Degenerative spondylolisthesis..guidelines based management

1. Dr. Ramkrishna Dahal
Fellow Spine Reconstructive Surgery
Grande International Hospital

2.  Spondylolysis :defect in pars
interarticularis
 Spondylolisthesis comes from
Greek spondylos (vertebra)
and olisthanein (to slip or fall)
 Spondyloptosis: the most
severe form of
spondylolisthesis, when the
body of L-5 has slipped into
the pelvis and is positioned
directly anterior to the sacrum

3.  Term Coined by Kilian
 First described by Herbiniaux who reported
a bony prominence anterior to the sacrum
◦ impediment to vaginal delivery
 Robert in 1855 suggested that listhesis
was possible only after lysis of the neural
arch
 Neugebauer “ Spondylolisthesis with intact
neural arch but with elongation “

4.  Junghanns first described degenerative
spondylolisthesis in 1930 as
pseudospondylolisthesis
 Mcnab – “Spondylolisthesis with intact
Neural arch”
 Renamed by Newman as degenerative
spondylolisthesis because of the associated
arthritic changes
 Diabetes and oophorectomy predisposes to
this condition

5. Wiltse, Newman, and
Macnab’s classification
Five types of
spondylolisthesis:
 Type I Dysplastic
 Type II Isthmic
 Type III
Degenerative
 Type IV Traumatic
 Type V Pathological

6.  Prevalence (Copenhagen OA study in
4500 patients)
◦ 2.7% in men
◦ 8.4% in woman
 More common in African Americans, diabetics,
and woman over 40 years of age
 Risk Factors:
◦ Sacralization of L5
◦ Sagittal orientation of facet
◦ If sagittal orientation of facet >45 deg, there
is 25 times more chance of DS than those
with <45 deg.

7.  Degenerative Spondylolisthesis
 Intersegmental instability is
present as a result of
degenerative disc disease and
facet arthropathy. [SPONDYLOSIS]
 The slip occurs from progressive
spondylosis within this 3-joint
motion complex.
 The L5 nerve root is usually
compressed from lateral recess
stenosis as a result of facet
and/or ligamentous hypertrophy

10.  Not simply sagittal slippage
 Rotatory deformity
◦ Asymmetric facet subluxation

11.  Differentiated from isthmic by intact pars
 Because the arch is intact and moves forward
with the L4 vertebral body, progressive spinal
stenosis occurs in addition to facet
degenerative changes
 Thories to explain the occurance of
degenerative spondylolisthesis include
sagittal facets and disc degeneration

12.  Clinical presentation
◦ backache
◦ leg pain
◦ neurologic claudication (68%)
◦ radiculopathy (32%)
◦ cauda equina (3%)

14.  Feel:
◦ Palpable step-off in higher-
grade slips
 Move:
◦ Usually preserved spinal motion
 Hamstring tightness
 Gait difficulty (worse with
high-grade slips)

15.  Xray: typical anterolisthesis
at L4-L5 with disc space
narrowing
 Standing Lat view
◦ 22% of L4-5 slips detected on
standing lat view were not
detected in supine MRI
 Flexion and extension
lateral views: instability
(>4mm translation, >10
degrees sagittal rotation)

17.  Wrong surgeries were done exacerbating the
patients symptoms!!!
 Only decompression done instead of
decompression with fusion with undetected
DS compromising further stability.

21.  Morphology subgroups:
Type A: advanced disc space collapse
without kyphosis
Type B: disc partially preserved with
translation of 5 mm or less
Type C: disc partially preserved with
translation of more than 5mm
Type D: kyphotic alignment
 Leg pain modifier;
◦ No leg pain – 0
◦ Unilateral leg pain – 1
◦ Bilateral Leg pain -2

23.  Distal lumbar flexion can result in pelvic
retroversion
 therefore, in cases of flexible sagittal
imbalance, pelvic retroversion may be
compensatory for lumbar canal stenosis

24.  The majority of patients do well with
conservative care.
 Progression of slip correlates with jobs that
require repetitive anterior flexion of the
spine.
 Slip progression is less likely to occur when
the disc has lost over 80% of its native height
and intervertebral osteophytes have formed.
 Progression of clinical symptoms does not
correlate with progression of the slip.

26.  Nonoperative
◦ NSAIDS
◦ Trunk stabilizing exercise/ Spinal flexor
exercises and low impact aerobic exercise
seem to benefit the patients
◦ Epidural steroid injection

27.  No RCTs or Placebo controlled trails
 Grade of recommendations: Insufficient
 Satisfactory short term pain relieve especially
in radiculopathy
 1st episode ineffective without fluoroscopy
◦ Try next episode under fluoroscopy
 1st episode ineffective under fluoroscopy
◦ Do not try next
 1st episode partially effective try next
episodes

28.  Operative treatment
◦ For unremitting back and
leg pain after non
operative treatment
◦ 10-15% patients

29. • Decompression
• Significant disc
collapse
without
pathological
motion on
dynamic x ray

30.  Patients with preserved disc
height
 Absence of osteophytes on x ray
 Small degree of motion on
dynamic x ray
 Fusion can be supplemented by
instrumentation

31.  Fusion can be achieved by
◦ posterior lumbar interbody fusion (PLIF)
◦ transforaminal lumbar interbody fusion (TLIF)
◦ anterior spinal fusion
◦ circumferential fusion/360 degree fusion

35.  Longer-term follow-up has shown that
obtaining a radiographically solid fusion
improves clinical results
 86% good or excellent results in solid
fusions and 56% in pseudarthrosis
 The necessity of instrumentation in the
treatment of lumbar stenosis with
spondylolisthesis remains an area of
intense investigation
 Concern of adjacent segment “transition
syndromes”

36.  Anterior Spinal Fusion
 Results are similar to
those obtained with
decompression and
instrumented fusion
 Additional morbidity
associated with the
anterior approach,
depending on
surgeon’s experience

37.  When indicated ???
◦ In revision cases with pseudoarthrosis
 Typical Complication
◦ Retrograde ejaculation: injury to superior
hypogastric plexus

38.  Decompression and Combined Fusion (360-
degree Fusion)
 Posterior interbody procedures often do not
allow safe excision of a contracted anulus and
anterior longitudinal ligament for height
restoration.
 The objective of interbody grafts at L4-
L5/L5-S1 is to re-create the segmental
lordosis of 20 to 30 degrees

39.  After repeated discectomies
 Unstable: >10 deg in flex/ext lat radiographs
 Back pain> leg pain
 B/L facetectomy

40.  Pseudoarthrosis 5-30%
◦ CT more reliable than MRI
 Adjacent segment disease 2-3%
 Dura tear
 Positioning Neuropathy

41.  Evidence based
guidelines regarding
treatment of
Degenerative
Spondylolisthesis

42. There is insufficient evidence to make a
recommendation for or
against the use of injections for the treatment
of degenerative lumbar
spondylolisthesis.
Grade of Recommendation: I (Insufficient Evidence)

43.  Does surgical decompression
alone improve
surgical outcomes in the
treatment of
degenerative lumbar
spondylolisthesis
compared to
medical/interventional
treatment
alone?

44. Direct surgical decompression
may be considered for the
treatment of
patients with symptomatic spinal
stenosis associated with low
grade
degenerative lumbar
spondylolisthesis whose
symptoms have been
recalcitrant to a trial of
medical/interventional treatment.
Grade of Recommendation: C

45.  For symptomatic single level degenerative
spondylolisthesis that is low-grade (< 20 %)
and without lateral foramina stenosis,
decompression alone with preservation of
midline structures provides equivalent
outcomes when compared to surgical
decompression with fusion.
◦ Grade of Recommendation: B (Suggested)

46.  The addition of instrumentation is suggested
to improve fusion rates in patients with
symptomatic spinal stenosis and
degenerative lumbar spondylolisthesis.
◦ Grade of Recommendation: B

47.  The addition of instrumentation is not
suggested to improve clinical outcomes for
the treatment of patients with symptomatic
spinal stenosis and degenerative lumbar
spondylolisthesis.

Grade of Recommendation: B

48.  There is insufficient evidence to make a
recommendation for or against the use of
reduction with fusion in the treatment of
degenerative lumbar spondylolisthesis.
◦ Grade of Recommendation: I (Insufficient Evidence)

49.  There is insufficient evidence to make a
recommendation for or against the use of
autogenous bone graft or bone graft
substitutes in patients undergoing
posterolateral fusion for the surgical
treatment of degenerative lumbar
spondylolisthesis.
◦ Grade of Recommendation: I (Insufficient Evidence)

50.  Facet joint effusion greater than 1.5mm on
supine MRI may be suggestive of the
presence of degenerative lumbar
spondylolisthesis. Further evaluation for the
presence of degenerative lumbar
spondylolisthesis should be considered,
including using plain standing radiographs.
◦ New recommendation statement Grade of
Recommendation: B

51. There is insufficient evidence to make a
recommendation for or against the use of
indirect surgical decompression for the
treatment of patients with symptomatic
spinal stenosis associated with low grade
degenerative lumbar spondylolisthesis
whose symptoms have been recalcitrant to
a trial of medical/interventional treatment.
Grade of Recommendation: I (Insufficient
Evidence)

52.  Surgical decompression with fusion is
suggested for the treatment of patients with
symptomatic spinal stenosis and
degenerative lumbar spondylolisthesis to
improve clinical outcomes compared with
decompression alone in single level disease.
 Grade of Recommendation: B

53.  There is insufficient evidence to make a
recommendation for or against efficacy of
surgical decompression with fusion, with or
without instrumentation, for treatment of
multi-level degenerative lumbar
spondylolisthesis compared to
medical/interventional treatment alone.
◦ Grade of Recommendation: I (Insufficient Evidence)

54.  While both minimally invasive techniques and
open decompression and fusion, with or
without instrumentation, demonstrate
significantly improved clinical outcomes for
the surgical treatment of degenerative lumbar
spondylolisthesis, there is conflicting
evidence which technique leads to better
outcomes.
◦ Grade of Recommendation: I
(Insufficient/Conflicting Evidence)

55.  L4-L5 most common
 4-5 times more common in female
 Differentiate from vascular claudication
 Standing Lat xray mandatory before any spinal
surgery
 Do not treat Xray, Treat patient

56.  No correlation between slip progression and
clinical symptoms
 Non operative treatment : Main stay of
treatment
 10-15 % ultimately need surgery
 Decompression with Fusion with/out
instrumentation has better outcome (Gr. B )