These children walk with a peculiar spastic gait called pelvic waddle or crouched gait. Scoliosis associated with spondylolisthesis may be found. The spondylolisthesis may be without symptoms or may present with dull low backpain which may radiate. Thre could be symptoms of claudication. Examination may reveal a step off during palpation fo the spine. Scoliosis may be present. In adults, there is insidious onset after 2nd or 3rd decade.
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Pain is mostly backache which occurs during the growth spurt. Sometimes the leg pain may also occur. The pain in the back is due to instability of the affected segment whereas pain the leg is due to irritation of the nerve root. Symptoms are aggravated by high activity or sports decrease on plan rest or with medication. Depending on severity of the listhesis, physical findings may vary. In mild cases, there may not be any finding on physical examination. In cases with moderate amount of slip, a step may be palpable at lumbosacral junction and motion of lumbar spine is restricted. Hamstring tightness may be felt on straight leg raising. With further slip, the patient assumes a lordotic posture above the level of the slip to compensate for the displacement. The sacrum becomes more vertical, and the buttocks appear heart shaped because of the sacral prominence. In severe slips, the trunk becomes shortened and often leads to complete absence of the waistline.
If the dysfunction of disc occurs in addition to these conditions, Spondylolisthesis may develop. A narrow facet angle is more prone to allow degenerative listhesis. Long standing instability may lead to microfractures of inferior articular processes and followed by deformation. The articular processes change the direction and become more horizontal and lead to Spondylolisthesis after the age of 40 years. Other risk factors for degenerative spondylolisthesis are women who had borne children had a significantly higher incidence essay of degenerative spondylolisthesis than nulliparous women. After lamminectomy for lumbar spinal stenosis diagnosis can be made on routine xrays. Ap and lateral views reveal the slip and associated degenrative changes may also be noted. . mri reveals neural compression and stenosis Presentation of Spondylolisthesis In most of the cases the medical consultation is sought because of postural and gait problems rather than the pain.
Degenerative spondylolisthesis is more common in people over age. It is more common in women and blacks. Facet joints for of the vertebral column restrain the motion of the spine Allow flexion and extension but restrict rotational movements while the disc itself acts as shock absorber. With age, as the degeneration sets, the facet joint may not remain competent and allow vertebral body to slip forward on the other. With slip and enlargement of facets with time, the canal space reduces leading to spinal stenosis. The degree of slip in degenerative spondylolisthesis is almost always a grade 1. Compare with developmental stenosis Horizontalisation of the lamina and the facets can predispose for the development of degenerative spondylolisthesis.
Risk of progression in spondylolytic patients is low. 4-5 An increased risk of progression has been noted in female gender, presentation at a young age, severe slip at time of presentation, nonisthmic type, increased lumboscaral kyphosis and high degree of bony dysplasia. In a skeletally immature patient, the lumbosacral kyphosis has been suggested to be most useful predictor of progression. Degenerative spondylolisthesis Degenerative spondylolistheis was first described by rosenberg in 1975. The most commonly affected level is L4-L5 followed by L3-L4. It may occur at two levels or even three levels simultaneously. It has also been reported in cervical spine.
What is anterolisthesis of l4
Trauamtic sopndylolisthesis following a stress fracture summary occurs in individuals with no posterior element dysplasia and with normal spino pelvic morphology. Spondylolysis is a pure stress fracture caused by micrortrauma due to repetitive loading of lumbosacral spine and is typically seen in athletes. . In contrast, individuals with developmental spondylolisthes have a genetic predisposition, variable degrees of vertebral dysplasia, a sacropelvic morphology that predisposes to abnormal spino-pelvic balance. During growth, these individuals undergo abnormal development of the sacrum and pelvis which leads to altered mechanical stresses. Those associated with high pelvic incidence, low sacral table angle and high sacral slope are subjected to higher shear stresses resulting in increased tension on L5 pars interarticularis. Those with lower pelvic incidence but a high sacral table angle and low sacral slope are predisposed to impingement of L4 and S1 posterior facets with posterior elements of L5 leading to repetitive trauma to L5 pars during gold extension movements.
Mechanical stresses play an important role in this process. This collective trauma may eventually result in a stress fracture of the pars interarticularis. Spondylolisthesis may occur when bilateral pars defects are present, which allows forward slippage of the vertebra (typically L5 on S1). Sports that involve repetitive hyperextension and axial loading of the lumbar spine may result in repetitive microtrauma to the pars interarticularis, resulting in spondylolysis and sometimes spondylolisthesis. Gymnastics, football, wrestling, weight lifting rowing, pole vaulting, diving, hurdling, swimming (especially the butterfly stroke baseball, tennis, sailing and volleyball are the sports that carry the risk. Gymnastics and football are generally considered the highest risk sports.
In children, wiltse. Postulated that there is some amount of hip flexor contracture. This puts weight-bearing forces on pars interarticularis. Progression of slip occurrs between 9 and 15 years age and more often with associated spina bifida occulta. Only 55 had mild symptoms when followed. Bilateral defect in pars inter articularis allows the vertebral body to slip forward and the neural arch, a loose fragment, remains behind.
At the defect there is fibrocartilagenous mass which can cause pressure on exiting nerve root. The reparative process causes cephalad pars stump to form hook. This hook may rest on the nerve root and will need removal while decompressing. Spondylolysis was higher in athletes. The incidence differed in various sports. Developmental spondylolisthesis needs to be differentiated from acquired traumatic spondylolisthesis caused by stress fracture.
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But essay when it occurs, it is associated with fast progression and severe neurological deficits. There is a congenital insufficiency of facet joints (of S1 or L5) disc complex, resulting in owl gradual attenuation of the pars interarticularis leading to ventral subluxation of L5 ventrally on the sacral facets and pedicles may get elongated as well, further contributing to the forward. The articular processes of the vertebrae are tipped too far forward with the facet joints are facing forward (sagittal or axial) instead of sideways (coronal). Another association is malformed sacrum with spina bifida. Studies have reported a familial predisposition. Developmental Spondylolisthesis Spondylolisthesis is present in 5 of the population and there is no gender difference in occurrence. Most spondylolistheses in children and adolescents are developmental. This type of spondylolisthesis generally is not noticed until later in childhood or even in adult life.
With elongation, low dysplastic, with lysis. Acquired, traumatic, acute fracture, stress fracture, post surgery direct surgery Indirect surgery pathological Local pathology systemic pathology degenerative primary secondary most spondylolistheses in children and adolescents are developmental. Meyerding Classification There is resume another classification by meyerding which is based on percentage of slip Grade 1: 25 of vertebral body has slipped forward Grade 2: 50 of vertebral body has slipped forward Grade 3: 75 of vertebral body has slipped forward. Level Sagittal (mm) Coronal (interpedicle) (mm) L1 16 22 L2 15 22 L3 14 23 L4 13 23 L5 14 24 The idea of normal values helps to determine the level of stenosis of the canal. Etiology, natural History, pathology dysplastic Spondylolisthesis Dysplastic spondylolisthesis forms the type i spondylolisthesis in Wiltse classification system. It is a true congenital spondylolisthesis that occurs because of malformation of the lumbosacral junction with small, incompetent facet joints. Dysplastic spondylolisthesis is very rare.
complaints. Type iii degenerative, this lesion results from intersegmental instability of a long duration with subsequent remodeling of the articular processes at the level of involvement. Type iv- traumatic, this type results from fractures in the area of the bony hook other than the pars interarticularis. This type results from generalized or localized bone disease and structural weakness of the bone. G osteogenesis imperfecta, infection. Marchetti and Bartolozzi attempted divided the condition into developmental and acquired forms. To classify according to this classification, it must be first determined if the condition is developmental or acquired. Classification of Marchetti-bartolozzi, developmental, high dysplastic, with lysis.
It is argued that it is difficult to predict progression or response to treatment. This classification scheme divides the spondylolisthesis in 5 types. Type i dysplastic, congenital abnormalities of essays the upper sacral facets or inferior facets of the fifth lumbar vertebra that allow slipping of L5. The congenital abnormalities of lumbosacral articulation include maloriented or hypoplastic facets, sacral deficiency or poorly developed pars interarticularis. There is no pars interarticularis defect. Type ii isthmic, there is a defect in the pars interarticularis that allows forward slipping of L5. There are three subtypes. IThe incidence at birth is zero but rises sharply to 5 at the age of 4 to 5 years.
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A radiographic analysis of degenerative spondylolisthesis at the essays L4-5 level. Anderson dg, limthongkul w, sayadipour a, kepler ck, harrop js, maltenfort m, vaccaro ar, hilibrand a, rihn ja, albert partment of Orthopaedic Surgery, thomas Jefferson University, the rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, pennsylvania 19107, usa. The term spondylolisthesis derived from the Greek spondylos, meaning vertebra, and olisthenein, meaning to slip. Spondylolisthesis is defined as anterior or posterior slipping of one segment of the spine on the next lower segment. Spondylolisthesis of L5 over S1, Image Credit: wikipedia, classification of Spondylolisthesis, there are two clasifications of spondylolisthesis. One is by wiltse, newman, and Macnabs classification of and other is by marchetti and Bartolozzi. Wiltse classification, it is based on etiological and topographical criteria.