Transcript Spondylolisthesis

Spondylolisthesis
Done By : Aliaa Hassan
Spondylolisthesis
Definition
The term "Spondylolisthesis" refers to a condition where
one of the vertebrae (usually L5) becomes misaligned
anteriorly (slips forward) in relation to the vertebra below.
This forward slippage is caused by a problem or defect
within the pars interarticularis. Occasionally, facet joint
and/or posterior neural arch defects may also cause this
syndrome as well.
The forward slippage does NOT always occur. This nonslipped pars defect is called a "Spondylolysis" and is
almost always a precursor to the actual forward slippage.
Spondylolisthesis
Spondylolisthesis
Developmental anatomy
 The first theory proposed a failure of ossification during
embryonic development, leading to a pars interarticularis
defect at birth
 The second theory demonstrated that the pars defect
began to appear around age six and became
progressively more common till age 16. After age 16, the
incidence fell and rarely developed after adolescence
 It is currently thought that the defect develops from
small stress fractures that fail to heal and form a chronic
nonunion.
Classification
Dysplastic spondylolisthesis
 Isthmic spondylolisthesis
DEGENERATIVE SPONDYLOLISTHESIS
TRAUMATIC SPONDYLOLISTHESIS
PATHOLOGICAL SPONDYLOLISTHESIS
 IATROGENIC SPONDYLOLISTHESIS
Dysplastic spondylolisthesis
 Is a true congenital spondylolisthesis that occurs because
of malformation of the lumbosacral junction with small,
incompetent facet joints.
 Very rare, but tends to progress rapidly
 Often associated with more severe neurological deficits.
Isthmic spondylolisthesis
SUB-TYPE A:
Is the most commonly found type of
spondylolisthesis in people under 50 years
of age.
It is believed that "biomechanical stress,"
such as repetitive mechanical strain from
heavy work or sports, causes a fatigue
fracture within the pars interarticularis.
Isthmic spondylolisthesis
SUB-TYPE B:
• This type of Isthmic spondylolisthesis is characterized by a
elongated pars without separation.
• It is believed that the elongation occurs secondary to "repeated,
minor trabecular stress fractures of the pars." Each time these
possible sub-acute stress fractures occur and heal, the vertebral
body is displaced farther and farther forward. Eventually, the pars
may fail to heal and result as a full pars defect.
SUB-TYPE C:
These types of spondylolisthesis' are extremely rare and result
from an acute pars fracture, often as result of traumatic lumbar
hyperextension injury
DEGENERATIVE SPONDYLOLISTHESIS
o This is the most common form of spondylolisthesis
in patients over 50 years of age and rarely occurs in
those under 50
o There is no fracture or elongation of the pars
interarticularis and the neural arch is intact. In
contrast, patients with isthmic spondyolisthesis
almost universally have widening of the central
spinal canal at the level of the slip. This narrowing
of the canal in degenerative spondylolisthesis has
been termed the "napkin ring effect.
DEGENERATIVE
SPONDYLOLISTHESIS
• The classic symptomology of patients with
symptomatic degenerative spondylolisthesis are
similar to those with symptomatic lumbar spinal
stenosis; which can be either neurogenic claudication
or radiculopathy (either unilateral or bilateral
radiculopathy) with or without low back pain.
• Neurogenic claudication is thought to result from
central canal narrowing that is exacerbated by the
listhesis (forward slip). The classic symptoms of
neurogenic claudication are bilateral (both legs)
posterior leg pain that worsens with activity, but is
relieved by sitting or forward bending.
TRAUMATIC SPONDYLOLISTHESIS
 This type of spondylolisthesis, which is
extremely
rare,
results
from
a
traumatically-induced fracture to the
neural arch other than the pars region.
 One of the examples is The "Hangman's
Fracture" in the cervical spine's second
vertebra (Axis) is a common and often
deadly example of such a traumatically
induced phenomenon. This type of fracture
is extremely rare in the lumbar spine.
PATHOLOGICAL SPONDYLOLISTHESIS
Generalized or systemic disorders of bone may
affect the neural arch of the spine and allow
spondylolysis or spondylolisthesis to occur.
– Osteoperosis
– Paget's disease
– Metastatic carcinoma
IATROGENIC SPONDYLOLISTHESIS
:
 Is a complication of lumbar anterior interbody fusion
(LAIF. Either the vertebrae above o below develops a
pars fracture.
 Laminectomy procedures will result in an overload of
weight-bearing stress on the contralateral pars and, in
some patients, result in a pars fracture.
symptoms
 Spondylolysis commonly is asymptomatic.
 Symptomatic patients often have pain with
extension and/or rotation of the lumbar spine.
 Common nerve symptoms
symptoms
Leg pain
Electric shock-like symptoms traveling down the
leg
Numbness or tingling in the legs and feet
Muscle weakness of the legs
Other symptoms can occur. bowel or bladder
dysfunction, or any numbness around the genitals,
These symptoms may be a sign of cauda equina
syndrome.
Limitations of Techniques
• Radiography of the lumbar spine is limited by its inability to
detect stress reactions in the pars interarticularis that have not
progressed to complete fracture.
• CT of the lumbar spine is not sensitive for detecting early acute
stress reactions in the pars interarticularis where there is only
marrow edema and microtrabecular fracture.
• MRI of the lumbar spine can easily identify acute stress reactions
in the pars interarticularis. However, direct identification of pars
defects (old stress) may be slightly more difficult with MRI than
with CT.
• BONE SCAN : easily identifies acute stress reaction in the pars
interarticularis, but cannot identify old pars defect.
Treatment
o If the slip is small and the symptoms are
manageable, then treatment is most often with
observation. In children, this may include activity
restrictions, such as withholding the child from
participation in some sports.
o When the slip is more significant, there may be a
higher risk of the problem progressing, and
surgery may be favored. In addition, patients who
have symptoms of nerve compression are more
likely to have surgery recommended.
Spondylolisthesis
Spondylolisthesis
Spondylolisthesis
Disorders of the neck
 Torticollis
 Klippel-Feil syndrome
Torticollis
Definition
Is a condition in which
the head is tilted
toward one side, and
the chin is elevated
and turned toward the
opposite side.
Types of torticollis
 Infantile torticollis
Acquired torticollis
Infantile torticollis
• causes:
 Birth trauma or intrauterine malposition
 Sometimes a mass (a sternomastiod tumor) in the affected muscle
may be noted, this appears at the age of two to four weeks, it
disappears gradually, but sometimes the muscle becomes fibrotic.
It is likely to disappear within the first five to eight months of life.
 Other less common causes such as tumors, infections,
ophthalmologic problems and other abnormalities should be
ruled out. For example, ocular torticollis due to cranial nerve IV
palsy. In this situation, the torticollis is a neurologic adaptation
designed to maintain binocularity.
Infantile torticollis
• treatment:
 If a child has sternomastoid tumor, subsequent
deformity may be prevented by gentle, daily
manipulation of the neck. In established cases, the
sternomastoid can be divided or elongated
 Ocular torticollis due to cranial nerve IV palsy should
not be treated with physical therapy. Rather the
treatment should be targeted at the extraocular muscle
imbalance
Acquired torticollis
• causes:
Acute disc prolapse (the most common
cause in adults)
Inflamed neck glands
Vertebral infection
Injuries of the cervical spine
Ocular disorders
Klippel-Feil syndrome
• It is caused by a failure in
the normal segmentation
or division of the cervical
vertebrae during the early
weeks of fetal development.
Klippel-Feil syndrome
• The most common
signs of the disorder
are short neck, low
hairline at the back
of the head, and
restricted mobility of
the upper spine.
Klippel-Feil syndrome
• Treatment is symptomatic and
may include surgery to relieve
cervical instability and
constriction of the spinal cord,
and to correct scoliosis. Physical
therapy may also be useful.
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