Spondylolisthesis

spondylolisthesis

Background

Spondolylolistes comes from the Greek words “spondylosis” meaning vertebra and “olistes” meaning slippage. It means when a vertebra slips relative to the underlying vertebra.

Different variants of Spondylolisthesis

There are many different anomalies of the vertebrae that can result in spondylolisthesis.

Type 1 – dysplastic

A type 1 usually occurs between the L5-S1, and is due to a congenital malformation of the upper part of the sacrum and facet joints. Can also is lost in the arch of L5 vertebra. Type 1 is often difficult to discern against a type 2 or type 2b because it often has a förlängd- or separated couples. It has seen an increased risk of neurological impairment in type 1 if parsing is intact, which can make the arc of L5 can compress the durasäcken at slip. Can slide more than 50%.

Type 2 – itmisk

A itmisk Type 2 is usually caused by a defect or fracture. Often happens that the fracture of the pars interartikularis of vertebral arch and it is the most common of all spondylolisteser. It can be found mostly in the L5 vertebra (90%) and is the second most common in L4. Unlike dysplastic so it slides usually not more than 30%. Itmiska spondylolisteser divided into 3 three groups; Type 2a, type 2b and type 2c.

Type 2a

Is a lytic spondylolisthesis. This means that there is a complete separation of both the arch and the vertebral body. It is believed to be caused by repeated stress fractures in the pars interarticularis. Seen mostly in men and athletes.

Type 2b

Is an extension of pars interarticularis probably caused by repeated stressfakturer.

Type 2c

Is an acute fracture of the pars interarticularis

factors

They often talk about the various factors that affect the itmiska spondylolisteser. The factors focusing on the biomechanical, genetic and hormonal. It is believed that our upright posture affects the forces charged pars interarticularis especially when standing and moving. Repeated flexion and extension movements alternatively rotational axial movements may stress the lumbar and thus give fractures of pars.

If there has been a fracture can heal these, this may in turn form a fibrous tissue that can cause an extension of the pars interarticularis which in turn can provide a spondylolisthesis.

Presence

  • Higher incidence of athletes (in particular; elite gymnasts 11-19%, weight lifters 23%, wrestler 7-30% & diver 43%)
  • 5-6ggr increased risk if a close relative has a spondylolisthesis
  • Prevalence 4-6% of the population
  • Eskimos higher risk 18:52%
  • African-Americans lower risk 2-3%

Trouble

Most often, you notice not to have any spondylolisthesis and go through life trouble free. If symptoms do occur, you get the most often during the growth spurt in puberty, but many people do not seek help until later in life. The most common sökorsaken for a spondylolisthesis is back pain. Often the pain muskoloskeletal and sits in the lower back. The pain is often referred into the buttocks and back of the thigh. Some may pain exacerbated by heavy lifting or movement. Often reduces the pain at rest. The receiving radiating pain is usually the elderly. Usually depends on the compression and stretching of the nerve roots of L5. If you have a larger slip between the vertebrae can durasäcken tease and give cauda equina symptoms of sensory disturbances in the perineum. One can also get disturbances of micturition and defecation.

Children

Children with a sharp slippage can get a “disturbance” in the sagittal balance. The emphasis shifted forward which gives a Kufos at the drift. The body then compensates by giving a long lordosis throughout the lumbar spine and sacrum is more vertical. Hips and knees flekteras easy. Hamstring muscles are shortened and the patient has an abnormal gait pattern.

Pain

It has not been able to show a connection between spondylolisthesis and back pain in middle-aged and older people. It has however to ensure that persons under 26 years of back pain have a higher prevalence. A young person with a spondylolisthesis looking for back pain, it is likely that it is listesen is symptomatic unlike in an elderly person with listes.

  • The disk above spondylolistesen often degenerate and can contribute to the pain.
  • Younger patients have better results from surgery, unlike older.
  • Women with spondylolisthesis do not have an increased risk of complications during cesarean section or labor.

Imaging tests

You start a radiological investigation on suspicion of a spondylolisthesis with a plain x-ray. One should take plain x-ray with a frontal, lateral and oblique lumbar spine. If you can not draw any conclusions on a plain x-ray, you should take a CT (computed tomography).

An MRI scan can be used to see if there is any effect on the nervous structures, and to see how degenerate disk is – important for possible surgery. They’re easy to miss a spondylolisthesis at MRI.

  • DT – Best on suspicion of spondylolisthesis.
  • Bone imaging – at fracture suspicion in the parse (acute fracture = sharply uptake of contrast agent)
  • MR – Easy to miss a spondylolisthesis. Good for the nervous structures and disc degeneration.

Spondylolisthesis and degree

To ascertain how extensive spondylolisthesis a patient, you can use slightly different measurement methods. If a vertebra has completely slipped off as it is referred to spondylolyptos. It can be at a severe spondylolisthesis see that the upper vertebra is often more wedge-shaped and some believe that it increases the risk of vertebra from sliding further.

Factors for increased slip

  • Dysplatisk spondylolisthesis
  • Spina bifida
  • Initial sliding over 30%
  • Low age at diagnosis
  • Female gender
  • Steep glide angle
  • Low lumbar Index

Studies suggest

  • Increasing slippage is rare in young patients with low grade of spondylolisthesis
  • Older patients slippage usually occurs very slowly. Some major slippage occurs more often than not.
  • Fused has continued slippage

Meyer Ding klassification

A common test is Meyer Ding klassificationen which measures the upper vertebra slippage percentage in relation to the lower vertebra.

  • Grade 1: 0-25% slip
  • Grade 2: 25-50% slip
  • Grade 3: 50-75% slip
  • Grade 4: 75-100% slip

lumbar index

Mirrors amount of wedge shape that the sliding vertebra has.

Type 3 – degenerative

A type 3 is caused by degenerative changes in the disc and facet joints. This in turn often causes a segmental instability. It has been seen that a Type 3 mostly occurs in women in the level of vertebra L4 to L5. L5 root is subjected to pressure, and there is no defect in the vertebral arch.

Type 4 – traumatic

A type 4 is a spondylolisthesis who has a fracture in the arc. The fracture is not localized in the pars. Arising from a sharp trauma, which may also give fractures of the pedicles and the facet joints.

Type 5 – pathologic

A type 5 is due to a tumor or metastasis. Alternatively, a metabolic bone disease.

Type 6 – iatrogenic

Due to extensive surgical decompression of the posterior structures. This means vertebral arch, facet joints. This can lead to instability in the segment.

Treatment

Most of spondylolisthesis, no or mostly mild discomfort from the back. Many people often do not even know their diagnosis. Those receiving complaints because of its sliding (slight slippage) has a good prognosis and can usually get by with only conservative treatment.

The typical patient is a young athlete suffering from intense back pain. If the patient does not improve within a few weeks and a plain x-ray of oblique projection does not reveal any analysis, you should also make bone imaging (to exclude traumatic analysis).

The treatment itself does not differ significantly even from other patients with back pain. It tries to combine:

  • Stabilizing low back training
  • Corset
  • Painkillers
  • Adapted activity level
  • Information on diagnosis and normal progress
  • Ev. training

Corset

Corsets have shown good results when dealing with young people – about 80% good or very good. You can also use the corset in a traumatic spondylolisthesis and you have seen the 3-month corset combined with stabilizing the lumbar exercise, in most cases can provide the conditions for the patient to heal lights. The patient can then return to activity within 6-12 months.

Operation

surgical Indications

Persistent back pain with or without leg pain that lasted at least one year and have not responded to conservative treatment. Some of the patients who do not respond to conservative treatment is surgery. For those who do not get well so they tend to be:

  • Under 30
  • Gliding over Meyer Ding grade 3 (50-75%) and grade 4 (75-100%)
  • Even those who have shown a rapid progression of the slip

operation methods

It can operate in many different ways, but the most common surgical methods are:

  • Decompression
  • Fusion
  • Merger with or without decompression
  • Reposition the dislocated vertebra
  • Direct Repair of lights

Decompression

It removes the fibrous tissue in the fracture gap and to perform a laminectomy (removing the loose vertebral arch). It has, however, means that decompression can increase drift postoperatively, after which they prefer fusion surgery.

Fusion

In a merger can choose several different methods. It has now been unable to show that someone is better than any other method. What you need to consider the merger is if you also need to expose the nerves ie a decompression. Often do a decompression of the patient radiating leg pain and you can see through the X-ray to the press on the nerve roots. If the patient has bone pain and only pain in the back usually do not perform a decompression.

Younger patients (under 25) Hands with fusion even though the patient has bone pain. It has been seen that the leg pain diminishes whatever. In a Meyer Ding grade 1-2 fuse to the upper sliding against the lower vertebra. At greater slippage Meyer Ding grade 3-4 then merge it to a higher level. You try to refrain from when putting screws in the sliding vertebra.

Fusion with reduction

A merger with the reduction means that returns the anatomical and sagittal balance. The chance that the merger will increase heals, but it also increases the risk of having neurological problems.

In situ fusion

One fuse vertebrae in its current position. Less risk of neurological problems.

direct Repair

It stabilizes the surgical defect in the pars interarticularis without making a fusion between the vertebrae.

Evidence for kirugi

It has been seen that the surgical treatment gives slightly better results than conservative treatment alone.

  • Older people with a posterolateral fusion was little better with surgery versus the conservatively treated control group
  • Better to function after surgery compared with conservative treatment
  • Residual effect even nine years later
  • Reduction of postoperative analgesics
  • The improvement in walk distance 2 years postoperatively