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.

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