Transcript Leg pain - Mehtaspine

SPONDYLOLISTHESIS
Jwalant S. Mehta
MS(Orth), D (Orth), MCh (Orth), FRCS (Tr & Orth)
Consultant Spine Surgeon, ABMU Health Board
OUTLINE OF THE TALK
¤ Classification
¤ Natural history
¤ Patho-physiology
¤ Treatment rationale
¤ Cases
SPONDYL
OLISTHESIS
1741 Nicholas Andry: hollow back
1782 Herbiniaux Belgian obstetrician
1854 Kilian slow displacement
‘Spondylolisthesis’
1855 Roberts: No slip if arch intact
CLASSIFICATIONS
Newman & Stone
JBJS Br 1963; 45: 39 - 59
Type
Name
Description
I
Congenital
Dysplastic abnormalities
II
Isthmic
A
Lytic (stress fracture)
B
Healed fracture (elongated, intact)
C
Acute high energy fracture
III
Degenerative
Segmental instability
IV
Traumatic
Fracture of hook other than pars
V
Pathologic
Underlying pathology
VI
Iatrogenic
Surgical excision of posterior elements
Wiltse, Newmann, MacNab
Clin Orthop 1976
MEYERDINGS GRADES
Low Grade
High Grade
I
II
III
IV
V
SLIP ANGLE
Important in grades III – V
SPINO-PELVIC MEASURES
PELVIC
INCIDENCE
Pelvic tilt
PI = PT + SS
Sacral slope
Low PT
High SS
High PT
Low SS
RELEVANCE OF PELVIC MEASURES
¤ PI quantifies the pelvic shape
¤ Pelvic morphology and spino-pelvic balance are
abnormal in spondylolisthesis
PATHO-PHYSIOLOGY
HOOK AND CATCH
Hook:
¤ Pedicle
¤ Pars inter-articularis
¤ Inferior process of the cephalad level
Catch:
¤ Superior process of the caudal level
PATHOPHYSIOLOGY
¤ Dysplastic pathway
¤ Traumatic pathway
Dysplastic pathway
Traumatic pathway
Weakness in the hook &
catch mechanism
Repetitive cyclic loads
(sports)
Body weight transmitted
through weak zone
Stress fracture of a
Normal pars
Soft tissue restraints:
plastic deformation
Hard cortical pars predisposes to fatigue
fracture and non-union
Growth plate overloaded
Predisposes to a vertical
subluxation
DYSPLASTIC CHANGES
¤ Proximal sacral rounding
¤ Trapezoidal L5
¤ Vertical sacrum
¤ Junctional kyphosis
¤ Compensatory hyper-lordosis
Contributes to the mechanics of
progression, but not causation
PROXIMAL SACRAL ROUNDING
Yue Spine 2005
PROXIMAL SACRAL ROUNDING
DISCAL OVER-LOADING
¤ Both the pathways lead to ↑ shear
loads, axial loads remaining constant
¤ Premature disc degeneration
Alternative loading pathway
Haher Spine 1994
The pain generators: Back pain
¤ Chronic muscle spasm (protective):
 ‘painful’
pars

Annular tears

Root compression / traction
Leg pain is the most common symptom
Moller Spine 2000
THE PAIN GENERATORS: LEG PAIN
¤ L5 compression / traction
¤ Abnormal motion
¤ Facet joint arthrosis
¤ Pars scar
¤ The disc above far-lateral
CLINICAL EVALUATION: HISTORY
¤ Symptoms:
Back pain
Leg pain
Neurology
¤ Severity
¤ Activities of daily living
CLINICAL EVALUATION: EXAMINATION
¤ Range and rhythm of trunk motion
¤ Neurology
¤ Sagittal alignment & gait
SAGITTAL ALIGNMENT
¤ Stance
¤ Gait
¤ Head over pelvis
¤ Hips and knees
IMAGING
¤ Erect radiographs:
AP
Lateral (to include the hips)
¤ MRI; CT
¤ Occasionally:
SPECT; Dynamic radiographs; Discography
PURPOSE OF IMAGING
¤ Disc degeneration (MRI / CT)
¤ Facet joint orientation, tropism, degeneration (MRI /
CT)
¤ Pelvic and spinal measures (Erect xrays)
DISC DEGENERATION
DISC DEGENERATION: MRI
Grade I
Grade II
Grade III
Grade IV
Grade V
Pfirrmann et al Spine 2001
FACET JOINTS
FACET JOINTS: ORIENTATION & TROPISM
¤ Mean facet joint angle:
Sagittal: anterior forces
Don JSDT 2008
Wang Spine 2009
Boden JBJS Am 1996
¤ Tropism
R –L: asymmetric loads
Mild < 5°
Moderate 7° – 15°
Severe > 15° Vanharanta Spine 1993
FACET DEGENERATION: CARTILAGE
1. Uniformly thick layer
2. Focal erosions
3. Areas of deficiency
with exposed bone
4. Cartilage absent
except traces
Grogan et al AJNR 1997
FACET DEGENERATION: SUB-CHONDRAL SCLEROSIS
1.
Thin layer of cortical
bone
2. Focal thickening
3.
Thick < ½ of the
surface
4. Dense cortical bone > ½
of the surface
Grogan et al AJNR 1997
FACET DEGENERATION: OSTEOPHYTES
1. No osteophyte
2. Small
3. Moderate
4. Large
Grogan et al AJNR 1997
Severe Spinal Stenosis
Centre for Spinal Studies and Surgery
Nottingham
WILTSE CLASSIFICATION:
III. DEGENERATIVE
 Instability phase: Kirkaldy Willis
 Posterior elements are intact
 L45;
F >M
 Disc:
¤ degeneration,
¤ ↓ height
 Facets:
¤ Tropism
¤ Abnormal sagittal orientation
¤ Facetal arthritis; subluxation
NATURAL HISTORY
NATURAL HISTORY: GENETICS
¤ 15 – 70% 1st degree relatives
Albanese JPO 1982
Wynne-Davies JBJS Br 1979
¤ Lysis commoner in boys
¤ Slips commoner in girls
¤ Eskimos 25% (arch defects)
Roche JBJS Am 1952
Stewart JBJS Am 1953
NATURAL HISTORY: ‘THE SLIP’
¤ 15% of persons with a pars lesion
¤ During the growth spurt
¤ Minimal change after 16 y
¤ No pain during progression
Bentley Spine 2003
EXTENT OF THE PROBLEM
¤ Most are asymptomatic
Seitsalo JBJS Br 1990
Danielson Spine 1991
Frennerd JPO 1991
¤ 90% slips at initial presentation do not progress
Seitsalo Spine 1991
PROGRESSION
PROGRESSION RISK
¤ > 20 y: more stable, less symptomatic, less likely to
progress
Ohmori JBJS Br 1995
¤ High level of athletic activity, no effect on
progression
Muschik JPO 1996
¤ Association with back pain ‘weak’
RISK OF PROGRESSION: HIGHER LEVELS
THE RISK OF PROGRESSION IN THE
YOUNG ADULT: DISC DEGENERATION
RISK FACTORS FOR SLIP
PROGRESSION IN SPONDYOLISTHESIS
(HENSINGER 1989)
Clinical
Radiographic
¤ Growth yrs (9 – 15)
¤ Type 1 (dysplastic)
¤ Girls > Boys
¤ Vertical sacrum
¤ Back pain
¤ >50 % slip
¤ Postural or gait abn
¤ Increasing slip angle
¤ Instability on flex/ext
views
RISK OF PROGRESSION: PROXIMAL SACRAL ROUNDING
TREATMENT RATIONALE
NATURAL HISTORY OF PROGRESSION
¤ Adolescents III+: likely to progress
¤ I, II after mid-adolescence: unlikely to progress
NON-OPERATIVE TREATMENT
¤ Always consider first……………….everytime!
¤ Improvement likely if back > leg pain
¤ Isthmic / degnerative with leg pain: improvement less likely
¤ Investigate / treat osteopaenia
NON-OPERATIVE TREATMENT: PAEDIATRIC
¤ Stop aggravating activities
¤ Gradual mobilisation
¤ Trunk strengthening
¤ Period of bracing
NON-OPERATIVE TREATMENT: ADULTS
¤ Exercises
¤ Aerobics
¤ NSAID’S
¤ Epidural steroids
MANAGEMENT DECISION
¤ Individualized for each patient
¤ Think of the natural history
¤ Severity and duration of symptoms
¤ Co-morbidities
SURGICAL INDICATIONS
¤ Severe back and leg pain
¤ Failed conservative trial
¤ Abnormal neurology
¤ +ve diagnostic injections
SURGICAL GOALS
¤ Address the pars defect & the rattler
¤ Decompress the foraminal stenosis
¤ Address the degenerate disc/s
¤ Address the dynamic instability
SURGICAL OPTIONS
1. In-situ postero-lateral fusion
2. Decompression + In-situ postero-lateral fusion
3. Additional inter-body fusion options
DECOMPRESSION: ABSOLUTE INDICATIONS
¤ Neurology
¤ Leg pain
¤ Sphincter dysfunction
¤ Claudication
DECOMPRESSION: EXTENT
¤ The Gill procedure: Removal of the loose laminar arch
¤ Foraminotomy + facetectomy
¤ Never in isolation
¤ Associated with ↑ pseudarthrosis rate
Carragee JBJS Am 1997
IN-SITU POSTERO-LATERAL FUSION
¤ L5 S1 only adequate
Burkus JBJS Am 1992
Frennerd Spine 1991
Ishikawa Spine 1994
¤ Improvement in leg pain even
when not decompressed
deLobrresse Clin Orthop 1996
POSTERIOR INSTRUMENTATION
¤ Better fusion rate, better
clinical outcomes
Zdeblick Spine 1993
Yuan Spine 1994
Bjarke Spine 2002
Deguchi J Spinal Dis 1998
Ricciardi Spine 1995
¤ Un-instrumented better for
osteoporortic bones
Moller Spine 2000
LEVELS TO INSTRUMENT
¤ Look at the changes at the
levels above
¤ Higher slip angle: retrolisthesis above the slip
INTER-BODY FUSIONS: THEORETICAL
CONSIDERATIONS
¤
Anterior column support
¤
Bio-mecahnically superior:
 Large area for fusion
 Grafts under compressive loads
¤
Degenerate disc removed
consider disc height
¤
Build in the lordosis
¤
Indirect reduction
INTER-BODY FUSIONS ( …… IF)
A LIF
P LIF
T LIF
INDICATIONS FOR SURGERY:
CHILDREN
¤ Low grade slip / ‘lysis…..non op measures effective
¤ Progression beyond Gr II
¤ At presentation, > Gr III
¤ Persisting pain; neurologic deficit
¤ Progressive postural deformity / gait abnoralities
SURGERY:
PAEDIATRIC / ADOLESCENT
¤ ‘ Lysis
 Intact disc on MR (Gr I slip)
 Direct repair of defect
¤ Grade I
 Asymptomatic….no surgery
¤ Grade II, III
 1 level bilateral lateral fusion
 Rarely decompression
 Documented progression; back pain
SURGERY:
PAEDIATRIC / ADOLESCENT
¤ Grade III+
 Asymptomatic: 2 level in situ….L4 – S1
 Slip angle < 55° good fusion rate
Post op: Hyper-extension cast + thigh extension
 Slip angle > 55° add anterior fusion
Post-op: recumbent during healing
¤ Severe slips
 Excise body ( Gaines procedure)
 L4 – S1 fusion
INDICATIONS FOR SURGERY:
ADULTS
¤ Non responsive to conservative measures
¤ Results better for leg than for back pain
¤ Isthmic / degenerative………persistent neurology; radicular
symptoms
¤ Back pain alone…….decompress & stabilise (↓ symptoms)
DEGENERATIVE SLIP
¤ Caudal + facet injections
¤ Decompress stenosis
¤ Non-instrumented or instrumented fusion
RECOMMENDATIONS
¤ Think of the natural history
¤ Look at each patient and analyse the problems
¤ Individualize the treatment plan
¤ If surgery is the last resort ………….
RECOMMENDATIONS
¤ Choose surgical targets carefully
¤ Ensure patient expectations match
with your goals
¤ In-situ PL fusion + decompression
¤ Add inter-body in ‘high risk’
situations
CASES
PROGRESSION ON WAITING LIST
FLEXION EXTENSION X RAYS
R
L
POST OP
CASE
CASE
CASE
RADIOLOGICAL RESULT
Centre for Spinal Studies and Surgery
Nottingham
CLINICAL RESULT
Centre for Spinal Studies and Surgery
Nottingham
CASE
RADIOLOGICAL
RESULT
Centre for Spinal Studies and Surgery
Nottingham
CLINICAL RESULT
Centre for Spinal Studies and Surgery
Nottingham