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Spondylolisthesis
Classification and external resources
X-ray of the lateral lumbar spine with a grade III spondylolisthe
the L5-S1 level.
ICD-10 M43.1
(http://apps.who.int/classifications/apps/icd/icd10on
gm40.htm+m431) , Q76.2
(http://apps.who.int/classifications/apps/icd/icd10on
gq65.htm+q762)
ICD-9 738.4 (http://www.icd9data.com/getICD9Code.ashx
icd9=738.4) , 756.12
(http://www.icd9data.com/getICD9Code.ashx?
icd9=756.12)
OMIM 184200 (http://www.ncbi.nlm.nih.gov/omim/184200
SpondylolisthesisFrom Wikipedia, the free encyclopedia
Spondylolisthesis describes the anterior
displacement of a vertebra or the vertebral
column in relation to the vertebrae below. It
was first described in 1782 by Belgianobstetrician, Dr. Herbinaux.[1] He reported
a bony prominence anterior to the sacrum
that obstructed the vagina of a small
number of patients.[2] The term
“spondylolisthesis” was coined in 1854,
from the Greek σπονδυλος = "vertebra"
and "ὁλισθος" = "slipperiness", "a slip".[3]
The variant "listhesis", resulting from
misdivision of this compound word, is
sometimes applied in conjunction with
scoliosis.[4] These "slips" occur most
commonly in the lumbar spine.
A hangman's fracture is a specific type of
spondylolisthesis where the C1 vertebra is
displaced anteriorly relative to the C2
ertebra due to fractures of the C2
ertebra's pedicles.
Contents
1 Signs and symtoms1.1 Low-grade isthmic1.2 High-grade isthmic1.3 Degenerative
2 Pathophysiology2.1 Developmental anatomy
3 Pathology4 Treatment
4.1 Conservative4.2 Surgical
4.2.1 Low-gradeisthmicspondylolisthesis4.2.2 High-grade
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DiseasesDB 12318 (http://www.diseasesdatabase.com/ddb12318
eMedicine radio/651
(http://www.emedicine.com/radio/topic651.htm)
MeSH D013168
(http://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?
field=uid&term=D013168)
isthmicspondylolisthesis
5 See also6 References7 External links
Signs and symtoms
Typical physical changes that occur in an individual with spondylolisthesis will be a general stiffening o
back and a tightening of the hamstrings, with a resulting change in both posture and gait. The posture wi
typically give the appearance that the individual leans forward slightly and/or that they are suffering from
lordosis. In more advanced cases, the gait of the individual may change to give the appearance of more o
"waddle" than a walk, where the individual rotates the pelvis more due to the decreased mobility in the
hamstrings. A result of the change in gait is often a noticeable atrophy in the gluteal muscles due to lack
use.
An individual suffering from spondylolisthesis will typically experience generalized pain in the lower ba
along with intermittent shocks of shooting pain beginning in the buttock traveling downward into the bac
the thigh and/or lower leg. Sciatica that extends below the knee and may be felt in the feet. Sometimes
symptoms include tingling and numbness. Sitting and trying to stand up may be painful and difficult.
Coughing and sneezing can intensify the pain. The individual may also note a "slipping sensation" when
moving into an upright position. An increase in activity level, for an individual experiencing pain of this
will likely cause the individual to experience an increase in pain levels in the day(s) following the activit
to inflammation of the soft tissues, which is alleviated with reduced activity and/or rest.
Low-grade isthmic
Patients with symptomatic low-grad (<50% slippage) isthmic spondylolisthesis typically present with act
related back pain and often with radicular symptoms as well, but despite the large number of individuals
radiographic evidence of isthmic spondylolisthesis, few of them become symptomatic or require treatmen
Additionally, the cause of pain in patients with isthmic spondylolisthesis remains unclear. The first theor
pain production was segmental instability with excessive forward translation during flexion. This notion w
logical from the mechanical standpoint as the pars defect eliminated the vertebral body’s primary restrain
forward translation, the inferior facet joint. This theory has now been evaluated by multiple radiographic
studies, none of which were able to demonstrate excessive forward translation as a common feature of is
spondylolisthesis. A more contemporary theory of pain generation is excessive tension on the annulus of
inferior disc and foraminal stenosis at the level of the slip. Excessive annular tension is also mechanically
logical as without the restraint of the inferior facet joints; the disc has to both resist shear forces from the
and compressive forces from the body’s mass. However, this theory does not explain why some patients
symptoms while so many others do not, since the inferior discs of all patients with isthmic spondylolisthe
are subjected to similar forces. 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. Since
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X-ray of a grade 4 spondylolist
at L5-S1 with spinal misalignm
indicated
mid-1950s, surgeons have been advocating the combination of decompression and fusion. A recent
biomechanical study of flexion-extension X-rays in patients with isthmic spondylolisthesis and normal
controls found paradoxical motion at the level of the slip in 46% of patients and 0% of controls without
pain. Paradoxical motion has not been previously reported in cases of spondylolisthesis, but its role in th
symptomatic and asymptomatic patient is unclear.
High-grade isthmic
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% 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% of
all isthmic slips, and the vast majority present during adolescence, most
during the early teenage years.
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. The
natural history of high-grade spondylolisthesis is also quite different
from those with low-grade slips. 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 manycases and are much more likely to cause pain. One natural history study by a Swedish researcher, Saraste
found that roughly 60% of patients with slips greater than 15 mm (which is roughly a Meyerding grade 2
reater) had persistent daily symptoms, including both back pain and radiculopathy. The low-grade slips
Saraste's study were symptomatic in only 10% of patients.
Some cases do eventually progress to complete spondyloptosis and prevention of progression is the prim
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 wit
high-grade spondylolisthesis who did not undergo surgery. Harris and Weinstein reported on eleven patie
after a mean follow-up of 18 years, all of which had greater than 50% slip and did not have surgery. Thipercent of patients were asymptomatic, 55% of patients had relatively mild symptoms, and only one (9%
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 eq
syndrome, severe neurologic symptoms, or incontinence. Forty-five percent of patients had some neurolo
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
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degenerative scoliosis with lateral listhesis (a deformity associated with advanced osteoarthritis of the lum
spine). The patients in this study were a group of 21 patients who had undergone classic posterior interla
fusion from L4 to S1 for their severe slip with. The surgically treated patients were less symptomatic with
reporting no symptoms and no limitations, 36% reporting mild symptoms, and 5% 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 ten
have more progression of their spondylolisthesis following surgery and more pain as well.
Degenerative
Unlike isthmic spondylolisthesis, degenerative spondylolisthesis is not associated with a neural arch defe
meaning that the forward translation of the vertebral body also causes narrowing of the central spinal can
the level of the slip. In contrast, patients with isthmic spondylolisthesis almost universally have widening
the central spinal canal at the level of the slip. This narrowing of the canal in degenerative spondylolisthe
has been termed the "napkin ring effect", an illustrative description as one imagines the spinal canal as a
of napkin rings with one of the rings slid forward in comparison to the others. The classic symptomology
patients with symptomatic degenerative spondylolisthesis are similar to those with symptomatic lumbar s
stenosis; which can be either neurogenic claudication or radiculopathy (either unilateral or bilateralradiculopathy) with or without low back pain.
Neurogenic claudication is thought to result from central canal narrowing that is exacerbated by the listhe
(forward slip). The classic symptoms of neurogenic claudication are bilateral (both legs) posterior leg pai
worsens with activity, but is relieved by sitting or forward bending.
Pathophysiology
Developmental anatomy
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 theo
proposed a failure of ossification during embryonic development, leading to a pars defect at birth, which
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. A population study by Fredrickson, et al. demonstrated that the pars defect began to appear aro
age six and became progressively more common until age 16. After age 16, the incidence fell and rarely
developed after adolescence. This study confirmed that the pars defect is the result of a defect in the
cartilaginous anlage of a vertebra but not apparent at birth. It is currently thought that the defect developsmall stress fractures that fail to heal and form a chronic nonunion. There have been reports that the defe
more common among athletes who participate in sports with repeated hyperextension, such as gymnastic
ballet, and American football.
Spondylolysis also runs in families and is more prevalent in some populations, suggesting a hereditary
component, such as a tendency toward thin vertebral bone. Spondylolysis is the most common cause of
spondylolisthesis. The hereditary factor (mentioned above) is quite notable, since the frequency of
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X-ray picture of a grade 1 isthm
spondylolisthesis at L4-5
spondylolisthesis among Inuit is 30–50%. (This statistic is controversial, however, because further
anthropological studies have shown that the occurrence of spondylolysis in Inuit people living in Wester
style communities is within the normal variancy at 7%. These people are hereditarily linked to the study
showing ~40%. It is theorized that the nomadic Inuit have a higher incidence of spondylolysis due to trau
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. Also, all other studies have shown a normal variance of
spondylolysis within cultures of 6-10%, further suggesting that spondylolysis is an environmental abnorm
and that a hereditary tie is very unlikely).
Pathology
Spondylolisthesis is officially categorized into five different types by the Wiltse classification system:
Dysplastic, Isthmic, Degenerative, Traumatic, and Pathologic.
Dysplastic spondylolisthesis is a true congenital spondylolisthesis that occurs because of malformation of
lumbosacral junction with small, incompetent facet joints. Dysplastic spondylolisthesis is very rare, but t
to progress rapidly, and is often associated with more severe neurological deficits. It is difficult to treat
because the posterior elements and transverse processes tend to be poorly developed, leaving little surfac
for a posterolateral fusion.
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% in the U.S. population. the spondylolytic defect is usually
acquired between the ages of 6 and 16 years, and that the slip often
occurs shortly thereafter. Once the slip has occurred, it rarely continues
to progress, although one study did find an association between disc
desiccation and slip progression during middle age. It is thought that the
ast majority of isthmic slips do not become symptomatic, but the
incidence of symptoms is unknown. One very long-term prospective
study by Fredrickson, et al. that followed a cohort of 22 patients from
the development of their slip into middle age, reported that many of the
patients experienced occasional back pain, but so does the vast majority
of people without isthmic spondylolisthesis. One patient did undergo spinal fusion at the slipped level, b
study could not verify if the isthmic slip was the indication for surgery. Roughly 90% of isthmic slips ar
rade(less than 50% slip) and 10% are high-grade (greater than 50% slip).
The most common grading system for spondylolisthesis is the Meyerding grading system for severity of sThe system categorizes severity based upon measurements on lateral X-ray of the distance from the poste
edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This dista
is then reported as a percentage of the total superior vertebral body length:
Grade 1 is 0–25%Grade 2 is 25–50%Grade 3 is 50–75%
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Grade 4 is 75–100%Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.
Degenerative spondylolisthesis is a disease of the older adult that develops as a result of facet arthritis an
facet remodeling. As the facets remodel, they take on a more sagittal orientation, allowing a mild slip to
These slips are very common: a study of osteoporosis found a 30% incidence among Caucasian women o
than 65 years and a 60% incidence among African-American women older than 65 years. Most slips are
asymptomatic but can worsen the symptoms of neurogenic claudication when associated with lumbar spistenosis. Degenerative spondylolisthesis with spinal stenosis is one of the most common indications for s
surgery among older adults, and current evidence suggests that patients have much better success rates an
more clinical benefit with decompression and fusion than with decompression alone.
Traumatic spondylolisthesis is very rare and may be associated with acute fracture of the inferior facets o
interarticularis. It is treated in the same manner as are other spinal fractures, and there are only a handful
case reports on this type.
Pathologic spondylolisthesis is the last type and is also very rare. This type can occur following damage
posterior elements from metastases or metabolic bone disease. These slips have been reported in cases oPaget’s disease of bone, tuberculosis, giant-cell tumors, and tumor metastases.
Treatment
The appropriate treatment of patients with isthmic spondylolisthesis is just as controversial as the cause o
symptoms. Patients with isthmic spondylolisthesis are usually divided into two general classes for both
treatment and for study: low grade isthmic spondylolisthesis (<50% slip) and high grade isthmic
spondylolisthesis (>50% slip). Patients with low grade spondylolisthesis are usually young adults (90% a
and 10% 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, hamstrtightness, radiculopathy, abnormal gait, or it may be asymptomatic.[5]
Conservative
Patients with symptomatic isthmic spondylolisthesis are initially offered conservative treatment consistin
activity modification, pharmacological intervention, and a physical therapy consultation. Anti-inflammat
medications (NSAIDS) in combination with acetaminophen (Tylenol) can be tried initially. If severe radi
component is present, a short course of oral steroids such as Prednisone or Methylprednisolone can be
considered. Physical therapy can evaluate and address postural and compensatory movement abnormaliti
such as hyperlordosis and hip flexor and lumbar paraspinal tightness. The majority of these patients alsopresent with chronically tight hamstrings. Physical modalities such as thermal treatment, electrical stimul
and lumbar traction can help with reactive muscle spasm, but typically are of short therapeutic duration w
done in isolation, and should be coupled with therapeutic exercise. Epidural steroid injections, either
interlaminarl or transforaminal, performed under fluoroscopic guidance can help with severe radicular (le
pain. Lumbosacral orthoses may be of benefit for some patients but should be used on a temporary basis
prevent spinal muscle atrophy and loss of proprioception.
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Surgical
Low-grade isthmic spondylolisthesis
Surgical treatment is only considered after at least 6 weeks and often only after 6–12 months of non-ope
therapy has failed to relieve symptoms. Several authors have noted that patients with only low-back pain
more likely to respond to non-operative therapy than patients with radiculopathy, but this has not been
formally documented and likely reflects the weakness of our current diagnostic system.[citation needed ]
Currently, there are no means of effectively differentiating a patient with low-back pain and an incidenta
finding of spondylolisthesis from a patient whose symptoms are the result of their spondylolisthesis. How
in cases of a bilateral radiculopathy in a dermatomal distribution that matches the patient’s segment with
spondylolisthesis, as well as radiologic evidence of slip (listhesis) progression, the differential diagnosis
narrower and the diagnostic accuracy higher.[citation needed ]
Posterolateral fusion
Posterolateral fusion in adult lumbar isthmic spondylolisthesis results in a significant improvement in 2 y
outcomes, but the difference between surgical and nonsurgical treatment narrows with time.[6] There has
one randomized controlled trial for low-grade isthmic spondylolisthesis that compared non-operative the
to surgery.[7][8][9] The study evaluated the severity of pain and limitations of daily function in patients w
'lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severel
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. [7][8] The benefits wer
reduced after nine years.[9] While the patients undergoing non-operative care did show some improveme
pain, their daily activities and physical function did not change during the follow-up period. The follow-u
was relatively short, but the study clearly favored surgery and was the first prospective randomized trial f
spondylolisthesis . This was also the first prospective trial demonstrating that surgery could be effective ftreatment of some types of low-back pain. Several other retrospective studies have found significant and
reliable benefit for patients with isthmic spondylolisthesis, but none compared the results of surgery to na
history of the disorder[citation needed ]. Nevertheless, posterolateral fusion for isthmic spondylolisthesis has
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 seve
authors, including Dr Leon Wiltse and Dr Eugene Carragee, to speculate about the effectiveness of
posterolateral fusion without a decompression for adult patients with both back and leg pain. In 1989, Dr
Peek and Wiltse, et al. reported on eight cases of adults with high-grade spondylolisthesis who presented
back pain and severe radicular pain.[10] 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 report
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 re
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of excellent relief of leg pain in cases of isthmic spondylolisthesis from posterolateral fusion without
decompression. Another study by de Loubresse, et al.[5] reported on 48 adults with low grade isthmic
spondylolisthesis and radiculopathy, half treated by posterolateral fusion or posterolateral fusion and a G
laminectomy . With respect to radicular pain during activity, 92% of patients treated by posterolateral fus
reported complete relief, while only 65% of those treated with fusion and decompression reported relief.
Several natural history studies have also reported that foraminal stenosis is common among asymptomati
isthmic patients and does not correlate well with radiculopathy.
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. [11] A
randomized controlled trial compared fusion with a decompression to fusion without a decompression in
cases of isthmic spondylolisthesis . The study enrolled 42 patients, all of which had both leg pain and ba
pain, but no evidence of cauda equina syndrome or motor strength less than 5-. The mean post-operative
follow-up was 4.5 years. Clinical success was evaluated by a series of visual analog scales (VAS) for leg
back pain, analgesic use, and overall function. Scores are numbered from 0–10 with lower scores meanin
pain. Success was defined as leg and back pain of three or less on the VAS scale with an analgesic scoresix (meaning only sporadic use of NSAIDs or Tylenol) and functional score above six (meaning infreque
limitations of activity that does not effect employment or important recreational activities). All smokers
received pedicle screw fixation to decrease the risk of pseudoarthrosis while non-smokers were not
instrumented. The results showed no benefit to performing a decompression for isthmic spondylolisthesis
fact, patients undergoing decompression had worse clinical outcomes and a higher rate of pseudoarthrosi
the patients managed without a decompression 96% of the reached clinical success (as defined above), pa
who received a decompression had a clinical success rate of only 66%. Interestingly, the rate of persisten
pain was much higher in the group managed with a decompression (average VAS for leg pain was 3.8 fo
patients after decompression versus 1.4 for those without). Although the number of enrolled patients was
the difference was statistically significant (p=0.01). The pseudoarthrosis rate among those who received adecompression was 22% compared to 0% for those without a decompression, pseudoarthrosis was strong
associated with persistent symptoms (p=0.0001). The results seem to strongly support the argument for fu
alone in the management of adults with isthmic spondylolisthesis. The majority of adults treated for isthm
spondylolisthesis are managed with an instrumented posterolateral fusion and a decompression, perhaps t
represents improper management of the disorder. The results of Dr. Carragee’s study should be verified w
large multi-center study with many more patients that hopefully can definitively answer the question of w
approach is most effective.
High-grade isthmic spondylolisthesis
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 fus
(ALIF), in situ circumferential fusion, instrumented posterolateral fusion, and surgical reduction with
instrumented posterior lumbar interbody fusion (PLIF). Advocates of these different techniques all cite sp
advantages of each approach, but they all have established risks and some are much more complication-p
than others.
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The role of surgical reduction in the treatment of high-grade isthmic is a controversial topic. Advocates o
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 lumb
spine that compensates for the lumbosacral kyphosis associated with the severe slip and many feel that th
hyper-lordosis will lead to early arthritis and low back pain. Seitsalo, et al. reported on the largest, long-t
cohort of adolescents operated on for high-grade isthmic spondylolisthesis with 87 patients and mean fol
up of 14 years. Of the patients, 54 had posterior interlaminar fusions, 30 had posterolateral fusion, and 3
an anterior interbody fusion (ALIF). The authors did note an association between hyper-lordosis and bacafter fusion in situ, particularly when contact and/or sclerosis is noted between adjacent spinous processe
called “kissing spinous processes”. This pain tends to be worsened by hyperextension, but is does not usu
cause much pain at rest or during normal activities. Overall, 63% of patients in the study were asymptom
24% reported frequent back pain, but only 7% had taken analgesics for back or leg pain in the last month
authors did note a significant progression of lumbosacral kyphosis in many of their patients. They also no
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 m
better than prior to surgery, still left several patients with significant symptoms and progression of deform
The authors felt that reduction may offer patients a better chance of excellent long-term outcomes.
Reduction became feasible with the development of pedicle screws, allowing the reduction to be maintai
Several authors have published the results of reduction with pedicle screws and posterior interbody fusio
posterolateral fusion. While the improvement in percent slipped and lumbosacral kyphosis is significant,
have noted a 10–20% rate of nerve root injury and a few cases reports of complete cauda equina, especia
with complete reduction of the deformity. While many of these injuries improve, several patients are left
permanent deficits. The clinical outcomes after reduction and instrumentation do not appear to be signifi
superior to fusion in situ using modern techniques, despite the higher complication rate. It should also be
that recurrence of deformity is common after reduction and many patients will either bend their hardware
bend at the sacrum, which is often fully segmented during adolescence. These facts have tarnished the no
of reduction and instrumentation for high-grade slips, but the technique is still utilized with theoretical band some authors, particularly Dr Harry Shufflebarger, has reported both low complication rates and goo
clinical outcomes. Dr. Shufflebarger currently performs reductions for all high-grade slips that are referre
him and is a leading advocate of the technique. It should also be noted that the use of pedicle screw fixat
much more extensive in the U.S. than other countries and that these surgeons are somewhat more inclined
reduce patients, at least partially, while instrumenting. The routine use of pedicle screws for one or two l
pediatric fusions (not long fusions for correcting scoliosis) is without proven benefit in clinical outcome
fusion rate, but is associated with more blood loss, increased rate of nerve root injury, and more cases of
reoperation.
Until very recently, there was no data comparing the long-term outcome of reduction with instrumented fto an uninstrumented in situ fusion. Poussa, et al. recently published the first long-term follow-up report
comparing reduction with instrumented posterolateral fusion to uninstrumented circumferential fusion in
with a mean follow-up of 14.8 years . There were two groups of eleven patients and the patients were no
randomized. The patient selection process reflected the differing opinions of surgeons at the author’s
institution. However the patients’ preoperative symptoms were the same and patient demographics were
identical. There was a tendency for patients with a greater percentage of vertebral slip to receive reductio
the degree of lumbosacral kyphosis was similar between the two groups. At final follow-up, patients also
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underwent physical exam and were asked to fill out an Oswestry Disability Index (ODI) and Scoliosis
Research Society Questionnaire-22 (SRS-22) .
Although the number of patients in the study was small, patient outcomes clearly favored the fusion in sit
roup. The average ODI score was 7.6 (range 0–20) in the reduction group and 1.6 (range 0–4) for the fu
in situ group (p<0.01). The SRS-22 similarly favored the fusion in situ with a total score of 103.9 (range
120) compared to an average of 90 (range 39–107) for the reduction group (p<0.05). The domains of pai
function differed most significantly between the two groups. Additionally, the radiographic measures diddiffer as greatly between the two groups as the authors had expected. Many of the reduction patients
experienced a recurrence of their deformity especially the lumbosacral kyphosis. At final follow-up, the
average kyphosis measured 20 degrees in the reduction group and 23 degrees in the circumferential group
Finally, MRI studies demonstrated a higher incidence of disc degeneration and psoas muscle atrophy. Th
authors concluded that reduction and instrumented fusion resulted in poorer long-term outcome than fusi
situ and that the deformity tended to recur following reduction. The increased risks and more extensive s
associated with reduction did not translate into better outcomes or permanent correction of deformity.
In addition to the ongoing debate of reduction versus fusion in situ, there is also new evidence emerging
what form of fusion is most effect for eliminating symptoms and controlling deformity. This discussion osurgical 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
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 . Anterior fusion is a rela
new technique to spine surgery, emerging during the last two decades. It involves either a retroperitoneal
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 interver
space; the graft is usually either a tricortical iliac crest or a femoral ring allograft. For circumferential fus
after completing the anterior fusion, the patient is turned and a one or two level posterolateral fusion with
instrumentation is performed. Circumferential fusion can either be performed under one run of generalanesthesia with patient repositioning or the procedure can be staged. Helenius, et al. followed 70 patients
mean period of 17 years who had been treated by one of the above procedures. Patient selection for each
procedure was not randomized, but represented an evolving technique at the Hospital for Invalid Children
Helsinki, Finland. At last follow-up each patient underwent physical exam, lumbar spine X-rays, and
completed several questionnaires including an Oswestry disability index (ODI), Scoliosis Research Socie
Questionnaire (SRS-22), and two 100 mm visual analog scales for leg and back pain. There were 21 pati
treated with posterolateral fusion (PLF), 23 patients treated with anterior fusion (ALIF), and 26 treated w
circumferential fusion (CIRC). No patient was intentionally reduced, although some reduction did take pl
during positioning and during placement of anterior grafts. There was no use of instrumentation. The pat
in the circumferential group had the worst preoperative slip and lumbosacral kyphosis by an average of 9and 10 degrees (p<0.05 and p<0.005). Otherwise, all patients had the same pre-operative symptoms and
ery similar demographics.
At final follow-up, the patients in the circumferential group had the best scores for function and pain by
statistically significant margin. Mean VAS back pain score was 22.6 mm for PLF, 24.1 for ALIF, and 5.5
CIRC. Mean VAS leg pain was 7.6, 16.1, and 2.0 for PLF, ALIF, and CIRC respectively. Total functiona
scores were also significantly better for the ODI (lower is better) and SRS-22 (higher is better), mean OD
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were 9.7, 8.9, and 3.0 for PLF, ALIF, and CIRC with SRS means of 89.7, 93.2, and 100. The standard
deviations were also different with the range of scores much narrower for CIRC compared to PLF or AL
No CIRC patient reported back pain at rest or was taking analgesics for back or leg pain. Three patients
both the PLF and ALIF group reported back pain often at rest. The CIRC patients showed the least progr
of deformity with both percent slip and kyphosis improving over the follow-up period, mostly the result
ertebral remodeling. Both the PLF and ALIF showed modest increases in kyphosis over the follow-up p
Finally, the complication rate for CIRC was not significantly higher than the other two techniques with a
towards fewer complications in the CIRC group, which is surprising since the circumferential fusion reprthe combination of the other two procedures. Nevertheless, the infection rate and blood loss were not
significantly higher and both stages of the operation could be completed together for the majority of case
Overall, the authors concluded that circumferential fusion provided the best long-term outcomes among t
three techniques with excellent long-term outcomes and a low complication rate.
See also
Spondylosis
Failed back syndrome
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External links
Spondylolisthesis: Back Condition and Treatment
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18/04/1Spondylolisthesis - Wikipedia, the free encyclopedia
Paghttp://en.wikipedia.org/wiki/Spondylolisthesis
(http://www.spineuniverse.com/displayarticle.php/article114.html)Lumbar Spine Surgery (http://www.aann.org/pubs/pdf/lumbar.pdf)Spondylolisthesis for health professionals(http://en.referencio.com/Spondylolisthesis_%28physicians%29)
Retrieved from "http://en.wikipedia.org/wiki/Spondylolisthesis"Categories: Deforming dorsopathies | Congenital disorders of musculoskeletal system
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