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Cheatography

Spondylolsthesis Cheat Sheet (DRAFT) by

- Spondylolisthesis and Scheuermann's

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Spondy­lol­ist­hesis

- Anterior displa­cement of a vertebra in relation to the segment below
- Occurs mainly at L5 then L4
- Spondy­lolysis = Pars intera­rti­cularis break

Imaging

- Only if: high degree of suspicion for pars defect
- Patients who do not improve with short term treatment
- MRI for suspected active spondy­/ne­uro­logical sympto­ms/disc lesions

DDx

- F#
- Infection
- Neoplasm
- Spondy­lolysis
- Growth Plate F#
- Scheue­rmanns
- Degene­ration
- Disc lesions
- Facet Syndrome
- Sprain­/Strain
- Myofascial Pain syndrome
- Hip/SI pathology
- Viscer­oso­matic referred pain

Classi­fic­ations

- Type I : Dyspla­stic: Congenital abnorm­ality of upper sacrum or neural arch of L5
- Type II : Isthmic: A: Fatigue F# of pars, B: Enlong­ated, intact pars C: Acute f# of pars
- Type III: Degene­rat­ive: facet and disc degene­ration
- Type IV: Trauma­tic: F# of neural arch other than pars
- Type V: Pathol­ogic: Bone disease - Paget's osteop­orosis, metastasis
- Type VI: Iatrog­enic: Above/­below spinal fusion

Type I:

- Rare, congenital thin pars
- Not present at birth
- Trapez­oidal L5, dome shape S1
- Elongated Neural Arch (SP to posterior vertebra body)

Type II

Isthmic Spondy­lol­ist­hesis
Most Common is IIA: Stress f#
Common in Athletes (Gymnast, Weight lifters, Divers) and Alaskan Indigenous People
Younger skeletal immature (thinner pars, immature isthmus, decreased ability of the disc to resist shear stress)

Clinical Features

Common in childh­ood­/ad­ole­scence
Further displa­cement rarely occurs after 18 years old
Step Defect (gap)
Hyperl­ordosis
Tight Hamstrings
Achy lumbro­sacral pain with standing or slow walking
Prominent Buttocks
Waddling Gait (stiff, short stride)
Prominence of the SP at the involved level
+ve Stork Test
Transverse Skin Fold - Advanced Slippage
Insidious onset back pain
Aggravated by activity - repetitive extension, rotati­on/­axial rotation
Spondy caused by pregnancy will notice increased symptoms
Assess for CE
ROM painful during ext
+ve Kemps, +Ve Mcgills +ve Yeomans
Lower Crossed signs
Sclera­tog­enous referral to thepos­terior thigh
Radicular complaints that change side common in Type III

Imaging

Arrow: Pars Defect
Active Spondy: developing stress f# of the pars, not yet broken.
S&S = Pain on palpation of the lumbos­acral region, +ve stork's test, negative plain film
Mana­gem­ent Boston overlap anti-l­ordotic brace, stop offending activity, Pain killers No NSAIDs, isometric contra­ction of muscles, pulsed Ultras­ound, Electrical bone stimul­ators, physical rehab
Best imaging = MRI

Meyerd­ing's grading

Grade V = Spondy­lop­tosis

Method of Taillard

a/b X 100 = % of displa­cement
Unstable spondy = >4mm transl­ation between flexion and extension

Inverted Napoleon's Hat Sign

Seen with >3 grade spondy

Type III

- Degene­rative Spondy
- Rarely passes Grade 1 and never passes grade 3
- 3 F's : Female, Fourth Lumbar Vertebra, Forty years or older
- Cartilage degene­ration - ligame­ntous laxity - tension on facet capsule, disc, ligaments, muscle instab­ility
- Can cause spinal stenos­is/­mye­lopathy
- Common in L4/5
- Anatomical risk factors:
Facet tropism
Sagittaly orientated facet joints
Lx hyperl­ordosis
L5 sacral­isation
Joint laxity

Cervical Dysplastic Spondy

- Common at C6
- Associated with spina bifida
- Congenital - hypopl­astic neural arch
- Usually asympt­omatic
- Flexio­n/E­xte­nsion x-rays needed
 

Scheue­rman's Disease

S&S
- Adolescent onset (13-17)
- More common in males
- Mid and lower Tx affected
- Pain, Fatigue + Defective posture
- Increased kyphosis
- Hyperl­ordosis of lx and cx
- Protru­berant Abdomen
- Hypertonic Hamstr­ings, iliopsoas and pecs

Imaging Features

- Kyphosis due to at least 3 contiguous segments
- Wedging of 5 degrees or more of each segment
- Irregular Endplates
- Loss of Disc Height
- Enlongated VB
- Schmorl's nodes in at least 4 segments

Management

- Explan­ation and reassu­rance
- SMT (above and below spondy) and soft Tissue work of lumbar erectors, hip abductors and hip flexors
- Flexion biased exercises
- Streng­thening of tx and lx extensors
- Postural Correction
- Stretc­hin­g/R­elaxing of Pecs and Hammies
- Boston bracing for 3-6 months
- If seriously deformed, consider referral for bracin­g/s­urgery
- Stopping of aggrav­ating activity for 2-6 months
- NSAIDs
- Flexio­n/d­ist­raction
- Home exercises - knee to chest, posterior pelvic tilt, dead bug, piriformis stretc­hing, abdominal streng­thening (10 weeks)
- Lifestyle advie: proper lifting, weight loss, aerobic exercise, mattress selection, sleep position, limit hypere­xte­nsion movements and avoid wearing high heels
- If conser­vative care fails, consider inject­ion­s/s­urgical consul­tation
- Criteria for surgical consul­tation: high- grade slip
slip progre­ssion
Neurol­ogical deficit
unresp­onsive to conser­vative care after 6 months

Criteria

Grade I spondy can return to sport if:
- Full pain free ROM
- Normal strength
- Approp­riate aerobic fitness
- Adequate spinal awareness of mechanics
- Ability to perform sports related skills without pain
- Avoid repetitive extens­ion­/lo­ading