What is the anatomy of the lumbar spine?
What is a spondylolisthesis?
Spondylolisthesis is a condition where one vertebral body moves forward in relation to the next. This forward ‘slip’ can occur for a variety of reasons. The most common varieties of spondylolisthesis are:
Degenerative spolndylolisthesis occurs mainly in women and occurs most commonly at the L4/5 level. Degenerative spondylolisthesis is due to degenerative changes in the facet joints at the posterior aspect of the spine. The loss of integrity in these joints allows the superior vertebra to move forward. This results in narrowing of the spinal canal or spinal stenosis, as well as narrowing of the exit foramina for the individual nerve roots.
Isthmic spondylolisthesis is a condition that is more common in males and occurs mostly at the L5/S1 level. It occurs when there are pars defects. The pars (or pars interarticularlis) are small areas of bone; one each side at the posterior aspect of the spine. It joins one facet joint to another. When the pars are fractured, or have a defect, the main part of the superior vertebra is allowed to ‘slip’ forward. In most cases this is a small slip, but it can be quite severe and rarely, the superior bone can have completely ‘slipped’ off the one below. This is called spondyloptosis and is fortunately very rare.
Isthmic spondylolisthesis is common but rarely requires surgery. The problems and their symptoms that occur due to isthmic spondylolisthesis are very similar to those described for degenerative spondylolisthesis. Surgery for this condition is performed only in patients who have significant symptoms that have not responded to more conservative treatment. Therefore, only a minority of people with this condition will require surgery during their lifetime.
Other forms of spondylolisthesis
Other forms of spondylolisthesis include trauma, congenital spinal dysplasia, tumour and infection.
What are the symptoms of spondylolisthesis?
The most common clinical symptoms of spondylolisthesis are:
What are the treatment options for spondylolisthesis?
When spondylolisthesis symptoms are mild, then conservative management such as physiotherapy may be appropriate. Cortisone injections may be useful to treat spondylolisthesis if the pain is mainly located in the back itself, particular if the origin is the facet joints. Cortisone injections are often used for the treatment of leg symptoms as well, but their effectiveness in the setting of spinal stenosis may be limited as the main issue is usually mechanical compression of the nerves rather than inflammation.
Cortisone will not relieve the mechanical compression of the nerve roots.
Surgery for spondylolisthesis is indicated for patients with significant symptoms including neurogenic claudication or radiculopathy that have not responded to conservative management.
What type of surgery is used to treat spondylolisthesis?
Surgery for spondylolisthesis usually involves a technique that will both decompress the affected nerve, but also restore stability and alignment to the lumbar spine. A number of factors are taken into account including the degree of the spondylolisthesis, the level, and number of levels involved, the overall alignment of the spine, and patient preferences.
For most patients, a decompression and fusion procedure will be performed. This may be in the form of a posterior lumbar interbody fusion (PLIF) which may be performed using an open or minimally invasive technique. Some patients may be better suited to minimally invasive approaches such as an extreme lateral interbody fusion (XLIF). Prof Owler will be able to discuss this with you at your consultation.
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