Spondylolysis and spondylolytic spondylolisthesis

Spondylolysis

Spondylolysis is a bony defect of the pars interarticularis and most often results from repetitive stress. Although spondylolysis is usually asymptomatic, symptomatic spondylolysis is the most common cause of identifiable back pain in children and adolescent athletes. A thorough history and physical exam, as well as appropriate imaging studies are helpful in diagnosis. General first-ine therapy for spondylolysis is conservative and consists of rest from sports, core strengthening, as well as spinal bracing. Patients who have failed conservative therapy may consider surgical repair. This article aims to review the epidemiology, pathophysiology, presentation, and treatment options of spondylolysis.

Iliocava junction to L4-L5 disc anatomical relationship in L5-S1 isthmic spondylolisthesis

BACKGROUND

Anterior lumbar interbody fusion finds a place in L5-S1 isthmic spondylolisthesis (ISPL) treatment. Extension of this arthrodesis at L4-L5 level is sometimes required. Anterior approach of the L4L5 disc is considered difficult due to the anatomical relationship between the iliocava junction (ICJ) and the spine.

HYPOTHESIS

Does the lumbosacral deformation induced by ISPL allows anterior approach of L4-L5 disc between the iliac?

STUDY DESIGN

Retrospective radiographic analysis of consecutive patients.

METHODS

This retrospective imaging study of a continuous series of 97 patients treated for an L5-S1 ISPL involved radiological parameters specific to ISPL and pelvic-sagittal balance. The distance between the ICJ and the L4 lower endplate was measured in millimeters. The factors influencing this distance were sought in order to identify a predictive model of high ICJ.

RESULTS

The ICJ took a cranial position with respect to the L4-L5 disc with an average distance of 1.8mm±16.4. This distance was statistically higher in the case of high-grade ISPL (p<0.01). The high ICJ position was correlated with a high Taillard index (r=0.39; CI_95% [0.13; 0.61]; p<.001) and a low lumbar-sacral angle (LSA) (r=-0.33; CI_95% [-0.56; -0.06]; p<0.01). Among the parameters specific to spino-pelvic statics, pelvic incidence, pelvic tilt and lumbar lordosis had similar correlations (r>0.30).

CONCLUSION

ISPL induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the ICJ. The anterior approach technique of L4-L5 disc in the presence of an L5-S1 ISPL is possible between the iliac veins for the large displacement and low LSA forms.

LEVEL OF EVIDENCE

IV, retrospective analysis.

The Relationship Between Sacral Slope and Symptomatic Isthmic Spondylolysis in a Cohort of High School Athletes: A Retrospective Analysis

BACKGROUND

Spondylolysis with and without anterolisthesis is the most common cause of structural back pain in children and adolescents, but few predictive factors have been confirmed. An association between abnormal sacropelvic orientation and both spondylolysis and spondylolisthesis has been supported in the literature. Sacral slope and other sacropelvic measurements are easily accessible variables that could aid clinicians in assessing active adolescents with low back pain, particularly when the diagnosis of spondylolysis is suspected.

OBJECTIVE

To examine the relationship between sacral slope and symptomatic spondylolysis in a cohort of active adolescents.

DESIGN

Case-control retrospective study.

SETTING

Academic outpatient physiatry practice.

PATIENTS

Seventy-four patients of primarily adolescent age (between 12 and 22 years old) with a chief complaint of low back pain and presence of lateral radiographs of the lumbar spine were enrolled. Cases (n = 37) were defined as subjects with evidence of spondylolysis on both radiograph and magnetic resonance imaging of the lumbar spine. Controls (n = 37) were defined as subjects without spondylolysis.

METHODS

Using a single sagittal radiograph, taken with the patient standing, a fellowship-trained interventional spine physiatrist measured the sacral slope of each subject (angle between the superior plate of S1 and a horizontal reference on sagittal imaging of the lumbosacral spine). Ages and genders were collected from medical records.

MAIN OUTCOME MEASUREMENTS

The primary outcome was mean sacral slope. Mean sacral slope of cases was compared with mean sacral slope of controls with the Student t-test.

RESULTS

Ages ranged from 12 to 22 for both groups, with no significant differences in age between the groups (cases: 16.8 ± 2.3 years; controls: 17.7 ± 2.7 years). The patients with spondylolysis (cases) consisted of 29 male and 8 female patients, whereas those without spondylolysis (controls) consisted of 15 male and 21 female patients (gender details for 1 patient were not available). The mean sacral slope among cases was 42.4°, whereas the mean sacral slope among controls was 37.4°. The difference achieved significance (P = .014).

CONCLUSIONS

The interdependence of positional parameters, such as sacral slope, with anatomic parameters, such as pelvic incidence, can affect lumbar lordosis and therefore upright positioning and loading of the spine. Sacral slope may be an important variable for clinicians to consider when caring for young athletes with low back pain, particularly when the index of suspicion for spondylolysis is high.

LEVEL OF EVIDENCE

IV.

Minimally invasive direct pars repair with cannulated screws and recombinant human bone morphogenetic protein: case series and review of the literature

OBJECTIVE

The objective of this study was to describe the use of a minimally invasive surgical treatment of lumbar spondylolysis in athletes by a fluoroscopically guided direct pars screw placement with recombinant human bone morphogenetic protein–2 (rhBMP-2) and to report on clinical and radiographic outcomes.

METHODS

A retrospective review was conducted of all patients treated surgically for lumbar spondylolysis via a minimally invasive direct pars repair with cannulated screws. Demographic information, clinical features of presentation, perioperative and intraoperative radiographic imaging, and postoperative data were collected. A 1-cm midline incision was performed for the placement of bilateral pars screws utilizing biplanar fluoroscopy, followed by placement of a fully threaded 4.0-mm-diameter titanium cannulated screw. A tubular table-mounted retractor was utilized for direct pars fracture visualization and debridement through a separate incision. The now-visualized pars fracture could then be decorticated, with care taken not to damage the titanium screw when using a high-speed drill. Local bone obtained from the curettage was then placed in the defect with 1.05 mg rhBMP-2 divided equally between the bilateral pars defects.

RESULTS

Nine patients were identified (mean age 17.7 ± 3.42 years, range 14–25 years; 6 male and 3 female). All patients had bilateral pars fractures of L-4 (n = 4) or L-5 (n = 5). The mean duration of preoperative symptoms was 17.22 ± 13.2 months (range 9–48 months). The mean operative duration was 189 ± 29 minutes (range 151–228 minutes). The mean intraoperative blood loss was 17.5 ± 10 ml (range 10–30 ml). Radiographic follow-up was available in all cases; the mean length of time from surgery to the most recent imaging study was 30.8 ± 23.3 months (range 3–59 months). The mean hospital length of stay was 1.13 ± 0.35 days (range 1–2 days). There were no intraoperative complications.

CONCLUSIONS

Lumbar spondylolysis treatment with a minimally invasive direct pars repair is a safe and technically feasible option that minimizes muscle and soft-tissue dissection, which may particularly benefit adolescent patients with a desire to return to a high level of physical activity.

Bone bridge formation across the neuroforamen 14 years after instrumented fusion for isthmic spondylolisthesis-a case report

This case report describes the first case of a bone bridge formation across the left L5/S1 neuroforamen after instrumented posterolateral fusion for L5/S1 isthmic spondylolisthesis. Our patient was a 70-year-old lady who had grade 2, L5/S1 isthmic spondylolisthesis and bilateral S1 nerve root compression. She suffered from mechanical low back pain and neurogenic claudication, with radicular pain over both S1 dermatomes. She underwent in-situ, instrumented, posterolateral fusion and was asymptomatic for more than 13 years before developing progressive onset of left radicular pain over the L5 dermatome. Imaging revealed a bisected left L5/S1 neuroforamen secondary to a bone bridge formation resulting in stenosis. The pars defect in this case may have had sufficient osteogenic and osteoinductive factors to heal following spinal stabilization. Although in-situ posterolateral fusion is an accepted surgical treatment for isthmic spondylolisthesis, surgeons should consider reduction of the spondylolisthesis and excision of the pars defects to avoid this possible long-term complication.

Particularities of anterior fusion in L4-L5 isthmic spondylolisthesis

PURPOSE

L4-L5 isthmic spondylolisthesis may be associated with lumbosacral transitional vertebrae (LSTV) and altered venous vascular anatomy. The objectives of this study were to describe the anatomical characteristics of L4-L5 ISPL and the intraoperative difficulties encountered during the approach for anterior lumbar interbody fusion (ALIF).

METHODS

This is a retrospective review of 20 ALIFs for L4-L5 ISPL. The anatomy of the common iliac veins confluence and the position of L4-L5 with respect to the projection of the iliac crest were analysed on CT-scan. Intraoperative difficulties were noted.

RESULTS

A LSTV was present in 60% of cases, associated with abnormally distal positioning of L4-L5 below the projection of the iliac crest. The common iliac veins confluence was abnormally proximal compared to L4-L5. No complication was noted, even if the approach was unusually difficult in 11 cases.

DISCUSSION

Anterior lumbotomies are difficult because the left common iliac vein courses transversely across the left anterolateral aspect of the L4-L5 disc and L5 vertebral body, increasing the risk of vascular injury. Those difficulties have led us to abandon lumbotomies to treat L4-L5 ISPL to favour a pure anterior approach (midline) or an exclusive posterior approach.

LEVEL OF EVIDENCE

IV (retrospective study).

Adjacent disc and facet joint degeneration in young adults with low-grade spondylolytic spondylolisthesis: A magnetic resonance imaging study

BACKGROUND/PURPOSE

Premature adjacent-level degeneration has been attributed to vertebral fusion, but spondylolisthesis has not been reported as a pathological factor responsible for the degeneration of adjacent disc and facet joint. We hypothesized that the degeneration of disc and facet joints in the adjacent levels is correlated with spondylolisthesis.

METHODS

Magnetic resonance images of 35 symptomatic young adults (16-29 years old) with low-grade L5-S1 spondylolytic spondylolisthesis (Meyerding Grade 1 or 2) and 50 symptomatic young referents (20-29 years old) with L5-S1 disc herniation without spondylolisthesis were recruited to compare the differences between disc and facet-joint degenerations at the olisthetic and adjacent levels using the Mantel extension test.

RESULTS

There were statistically significant degenerative changes of the discs and facet joints at the olisthetic and adjacent levels of patients with spondylolytic spondylolisthesis compared with the reference group. There is a trend that the disc and facet joints degenerate the most at the olisthetic level and become less affected at adjacent levels away from the lesion of pars defect.

CONCLUSION

Low-grade spondylolytic spondylolisthesis was associated with significant degenerations of the disc and facet joints at olisthetic and adjacent levels in young adults.

Current concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis

Treatment of spondylolysis and spondylolisthesis remains a challenge for orthopaedic surgeons, neurosurgeons and paediatrics. In spondylolisthesis, it has been clearly demonstrated over the past decade that spino-pelvic morphology is abnormal and that it can be associated to an abnormal sacro-pelvic orientation as well as to a disturbed global sagittal balance of spine. This article presents the SDSG (Spinal Deformity Study Group) classification of lumbosacral spondylolisthesis. The proper treatment of spondylolisthesis is dependent on recognizing the type of slip, sacro-pelvic balance and overall sagittal balance and its natural history. Although a number of clinical radiographic features have been identified as risk factors, their role as primary causative factors or secondary adaptative changes is not clear. The conservative treatment of adult isthmic spondylolisthesis results in good outcome in the majority of cases. Of those patients who fail conservative treatment, success with surgery is quite good, with significant improvement in neurologic function in those patients with deficits, as well as improvement in patients with back pain.

Avaliação dos pacientes submetidos à descompressão e artrodese póstero-lateral devido à espondilolistese degenerativa com dois anos de acompanhamento

OBJETIVO: Avaliar os resultados da descompressão e da artrodese póstero-lateral na espondilolistese degenerativa em pacientes que têm como sintoma principal a claudicação neurogênica. MÉTODO: Foram selecionados 21 pacientes com espondilolistese degenerativa, com indicação de tratamento cirúrgico. Foram avaliados 8 homens e 13 mulheres com idades entre 36 e 77 anos. O procedimento cirúrgico padronizado foi a artrodese póstero-lateral com instrumentação e descompressão associada. Os pacientes foram avaliados por VAS, índice de Oswestry e Roland-Morris no pré-operatório, com um mês, seis meses, um ano e dois anos de seguimento. Os dados foram analisados estatisticamente com nível de significância de 5%. RESULTADOS: O nível mais frequentemente operado foi L4-L5, com 52,38%. A VAS teve melhora significativa de 53,48% nos 6 meses após o procedimento. O Índice de Incapacidade de Oswestry apresentou piora no primeiro mês, evolução para melhora da capacidade até o sexto mês, e permaneceu constante até o fim do acompanhamento. Segundo o questionário de Incapacidade de Roland-Morris, houve melhora progressiva significativa até o sexto mês e, por último, uma leve piora. CONCLUSÃO: Os pacientes com espondilolistese degenerativa submetidos à artrodese póstero-lateral instrumentada e descompressão apresentaram melhora significativa da qualidade de vida e da dor após dois anos de acompanhamento.

Spondylolysis, spondylolisthesis, and lumbo-sacral morphology in a medieval English skeletal population

The prevalence of spondylolysis and spondylolisthesis was studied in an adult skeletal series from a rural English medieval archaeological site. Attempts were made to evaluate the association of three aspects of lumbo-sacral skeletal morphology (pelvic incidence (a measure of the anterior inclination of the sacral table), lumbar transverse process width, and the presence of lumbo-sacral spina bifida occulta) with spondylolysis and spondylolisthesis. Results indicated a high prevalence of spondylolysis compared with a modern reference population, but few cases of spondylolisthesis were identified. Analysis of prevalence with respect to age suggests that in the study population, pars interarticularis defects generally formed late in the growth period or early in adult life. The study group showed a high mean pelvic incidence compared with modern Western Europeans, indicating a more steeply inclined sacral table, which may have elevated the risk of developing pars interarticularis defects. However, no statistically valid association could be demonstrated between the presence/absence of spondylolysis and pelvic incidence in the study material. There was no evidence for a link between lumbar transverse process index or lumbo-sacral spina bifida occulta and spondylolysis/spondylolisthesis. It is concluded that the potential role of lumbo-sacral morphology, as well as of activity regimes, should be considered when interpreting spondylolysis in paleopathological studies. If the frequency of spondylolysis is to some extent an indicator of past activity regimes, it may reflect lifestyle in younger individuals rather than in mature adults. Further work investigating the link between spondylolysis and lumbo-sacral morphological variables in premodern populations would be of value.

Radiographic classification of L5 isthmic spondylolisthesis as adolescent or adult vertebral slip

STUDY DESIGN

A radiographic and morphologic study was conducted to investigate low-grade spondylolisthesis in cases with preexisting isthmic spondylolysis of L5.

OBJECTIVE

To distinguish radiographically between vertebral slips before and after skeletal maturity as determined by deformities of the sacral endplate.

SUMMARY AND BACKGROUND DATA

Very few reports have shown that spondylolisthesis with preexisting isthmic defects of L5 develops frequently in adulthood. The prognostic factors of the vertebral slip have remained unclear. It is hard to determine the onset time of low-grade spondylolisthesis.

METHODS

This study examined plain radiographs of 367 adult patients with pars defects of L5 (213 without slippage and 154 with Grade 1 or 2 spondylolisthesis) and 310 control subjects, ages 20 to 59 years at the first visit. The following parameters were measured and analyzed for each age decade: the sacral table index (anteroposterior width of the sacral endplate expressed as a percentage of the anteroposterior diameter of the upper L5 endplate), the sacral table angle (formed by the sacral endplate with the posterior wall of S1), the relative thickness of the L5 transverse process, and the iliac crest height.

RESULTS

The prevalence of patients with slippage who met deformity criteria (sacral table index > 102% [the mean plus 2 standard deviations of the controls] and sacral table angle </=97 degrees [the mean of the controls]) remained almost one fourth during all decades. On the contrary, the prevalence of patients with slippage who met normal-shape criteria (sacral table index </=102% and sacral table angle >/=89 degrees [mean minus 2 standard deviations of the controls]) was 0% in the third decade, but increased remarkably in the fifth and sixth decades. Of the 213 patients without slippage, 8 patients in whom new slippage developed during long-term follow-up evaluation all had a normally-shaped sacral table. The prevalence of patients without slippage decreased gradually with age, and elderly patients had relatively broader transverse processes and a higher iliac crest line.

CONCLUSIONS

The authors considered that the slips with and those without deformities of the sacral table had developed in adolescence and adulthood, respectively. Using new radiographic parameters that indicate widening and tilting of the sacral table, low-grade isthmic spondylolis thesis can be categorized into "adolescent and adult vertebral slips."

Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis

STUDY DESIGN

A randomized, controlled trial, test--retest design, with a 3-, 6-, and 30-month postal questionnaire follow-up.

OBJECTIVE

To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis.

SUMMARY OF BACKGROUND DATA

A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine (deep abdominal muscles and lumbar multifidus), considered to provide dynamic stability and fine control to the lumbar spine. In no study have researchers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised.

METHODS

Forty-four patients with this condition were assigned randomly to two treatment groups. The first group underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The activation of these muscles was incorporated into previously aggravating static postures and functional tasks. The control group underwent treatment as directed by their treating practitioner.

RESULTS

After intervention, the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at a 30-month follow-up. The control group showed no significant change in these parameters after intervention or at follow-up.

SUMMARY

A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.