Pars Interarticularis Defect Repair Direct repair of the pars interarticularis involves local bone grafting of the pars defect following adequate debridement and decortication followed by osteosynthesis across the graft site. This may be accomplished by pedicle screw fixation of the involved level attached to an ipsilateral hook-rod construct allowing compression, direct screw compression through the lamina into the pedicle, or through tension band wiring of the ipsilateral transverse process to the spinous process. This is considered an acceptable approach for patients 30 years in the absence of disk degeneration. This procedure assumes that the anatomic defect is the cause of the pain, preferably determined through presurgical selective pars injections. This procedure often is not used in adults with isthmic spondylolisthesis due to the frequent coexistence of symptomatic degenerative disk disease.4,11 Decompression and In restaurant Situ posterolateral Fusion An in situ posterolateral fusion is the most widely selected means of surgically managing an ismmic spondylolisthesis (Figure. This involves placement of autologous bone graft along the decorticated posterolateral spinal elements (ie, transverse processes, lateral aspect of superior articular facet, and sacral ala). In the majority of cases, only a single motion segment involving the level of the pars defect is fused. In patients with evidence of supra or subadjacent advanced degenerative disk disease, an adjacent mobile retrolisthesis, a high grade slip (grade iii or iv or slip angle, extension of the fusion to the supra or subadjacent level often is recommended (Figure 5).
Indications for Surgical Treatment If the symptoms related to an isthmic spondylolisthesis do not improve with conservative management and significantly disrupt me lifestyle of die patient, surgical management may be considered. In general, the indications for surgical intervention in me setting of adult istiimic spondylolisthesis include4: * failure of an adequate trial of conservative merapy for disabling back and leg pain, * symptomatic radiographic instability, * documented slip progression greater than grade ii, * a wallpaper symptomatic. There are several documented predictors of outcomes following surgical intervention for symptomatic isthmic spondylolisthesis. In one study, patients involved in workers' compensation or disability claims due to new onset low back pain in the setting of low-grade spondylolisthesis were found to be less likely to achieve significant pain relief or improvement of function after fusion with or without decompression.9. Schnee et al' found advanced patient age (up to 75 years) had no adverse effect on surgical outcome. Patients 55 years, however, were found to have significantly increased risks of poor employment and baseline pain profiles. Additionally, patients who have previously undergone two or three prior operations with or without the diagnosis of pseudarthrosis also have poor outcomes following surgical intervention.10 surgical options once the decision for surgical intervention is made, the choice of surgical procedure is predicated on specific clinical. The operative approach, the number of spinal levels involved, and whether to perform a decompression, a fusion, or to use adjunctive internal fixation are the major decision points. Surgical treatment options include: 1) pars interarticularis defect repair, 2) fusion with or without decompression, 3) instrumented posterolateral fusion with or without decompression, 4) interbody fusion alone or combined with posterior stabilization with or without decompression, and 5) a reduction of the listhetic deformity.
Common nonoperative treatment methods include the use of nonsteroidal anti-inflammatory drugs in combination with an exercise program that includes stretching, strengthening, and a flexibility program. Weight loss, if appropriate, should be an initial goal for an overweight patient with an isthmic spondylolisthesis. Some clinicians advocate using external bracing for evaluation of the potential effectiveness of future spinal fusion; however, the consensus on its predictive power is controversial. Spinal injection of corticosteroids into the epidural space or facet joint also may be of some temporary value. Narcotics, however, should only be used for acute exacerbations of symptoms and only for a brief time period. Chronic narcotic use in the setting of prolonged back pain will only contribute to the long-term disability of the patient's spinal disorder due to the potential for drug addiction and the secondary effects of central nervous system depression. Interestingly, a recent study by moller and Hedlund8 has shown that the outcome of treatment for symptomatic adult istiimic spondylolisthesis unresponsive to conservative treatment is better with an in situ posterolateral fusion than with an exercise program.
Isthmic Spondylolisthesis and Spondylolysis - medscape
Deep palpation of the spinous process above the level of the slip may movie elicit tenderness. A spinous process step-off may be felt immediately above a grade ii or higher slip. Forward flexion of the trunk may be limited by paravertebral muscle spasms. Hamstring tightness, although uncommon, may be present in severe slips. At the lumbosacral junction, a palpable prominence may occur in high-grade slips as L5 translates and rotates anteroinferioriy over S 1, producing a kyphotic deformity.7 This leads to a compensatory lumbar hyperlordosis and an appearance of trunk shortening.
The nerve roots that exit adjacent to the pars defect may be compressed by either hypertrophied fibrocartilage that fills and occupies the defect, osteophytes adjacent to the defect, or degenerative hypertrophic facets caudal to the defect.7 The sacral roots also may be stretched. This may result in bladder and bowel dysfunction. Treatment surgery is rarely required in adults patient with symptoms related to an isthmic spondylolisthesis. In fact, initial restriction of the patient's activities, spinal and abdominal muscular rehabilitation, me judicious use of anti-inflammatory medications, and in some cases the use of epidural steroid injections may suffice. Nonoperative management Nonoperative treatment therapies are aimed at reducing symptoms in die short term, as symptoms tend to run a course of acute exacerbation followed by remission.4 Treatment strategies usually are prescribed for a course of 4 weeks to 3 montiis to educate patients. The speed of symptom improvement often is correlated wim me patient's complicity with his or her therapy.
In grade i, the displacement is s25 of the anteroposterior diameter of the vertebrae below; grade ii, between 25 and 50; grade iu, between 50 and 75; and grade iv, 75 (Figure 2). A complete displacement or separation is termed a spondyloptosis. Slip, progression, radiographically, there is welldocumented evidence of slip progression in children and adolescents; however, adult progression of isthmic spondylolisthesis has rarely been described in the literature. Floman6 postulated that slip progression after skeletal maturity is almost always related to disk degeneration at the slip level. Therefore, slippage in the adult population is most likely to develop in the fourth or fifth decades of life. The capacity for the intervertebral disk to resist anterior shear forces is greatly diminished as the disk degenerates, thereby leading to the potential for slip progression in the setting of compromised posterior elements (ie, the pars interarticularis).
Interestingly, in Floman's study,6 slip progression was uniformly accompanied by disk degeneration below the level of the pars defect. The presence of disk degeneration may explain how an asymptomatic lesion present for two to three decades may insidiously or suddenly, following a traumatic event, become symptomatic (Figure 3). Clinical presentation, the majority of people with an isthmic spondylolisthesis are asymptomatic. If symptoms develop, they usually consist of back and leg pain. Back pain typically is intermittent, aggravated by strenuous activity and relieved with rest. Leg pain is a frequent complaint in adults and may be sciatic (ie, radicular referred, or claudicant in nature. Radicular symptoms include pain, numbness, and paraesthesias in a dermatomal pattern. Symptoms of tight hamstrings, present frequently in children with isthmic spondylolisthesis, are not usually seen in adults.
Assessment of lumbosacral kyphosis in spondylolisthesis
The prevalence of a pars defect is 4-6 in the general population4; however, add a slippage component, if present, often is low japanese grade and asymptomatic. Figure 1: Lateral radiograph of an isthmic spondylolysis involving the ls vertebrae. An obvious defect in the pars interarticularis is noted at this level. Figure 2: The meyerding classification system for grading spondylolisthesis is dependent on the degree of displacement of the superior vertebrae on the vertebrae below. The categories are: grade i, 0-25; grade ii, 25-50; grade iii, 50-75; and grade iv, 75-1. Figure 3: Lateral radiograph of a grade I/ii isthmic spondylolisthesis involving the L5-S1 level. Note the significant degree of disk space narrowing. Spondylolisthesis also is graded by the meyerding5 classification depending on the degree of displacement of the superior vertebra on the vertebra below.
These include a pars interarticularis repair, gill laminectomy and essay adjunctive fusion, instrumented posterolateral fusion or interbody fusion with instrumented posterolateral fusion, anterior interbody fusion, or anteroposterior decompression and instrumented fusion procedure. The method chosen depends on the clinical scenario and the surgeon's experience. Classification, wiltse et al3 classified isthmic spondylolisthesis into three subtypes based on the appearance of the pars interarticularis defect. Subtype a is the lytic type in which there is a fatigue fracture of the pars with complete bony separation. Subtype b describes an elongation of the pars without separation. This is believed to occur due to repeated microfractures of the pars interarticularis leading to progressive elongation. This type may eventually progress to a nonunion, transforming a subtype b into a subtype a lesion. Subtype c is an acute pars fracture. This lesion results in a spondylolysis, but over time may progress to an olisthetic component.
surgical intervention may be warranted. The goals of surgical intervention in an adult patient with an isthmic spondylolisthesis are to improve the symptoms of low back pain, neurological dysfunction (ie, weakness and posture and gait by stabilizing the listhetic segment; and to relieve radiating discomfort. The results of surgical treatment for isthmic spondylolisthesis in children and adolescents have been well documented. Qinical success rates for in situ posterolateral fusion in this population ranges from 80- 100.1. Indications and surgical outcomes of adult disease vary in the literature. Haraldsson and Willner2 observed that in adults, instability is not the only pain generator as in children and adolescents. An adult also may have symptoms related to disk degeneration and nerve compression that cannot be resolved by fusion alone. Several well-supported methods of surgical intervention in adults have been reported.
Depending on patient age, progression, degree of slippage, and symptoms, different therapeutic approaches have been proposed and are described in this paper. keywords "Adolescent, pediatric, Spondylolisthesis, spondylolysis author "G. Mazza and Aulisa,. Aulisa year "2001 doi "10.1007/s language "English volume "17 pages "644-655 journal "Child's Nervous System issn "0256-7040 publisher "Springer Verlag number "11. Spondylolisthesis is defined as an anterior or posterior displacement or slippage of one vertebrae on another. Bilateral defects in the pars interarticularis of the superior vertebra with resultant anterior displacement of its body on the vertebrae below describes an isthmic spondylolisthesis. If there is no translation at the functional spinal unit, the defect in the pars interarticularis is described as a spondylolysis (Figure 1 ). This spinal condition (spondylolysis, spondylolisthesis ) may, ln rare situations, cause lower back pain in the adult oliver patient.
High-grade spondylolisthesis: gradual reduction using Magerl
Title "Spondylolysis and spondylolisthesis in the pediatric and adolescent population abstract "This article is a review of spondylolysis and spondylolisthesis in younger age groups. Since herbinaux first described the pathology (1782 many classifications and theories of etiopathogenesis have been proposed. The congenital and isthmic types, as classified by wiltse, are the most frequent in younger age groups, but the postsurgical progressive forms (3-5) have been described as increasing in frequency secondary to neoplastic surgery in children. The general incidence is 4-5 at the age of 6 years, and in 30-50 of cases these types do not progress to spondylolisthesis. Most cases are asymptomatic (80). Standard radiographic examinations (a-p, l, wood oblique) are helpful in diagnosis and can suggest what the prognosis will be in terms of the evolution, and also what treatment is indicated (degree of slippage, slip angle, lumbar and lumbosacral index, spti). A bone scan (pbs and spect) is useful in the early stages of spondylolysis (pre-spondylosis). Although the ct scan is the most accurate examination, mri is becoming important for diagnosis because of the frequency with which it is used as a primary investigation method.