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					Spondylolisthesis
From Wikipedia, the free encyclopedia

Not to be confused with spondylosis, spondylitis, or spondylolysis.
                      Spondylolisthesis
              Classification and external resources




         X-ray of the lateral lumbar spine with a grade III
               spondylolisthesis at the L5-S1 level.

ICD-10                             M43.1, Q76.2
ICD-9                               738.4, 756.12

OMIM                                184200

DiseasesDB                          12318

MedlinePlus                         001260

eMedicine                           radio/651

MeSH                                D013168


Spondylolisthesis is the anterior or posterior displacement of a vertebra or the vertebral column in relation
to the vertebrae below. The variant "listhesis," resulting from misdivision of this compound word, is
sometimes applied in conjunction with scoliosis.[1] These "slips" (aka "step-offs") occur most commonly in
the lumbar spine. Spondylolysis (a defect or fracture of the pars interarticularis of the vertebral arch) is the
most common cause of spondylolisthesis. This is not to be confused with a slipped disc, where one of the
spinal discs in between the vertebrae has ruptured.
A hangman's fracture is a specific type of spondylolisthesis where the C2 vertebra is displaced anteriorly
relative to the C3 vertebra due to fractures of the C2 vertebra's pedicles.


Contents
        1 Classification
             o 1.1 Grading
        2 Signs and symptoms
             o 2.1 Low-grade isthmic
             o 2.2 High-grade isthmic
             o 2.3 Degenerative
        3 Pathophysiology
        4 Treatment
             o 4.1 Conservative management
             o 4.2 Surgical
                        4.2.1 Low-grade isthmic spondylolisthesis
                        4.2.2 High-grade isthmic spondylolisthesis
        5 Prognosis
        6 History
        7 See also
        8 References
        9 External links


Classification
Spondylolisthesis is officially categorized into five different types:.[2][3]
    Dysplastic spondylolisthesis is a rare congenital spondylolisthesis occurring because of a
        malformation of the lumbosacral junction resulting in small, incompetent facet joints.[citation needed]
X-ray picture of a grade 1 isthmic spondylolisthesis at L4-5
     Isthmic spondylolisthesis is the most common form of spondylolisthesis. Isthmic
         spondylolisthesis (also called spondylolytic spondylolisthesis) is a common condition with a
         reported prevalence of 5–7 percent in the US population. A slip or fracture of the intravertebral
         joint is usually acquired between the ages of 6 and 16 years, but remains unnoticed until
         adulthood. Roughly 90 percent of these isthmic slips are low-grade (less than 50 percent slip) and
         10 percent are high-grade (greater than 50 percent slip).[3]
     Degenerative spondylolisthesis is a disease of the older adult that develops as a result of facet
         arthritis and joint remodeling. Joint arthritis, and ligamentum flavum weakness, may result in
         slippage of a vertebrae. Degenerative forms are more likely to occur in women, persons older than
         fifty, and African-Americans.[3]
     Traumatic spondylolisthesis is very rare and results from acute fractures in various areas of the
         neural arch, other than the pars.[4]
     Pathologic spondylolisthesis has been associated with damage to the posterior elements[which?]
         from metastases or metabolic bone disease. These slips have been reported in cases of Paget's
         disease of bone, tuberculosis, giant-cell tumors, and tumor metastases.[citation needed]


Grading
The most common grading system for spondylolisthesis is the Meyerding grading system for severity of
slip. The system categorizes severity based upon measurements on lateral X-ray of the distance from the
posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body.
This distance is then reported as a percentage of the total superior vertebral body length:
      Grade 1 is 0–25 percent
      Grade 2 is 25–50 percent
      Grade 3 is 50–75 percent
      Grade 4 is 75–100 percent
      Over 100 percent is Spondyloptosis, when the vertebra completely falls off the supporting
         vertebra.[citation needed]


Signs and symptoms
General stiffening of the back and a tightening of the hamstrings, with a resulting change in both posture
and gait. A leaning-forward or semi-kyphotic posture may be seen, due to compensatory changes. A
"waddle" may be seen in more advanced causes, due to compensatory pelvic rotation due to decreased
lumbar spine rotation. A result of the change in gait is often a noticeable atrophy in the gluteal muscles due
to lack of use.[citation needed]
MRI of L5-S1 Spondylolisthesis
Generalized lower-back pain may also be seen, with intermittent shooting pain from the buttocks to the
posterior thigh, and/or lower leg via the sciatic nerve. Additional symptoms may include tingling and
numbness. Coughing and sneezing can intensify the pain. An individual may also note a "slipping
sensation" when moving into an upright position. Sitting and trying to stand up may be painful and
difficult.[citation needed]


Low-grade isthmic
Isthmic spondylolisthesis refers to spondylolisthesis due to degeneration of the pars interarticularis[2] When
symptomatic, patients with symptomatic low-grade (<50 percent slippage) isthmic spondylolisthesis
typically present with activity-related back pain and often with radicular symptoms as well.[citation needed]
Patients with low grade spondylolisthesis are usually young adults (90 percent adults and 10 percent
adolescents) who present with low back pain and often with radiculopathy. High grade spondylolisthesis
may also present with back pain, but may also present with cosmetic deformity, hamstring tightness,
radiculopathy, abnormal gait, or it may be asymptomatic.[5]


High-grade isthmic
X-ray of a grade 4 spondylolisthesis at L5-S1 with spinal misalignment indicated
High-grade isthmic spondylolisthesis and dysplastic spondylolisthesis are regarded as separate clinical
entities from low-grade isthmic slips. High-grade slips are defined as those with greater than 50 percent
forward displacement. These slips are also accompanied by a significant amount of lumbosacral kyphosis,
which is forward bending of the L5 vertebral body over the sacral promontory. Rounding of the sacral body
and trapezoidal deformation of L5 are also common features. High-grade slips are much rarer than low-
grade slips, representing less than 10 percent of all isthmic slips, and the vast majority present during
adolescence, most during the early teenage years.[citation needed]
Unlike low-grade slips, many patients present without pain. Instead symptoms like bodily deformity,
neurologic abnormalities, tight hamstrings, and abnormal gait are often the reason for consultation.[citation
needed]

Degenerative
Patients with isthmic spondylolisthesis almost universally have a neural arch defect, meaning widening of
the central spinal canal at the level of the slip. In contrast, in degenerative spondylolisthesis the forward
translation of the vertebral body also causes narrowing of the central spinal canal at the level of the slip,
termed the "napkin ring effect" depecting the spinal canal as a series of napkin rings with one of the rings
slid forward in comparison to the others. The classic symptomology of patients with symptomatic
degenerative spondylolisthesis are similar to those with symptomatic lumbar spinal stenosis; either
neurogenic claudication or radiculopathy (either unilateral or bilateral radiculopathy) with or without low
back pain.[citation needed]
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.


Pathophysiology
              This section needs additional citations for verification. Please help improve this article by
              adding citations to reliable sources. Unsourced material may be challenged and removed.
              (December 2008)
In the late 1890s, several cadaver studies demonstrated the characteristic pars defect of isthmic
spondylolisthesis, leading to many different theories concerning the etiology of the defect. The first theory
proposed a failure of ossification during embryonic development, leading to a pars defect at birth, which
then progressed to an isthmic slip after the infant began ambulating. Following the development of the
Roentgenogram in 1895, population X-ray studies showed that isthmic spondylolisthesis is, in fact, quite
common. There have been reports that the defect is more common among athletes who participate in sports
with repeated hyperextension, such as gymnastics, ballet, and American football.[citation needed]
Spondylolysis also runs in families and is more prevalent in some populations, suggesting a hereditary
component, such as a tendency toward thin vertebral bone. For example, the frequency of spondylolisthesis
among the Inuit has been found to be 30–50 percent, as compared with an incidence in the general
population of 4–6 percent. It is theorized that the nomadic Inuit have a higher incidence of spondylolysis
due to trauma acquired as infants by being carried in an amauti. While in an amauti, the baby is put into
compressive extension with each step taken by the mother.[6]
Pain. The cause of pain in patients with isthmic spondylolisthesis remains unclear[citation needed]. The first
theory of pain production was segmental instability with excessive forward translation during flexion.
however, this has not been demonstrated radiographically.[citation needed] A more contemporary theory of pain
generation is excessive tension on the annulus of the inferior disc and foraminal stenosis at the level of the
slip.[citation needed] However, this theory has not explained the variance in symptoms experienced by patients.
Foraminal stenosis is also thought to play a role, but long-term studies on surgical outcome have shown
that many patients have poor results following decompression alone. Though, most likely pain in patients
with Spondylolisthesis is simply caused by the actual slippage of the disc in the spinal column.


Treatment
The appropriate treatment of patients with isthmic spondylolisthesis is controversial.[citation needed] For the
purposes of treatment and study, patients with isthmic spondylolisthesis are usually divided into two
general classes: low grade isthmic spondylolisthesis (<50 percent slip) and high grade isthmic
spondylolisthesis (>50 percent slip).[5]


Conservative management
Patients with symptomatic isthmic spondylolisthesis are initially offered conservative treatment consisting
of activity modification, pharmacological intervention, and a physical therapy consultation.
      physical therapy can evaluate and address postural and compensatory movement abnormalities
          such as hyperlordosis and hip flexor and lumbar paraspinal tightness. Other modalities such as
          thermal treatment, electrical stimulation and lumbar traction can help with reactive muscle spasm,
          but should be coupled with therapeutic exercise.[citation needed]
      Anti-inflammatory medications (NSAIDS) in combination with acetaminophen (Tylenol) can be
          tried initially. If severe radicular component is present, a short course of oral steroids such as
          Prednisone or Methylprednisolone can be considered. Epidural steroid injections, either
          interlaminarl or transforaminal, performed under fluoroscopic guidance can help with severe
          radicular (leg) pain. Lumbosacral orthoses may be of benefit for some patients but should be used
          on a temporary basis to prevent spinal muscle atrophy and loss of proprioception.


Surgical
Degenerative spondylolisthesis with spinal stenosis is one of the most common indications for spine
surgery among older adults, and current evidence suggests that patients have much better success rates and
more clinical benefit with decompression and fusion than with decompression alone.[citation needed]

Low-grade isthmic spondylolisthesis
Surgical treatment is only considered after at least 6 weeks and often only after 6–12 months of non-
operative therapy has failed to relieve symptoms.[citation needed] Modalities of surgical treatment include:
Posterolateral fusion.
Posterolateral fusion in adult lumbar isthmic spondylolisthesis results in a significant improvement in 2-
year outcomes, but the difference between surgical and nonsurgical treatment narrows with time.[7] There
has been one randomized controlled trial for low-grade isthmic spondylolisthesis that compared non-
operative therapy to surgery.[8][9][10] The study evaluated the severity of pain and limitations of daily
function in patients with 'lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or
sciatica, and a severely restricted functional ability in individuals 18 to 55 years of age'. At two years
follow-up, patients who underwent surgery had significantly better scores for both pain and daily
function.[8][9] The benefits were reduced after nine years.[10] Nevertheless, posterolateral fusion for isthmic
spondylolisthesis has been one of the least controversial surgeries for spinal pathology and has consistently
demonstrated good outcomes[citation needed].

The success of stand-alone posterolateral fusion for treating adolescent isthmic spondylolisthesis led
several authors, including Dr Leon Wiltse and Dr Eugene Carriagee, to speculate about the effectiveness of
posterolateral fusion without a decompression for adult patients with both back and leg pain. In 1989, Drs.
Peek and Wiltse, et al. reported on eight cases of adults with high-grade spondylolisthesis who presented
with back pain and severe radicular pain.[11] These patients were all treated with an in situ uninstrumented
posterolateral fusion and followed for an average of 5.5 years. At final follow-up, all eight patients reported
complete relief of their back pain and leg pain, no patients were taking analgesics for back pain, and all
patients were unrestricted with respect to work and recreational activities. The mean time to complete
resolution of symptoms was 2.8 months and all patients achieved a solid fusion. No patients underwent
subsequent surgery for either back pain or leg pain throughout the follow-up period. This was the first
report of excellent relief of leg pain in cases of isthmic spondylolisthesis from posterolateral fusion without
decompression.

Fusion with decompression
The addition of decompression does not appear to improve clinical outcome in addition to fusion for the
treatment of low-grade isthmic spondylolisthesis in patients without serious neurological deficit. A
randomized controlled trial compared fusion with a decompression to fusion without a decompression in
adult cases of isthmic spondylolisthesis . The study enrolled 42 patients and showed no benefit to
performing a decompression for isthmic spondylolisthesis; in fact, patients undergoing decompression had
worse clinical outcomes and a higher rate of pseudoarthrosis.[12]

High-grade isthmic spondylolisthesis
               This section needs additional citations for verification. Please help improve this article by
               adding citations to reliable sources. Unsourced material may be challenged and removed.
               (December 2008)


There are several forms of surgery that have been advocated for the treatment of high-grade isthmic
spondylolisthesis, including posterior interlaminar fusion, in situ posterolateral fusion, in situ anterior
fusion (ALIF), in situ circumferential fusion, instrumented posterolateral fusion, and surgical reduction
with instrumented posterior lumbar interbody fusion (iPLIF). Advocates of these different techniques all
cite specific advantages of each approach, but they all have established risks and some are much more
complication-prone than others.[citation needed]
The role of surgical reduction in the treatment of high-grade isthmic is a controversial topic. [citation needed]
Advocates of surgical reduction state that fusion in situ leaves too much residual deformity and impairs the
natural mechanics of the lumbar spine. Patients with high-grade isthmic tend to have hyper-lordosis of the
lumbar spine that compensates for the lumbosacral kyphosis associated with the severe slip and many feel
that this hyper-lordosis will lead to early arthritis and low back pain. Seitsalo, et al. reported on the largest,
long-term cohort of adolescents operated on for high-grade isthmic spondylolisthesis with 87 patients and
mean follow-up of 14 years. Of the patients, 54 had posterior interlaminar fusions, 30 had posterolateral
fusion, and 3 had an anterior interbody fusion (ALIF). The authors found a significant progression of
lumbosacral kyphosis in many of their patients. They also noted that patients undergoing single-level
fusions had much worse outcomes (p<0.0001) and they recommend fusing patients to L4 in virtually all
cases. The authors also concluded that the clinical outcome, while much better than prior to surgery, still
left several patients with significant symptoms and progression of deformity. The authors felt that reduction
may offer patients a better chance of excellent long-term outcomes.[citation needed]

Reduction became feasible with the development of pedicle screws, allowing the reduction to be
maintained. Several authors have published the results of reduction with pedicle screws and posterior
interbody fusion with posterolateral fusion. While the improvement in percent slipped and lumbosacral
kyphosis is significant, many have noted a 10–20 percent rate of nerve root injury and a few cases reports
of complete cauda equina, especially with complete reduction of the deformity. While many of these
injuries improve, several patients are left with permanent deficits. The clinical outcomes after reduction and
instrumentation do not appear to be significantly superior to fusion in situ using modern techniques, despite
the higher complication rate. It should also be noted that recurrence of deformity is common after reduction
and many patients will either bend their hardware or bend at the sacrum, which is often fully segmented
during adolescence. These facts have tarnished the notion of reduction and instrumentation for high-grade
slips, but the technique is still utilized with theoretical benefits and some authors, particularly Dr Harry
Shufflebarger, has reported both low complication rates and good clinical outcomes. Dr. Shufflebarger
currently performs reductions for all high-grade slips that are referred to him and is a leading advocate of
the technique. It should also be noted that the use of pedicle screw fixation is much more extensive in the
US than other countries and that these surgeons are somewhat more inclined to reduce patients, at least
partially, while instrumenting. The routine use of pedicle screws for one or two level pediatric fusions (not
long fusions for correcting scoliosis) is without proven benefit in clinical outcome or fusion rate, but is
associated with more blood loss, increased rate of nerve root injury, and more cases of reoperation.[citation
needed]



Until very recently,[when?] there was no data comparing the long-term outcome of reduction with
instrumented fusion to an uninstrumented in situ fusion. Poussa, et al. recently[when?] published the first
long-term follow-up report comparing reduction with instrumented posterolateral fusion to uninstrumented
circumferential fusion in situ with a mean follow-up of 14.8 years, and concluded that reduction and
instrumented fusion resulted in poorer long-term outcome than fusion in situ and that the deformity tended
to recur following reduction. The increased risks and more extensive surgery associated with reduction did
not translate into better outcomes or permanent correction of deformity.[citation needed]

In addition to the ongoing debate of reduction versus fusion in situ, there is also new evidence emerging as
to what form of fusion is most effect for eliminating symptoms and controlling deformity. This discussion
of surgical technique has been much enhanced recently by the publication of a long-term follow-up study
comparing three different techniques of fusion in situ for treating high-grade spondylolisthesis. The study
by Helenius, et al. compared the outcomes for posterolateral fusion, anterior interbody fusion (ALIF), and
circumferential fusion that is a combination of posterolateral and anterior fusion.[citation needed] Anterior fusion
is a relatively new technique to spine surgery, emerging during the last two decades. It involves either a
retroperitoneal or transperitoneal (through the abdomen) approach to the lumbosacral junction with
mobilization of the iliac arteries and veins. The surgeon then performs a total discectomy and places a bone
graft into the intervertebral space; the graft is usually either a tricortical iliac crest or a femoral ring
allograft. For circumferential fusion, after completing the anterior fusion, the patient is turned and a one or
two level posterolateral fusion without instrumentation is performed. Circumferential fusion can either be
performed under one run of general anesthesia with patient repositioning or the procedure can be staged.
Helenius, et al. followed 70 patients for a mean period of 17 years who had been treated by one of the
above procedures and concluded that circumferential fusion provided the best long-term outcomes among
the three techniques with excellent long-term outcomes and a low complication rate.[citation needed]


Prognosis
The majority of low-grade slips are asymptomatic and do not progress past a patient’s initial presentation.
Prospective studies on children with low-grade slips have demonstrated that once a slip occurs, it rarely
worsens, even after 40+ years of follow-up. However, high-grade slips do continue to progress in many
cases and are much more likely to cause pain. One natural history study by a Swedish researcher, Saraste,
found that roughly 60 percent of patients with slips greater than 15 mm (which is roughly a Meyerding
grade 2 or greater) had persistent daily symptoms, including both back pain and radiculopathy. The low-
grade slips in Saraste's study were symptomatic in only 10 percent of patients.[citation needed]
Some cases do eventually progress to complete spondyloptosis and prevention of progression is the primary
focus of surgery for high-grade slips. Why low-grade slips tend not to progress and why certain slips
ultimately become severe is not known. There have been few long-term follow-up studies on patients with
high-grade spondylolisthesis who did not undergo surgery. Harris and Weinstein reported on eleven
patients after a mean follow-up of 18 years, all of which had greater than 50 percent slip and did not have
surgery. Thirty-six percent of patients were asymptomatic, 55 percent of patients had relatively mild
symptoms, and only one (9 percent) was disabled. The patients with mild symptoms were all able to work
and participate in recreational activities, although they did need to make modifications to their lifestyle. No
patient developed fulminant cauda equina syndrome, severe neurologic symptoms, or incontinence. Forty-
five percent of patients had some neurologic abnormalities on exam, including weakness, paresthesias, and
diminished deep tendon reflexes. Patient symptoms were primarily related to mild to moderate neurologic
symptoms, muscle weakness, especially abdominal muscles, inactivity/deconditioning, obesity, lack of
spinal mobility, and the late development of degenerative scoliosis with lateral listhesis (a deformity
associated with advanced osteoarthritis of the lumbar spine). The patients in this study were a group of 21
patients who had undergone classic posterior interlaminar fusion from L4 to S1 for their severe slip with.
The surgically treated patients were less symptomatic with 57 percent reporting no symptoms and no
limitations, 36 percent reporting mild symptoms, and 5 percent reporting severe symptoms12. It should also
be noted that the outcomes of posterior interlaminar fusions were poorer than newer posterolateral and
circumferential techniques now utilized. Patients with posterior-only fusions tend to have more progression
of their spondylolisthesis following surgery and more pain as well.[citation needed]


History
It was first described in 1782 by Belgian obstetrician, Dr. Herbinaux.[13] He reported a bony prominence
anterior to the sacrum that obstructed the vagina of a small number of patients.[14] The term
“spondylolisthesis” was coined in 1854 from the Greek σπονδυλος = "vertebra" and "ὁλισθος" =
"slipperiness," "a slip."[15]


See also
        Spondylosis
        Failed back syndrome


References
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SANTA BARBARA BEST SPINE AND ORTHOPEDIC DOCTORS IN CALIFORNIA
401 East Carrillo Street,
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PH 805-563-3307 FAX 805-563-0998

Attending Staff

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       Michael Price, MD

       Michael Kenly, MD

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       Ken Nisbet, PA-C, MSPAS

       Jesse Jacobs, PA-C, MSPAS

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326 West Main Street, Suite 120
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    Alan Moelleken, MD

    Michael Price, MD

    Michael Kenly, MD

    David Lee, MD

    David Pires, DO

    Ken Nisbet, PA-C, MSPAS

    Terry Brightwell, DC

    Jesse Jacobs, PA-C, MSPAS

    Darren Richards, PA-C, MSPAS

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2725 16th Street
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Attending Staff
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    Michael Kenly, MD

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    Michael Kenly, MD

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    David Lee, MD

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