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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_31_библиотеки_им_акад_М_И_Перельмана
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M. Ruf
a
b
cd
Fig. 24.1 A 2-year-old girl with the anterior bar at L2–3 (failure of segmentation); lateral radiograph (a) and 3D-CT (b). Postoperative lateral radiographs following osteotomy of the bar through
a posterior approach, insertion of a cage and instrumentation L1–4 (c); follow-up at the age of
14years (d). Please note the correction to a physiological sagittal prole and the further growth of
the spine. Lordosis increases by anterior growth against the posterior instrumentation (tension band)
24 Congenital Kyphosis
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a
c
b
d
e
Fig. 24.2 A 22-year-old patient with posterior hemivertebrae T10 and T11, completely fused (a,
b). The patient developed progressive myelopathy with spastic paraparesis (c). Postoperative
radiographs following posterior hemivertebrectomy and fusion (d, e); slow neurological recovery.
Early surgery in childhood would probably have avoided the neurologic impairment
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M. Ruf
Further Readings
1. McMaster MJ, Singh H.Natural history of congenital kyphosis and kyphoscoliosis. A study of
one hundred and twelve patients. J Bone Joint Surg Am. 1999;81(10):1367–83.
2. Atici Y, Sökücü S, Uzümcügil O, Albayrak A, Erdoğan S, Kaygusuz MA.The results of
closing wedge osteotomy with posterior instrumented fusion for the surgical treatment of
congenital kyphosis. Eur Spine J. 2013;22(6):1368–74.
3. Wang S, Aikenmu K, Zhang J, Qiu G, Guo J, Zhang Y, Weng X.The aim of this retrospective
study is to evaluate the efcacy and safety of posterior-only vertebral column resection (PVCR)
for the treatment of angular and isolated congenital kyphosis. Eur Spine J. 2017;26(7):1817–25.
Spondylolysis andSpondylolisthesis
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25
YannPhilippeCharles
25.1 Definition
Spondylolysis represents the non-union of the isthmus (inter-articular portion) of
lumbar vertebrae. The most frequent level is L5, but spondylolysis may also occur
at L4 or L3. Spondylolisthesis is dened as anterior slippage (olisthesis) of the cranial vertebra over the caudal vertebra, mostly at L5-S1 (Fig.25.1); it is the source
of localized kyphosis L5-S1 (prognostic factor). The severity of spondylolisthesis is
classied according to Meyerding: <25% (grade 1), 25–50% (grade 2), 50–75%
(grade 3), and >75% (grade 4) (Appendix K). Grades 1 and 2 are dened as lowgrade spondylolisthesis, whereas grades 3 and 4 account for high-grade spondylolisthesis. Complete anterior luxation of the cranial vertebra is dened as
spondyloptosis.
25.2 Natural History
The pathophysiology of spondylolysis is assimilated with a fatigue fracture of the
inter-articular portion (isthmus), which occurs during growth. Different factors
might explain the non-union of the isthmus. Dysplastic isthmus shapes can lead to
spondylolysis (Fig.25.2). Repeated microtrauma such as hyperextension (gymnastics) during the growth period has been described as a risk factor. However, a genetic
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_25).
Y. P. Charles (*)
Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Faculté de Médecine,
Maïeutique et Sciences pour la Santé, Université de Strasbourg, Strasbourg, France
e-mail: YannPhilippe.CHARLES@chru-strasbourg.fr
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_25
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Fig. 25.1 Spondylolisthesis
at L5-S1with an anterior
slippage of L5 (Meyerding
grade 2). The arrow
indicates spondylolysis at
L5 (Appendix K)
Y. P. Charles
1
1
2
2
3
3
4
4
Fig. 25.2 Sagittal CT
view demonstrating
spondylolysis of a
dysplastic L5 isthmus
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predisposition might explain the spondylolysis prevalence of 7% in Caucasian populations. A large sagittal pelvic width (high pelvic incidence) is associated with
large lumbar lordosis, which enhances stress at the L5 isthmus and thus predisposes
to spondylolysis. The severity of spondylolisthesis can progress during growth and
create a kyphotic deformity at the lumbosacral junction if high-grade olisthesis is
reached. In spondylolisthesis grades 3 and 4, and in spondyloptosis, L5 and S1
nerve roots are stretched and radicular symptoms can occur. At the adult age, spondylolisthesis often leads to premature intervertebral disc degeneration, which can
cause low-back pain (Chap. 41).
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25.3 Physical Examination
Orthopedic examination of the spine, the hips, and the lower limbs should be carried
out in addition to neurologic examination. The patient is asked if low-back pain is
present, which is assessed on a visual analog scale (VAS 1–10). Leg pain and paresthesia can also be present. It should be checked if leg pain follows a typical pattern
of the L5 or S1 nerve root dermatomes, also known as sciatica or radicular pain.
Incomplete posterior leg pain (e.g., stopping at the thigh, knee, or calve level) can
mimic sciatica and is described as pseudo-radicular pain. This type of pain represents muscular pain originating from the back or pain from shortened hamstring
muscles.
Palpation of the painful level in the lumbosacral area and of paravertebral muscle
tightness is performed. In high-grade spondylolisthesis, lumbosacral kyphosis
might be observed clinically. The lumbar range of motion is then measured using
the Schober method by drawing two points: one at the upper sacral level and another
one 10cm above. The normal range of motion of the lumbar spine is observed if the
distance between both points increases to 15cm in maximal anterior trunk exion
(Schober 10/15cm). Any shorter distance indicates the limited range of motion of
the lumbar spine.
The neurologic examination focuses on radicular sensory and motor testing
(Video 25.4). The sensory examination should investigate paresthesia and a pinprick test should be performed. The motor examination requires muscle strength
testing according to the Medical Research Council scale from 1 to 5. In high-grade
spondylolisthesis, weakness can be observed in some patients, typically at L5.
Furthermore, the sphincter function should be investigated by asking the patient if
voiding abnormalities are present (Video 25.4).
25.4 Imaging
The standard radiographic examination consists of anteroposterior (AP) and lateral
radiographs of the lumbosacral spine, and sagittal alignment should be measured on
lateral full spine radiographs (EOS); lateral radiographs also allow the surgeon to
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Fig. 25.3 Oblique
radiograph of the
lumbosacral spine
demonstrating the typical
“Scottie dog” image,
where the collar represents
the spondylolysis
Y. P. Charles
quantify the amount of L5-S1 kyphosis. The lateral view usually shows spondylolysis and the amount of spondylolisthesis can be evaluated (Fig.25.1). In spondyloly-
sis without olisthesis, oblique radiographs of the lumbosacral spine can be helpful
in identifying the non-union, appearing as a typical “collar of the Scottie dog”
image (Fig.25.3).
Computed tomography (CT) scan provides good-quality images of bony lesions.
If the presence of spondylolysis is unclear on previous plain radiographs, CT represents a helpful diagnostic tool to clarify the diagnosis (Fig.25.4). However, radiation caused by CT should be avoided whenever possible in children and adolescents.
Therefore, this exam should not be considered in the rst line.
In patients with low-back pain, magnetic resonance imaging (MRI) is indicated
to evaluate the intervertebral disc (Fig.25.5). Disc degeneration can contribute to
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Fig. 25.4 Axial CT scan
showing bilateral
spondylolysis (non-union)
at the isthmus of L5
Fig. 25.5 T2-weighted
sagittal MRI demonstrating
intervertebral disc
degeneration at the level of
spondylolisthesis L5-S1
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low-back pain in adolescents and adult patients. Furthermore, MRI is indicated
when evaluating lateral recess and foraminal stenosis. At L5-S1, the L5 nerve root
is stretched by the olisthesis and the bro-cartilaginous nodulus (Gill nodulus) at
the level of the spondylolysis narrows the intervertebral foramen.
Y. P. Charles
25.5 Differential Diagnosis
In children and adolescents, non-specic low-back pain (muscular strain) might be
considered (Chap. 11). Among deformities, Scheuermann’s disease (Chap. 22) and
lumbosacral congenital malformations can cause back pain (Chap. 32). Vertebral
trauma should be investigated. Inammatory disorders (arthritis), primary or secondary neoplasms, and infections (spondylodiscitis, Pott’s disease) are rare in
children.
Degenerative spondylolisthesis represents another entity which is encountered in
elderly patients. It usually develops at L4-L5 and is associated with degenerative
changes of the lumbar spine such as facet joint osteoarthritis and spinal canal stenosis (Chaps. 45 and 46). Spondylolysis is not present in this type of olisthesis.
25.6 Treatment Options
The management of spondylolysis and low-grade spondylolisthesis is mainly conservative. During the growth period, sports should be stopped, temporarily.
Analgesic and anti-inammatory drugs might be prescribed and a brace can be prescribed to patients who complain of pain. In adult patients, CT-guided inltration of
the spondylolysis can be performed. Physical therapy mainly focuses on paravertebral muscle reinforcement and hamstring muscle stretching. In young patients, surgical isthmus reconstruction and fusion are rarely indicated. In adult patients with
intervertebral disc degeneration and low-back pain despite conservative measures,
surgical treatment by posterior or anterior (ALIF) fusion might be indicated.
High-grade spondylolisthesis usually represents a surgical indication for L5
nerve root decompression (posterior arch resection of L5) combined with posterior
and interbody fusion; surgery should reduce the amount of slippage and the local
L5-S1 kyphosis. Non-instrumented fusion can only be applied to children. Adult
patients usually require a fusion from L4-S1 (Fig.25.6). Different interbody fusion
techniques exist, including interbody fusion cages (PLIF, TLIF) or trans-sacrumlumbar grafts. The amount of required reduction should be assessed preoperatively
(Videos 25.3, 25.4, 25.6 and 25.7). In situ fusion represents a reasonable approach
in balanced spinopelvic alignment. The reduction should be performed with caution
in unbalanced alignment (retroverted pelvis with high pelvic tilt).
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Fig. 25.6 Pre- and postoperative radiographs demonstrating the principle of surgical treatment in
high-grade spondylolisthesis by nerve root decompression, posterior instrumentation L4-S1, spondylolisthesis reduction, and posterolateral and inter-body fusion
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25.7 Expected Outcomes
Conservative treatment usually provides an improvement in the quality of life in
spondylolysis and low-grade spondylolisthesis. Surgical treatment is appropriate in
high-grade spondylolisthesis, providing improved spinopelvic alignment and good
functional outcomes.
25.8 Potential Complications
Neurologic complications represent the main risk of surgical treatment in highgrade spondylolisthesis. Complete reduction carries a risk of L5 nerve root stretching and paralysis.
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