spondilolistesis ppt

SPONDILOLISTESIS Presented by:

Dwinda Aulia (C111 09 790) Aznamry (C111 09 808)Nidha Chusna (C111 09 766) Wiyasih Widhoretno (C111 09 779)

Marco Angelo (C111 10 160) Agung Pratama (C111 09 774)Okto Sofyan H (C111 10 106) Pupu Ayu (C111 09 297)

Advisor:dr. Syarif Hidayatullah

dr. Zuwanda Thendr. Angga Angriawan

Supervisor:dr. Notinas Horas, M.Kes, Sp.OT

Orthopaedic and Traumatology DepartmentMedical Faculty of Hasanuddin University

Makassar,2015

The word spondylolisthesis comes from the Greek language support differences consist of the word :

" spondylo " What Means the spine ( vertebrae )

" listhesis " The Means shifted . Then Spondilolistesis is a shift in the vertebral body ( usually the next ) Against Its located underneath the vertebral body .

DEFINITION

ANATOMY

ANATOMY

EPIDEMOLOGY

Spondilolistesis occurs in 5-6 % male population and 2-3 % in female

Approximately 82% of cases of isthmic spondylolisthesis occur at L5-S1.  Another 11.3% occur at L4-L5.

Spondylolistesis etiology is multifactorial.

Congenital predisposition appears on spondylolisthesis type 1 and 2, and posture, gravity, rotational pressure and stress / pressure high concentrations in the body axis plays an important role in the shift.

ETIOLOGY

Spondylolisthesis occurs when there’s bilateral defects in the vertebral pars intrarticulariss which permit the vertebral body to slip anteriorly. Usually occurs at level (L5,S1)

Spondylolysis is the most common cause for spondylolisthesis. It’s a unilateral or bilateral defect in the vertebral pars interarticularis result from stress fracture.

PATHOPHYSIOLOGY

spondylolysis typically is acquired as the bone "fatigues" from recurrent microtrauma during excessive lumbar hyperextension or repeated lumbar flexion and extension.

repeated Hyperflextion and extension of the joints are more common in athletes.

(diving, weight lifting, wrestling and football)

• Spondylolysis progresses to spondylolisthesis in approximately 15% of cases. Progression to spondylolisthesis is correlated with persistent pain and lack of healing.

It can be classified into 6 distinct categories as the following ( developed by Wiltse, Macnab, and Newman ):

Type I: Congenital spondylolisthesis

Type II: Isthmic spondylolisthesis

Type III: Degenerative spondylolisthesis

Type IV: Traumatic spondylolisthesis

Type V: Pathologic spondylolisthesis

Type VI: Postsurgical (iatrogenic)

CLASIFICATION

Grades ( Myerding Classification)

Wiltse classification of spondylolisthesis

Wiltse classification of spondylolisthesis

• The patient is usually asymptomatic

• Cardinal symptoms are :• Mechanical low back pain• Leg pain

• Additional but less frequent symptoms are :

• Discogenic back pain• Facet joint pain• Numbness and tingling• Motor weakness

SYMPTOMS

1- Tenderness to deep palpation of the spinous process above the slip (typically L4) & causes radicular pain due to palpation.

2- Muscle tightness (Tight hamstrings muscle) that is associated with all grades of spondylolisthesis occurs at a rate of 80%.

It commonly results in an abnormal gait & inability of the patient to flex the hip with the knees extended.

SIGNS

3- Paraspinal muscle spasm and tenderness are usually present.

4- Limited forward flexion of the trunk is common with reduced straight-leg raising, which may cause pain

5- Postural deformity and a transverse abdominal crease are seen as a result of the pelvis being thrust forward.

Phalen-Dickson sign

• bent-knee, hip-flexed posture with high-grade spondylolisthesis

One-legged hyperextension test (stork test):

• Use To differentiation between spondylolysis (+) and spondylolisthesis(-)

PHYSICAL EXAM

With increasing slippage, the sacrum becomes relatively more vertical, impairing hip extension and compelling the patient to walk with a knee-

flexed, hip-flexed gait

Phalen-Dickson sign

A positive one-legged hyperextension test while standing on one leg and bending backward, pain is experienced in the ipsilateral back.

One-legged hyperextension test (Stork test):

In most cases it is not possible to see visible signs of spondylolisthesis by examining a patient

Patients typically have complaints of pain in the back with intermittent pain to the legs. Spondylolisthesis can often cause muscle spasms, or tightness in the hamstrings

Spondylolisthesis is easily identified using plain radiographs

DIAGNOSIS

1- Radiography: lateral view of lumbar spine is especially useful in detection Spondylolisthesis.

2- Computed Tomography: CT SCANNING axial or sagittal image of the lumbar spine can be performed with or without contrast enhancement.

3- Magnetic Resonance Imaging (MRI): has the distinct advantage of imaging of the spine in any plane. Typically, the axial and sagittal planes are used.

DIAGNOSTIC TESTS

A)-Lateral lumbar spine. Note the pars defects (arrow) and anterior displacement of the L5 vertebra.

B)-Oblique lumbar spine. Observe the clearly visible lucent collar (arrow).

Sagittal CT reconstruction image shows the pars defect

along with grade 1 spondylolisthesis.

Spondylolisthesis. Axial CT image shows bilateral

spondylolysis (arrows). Note elongation of the spinal canal

at this level

Spondylolisthesis. Oblique projection radiograph shows the presence of bilateral pars defects (arrows), with an appearance resembling a Scottie dog with a collar. (The collar is the pars

defect.)

Treatment for spondylolisthesis depends on several factors, including the age and overall health of the person, the extent of the slip, and the severity of the symptoms.

Treatment most often is conservative and more severe spondylolisthesis might require surgery.

TREATMENT

1.Conservative treatment o Bed rest.

o Avoidance of activities if there is >25% slippage.

o Non-steroidal anti-inflammatory drug (NSAID).o Epidural steroid injections(ESI)

Generally, an ESI is given only when other treatments aren't working.

o A brace or back support might be used to help stabilize the lower back and reduce pain.

o Physical therapy:

Stabilization exercises are the mainstay of treatment. These exercises strengthen the abdominal and/or back muscles, minimizing bony movement of the spine.

These measures only provide temporary relief.

2. Surgical treatment Surgery might be necessary if the vertebra

continues to slip or if the pain is not relieved by conservative treatment and begins to interfere with daily activities.

The main goals of surgery for spondylolisthesis are:

1) to relieve the pain associated with an irritated nerve,2) to stabilize the spine where the vertebra has slipped

out of place, 3) and to increase the person’s ability to function.

The main types of surgical treatment for spondylolisthesis include:

1)laminectomy (decompression)

2)Fusion

1. Laminectomy When the vertebra slips forward, the

nearby nerves that exit the spine can become pinched or irritated.

In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal.

The goal is remove the lamina and release pressure on the nerves .

2. Fusion A spinal fusion is normally done immediately

after laminectomy for spondylolisthesis.

It is designed to fuse the two vertebrae into one bone and stop the slippage from worsening.

The fusion is used to lock the vertebrae in place and stop movement between the vertebrae.

Types :

A. Traditional FusionB. Minimally invasive surgical spine fusion

failure to perform fusion

nerve root injury

infection and bleeding from surgical procedures

Leak on LCS

COMPLICATIONS

Patients with acute fractures and bone minimal shift would likely return to normal if the fracture is improved

Patients with vertebral changes are progressive and degenerative likely to experience symptoms that are intermittent.

The risk for degenerative spondylolisthesis increases with age, and the progressive shift of vertebrae occurred in 30% of patients.

PROGNOSIS