Spondylolisthesis
A spondylolisthesis, colloquially called a spondylolisthesis or Germanized a spondylolisthesis, is an instability of the spine, in which the upper portion of the spine with the slipped vertebra over the underlying vertebral body anteriorly ( forward ) slides ( Ventrolisthesis or anterolisthesis ). In the opposite case one speaks of a retrolisthesis.
The word derives from the Greek: σπόνδυλος, " swirl ", and ancient Greek ὀλίσθησις olisthesis, " sliding". Therefore, the correct hyphenation is also Spondyl - olisthesis, although spondylo - listhesis is also often used. Likewise, should the short form " olisthesis " and not " Listhese " hot.
Often the spondylolisthesis is a chance finding or only connected with small complaints. Depending on the strength of spondylolisthesis but long-term single or multiple nerves can be pinched and stretched in the spinal canal. This can cause nerve damage and lead to loss of function of a nerve. It paralyzes occur, affecting both legs and the function of the bladder and rectum. At the same wear disc ( herniated disc ) and facet joint ( spondylarthrosis ) in the corresponding segment excessively, which can sometimes cause severe pain.
- 3.1 Non- operative therapy
- 3.2 Surgical treatment
Differentiation on the cause and severity
Causes
Spondylolisthesis can have various causes, are currently (2007) listed the following forms are known, of which in turn partially exist two subtypes:
- Dysplastic ( malformed ) Form: Here there is a structural fault of the lumbosacral ( between lumbar spine and sacrum) transition, which leads to the slipping of the vertebral body.
- Isthmic form: The interarticular ( between joints ) of the vertebral arch is only cartilaginous - not ossified - and thus a weak point. A fracture ( Lysespalt ) this allows the slipping of the vertebral body.
- Degenerative form: wear -related changes of the intervertebral space and / or facet joint can slide the vertebral body.
- Traumatic Form: An injury-related fracture outside the interarticularis of the vertebral arch leads to Ventralgleiten of the vertebral body.
- Pathological form: A bone disease leads to decreased bone strength in the pars interarticularis of the vertebral arch and with subsequent fracture thus the slipping of the vertebral body.
- Postoperative Form: As a result of spinal surgery can slide off the vertebra various changes in the operated segment.
Severities
After Meyerding (MD) There are four stages of severity:
- MD I °: displacement of the vertebral bodies to each other by less than 25 % of the vertebral body depth,
- MD II °: offset 25-50%,
- MD III °: offset by 50-75 %,
- MD IV °: offset by more than 75 %.
Have the vortex lost contact with each other and slide the top open to forward - down, one speaks of a spondyloptosis (MD V °).
Diagnostics
Usually it is an incidental finding on radiographs. For back pain with radiating symptoms into the legs an x-ray in two planes of the lumbar spine can be done.
Position and posture of the person concerned have an impact at the time of diagnosis. A spondylolisthesis can possibly occur only with certain movements, so it makes sense for suspicion that functional imaging can be performed. These are two additional x-rays while standing in prevention and in return inclination.
With the CT or MRI anatomy can be illustrated in detail, but the severity can be underestimated. MRI is very suitable for the evaluation of the discs and of the nerves. The CT is particularly well suited in questionable cases to prove or exclude the bony defect ( spondylolysis ).
Figure 2: spondylolisthesis, stage 1, in CT.
Figure 3: spondylolisthesis L5/S1, stage 2-3, sagittal MR, spinal canal free.
Figure 4: The nerves exit hole L5 is concentrated.
Figure 1 is the conventional radiograph of a vertebral slippage between the vertebrae 4 and 5 of the lumbar spine. The severity lies on the border between the stage 1 and 2 right of the picture is also the bony disruption of the vertebral arch ( spondylolysis ). So there is a "right" Spondylolistese (also called spondylolisthesis cause ).
Figure 2 shows the sagittal reconstruction of a nearly horizontal scale CT scan of the lower lumbar spine. The upper vertebra has slipped against the lower by 7.4 mm, the disc tissue is highly degenerate, so it is here partly as a black spot (vacuum phenomenon ) for display. The spinal canal is narrowed, here the dural sac is concentrated. The top vertebra slides with the disc from ventral.
Figure 3 shows a spondylolisthesis L5/S1 laterally in the MR. The vertebrae are displaced by 18 mm (stage 2-3). The intervertebral disc is deformed, reduced height of the disc space L5/S1. The spinal canal is expanded. This is typical of a "true" spondylolisthesis.
Figure 4 is from the same study as Figure 3, it shows a foramen stenosis, which can be related to the spondylolisthesis. The L5 spinal nerve (yellow circle) is thereby raised; by severe symptoms in the coverage area of this nerve can be explained.
Treatment
There is currently no valid guideline for the treatment of spondylolisthesis. The procedure according to study location or personal experience of the physician. Common one is the back muscles toning, lordosis diminishing back exercises.
Essential for the therapeutic decision is to determine whether it is a true spondylolisthesis with spondylolysis or a Pseudospondylolisthesis eg acts with accompanying spinal stenosis.
Non- surgical therapy
Due to the unclear situation first study should not be taken surgically.
In addition to painkillers and pain relief by infiltration therapy or PRT can be done. Even medical massage can relieve pain. The administration of muscle relaxants has no positive effect.
In some cases, a trunk orthosis is adapted to relieve the discomfort. A stabilization of the muscles through physical therapy may be helpful.
Surgical treatment
Surgical therapy may be considered if
- The conservative pain can not be controlled,
- Spondylolisthesis in a short time greatly increases,
- Muscular failures occur or
- Urinary retention or a fecal incontinence occurs.
The surgeon during the operation, for example, attempts return the vertebral body to the original position and then to splint (spondylosis ). This greater engagement is usually a front ( anterior ) or back ( dorsal) spinal access and carried out in one or two sessions. Whether surgery is really necessary and which method is used, however, depends on the symptoms and is determined by the attending physician.
There is in addition to the basic surgical risks in addition the risk of nerve injury by the inserted screws, and the risk of postoperative scarring that can cause severe pain under certain circumstances than the underlying disease. These complications are summarized as Failed back surgery syndrome.