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 Then
dr. Angga Angriawan

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

Orthopaedic and Traumatology Department

Medical Faculty of Hasanuddin University
Makassar,2015

DEFINITION
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 .

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 L4L5.

ETIOLOGY

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.

PATHOPHYSIOLOGY

Spondylolisthesis occurs
when theres 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. Its a
unilateral or bilateral
defect in the vertebral pars
interarticularis result from
stress fracture.

 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

CLASIFICATION
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)

Grades

( Myerding
Classification)

Wiltse classification of
spondylolisthesis

Wiltse classification of
spondylolisthesis

SYMPTOMS

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

SIGNS

1- Tenderness to deep palpation of

the spinous process above the slip
(typically L4) & causes radicular pain
due to palpation.
2Muscle
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

3- Paraspinal muscle spasm and

tenderness are usually present.
4- Limited forward flexion of the
trunk is common with reduced straightleg raising, which may cause pain
5- Postural deformity and a
transverse abdominal crease are seen
as a result of the pelvis being thrust
forward.

PHYSICAL EXAM
Phalen

Phalen-Dickson sign

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

One-legged hyperextension test (Stork test):

A positive one-legged hyperextension test while

standing on one leg and bending backward,
pain is experienced in the ipsilateral back.

DIAGNOSIS
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

DIAGNOSTIC TESTS
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.

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

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.

1.Conservative treatment
o Bed rest.
o Avoidance of activities if there is >25%
slippage.
o Epidural steroid injections(ESI)

o Non-steroidal
Generally,
anti-inflammatory
an ESI is givendrug
only when
(NSAID).
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 persons 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.
B.

Traditional Fusion
Minimally invasive surgical spine fusion

COMPLICATIONS

failure to perform fusion

nerve root injury
infection and bleeding from surgical
procedures

Leak on LCS

PROGNOSIS

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.