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Spondylolisthesis

Spondylolisthesis
Objectives
  1. List the types of spondylolisthesis described by Wiltse, and fully describe the types seen in children and adolescents
  2. Describe commonly used radiographic parameters used to quantitate the severity of spondylolisthesis
  3. Discuss the etiology of spondylolisthesis
  4. Discuss the risk of progression of a child or adolescent with spondylolisthesis, and factors which contribute a higher risk of progression
  5. Discuss factors related to symptoms in patients with spondylolisthesis
  6. Describe physical findings associated with mild and severe spondylolisthesis
  7. Discuss indications for surgery for spondylolisthesis, including specific procedures useful for both mild and severe slippage

Discussion points
  1. Why is the back immobilized in flexion to treat spondylolysis and placed in extension to reduce severe spondylolisthesis?
  2. Is reduction of severe spondylolisthesis a good idea?

Discussion
Spondylolisthesis is a relatively common but enigmatic condition of the lower lumbar spine. The term "listhesis" describes a slip as being an integral part of the condition. Wiltse described 5 types of spondylolisthesis, his classification has been used by virtually all writers on the subject to the present time. Type I is dysplastic or congenital, and is characterized by defective formation of the L5-S1 facet joints. Type II, isthmic, denotes a lesion in the pars interarticularsis. Type II is subdivided into three causes; IIA is secondary to a stress fracture of the pars, IIB denotes an intact but elongated pars, and IIC, an acute fracture. Types III (degenerative), IV (traumatic) and V (pathologic) are not seen in children. Type I lesions comprise about 15-20% in Wiltse's reports.

The incidence of pars defects have been calculated at 4-5% in 6 year olds, increasing to 6% in adults. Most remain asymptomatic and do not progress. Progression of slip is usually reported at about 4-5% into adult life. Eskimos have a much higher incidence of spondylolisthesis. Heredity is a definite factor in etilogy, with 19-69% of first-degree relatives reported as also having spondylolysis or spondylolisthesis. Repetitive stress is well documented as an etiologic factor, especially if extension of the back is an integral part of the stress (football linemen, gymnasts). However, deterioration was not noticed in a study of patients with spondylolisthesis who continued to participate in sports. Progression of slip appears to be most common during the adolescent growth spurt.

In symptomatic patients with small degrees of slippage, physical findings are essentially the same as for spondylolysis -localized pain at L5, increased with extension of the lumbar spine, and (usually) hamstring contracture. With increased slippage, forward bending is limited, and more severe hamstring tightness. When slippage is severe, the trunk is shortened, with a visible stepof at the lumbosacral joint. The pelvis rotates anteriorly, producing a kyphosis at the lumbosacral joint, and the patient often stands with extended hips and flexed knees. Neurologic findings are unusual in children, most often affected is extensor hallucis longus strength or diminished ankle jerks. Routine imaging should include a standing lateral of the LS spine, non-weightbearing obliques and a cranially directed view of the lumbosacral joint. Supine and weightbearing laterals can demonstrate instability. More sophisticated imaging is not necessary except in the presence of neurologic deficit or severe slippage. Customarily, radiographic quantification includes the percentage of slip (either expressed as a percentage or in quadrants; grade I least, grade IV most, V, off the sacrum). The slip angle measures the lumbosacral kyphosis, which many consider the most important parameter as a forward tilt of S1 simulates a slide on which L5 can slip anteriorly. Sacral inclination decreases as lumbosacral kyphosis increases, the sacrum becoming vertical in severe cases.

Spondylolisthesis is most often asymptomatic, and the true incidence of this condition in the general population is not known. In individuals identified as having spondylolisthesis, most of the slippage occurs before the condition is identified, subsequent slippage being unusual.
Obviously, most individuals with spondylolisthesis require little or no treatment, especially as we do not know the true incidence of the condition or the natural history in those individuals who have not been identified as having the condition. General recommendations, which obviously are not based on strong data, indicate periodic follow-up and standing radiographs for asymptomatic growing children with spondylolisthesis. A recently described sagital peovic tilt index can identify children at little risk for progression. Nonoperative management is effective for the majority of symptomatic children and adolescents, consisting of abdominal strengthening, postural control, hamstring stretching, and occasional bracing. Present thought dictates surgical intervention for children or adolescents with persistent symptoms not controlled by nonoperative management, or for those with slippage > 50%, even if asymptomatic. The gold standard for surgical treatment is the posterolateral fusion advocated by Wiltse. Prevalent opinion at present is that nerve root decompression is rarely, if ever, necessary for children or adolescents; regardless of the severity of slippage. Techniques for reduction of severe slippage have been reported, but most have a significant incidence of neurologic complications. Preoperative correction by extension of the sacrum is safer than acute intraoperative correction. Notable exceptions are the report by Shufflebarger of the Harms technique reported at the 1998 meeting of the Scoliosis Research Society, and the recent papers of Laursen and Molinari. Surgeons performing insitu fusion should be aware of the occasional occurrence of cauda equina syndrome, a potentially disastrous complication.

References
  1. Bell DF, Ehrlich MG, Zaleske DJ. Brace treatment for symptomatic spondylolisthesis. Clinical Orthopaedics & Related Research 1988( 236): 192-8. 2
  2. Bernicker JP, Kohl HW, 3rd, Sahni I, Esses SI. Long-term functional and radiographic follow-up of surgically treated isthmic spondylolisthesis. American Journal of Orthopedics (Chatham, NJ) 1999; 28( 11): 631-6.
  3. Burkus JK, Lonstein JE, Winter RB, Denis F. Long-term evaluation of adolescents treated operatively for spondylolisthesis. A comparison of in situ arthrodesis only with in situ arthrodesis and reduction followed by immobilization in a cast. Journal of Bone & Joint Surgery -American Volume 1992; 74( 5): 693-704.
  4. Dubousset J. Treatment of spondylolysis and spondylolisthesis in children and adolescents. Clinical Orthopaedics & Related Research 1997( 337): 77-85.
  5. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. Journal of Bone & Joint Surgery -American Volume 1984; 66( 5): 699-707.
  6. Hensinger RN. Spondylolysis and spondylolisthesis in children and adolescents. Journal of Bone & Joint Surgery -American Volume 1989; 71( 7): 1098-107.
  7. Laursen M, Thomsen K, Eiskjaer SP, Hansen ES, Bunger CE. Functional outcome after partial reduction and 360 degree fusion in grade III-V spondylolisthesis in adolescent and adult patients. Journal of Spinal Disorders 1999; 12( 4): 300-6.
  8. Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine 1999; 24( 24): 2640-8.
  9. Meyers LL, Dobson SR, Wiegand D, Webb JD, Mencio GA. Mechanical instability as a cause of gait disturbance in high-grade spondylolisthesis: a pre-and postoperative three-dimensional gait analysis. Journal of Pediatric Orthopedics 1999; 19( 5): 672-6.
  10. Molinari RW, Bridwell KH, Lenke LG, Ungacta FF, Riew KD. Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches. Spine 1999; 24( 16): 1701-11.
  11. Muschik M, Hahnel H, Robinson PN, Perka C, Muschik C. Competitive sports and the progression of spondylolisthesis. Journal of Pediatric Orthopedics 1996; 16( 3): 364-9.
  12. Muschik M, Zippel H, Perka C. Surgical management of severe spondylolisthesis in children and adolescents. Anterior fusion in situ versus anterior spondylodesis with posterior transpedicular instrumentation and reduction. Spine 1997; 22( 17): 2036-42; discussion 43.
  13. Newton PO, Johnston CE, 2nd. Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis. Journal of Pediatric Orthopedics 1997; 17( 6): 754-61.
  14. Pizzutillo PD, Hummer CDd. Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. Journal of Pediatric Orthopedics 1989; 9( 5): 538-40.
  15. Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. Journal of Pediatric Orthopedics 1987; 7( 6): 631-8.
  16. Schoenecker PL, Cole HO, Herring JA, Capelli AM, Bradford DS. Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction [see comments]. Journal of Bone & Joint Surgery -American Volume 1990; 72( 3): 369-77.
  17. Schwab FJ, Farcy JP, Roye DP, Jr. The sagittal pelvic tilt index as a criterion in the evaluation of spondylolisthesis. Preliminary observations. Spine 1997; 22( 14): 1661-7.
  18. Seitsalo S, Osterman K, Hyvarinen H, Schlenzka D, Poussa M. Severe spondylolisthesis in children and adolescents. A long-term review of fusion in situ. Journal of Bone & Joint Surgery - British Volume 1990; 72( 2): 259-65.
  19. Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthopedic Clinics of North America 1999; 30( 3): 487-99, ix.
  20. Takahashi K, Yamagata M, Takayanagi K, Tauchi T, Hatakeyama K, Moriya H. Changes of the sacrum in severe spondylolisthesis: a possible key pathology of the disorder. Journal of Orthopaedic Science 2000; 5( 1): 18-24.
  21. Wiltse LL, Hutchinson RH. Surgical treatment of spondylolisthesis. Clinical Orthopaedics & Related Research 1964; 35: 116-35.
  22. Wiltse LL, Jackson DW. Treatment of spondylolisthesis and spondylolysis in children. Clinical Orthopaedics & Related Research 1976( 117): 92-100.
  23. Wiltse LL, Winter RB. Terminology and measurement of spondylolisthesis. Journal of Bone & Joint Surgery -American Volume 1983; 65( 6): 768-72.

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