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Clinical Imaging and Diagnosis > Spondylolisthesis > Flashcards

Spondylolisthesis Flashcards

1
Q

What is Spondylolysis?

A

Stress fracture through the pars interarticularis of the lumbar vertebrae

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2
Q

What is Spondylolisthesis / Anterolisthesis?

A

Anterior displacement of one vertebral body with respect to the adjacent vertebral body

AKA Anterolisthesis
When one VB displaces anteriorly in relation to the adjacent VB
M/C in lower lumbar spine (L5/S1 and then L4/L5)
Can occur in cervical spine and rarely, except for trauma, in the thoracic spine

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3
Q

What is Retrolisthesis?

A

Posterior displacement of one vertebral body with respect to the adjacent vertebral body

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4
Q

What is Spondyloptosis?

A

A 100% displacement whereby the cephalad vertebra drops below the level of the superior end plate of the caudad vertebra (typically the sacrum)

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5
Q

What are the symptoms of Spondylolisthesis?

A
  • pain
  • radicular or mechanical symptoms
  • pain worsens with activity and improves with rest
  • muscle spasms which may lead to
  • back stiffness
  • tight hamstrings
  • difficulty standing and walking
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6
Q

90% of all Spondylolisthesis and/or spondylolysis occurs at what spinal level?

A

L5

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7
Q

5% of all Spondylolisthesis and/or spondylolysis occurs at what spinal level?

A

L4

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8
Q

3% of all Spondylolisthesis and/or spondylolysis occurs at what spinal level?

A

L1, L2, and L3

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9
Q

2% of all Spondylolisthesis and/or spondylolysis occurs at what spinal level?

A

C5, C6, and C7

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10
Q

What physical examination would you do for Spondylolisthesis?

A

a step-off over the SP may be indicative of spondylolisthesis, particularly over the L5–S1 level
- pain localised to the pars interarticularis region (In Spondylolysis)

Forward flexion - diminished secondary to excessive hamstring tightness
- does not increase symptoms
- may provide relief in some cases
- Extension & Rotation - cause discomfort

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11
Q

What special tests can you use to test for Spondylolisthesis?

A
  • Stork test – Positive
  • reproduction of similar pain
  • suggestive of spondylolysisand possible spondylolisthesis that needs further evaluation with imaging.
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12
Q

What imaging can be used for Spondylolisthesis?

A
  • Plain radiography (AP + Lateral + Flexion/Extension views) – STANDARD for initial Dx
  • CT scan – high sensitivity and specificity for Dx associated with pars defect
  • MRI scan – to show associated soft tissue and disc abnormalities
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13
Q

What are the lines of measurement used for Spondylolisthesis?

A

Meyerding’s method (a percentage estimate)
- M/c grading method
- Grading based on the degree of displacement

  1. Ulmann’s Line
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14
Q

What is Meyerding’s Method grading?

A
  • M/c grading method
  • Grading based on the degree of displacement

Grade I: 0 to 25% - anterior displacement
Grade II: 25 to 50%
Grade III: 50 to 75%
Grade IV: 75 to 100%
Grade V: spondyloptosis - Rare

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15
Q

What is Ullman’s line?

A

Straight line drawn at right angles to the sacral base line

The anterior corner of L5 should be at or posterior to this line.

Supports analysis of low lumbar segment relationships.

Particularly useful at L5-S1 level.

May be applied to L4-L5 level but not above this level.

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16
Q

What is the treatment of Spondylolisthesis?

A

Conservative therapy
- nonsteroidal anti-inflammatory drugs (NSAIDs)
- physiotherapy / chiropractic care
- Heat
- Light exercise
- Traction
- Brace
- Bed rest

Surgery
- If conservative treatment fails
- e.g., decompression, fusion with or without instrumentation, or interbody fusion

17
Q

What are the different types of Spondylolisthesis?

A

Type I – Dysplastic
Type II – Isthmic
Type III – Degenerative
Type IV – Traumatic
Type V – Pathologic
Type VI – Iatrogenic

18
Q

What is Type I – Dysplastic?

A

Congenital defect (present from birth)
absent or underdeveloped facet joints (facet joints sagittally oriented than the typical coronal orientation)
Elongated inferior articular process
Elongated pedicles

Upper sacrum or arch of L5 causes listhesis
Pars usually normal
High association with spina bifida occulta
Females > Males (2:1)
M/C in paediatrics
Accounts for 14-21% of all spondylolistheses
Symptoms:
Asymptomatic – childhood
LBP - adolescence

19
Q

What are the radiological findings in dysplastic spondylolisthesis?

A

forward slip and tilt of the L5 vertebral body results in an axial image through the vertebra, producing the ‘Napoleon’s hat’ sign

Lateral radiograph demonstrates approximately 70% slip, with posterior wedging of L5 and rounding of the superior endplate of S1. Note the pars defect of L5 (arrows).The pars may be elongated and intact or fragmented.

Lateral radiograph demonstrates congenital absence of the inferior articular processes of L3 with associated grade 1 L3/4 spondylolisthesis.

20
Q

What is Type II: Isthmic?

A

Aka spondylolytic spondylisthesis or spondylolysis
Unilateral or Bilateral pars interarticularis defect
No VB movement UNLIKE Spondylolisthesis
L5/S1 most commonly affected segment

M/C in adolescent and young adults
Male > Females (2:1)
Symptoms – Asymptomatic
- LBP or leg pain or both (worsened with activity or sports)
Cause undetermined but prevalence in sports involving repetitive hyperextension (gymnasts, weightlifters, wrestling)
Flexion/Extension views – identify degree of instability
3 subcategories

  1. Lytic – most common in pediatrics and athletics
  2. Elongated – similar to lytic BUT Pars INTACT
  3. Acute fracture – Trauma causing pars fracture
21
Q

What are the 3 subcategories of Isthmic?

A
  1. Lytic – most common in pediatrics and athletics
  2. Elongated – similar to lytic BUT Pars INTACT
  3. Acute fracture – Trauma causing pars fracture
22
Q

What are the radiological features of Isthmic spondylolisthesis?

A

A radiolucent defect in the pars is best visualized on oblique lumbar projections through the “neck” or “collar” of the “Scotty Dog.”
The stepladder sign is produced by malalignment of the zygapophyseal joints at the involved level seen on oblique.

23
Q

What is Type III: Degenerative?

A

Secondary to longstanding degenerative changes and intersegmental instability - causing facet remodeling
PARS INTACT
No more than 25% anterior displacement. (usually only 10 - 15%)
More common at L4 than at either L3 or L5 – due to greater mobility of L4
More common in >50yoa
Females > Males (3:1)
LB and Leg pain – due to disc and facet degeneration
Unlikeisthmic spondylolisthesis, degree of slip of degenerative spondylolisthesis typically not graded as it is almost always a grade 1 or 2.

24
Q

How does degenerative spondylolisthesis display on radiographs?

A

lower lumbar spine shows degenerative L4/5 spondylolisthesis above a transitional L5 vertebral body. Malalignment of the spinous processes with anterior slip of the L4 spinous process relative to L5 allows differentiation from isthmic spondylolisthesis.Degenerative spondylolisthesis and associated spinal stenosis

Sagittal T2W FSE MRI showing L4/5 spondylolisthesis and central canal stenosis, manifesting as complete loss of cerebrospinal fluid around the cauda equina

25
Q

What is Type IV: Traumatic?

A

Secondary to fractures in the area of the neural arch (e.g., pedicle or facet joint) other than the pars interarticularis.
Rare
It is common at C2 and is referred to as a Hangman’s fracture, aka Traumatic Spondylolisthesis.

26
Q

What are the radiological findings of Traumatic spondylolisthesis?

A

This patient had a forceful (traumatic ) hyperextension of the upper cervical region and sustained a fracture (and soft tissue tearing) of the posterior (neural) arch of C2 (black arrow).

Consequently, there is anterior displacement of the C2 body on the C3 body. Note the subtle misalignment.

(Note C2 is anatomically, an atypical vertebra).

27
Q

What is Iatrogenic?

A

Not an official Type
Two types under Iatrogenically induced lesions due to alteration in stress resulting from spinal surgery:
1. Above or below a surgical fusion.
2. Removal of “Too Much” material in a posterior decompressive laminectomy.

Also known as Spondylolisthesis Acquisita

Clinical Imaging and Diagnosis (16 decks)

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