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Spondylolyse chez l'enfant

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SPONDYLOLYSE: solution de continuité au niveau de l’isthme de la vertèbre

SPONDYLOLYSTHESIS: « glissement en avant d’un corps vertébral, provoqué par la rupture de la continuité ou l’élongation des isthmes » (TAILLARD)

Publié dans : Santé & Médecine
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Spondylolyse chez l'enfant

  1. 1. LA SPONDYLOLYSE ET LE SPONDYLOLISTHESIS CHEZ L’ENFANT R. ELBAUM CLINIQUE EDITH CAVELL CHU ERASME
  2. 2. DEFINITION • SPONDYLOLYSE: solution de continuité au niveau de l’isthme de la vertèbre • SPONDYLOLYSTHESIS: « glissement en avant d’un corps vertébral, provoqué par la rupture de la continuité ou l’élongation des isthmes » (TAILLARD)
  3. 3. Rappel Historique Herbiniaux : 1782 « Projection du rachis en avant dans certaines formes de dos creux » - Meyerding 1932 : Première classification Arthrodèse postérieure médiane - Jenkins 1936 : - Réduction - Arthrodèse antérieure - Gill 1955 : Résection arc postérieur - Kimura 1968 : Reconstruction isthmique - Harrington 1976 : Instrumentation en distraction - Wiltse : 1976 - Classification en 5 types Boxall : 1979 Cyphose lombo-sacrée Newell LM. Spondylolysis, an historical review. Spine 1995
  4. 4. ANATHOMOPATHOLOGIE
  5. 5. ANATHOMOPATHOLOGIE La spondylolyse, entité médicale et entité paléopathologique Ludovic Debono (1)*, Bertrand Mafart (2) 2004
  6. 6. Classification de MEYERDING (1932) GRADE 1 GRADE 2 GRADE 4GRADE 3
  7. 7. Classification de Wiltse et Newmann 1976 Type 1 Forme congénital ou dysplasique avec dysplasie des arcs postérieurs et massif articulaire fuyant Type 2 isthmique pur par lyse acquise avec rupture ou allongement de l’isthme Type 3 Dégénératif Type 4 ,5 et 6 macrotraumatique,pathogène ou iatrogène
  8. 8. Classification de Marchetti 1997 SPL Type 1 développemental SPL avec lyse congenitale surajoutée SPL avec allongement isthmique Type 2 Acquis Traumatique Iatrogène Pathologique Dégénératif
  9. 9. ETHIOPATHOGENIE • SPL et LISTHESIS sont des lésions acquises • Il n’existe pas de forme néonatale (1 cas décrit chez 1 nouveau né de 3mois!) • La spondylolyse n’apparaît qu’après l’âge de la marche • La plupart surviennent entre 5 et 7ans
  10. 10. Facteurs Favorisants • Génétique • Traumatique • Trophostatique • Dysplasique Multifactorielle Taillard (Clin.Orthop. 1976)
  11. 11. Facteurs Génétiques -Prédominance - Masculine dans les formes peu ou pas déplacées - Féminine dans les formes très déplacées Variabilité ethnique - 5,6 % : sujets de race blanche - 1,9 % : sujets de race noire - 20% à 60 % : communauté eskimos J.L Jouve
  12. 12. Facteurs morphologiques Pente sacrée Incidence lombo-pelvienne
  13. 13. Facteurs morphologiques Angle LS sup à 90° pas de cyphose couple charnière équilibré Cyphose LS Angle LS inf à 90° Couple charnière déséquilibre Sacrum horizontal Sacrum vertical
  14. 14. L’évolution et la gravité de la spondylolyse est liée à la gravité de la dysplasie initiale et de la morphologie sacrée.
  15. 15. Facteurs Traumatiques  Traumatismes aigus à haute énergie 1 - UN TRAUMATISME AIGU NE GENERE PAS A LUI SEUL DE SPONDYLOLYSE ISOLEE 2 - UN TRAUMATISME AIGU N’AGGRAVE PAS A LUI SEUL UN SPONDYLOLISTHESIS DE BAS GRADE -Floman Y. J Spinal Dis 1991 300 fractures thoracolombaires 7 spondylolisthésis grade 1 associés Aucun spondylolisthésis aggravé par la fracture sus jacente 3 - UN TRAUMATISME AIGU PEUT AGGRAVER UN SPONDYLOLISTHESIS DE HAUT GRADE J.L Jouve
  16. 16. Facteurs Traumatiques ou Fractures de Stress? Effet « WOODI WOOD PECKER »
  17. 17. Spondylolyse et activite sportive Sur 1430 Athlètes(Rossi) Pourcentage global: 17,7% DE LYSE ISTHMIQUE SELON LE SPORT: •PLONGEURS 63% •HALTEROPHILES 36% •GYMNASTES 33% •LUTTEURS 33% •AUTRES ATHLETES 22%
  18. 18. Les spondylolyses chez l’enfant. quelques chiffres: • 4% A L’AGE DE 6ANS • 6% A L’AGE ADULTE • EGALE DANS LES DEUX SEXES • 15% FORMES FAMILIALES (Winne, Davis et Scott) • 30 à 60% CHEZ LES ESQUIMAUX
  19. 19. HISTOIRE NATURELLE 1 Rupture isthmique dans la petite enfance sous l’effet de facteurs favorisants (Age de survenue entre 3 et 12 ans) 2 Glissement vertébral significatif durant une période brève 3 Stabilisation dans une nouvelle situation d’équilibre Formes peu ou pas déplacées Formes très déplacées Asymptomatique Persistance d’un glissement mineur lié à la dégénérescence discale (80%) Symptomatique (20%) J.L Jouve
  20. 20. HISTOIRE NATURELLE Rupture isthmique du grand enfant parfois de l’adolescent sous l’effet de facteurs favorisants (microtraumatismes +++) SPONDYLOLYSE UNI OU BILATERALE Consolidation spontanée ou après traitement Pérennisation de la lyse Formes peu ou pas déplacées « Fracture de fatigue » J.L Jouve
  21. 21. TU… G 2002 2 003 2006
  22. 22. HISTOIRE NATURELLE Rupture ou allongement isthmique du petit enfant sous l’effet de facteurs favorisants (dysplasiques +++) Glissement rapide Formes à grand déplacement Haut grade Formes à sacrum horizontal Bon pronostic Formes à sacrum vertical Mauvais pronostic J.L Jouve
  23. 23. BEN…Z 2003 2005
  24. 24. Evolution du glissement • 50 à 65% des SPL présenteront un glissement (Congdon & Chandler) • Glissement lent et progressif entre 12 et 17 ans (Taillard) • Rare après 20 ans (sauf SPL dégénératif) • SPL Grade 1 à 2: évolutivité faible • SPL Grade 3 à 4: Ptose possible mais jamais brutale
  25. 25. TABLEAU CLINIQUE
  26. 26. TABLEAU CLINIQUE • Asymptomatique (80%) • Rétraction ischio-jambiers++ (faux Lassegue) • Lombalgie aigue inaugurale (témoin d’une rupture isthmique aigue) • Lombalgie chronique ou récurrente (+/- 1an) • Cyphose lombo-sacrée • Radiculalgie L5/S1(parx) • Syndrome queue de cheval (SPL Gr4) • Scoliose associée
  27. 27. SPONDYLOLISTHESIS
  28. 28. SPONDYLOPTOSE
  29. 29. Contracture des ischiojambiers
  30. 30. BILAN RX
  31. 31. BILAN RX: LE 3/4 « le collier du petit chien »
  32. 32. BILAN RX
  33. 33. Scintigraphie au Technétium
  34. 34. BILAN: CT SCAN
  35. 35. BILAN:IRM
  36. 36. PRISE EN CHARGE DES SPONDYLOLYSES ET SPONDYLOLYSTHESIS SYMPTOMATOLOGIE GRADE AGE TYPE
  37. 37. SPONDYLOLYSES PEU ou PAS DEPLACEES ASYMPTOMATIQUE : Aucun traitement Surveillance radiologique annuelle Aucune contre indication sportive SYMPTOMATIQUE : Traitement conservateur : •Repos sportif •Rééducation,Physio •Antalgiques, AINS •corset ou lombostat Echec du traitement conservateur : •Reconstrution isthmiques +++ •Arthrodése postérolatérale (Wiltse)
  38. 38.  En cas de lombalgie aigue • Soit rechercher la consolidation de l’isthme Plâtre bermuda ou corset hémiculotte 3mois (Dubousset) Corset en délordose 30-60% consolidation (Pagnotta) • Soit attendre la sédation des plaintes: -Antalgiques mineurs - Lombostat souple - Suspension des activités sportives Reprise des activités sportives dès la sédation de la douleur
  39. 39.  En cas de lombalgie chronique • AINS • Traitement fonctionnel par programme de réeducation intensif • Lombostat ,corset pantalon • Sports autorisés natation,vélo,yoga… • Attendre une année de recul • En cas d’échec ou de récidive 1. Reconstruction isthmique 2. Arthrodèse postérolatérale de Wiltse
  40. 40. Reconstruction Isthmique VISSAGE (Coll Bergoin) )
  41. 41. Arthrodèse postérolatérale de Wiltse Coll Nordin
  42. 42. – Arthrodèse intersomatique antérieure – Arthrodèse postéro-latérale – Arthrodèse intersomatique postérieure – Arthrodèses combinées – Réduction du glissement quand il est important – … SPONDYLOLYSES A GRAND DEPLACEMENT
  43. 43.  REDUCTION PAR HAMAC Coll St Vincent de Paul
  44. 44. L’AVENIR?
  45. 45. CONCLUSION • la spondylolyse de l’enfant est une anomalie fréquente et asymptomatique dans la majorité des cas. • Elle nécessite une simple surveillance clinique et radiologique. • Elle justifie d’un traitement orthopédique ou chirurgicale dans des indications spécifiques ou dans les formes symptomatiques.

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