Contralateral sideNeural foramen

Risk for dural tear

Operative Treatment

LaminoplastyHinging open the lamina on one side, interpositioning

the resected spinous process Increased size of spinal canal X-Stop

Device designed to selectively impart relative flexion at one symptomatic motion segment of the spine

The X-STOP® Spacer

Supraspinousligament

Spinousprocess

Spacer only limits extension

Wings prevent side-to-side and upward migration

Preserves your supraspinous ligament, which prevents backward migration

Preserves anatomy

Treats LSS symptoms, not “anatomy”

Compared to traditional LSS surgery, X-STOP benefits include:

Can be done under local anesthesia Can be done as an outpatient procedure No removal of the lamina (vertebral bone) or

ligaments that protect and stabilize the spine Potential of a shorter recovery

The X-STOP Spacer

STENOSIS

STENOSIS

Compresses the exiting nerve root

FORAMINAL STENOSIS

CANAL SHAPE Round Triangular Trefoiled

(15%) Trefoiled &

asymmetric

POSTURE

Root symptoms Unilateral No claudication Acute or chronic

FORAMINAL STENOSIS

Claudication Radicular pain Weakness is rare Acute or chronic

LATERAL RECESS STENOSISLATERAL RECESS STENOSIS

CENTRAL STENOSIS

Varied presentation Classically with

neurogenic claudication

Some may only have back pain

Rarely painless progressive weakness

X-RAY

SPINAL STENOSIS

MRI

Non-invasive Soft tissue

visualization Gold standard

MRI

Sagittal images Visualization of

foramen

Excellent for intra-canal pathology

Poor for foraminal pathology

Replaced by MRI

MYELOGRAPHYMYELOGRAPHY

Excellent visualization of spinal canal

CT-MYELOGRAPHY

EPIDURAL STEROID

Commonly prescribed 50% short-term efficacy Not as selective May not require

fluroscope

Facet joint injection or RF

Medial branch block or RF

Transforaminal epidural injection

Intradiscal procedure:DiscographyProvacation testOzone discectomy Laser discectomy Percutanous disc decompressionIDET

Epiduroscopy and adhesolysisEpidural injection

d

TRANSFORAMINAL ROOT BLOCK

Highly selective Diagnostic as well as

therapeutic Delivers medicine to

the floor of spinal canal

FACET INJECTION

Facet for back pain Not for radicular pain May act as epidural in

40% of cases

OPERATIVE TREATMENT

Decompression of neural element

Stabilization of unstable segment

FUSION

Sagittal instability Scoliosis Iatrogenic pars defect Greater than 50%

facet joint resection

INSTRUMENTATION