Paedriatric

Question 1

what does paediatric spondylolisthesis and spondylolysis cause?

Answer 1

• Back pain in children/adolsescents

Question 2

What is spondylosis?

Answer 2

• Antomical Defect in pars interarticularis with adjacent bone sclerosis
• one of most common cuases of back pain in children/adolscents
• defects are not Present at birth- not congential
• develop over time

Question 3

What is aetiology of spondylosis in paeds pts?

Answer 3

• Reptitive hperextension
• prevalence as high as 47% in gymnasts

Question 4

Define spondylolylisthesis?

Answer 4

• Forward translation of one vertebra on another
• 15% of those children with spondylosis progress onto spondylolythesis

Question 5

What level of spondylolytheis is common in children?

Answer 5

• L5-S1 in children ( L4/5 in adults)

Question 6

What is the risk of progression in spondolythesis?

Answer 6

• _the larger the slip t_he more likely the progression
• dysplastic slips are likely to progress

Question 7

what is the spondolylisthesis classification?

Answer 7

• Wiltse and Newman
• Type 1- dysplastic
• Type
  
  • 2a- Isthmic- fatigue fracture pars interarticularis
  • type 2b- Isthmic- elongated pars
  • type 2c- Isthmic- acute fracture pars
• Type 3- degenerative
• Type 4- traumatic
• type 5- neoplastic

Question 8

Describe the grade of spondylolithesis?

Answer 8

• Myerding
• grade 1- <25%
• Grade 2 25-50%
• Grade 3 50-75%
• Grade 4 75-100%
• Grade 5- spondyloptosis

Question 9

What are the signs and symptoms of spondylolythesis and spondylolysis?

Answer 9

Symptoms

• most spondylolysis are asymptomatic
• activity related back pain/buttock pain
• Hamstring tightness
• radicular pain- L5 nerve root
• bowel & bladder symptoms
• Listhetic crisis
  
  • back pain worsened by extension , relief by rest
  • hamstring spasm walk with crouched gait

Signs

• Flattening of lumbar lordosis
• palpable step off of spinous process
• limitation of flexion/extension
  
  • pain with single leg standing lumbar extension
  • politeal angle for hamstring tightness
• Neuro exam

Question 10

What imaging is useful in spondylolithesis/ spondylolysis?

Answer 10

Xray Spondylosis

• Lateral
  
  • defect in pars- 80%
• Oblique
  
  • may show elongation in pars and sclerosis- scotty dog sign
• AP
  
  • may see sclerosis of the stress rxn

Bone Scan

• Most sensitive- lesion maybe cold

excellent screening tool for children with lower back pain

CT

• delinate the anatomy of the lesion

pars stress reaction will show up as sclerosis on xray+ CT

SPECT- single photon emission computer tomography

• best when xrays are negative

Question 11

What imaging is useful for spondolyothesis?

Answer 11

• Xray
  
  • lateral to measure slip and grade
  • Slip grade = measure angle between superior endplate L5 and a line perpendicular to posterior border of sacrum
  • Slip angle >50^o greater risk of slippage
  • pelvic incidence
  • pelvic tilt
  • pelvic slope
• CT
  
  • to delinate anatomy of pars
• MRI
  
  • if neurology

Question 12

What is the tx for spondylolysis/ spondylothesis?

Answer 12

Non operative

• observations with no activity limitations
  
  • asymptomatic pt with low grade spondylolysis/spondylothesis
• PT and activity restriction
  
  • symptomatic isthmic spondylolysis
  • symptomatic low grade spondylothesis
• TSLO bracing 6-12 wks
  
  • acute pars stress rxn spondylolysis

Operative

• pas interarticularis repair
  
  • for L4 & above to L1 isthmic defect that has failed non op mx
  • multiple pars defects
  • Midline approach, repair with screw, tbw sublaminar hook
  • only decompress if signs of stenosis
• L5-S1 insitu- posterolateral fusion with bone grafting
  
  • L5 spondylolysis that failed non op tx
  • low grade spondylolithesis myerding grade 1-2
    
    • failed non op tx
    • is progressive
    • neurological deficits
    • dysplastic due to high propensity for progression
    • midline incision
    • insitu fusion without instrumentation preferred method
    • immobilise in TLSO post op
• L4-S1 posterolateral fusion+/- reduction +/- ALIF
  
  • high grade isthmic spondylithesis - Myerding 3-5
  • Reduction is extremely controversial - no accepted guidelines

Question 13

What are the risks of reduction of the spondylolisthesis?

Answer 13

pros

• Can restore sagittal alignment adn reduce lumbrosacral kyphosis

Disadvantage

• Risk of complication 8-30%
  
  • L5 most common nerve root injury with reduction
  • Sexual dysfunction
  • Catastrophic neurological injury

Question 14

What are the complications of Spondylolithesis?

Answer 14

• Neurological deficits
• Pseudoarthrosis
• Progression of slippage
• Hardware failure