Spondylolysis and Spondylolisthesis in The Pediatric Patient

Overview

Terminology: Spondylo (Spine) Lysis (Break) Listhesis (Slip)

This condition is commonly present in about 5% of the population and may be asymptomatic

• Dysplastic is usually a congenital abnormally of the facets and posterior elements.
• Isthmic (pars) is the bony zone between the facet joints a region subject to break.
  • lytic (stress fracture),
  • elongated (repetitive micro-fractures with /healing
  • acute fracture (single event)

Activity-related with onset of low back pain., usually around the L5-S1. Typical in persons with a history of trauma – commonly among gymnasts, linemen, wrestlers.

• Slip more than 50%, adolescent growth spurt, in females
• Lysis: females less than males (2:1), listhesis females greater than males (4:1)
• Radiculopathy is pain radiating to the lower extremities
  • Lysis may lead to scar tissues formation
  • Dysplastic – with stretch on affected nerve roots by the intact arch
  • Isthmic – narrowing of the nerve root canal (foraminal stenosis)

Clinical Exam

• Lumbar hyperlordosis/ flat buttocks
• Tight hamstring
• Crouched gait/ tilted pelvis

Imaging

• Plain X-rays in the standing position with oblique side view
• CT– best for bony pathology; localize lesion; confirm diagnosis; plan surgery
• MRI –
  • Neuro deficit or unusual presentation
  • Adjacent level hydration status
• SPECT or bone scan with increased uptake may indicate the potential of the break to heal in children.

Surgical Options

• Pars Repair: Good for spondylolysis with low grade slip in children
• Fusion in Situ: High fusion rate for single level L5-S1 and low grade with or without instrumentation
• Posterior Fusion with interbody Fusion (TLIF/PLIF)
• The type of surgery should be tailored to patient symptoms, Degree of slippage and neurologic status

The Role of instrumentation

• Higher fusion/complication rates

Anterior Fusion will increase arthrodesis rate

• High grade slips have a high incidence of neurologic complication if reduction is attempted. The slip angle reduction is more relevant than percent slip reduction for a good functional outcome.

Author

Prof. Oheneba Boachie-Adjei

CEO, FOCOS Orthopedic Hospital

Orthopedic Surgeon, FOCOS Orthopedic Hospital