Unit 6 power point- imaging

Spondylolisthesis: 

Spondylolisthesis 10/11/11 Kristen Verba Ashley Powell

Spondylolisthesis:: 

Spondylolisthesis: Forward slipping of one vertebral in relation to the vertebral segment immediately below

Pars Interarticularis: 

Pars Interarticularis Between the inferior and superior articular processes Anterior to the lamina Posterior to the pedicle Considered to be the weakest potion of the vertebra

Etiology and Incidence: 

Etiology and Incidence Spondylolytic Spondylolisthesis Bilateral fracture of the pars interarticularis ( spondylolysis ) Vertebral body, pedicles, and superior articular processes translate anterior Inferior articular processes, lamina, and spinous process is left behind Forward slippage is progressive during growth spurts, usually does not progress farther in adulthood

Etiology and Incidence: 

Etiology and Incidence Degenerative Spondylolisthesis Caused by degenerative disc disease and subluxation of the posterior facet joints May present as a forward translation ( anterolisthesis ) or backward translation ( retrolisthesis )

Etiology and Incidence: 

Etiology and Incidence 3. Isthmic Spondylolisthesis 2:1 ratio of males to females Females are 4x more likely to have a progression of the slippage Elongation of the pars typically occurs between the ages of 5-7 and in the teenage years, coinciding with growth spurts Symptoms usually occur during the fourth or fifth decade of life, if at all Also referred to as Congenital Spondylolisthesis, however the deformity does not occur until the child is weight-bearing

Incidence of spondylolisthesis: 

Incidence of spondylolisthesis Affects 4-8% of the general population 4-6% have a lytic lesion 2-4% have an isthmic elongation Between near relatives incidence increases to 25-30% 50% of spondylolysis never progress to spondylolisthesis

Patient Symptoms: 

Patient Symptoms Backache Localized lumbosacral pain Gluteal pain Lower limb pain Parathesia in the lower extremities Stiffness after exercise Deep aching pain Exacerbated with lifting and weight bearing Alleviated with rest and lying supine Onset mid-morning, after standing Possible cauda equina symptoms

Examination Findings: 

Examination Findings Posture: Increased lumbar lordosis, flexed knee stance Palpation: depression above the level of listhesis ( lytic and isthmic ) OR at the level (degenerative), tenderness at the spinous process of the slipped vertebra, hypertonicity of paraspinals surrounding involved segments AROM: limited lumbar forward bending PROM: hamstring tightness

Examination Findings: 

Examination Findings Neurological: usually negative, possible parathesia if nerve roots are compromised Gait: stiff waddling gait Imaging: lateral radiograph to confirm the listhesis , oblique radiograph to detect a lysis

Prognosis: 

Prognosis Unilateral pars defect has a greater chance of healing than bilateral With an acute fracture rigid immobilization is indicated to increase the speed of recovery Bilateral pars defect substantially decreases the chance of bone healing, even with immobilization

Role of Imaging in Diagnosis: 

Role of Imaging in Diagnosis Radiograph Lateral Used to confirm the presence and direction of listhesis Grading of the slippage using one of several methods Oblique Used to confirm the presence of pars fracture 30 degree cranial tilt radiograph may be more sensitive to identify the lysis than typical oblique view Meyerding classification system Based on the amount of slippage Grade I: 0-25% Grade II: 26-50% Grade III: 51-75% Grade IV: 76-99% Spondyloptosis : 100%

Role of Imaging in Diagnosis (cont): 

Role of Imaging in Diagnosis (cont) MRI Axial To detect decreased space for nerve roots and spinal canal Sagittal To visualize the status of the intervertebral disc at the involved segment Bone Scan To determine the acuteness of the lysis Acute fracture will present with an increased uptake of the contrast, as known as a “hot spot” According to Blanda , et.al., 13% of patients with spondylolysis had normal oblique radiographs and abnormal bone scan

Role of Imaging in Management: 

Role of Imaging in Management Lateral radiograph will assist in decision making in conservative management Grade I and II activity modification will typically be sufficient to resolve symptoms Bracing or surgical intervention indicated for Grade III and higher MRI provides information on the need for decompression or fusion based on the neural damage Bone scan guides treatment by revealing if the fracture is active or inactive

Lateral Radiograph: 

Lateral Radiograph A: Alignment: General Skeletal Architecture: The pars interarticularis is lengthened on the 5 th lumbar vertebra compared to normal at the 4 th lumbar vertebra. General Contour of Bone: Bone cortices appear normal. Alignment of Bones to Adjacent Bones: There is an anterior translation of the 5th lumbar vertebra on the sacral base with ~25% of the joint surfaces no longer in contact. The posterior border of the vertebrae and the spinolaminar border are both disrupted at the L5-S1 level, indicating possible compromise of the spinal canal. B: Bone Density: The bone density appears to be normal. No textural abnormalities or local bone density changes. C: Cartilage Spaces: Decreased disc height at L5-S1. The disc angle of L4-5 is increased from the normal of ~8 degrees seen at L3-4. S: Soft Tissues: Not applicable

Axial CT Scan: 

Axial CT Scan Top Image: “hot spots” in the lamina of L5 vertebrae. (active spondylolisthesis) Good visualization of spinal canal, note there are no occlusions of the cord at this level Soft tissue appears healthy

MRI: 

MRI MRI demonstrates compromise to the spinal canal Can assess disc involvement

Questions: 

Questions Please suggest an imaging study that would give valuable information regarding the stability of the spondylolisthesis. What would you see? Your patient’s CT scan does not indicate an active spondylolisthesis. What are other diagnoses that may be causing the patient’s low back pain?

References:: 

References: Barash HL, Galante JO, Lambert CN, et al. Spondylolisthesis and tight hamstrings. J Bone Joint Surg Am 52: 1319-1328, 1970. Blanda J, Bethem D, Moats W, et.al. Defects of Pars Interarticularis in Athletes: A Protocol for Nonoperative Treatment. Journal of Spinal Disorders . 1993; 6(5): 406-411. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 4 th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 887-888. http://www.coastalneurosurgery.com.au/_data/docs/august%202010%20updates/mri%20of%20grade%204%20spondylolisthesis%20200x266.jpg . Accessed on 10/11/11. http://www.radiologyteacher.com/id/2/152-1-0-1.jpg. Accessed on 10/10/11. http://www.sandiego-spine.com/subject.php?pn=isthmic-spondy-034a . Accessed on 10/4/11. Meyerding HW: Spondylolisthesis. Surg Gynecol Obstet. 54: 371-377, 1932. McPhee B: Spondylolisthesis and spondylolysis , in Youman JR ( ed ): Neurological Surgery: A Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical Problems, ed 3. Philadelphia; WB Saunders, 1990: (4)2749-2784. Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System. 3 rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1992:373-375.