orthopedics 5th year, 5th lecture (dr. hamid)
DESCRIPTION
The lecture has been given on May 18th, 2011 by Dr. Hamid.TRANSCRIPT
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