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Spondylolysis and Spondylolisthesis

What are spondylolysis and spondylolisthesis? Your lower back is called your lumbar spine. It is made up of five bones called lumbar vertebrae. The vertebrae have two major parts, a solid part called the body and a bony ring through which the lower part of the spinal cord and nerves travel. Between the bodies of the vertebrae is shock absorbing material called disks. Part of the ring of each vertebra touches the vertebra above it and the vertebra below it. Spondylolysis is a condition where there is a break in one or both sides of the ring of a vertebra. Spondylolisthesis is a condition in which a break in the ring allows the body of the vertebra to slip forward. Spondylolysis and spondylolisthesis most commonly occur at the fourth or fifth lumbar vertebrae. These conditions are also called stress fractures. How does it occur? Spondylolysis and spondylolisthesis result from repetitive extension of the back (bending backward). This weakens the rings of the lumbar vertebrae, eventually leading to a break (fracture) in a ring. Less commonly, these conditions may result from an injury to the back. Some people may be born with weak vertebral rings. Gymnasts, dancers, and football players are most commonly diagnosed with these conditions.

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What are the symptoms? You may have low back pain or spasms, or you may have no symptoms at all. You may have pain all the time or only from time to time. Spondylolysis or spondylolisthesis usually do not damage the nerves. How is it diagnosed? Your healthcare provider will examine your back and look for tenderness along your vertebrae or spasm in the muscles next to your vertebrae. You will have an X-ray to check for a break in the ring of a vertebra or slippage of a vertebra. You may have a bone scan, CT scan, or an MRI. How is it treated? If the break is new and your provider thinks that the bones can heal without surgery, you may need to wear a brace for 1 to 3 months. Severe cases of spondylolisthesis may require surgery. To treat this condition:

Put an ice pack, gel pack, or package of frozen vegetables, wrapped in a cloth on the area every 3 to 4 hours, for up to 20 minutes at a time. Take an anti-inflammatory medicine such as ibuprofen, or other medicine as directed by your provider. Nonsteroidal anti-inflammatory medicines (NSAIDs) may cause stomach bleeding and other problems. These risks increase with age. Read the label and take as directed. Unless recommended by your healthcare provider, do not take for more than 10 days.

When can I return to my normal activities? Everyone recovers from an injury at a different rate. Return to your activities depends on how soon your back recovers, not by how many days or weeks it has been since you started having symptoms. In general, the longer you have symptoms before you start treatment, the longer it will take to get better. The goal is to return to your normal activities as soon as is safely possible. If you return too soon you may worsen your injury. It is important that you fully recover from your back pain before you return to any strenuous activity. You must be able to have the same range of motion that you had before your injury. You must be able

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to walk and twist without pain. How can I prevent these conditions? You can best prevent these conditions by having strong back and abdominal muscles and by not being overweight. To help prevent these injuries, do back exercises and avoid activities that force the back to extend, such as tackling in football.

Spondylolisthesis
Medical Codes

ICD-9-CM: 738.4, 756.12

Definition

Reed Group

Spondylolisthesis describes a condition of a forward slippage of one vertebra over another, which may or may not be associated with demonstrable instability. The vertebrae of the spine are stacked one on top of the other and held in place by ligaments, muscles, joints, and discs. The healthy spine is flexible and moves in many planes, including flexion, extension, and rotation. There are five types of spondylolisthesis (congenital/dysplastic, isthmic, degenerative, traumatic, and pathological). Congenital or dysplastic spondylolisthesis is a defect in the posterior part of L5 or S1, and

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the abnormal orientation of the bones permits forward slippage of one vertebra on another. It is a rare condition and is frequently associated with neurologic involvement. The severity of subluxation is graded as follows: Grade I is 0% to 25%, Grade II is 26% to 50%, Grade III is 51% to 75%, and Grade IV is more than 75% of vertebral slippage as evidenced on x-ray (Devereaux). The most common type of spondylolisthesis is isthmic or spondylolytic spondylolisthesis. Spondylolysis, which is generally a stress fracture in the posterior part of the vertebra, called the pars interarticularis, is present in this type of spondylolisthesis. Spondylolysis is the most common cause of spondylolisthesis. Isthmic spondylolisthesis most commonly occurs in the lumbar region, at the level between the fifth lumbar vertebra and the first sacral vertebra (L5-S1 level). Degenerative spondylolisthesis is an acquired condition related to chronic degenerative disc disease and the associated changes that may lead to segmental instability The pars interarticularis is not affected in degenerative spondylolisthesis. The degeneration of intervertebral discs (degenerative disc disease) results in narrowing of the disc space, which allows the supporting structures to become lax and can lead to segmental instability, most common at L4-L5. The facet joints are also affected: the result is persistent slippage (subluxation) of the facet joints with decreased resistance to forward slippage of one vertebra on another. The slippage is limited by the structures at the back of the spine that are still intact. Degenerative spondylolisthesis is more common in women and occurs most often at L4-5. Spondylolisthesis can also be caused by a traumatic fracture (traumatic spondylolisthesis) of the posterior elements of the vertebra, by destruction of the posterior aspect of the spine through tumor, infection, or osteoporosis (pathological spondylolisthesis), and by spinal surgery (postsurgical spondylolisthesis).

Risk: Individuals at risk for spondylolisthesis include those who have spondylolysis and those with an abnormal forwardcurvature of the lumbar spine (lordosis). The risk is increased in individuals who engage in contact sports (football, volleyball, or soccer), certain kinds of gymnastics, or weight lifting. Individuals with radiographic osteoarthritis and postmenopausal women with osteoporosis are also at greater risk of developing spondylolisthesis.

Spondylolytic (isthmic) spondylolisthesis is most common in white males (Froese). Women are more likely to progress to a higher degree of slippage than men (Froese).

Degenerative spondylolisthesis is three times more common in blacks than whites and usually occurs after the age of 40 (Irani). It is more common in females than males by 5 to 1 (Froese).

Congenital spondylolisthesis is twice as common in females as in males, and symptom onset is usually during adolescence (Irani). Incidence and Prevalence: In the US, the incidence of isthmic spondylolysis is 6% to 7%, with 11.3% of

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cases occurring at the L4-L5 level, and 82% occurring at the L5-S1 level (Froese). The prevalence of degenerative spondylolisthesis is 5.8% in men and 9.1% in women (Vokshoor).

The prevalence of spondylolisthesis in osteoporotic women is 28.4%, with 12% occurring at the L3-L4 level, 73% occurring at the L4-L5 level, and 28% occurring at the L5-S1 level (Nizard).

The incidence of postoperative spondylolisthesis is 11% to 14% at the vertebral level above the fused segments (Nizard).

Source: Medical Disability Advisor

Diagnosis History: Low back pain is the most common presenting symptom. Individuals with spondylolisthesis may also present with lordosis, localized tenderness over the spine just above the pelvis, pain in the thighs or buttocks, tightness in the hamstrings, and back stiffness. Isthmic spondylolisthesis may be an incidental finding on imaging studies that becomes apparent during the evaluation of low back pain in adults, and must be evaluated in the context of degenerative disc disease or other causes of low back pain.

Individuals with severe grades of slippage may not be able to walk normally, and stumble or drag their feet instead. Neurologic signs often correlate with the degree of slippage. In describing pain, individuals may report that it is aggravated when they rise out of a sitting position, walk up stairs or inclines, get in and out of cars, and lean backward (extension). The pain is relieved at rest when lying flat with the knees bent, or leaning forward (flexion).

Degenerative spondylolisthesis is generally seen in older patients, who may present with low back pain, symptoms of neurogenic claudication (heaviness in the legs with walking that is alleviated by sitting), radiculopathy, or a combination of those symptoms.

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Physical exam: A complete examination of the lumbar spine, including musculoskeletal and neurological components, is performed to rule out any other underlying pathology and to determine the extent of nerve involvement. Findings of the exam may reveal decreased sensation and tendon reflexes and weakness of lower leg muscles. Examination of the spine by manual touching and massaging of the areas of concern (palpation) may reveal a step-off in higher-grade slippage. Findings are also likely to reveal a limited range of motion of the spine; increased pain when leaning backward; relief of pain when leaning forward; clumsy, swayed walking (waddling gait); and tight hamstrings. Tests: Spondylolisthesis is usually identified by plain x-rays (radiographs). Additional studies such as MRI and CT scans will routinely be performed to evaluate for nerve involvement, degenerative disc disease, disk herniation, spondylosis, and spinal stenosis. The amount and percentage of slippage should be measured on a standing lateral x-ray. A change in the percentage of slippage when the individual bends forward or leans backward is an indication of dynamic instability. This means that the amount of vertebral slippage changes with spinal motion.

In cases of spondylolysis, the diagnosis may not be evident in plain x-rays. Oblique plain films may be helpful. Both CT and MRI can define damage to the pars interarticularis (pars defect) and nerve root impingement, although CT may be better for the purposes of identifying the bony defect, and MRI may reveal more detail about neurologic involvement. MRI also helps define the status of the disc at the impaired level and the level adjacent to the slip.

If the spondylolysis is believed to be recent, a bone scan may be useful to confirm or exclude an acute fracture.Electromyography (EMG) and nerve conduction studies check nerve function.

Source: Medical Disability Advisor

Treatment
Conservative treatment for spondylolisthesis includes rest (not excessive), activity modification (to minimize offending activity), physical therapy (to strengthen trunk muscles, especially the abdominals, and to stretch the hamstrings), and analgesics. Corsets or braces are also prescribed when necessary to minimize motion across the area of the slippage and to decrease pain.

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Surgical intervention is considered when conservative therapy fails, pain becomes disabling, or a progressive neurological deficit occurs. Age is not a contraindication to surgery. Many elderly individuals seem to benefit a great deal from surgical intervention. The primary surgical procedure for treating spondylolisthesis is spinal fusion, in which 2 or more vertebrae are united by bone graft (with or without instrumentation) that heals to prevent further slippage of the vertebrae. Internal fixation devices, usually pedicle screws with or without an underbody fusion cage, may be used to enhance stability and thus the chances of successful fusion. Posterior lumbar interbody fusion (PLIF) enjoys a high success rate for Grades I and II spondylolisthesis, with nearly 100% of individuals experiencing a solid fusion (Brislin; Vokshoor). More severe grades of slippage may require both anterior and posterior fusion. If there is neurologic deficit, a decompression may be performed in addition to the fusion. In decompression for spondylolisthesis, the surgeon removes bone and ligamentous tissue compressing the lumbar nerve roots.

Source: Medical Disability Advisor

Prognosis
In young patients with spondylolisthesis, surgical fusion with or without decompression may be curative, and no further intervention may be required. Individuals who have sustained an acute fracture with minimal slippage may completely recover if the fracture heals. Individuals with progressive degenerative changes may continue to have intermittent symptoms. Surgery (fusion, decompression) can be curative, but some individuals may experience only partial or intermittent relief. The risk of degenerative spondylolisthesis increases with age, and progression of vertebral slippage occurs in 30% of individuals (Nizard). If vertebral slippage progresses, the neural foramen may narrow, causing nerve compression orsciatica that may require surgical decompression. Surgical outcomes are improved when fusion is performed in addition to decompression (Sengupta).

Source: Medical Disability Advisor

Rehabilitation
Rehabilitation for spondylolisthesis varies depending on the severity of the disease and the symptoms. If the spinal cord is compromised, see Spinal Cord Injury. If surgery is considered, the literature suggests that a 6-week period of rehabilitation treatment should be undertaken prior to surgical intervention. Rehabilitation includes modalities such as heat and cold to control pain (Braddom). Once pain is controlled, general stretching and strengthening exercises of the trunk are indicated and progressed as tolerated. Therapists teach a home exercise program to complement the supervised rehabilitation. Individuals should be advised to continue these exercises on a regular basis, including after discharge from therapy, regardless of symptoms (Matsunaga). Instruction in proper posture and body mechanics for all activities of daily living should be reviewed.

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If pain is severe see Low Back Pain for additional guidelines. If surgery is indicated for severe and progressive spondylolisthesis, a postoperative protocol must be followed (Moller). This will include ambulation and transfer training, possibly with an orthosis to stabilize the trunk. Following surgery, some individuals may benefit from occupational therapy to assess the need for devices to promote independence in daily activities. After several weeks, general low back stretching, strengthening and stabilization exercises can be initiated and progressed as indicated by the treating physician. Whether managed operatively or nonoperatively, an ergonomic assessment may be beneficial prior to return to work. FREQUENCY OF REHABILITATION VISITS Nonsurgical Specialist Physical Therapist Surgical Specialist Physical Therapist Spondylolisthesis Up to 6 visits within 6 weeks Spondylolisthesis Up to 15 visits within 6 weeks

Note on Surgical Guidelines: Rehab usually begins after tissue healing, about 6 to 8 weeks after surgery. The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor

Complications
Progression of the slippage with increased pressure or traction on the spinal nerve roots may complicate treatment. For individuals requiring surgery to stabilize the spondylolisthesis, complications include nerve root injury (less than 1%), cerebrospinal fluid leak (2% to 10%), fusion failure (5% to 25%), and infection and hemorrhage from surgery (1% to 5%). Among individuals who smoke, the nonunion rate of lumbar fusion is up to 50% (Vokshoor).

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Source: Medical Disability Advisor

Return to Work (Restrictions / Accommodations)

Work restrictions may include the elimination of overhead work that involves hyperextension of the back. The individual may also be restricted in performing unassisted heavy lifting, repetitive bending, or pushing heavy objects. Some individuals may not be able to perform activities that require twisting at the waist. Use of a rigid corset (orthotic) may be needed to limit motion of the spine. Safety issues should be evaluated, as well as drug-testing policies, since individuals may need to take pain medication. Individuals with severe pain and hamstring spasm, individuals with Grade III or IV vertebral slippage, and individuals who have had spinal fusion are generally restricted to sedentary, light, or moderate work.

Source: Medical Disability Advisor

Spondylolisthesis
Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a condition of thespine whereby one of the vertebra slips forward or backward compared to the next vertebra. Forward slippage of one vertebra on another is referred to as anterolisthesis, while backward slippage is referred to as retrolisthesis. Spondylolisthesis can lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis).

What causes spondylolisthesis?

There are five major types of lumbar spondylolisthesis. 1. Dysplastic spondylolisthesis: Dysplastic spondylolisthesis is caused by a defect in the formation of part of the vertebra called the facet that allows it to slip forward. This is a condition that a patient is born with (congenital).

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2. Isthmic spondylolisthesis: In Isthmic spondylolisthesis, there is a defect in a portion of the vertebra called the pars interarticularis. If there is a defect without a slip, the patient has spondylolysis. Isthmic spondylolisthesis can be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions including gymnasts, and football linemen. 3. Degenerative spondylolisthesis: Degenerative spondylolisthesis occurs due to arthritic changes in the joints of the vertebrae due tocartilage degeneration. Degenerative spondylolisthesis is more common in older patients. 4. Traumatic spondylolisthesis: Traumatic spondylolisthesis is due to direct trauma or injury to the vertebrae. This can be caused by afracture of the pedicle, lamina or facet joints that allows the front portion of the vertebra to slip forward with respect to the back portion of the vertebra. 5. Pathologic spondylolisthesis: Pathologic spondylolisthesis is caused by a defect in the bone caused by abnormal bone, such as from atumor.

What are the risk factors for spondylolisthesis?

Risk factors for spondylolisthesis include afamily history of back problems. Other risk factors include a history of repetitive trauma or hyperextension of the lower back or lumbar spine. Athletes such as gymnasts, weight lifters, and football linemen who have large forces applied to the spine during extension are at greater risk for developing isthmic spondylolisthesis.

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What are the symptoms of spondylolisthesis?
Comment on
The most common symptom of spondylolisthesis islower back pain. This is often worse after exercise especially with extension of the lumbar spine. Other symptoms include tightness of the hamstrings and decreased range of motionof the lower back. Some patients can develop pain, numbness, tingling orweakness in the legs due to nerve compression. Severe compression of the nerves can cause loss of control of bowel or bladder function, or cauda equina syndrome.

How is spondylolisthesis diagnosed?

In most cases it is not possible to see visible signs of spondylolisthesis by examining a patient. Patients typically have complaints of pain in the back with intermittent pain to the legs. Spondylolisthesis can often cause muscle spasms, or tightness in the hamstrings.

Spondylolisthesis is easily identified using plain radiographs. A lateral X-ray (from the side) will show if one of the vertebra has slipped forward compared to the adjacent vertebrae. Spondylolisthesis is graded according the percentage of slip of the vertebra compared to the neighboring vertebra.

1. Grade I is a slip of up to 25%, 2. grade II is between 26%-50%, 3. grade III is between 51%-75%,

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4. grade IV is between 76% and 100%, and 5. Grade V, or spondyloptosis occurs when the vertebra has completely fallen off the next vertebra. If the patient has complaints of pain, numbness, tingling or weakness in the legs, additional studies may be ordered. These symptoms could be caused by stenosis or narrowing of the space for the nerve roots to the legs. A CT scan or MRI scan can help identify compression of the nerves associated with spondylolisthesis. Occasionally, a PET scan can help determine if the bone at the site of the defect is active. This can play a role in treatment options for spondylolisthesis as described below.

What is the treatment for spondylolisthesis

The initial treatment for spondylolisthesis is conservative and based on the symptoms.

A short period of rest or avoiding activities such as lifting and bending and athletics may help reduce symptoms.

Physical therapy can help to increase range of motion of the lumbar spine and hamstrings as well as strengthen the core abdominal muscles.

Anti-inflammatory medications can help reduce pain by decreasing theinflammation of the muscles and nerves.

Patients with pain, numbness and tingling in the legs may benefit from anepidural steroid (cortisone) injection.

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Patients with isthmic spondylolisthesis may benefit from a hyperextension brace. This extends the lumbar spine bringing the two portions of the bone at the defect closer together and may allow for healing to occur.

For patients whose symptoms fail to improve with conservative treatment surgery may be an option. The type of surgery is based on the type of spondylolisthesis. Patients with isthmic spondylolisthesis may benefit from a repair of the defective portion of the vertebra, or a pars repair. If an MRI scan or PET scan shows that the bone is active at the site of the defect it is more likely to heal with a pars repair. This involves removing any scar tissue from the defect and placing some bone graft in the area followed by placement of screws across the defect.

If there are symptoms in the legs the surgery may include a decompression to create more room for the exiting nerve roots. This is often combined with a fusion that may be performed either with or without screws to hold the bone together. In some cases the vertebrae are moved back to the normal position prior to performing the fusion, and in others the vertebrae are fused where they are after the slip. There is some increased risk of injury to the nerve with moving the vertebra back to the normal position.

Can spondylolisthesis be prevented?

Spondylolisthesis cannot be completely prevented. Certain activities such as gymnastics, weight-lifting and football are known to increase the stress on the vertebrae and increase the risk of developing spondylolisthesis.

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What are the complications of spondylolisthesis?
Complications of spondylolisthesis includechronic pain in the lower back or legs, as well as numbness, tingling or weakness in the legs. Severe compression of the nerve can cause problems with bowel or bladder control, but this is very uncommon.

What is the outlook for spondylolisthesis?

The outlook for patients with spondylolisthesis is good. In most cases patients respond well to a conservative treatment plan. For those with continued severe symptoms, surgery can help alleviate the leg symptoms by creating more space for the nerve roots. The back pain can be helped through a lumbar fusion.

Spondylolisthesis At A Glance

Spondylolisthesis is a forward or backward slippage of one vertebra on an adjacent vertebra.

Causes of spondylolisthesis include trauma, degenerative, tumor, and birth defects.

Symptoms of spondylolisthesis include lower back or leg pain, hamstring tightness, and numbness and tingling in the legs.

Most people with spondylolisthesis can be treated conservatively, without the need for surgery.

Patients who fail to improve with conservative treatment may be a candidate for surgery.

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I was diagnosed in 1991 with Spondylolithesis at L5 S1. I was 16. At that time, I tried the medications, physical therapy and back brace. After 2 years of pain and trying to be a normal teenage girl I made the decision to have the spinal fusion surgery in May 1993. For me, it was one of the best decisions I ever could have made! I had the old style surgery with the battle scars to prove it. It was a week in the hospital, 12 weeks on bed rest, 18 months for the bone in my hip to grow back and to this day my hip tells me when it is going to rain, but I would not trade that! I have not had handicap parking since 1994. I do not take pain medication. I do have regular massages which is all I need to keep the remaining discomfort at bay. As my doctor put it, the surgery is not a cure but a treatment option. He is retired now or I would be recommending him to all of you. He gave me my life back. Don't give up until you find the right treatment option for you.

I was diagnosed at age 12 due to lower back pain. Mine is the congenital type. I finally knew it was time to do something at age 45 when I had horrific pain down my legs alternating with numbness. A simple x-ray revealed that I no longer had a disk between L5 and S1. After an anterior-posterior decompression and fusion, I live withchronic pain, but have a stable back. I am able to exercise regularly and move better than I have in years. Even though I take medication for pain everyday, I am very happy with my result.

I am 49 and was diagnosed with spondylolethisis, anterior grade 4, along with spinal stenosis, and bone spurs. I'm deteriorating; it has caused scoliosis and I have now been diagnosed with neuropathy in my left leg. I was hit by a car at age 4, which broke my pelvis in two places and my left femur. I was in traction, a body cast, and had to learn to walk all over again. My left leg is inches longer then my right. I was never to run again and walked with a limp, yet ended up being a very strong top athlete. I've had three kids, whom I played with and trained in sports. I just stopped playing softball five

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years ago. I also biked, hiked, adventured raced, and did so many outdoor things. But eight months ago, all this came to an abrupt end. I fell down some stairs, which really did some damage. When my X-rays were read, the doctors discovered my condition. September 13th, 2012, began a very fast deterioration. The hip cramps at night keep me from sleeping, the pain in my left hip travels around to my quad to my knee, down my shin, to the top of my foot, where it sometimes leaves me in tears. It's so unbearable. I can hardly walk anymore; I'm losing motor control. It's taking a toll on my speech, my focus, and my attitude. Stretching does not help, nor does icing or adjustments. Only a high dose of pain meds help, but they make me violently ill and depressed, and I sleep for two days sometimes. I'm told I will more than likely be paralyzed by 60, and I'm 49. My nerve damage is getting so severe that I may not make it another 4-5 years. I have three grandbabies, and I can't even hold them, let alone play with them. I've read about the surgeries and I am getting to the point of desiring it. At one time, I was against surgery and tried to keep people away from it with the very positive and effective body work I've done. I want my life back so bad and I'm feeling resentful and suffering major depression. I read someone else's post about how other people in their life diminish the pain they suffer. Well, you are not the only one. It frustrates me that anyone can call what we suffer minimal, undermine us, or call us hypochondriacs. I'd love to see any one of them spend time in our bodies for just a day, or maybe from the time we have to get out of bed each day up to trying to get into the shower. And then they get upset with us for how cranky we are. I'm glad that I could vent how I'm feeling. Some days I cry out of frustration. From being an athlete to nothing. Losing 30 pounds, suffering atrophy, and muscle loss everywhere. I've lost my butt muscles and none of my clothes fit. I've even been accused of being on meth! I want my life back.

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I am 47 and was diagnosed with Spondylolisthesis and Spinal Stenosis 10 years ago. Although the doctors tell me that it is mild spondylolisthesis, only grade one, I am mostly in some sort of pain daily. My biggest problem is the dreaded Sciatica, I have to be so careful and avoid at all costs lifting, pulling or pushing anything around, I am a farmer so a lot of heavy work is involved daily, but I have someone to help out with the heavy work. When the doctor uses the word mild I feel like slapping him across the face and asking him how mild does that feel. Pain is pain and living with it daily can be depressing, but I refuse to let it control me, which it used to do. I do not take any medication such as anti inflammatory, this are pure poison to anyone's stomach. I would rather suffer back pain than to partake in any type of anti inflammatory drug.

SOURCE: http://www.medicinenet.com/spondylolisthesis/

Lumbar Spondylolisthesis
A Patient's Guide to Lumbar Spondylolisthesis
Introduction

Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. This guide will help you understand

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how the problem develops how doctors diagnose the condition what treatment options are available

Anatomy
What parts of the spine are involved? The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body's main upright support. The section of the spine in the lower back is called the lumbar spine.

The lumbar spine is made of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Each vertebra is formed by a round block of bone, called

a vertebral body. A circle of bone attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, these bony rings create a

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hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord only extends to L2. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse's tail.

Two sets of bones form the spinal canal's bony ring. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is called the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring. Intervertebral discs separate the vertebral bodies. The discs normally work like shock absorbers. They protect the spine against the daily pull of gravity. They also protect the spine during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

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The lumbar spine is supported by ligaments and muscles. The ligaments, which connect bones together, are arranged in layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to thesacrum (the bone below L5) and pelvis.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

The anatomy of the lumbar spine is often discussed in terms of spinal segments. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the facet joints that link each level of the spinal column.

Causes

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Why do I have this problem? Spondylolisthesis may very rarely be congenital, which means it is present at birth. It can also occur in childhood as a result of injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis. Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected more often than men. The effect of the female hormone estrogen on ligaments and joints is to cause laxity or looseness. The higher levels of estrogen in women may account for the greater incidence of spondylolisthesis. Degenerative spondylolisthesis mainly involves slippage of L4 over L5. In younger patients (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this. First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction. Facet joints are small joints that connect the back of the spine together. Normally, the facet joints connecting L5 to the sacrum create a solid buttress to prevent L5 from slipping over the top of the sacrum. However, when problems exist in the disc, facet joints, or bony ring of L5, the buttress becomes ineffective. As a result, the L5 vertebra can slip forward over the top of the sacrum.

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A condition called spondylolysis can lead to the slippage that happens with spondylolisthesis. Spondylolysis is a defect in the bony ring of the spinal column. It affects the pars interarticularis, mentioned earlier. This defect is most commonly thought to be a stress fracture that happens from repeated strains on the bony ring. Participants in gymnastics and football commonly suffer these strains. Spondylolysis can lead to the spine slippage when a fracture occurs on both sides of the bony ring. This slippage is called spondylolisthesis. The slippage is graded from I through IV, one being mild, IV often causing neurological symptoms. The back section of the bony ring separates from the main vertebral body, so the injured vertebra is no longer connected by bone to the one below it. In this situation, the facet joints can't provide their normal support. A traumatic fracture in the bony ring can lead to slippage when the fracture goes completely through both sides of the bony ring. The facet joints are no longer able to provide a buttress, allowing the vertebra with the crack in it to slip forward. This is similar to what happens when spondylolysis (mentioned earlier) occurs on both sides of the bony ring, but in this case it happens all at once.

Degenerative changes in the spine (those from wear and tear) can also lead to spondylolisthesis. The spine ages and wears over time, much like hair turns gray. These changes affect the structures that normally support healthy spine alignment. Degeneration in the disc and facet joints of a spinal segment causes the vertebrae to move more than they should. The segment becomes loose, and the added movement takes an additional toll on the structures of the spine. The disc weakens, pressing the facet joints together.

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Eventually, the support from the facet joints becomes ineffective, and the top vertebra slides forward.

Symptoms
What does the condition feel like? An ache in the low back and buttock areas is the most common complaint in patients with spondylolisthesis. Pain is usually worse when standing, walking, or bending backward and may be eased by resting or bending the spine forward. Leaning on a counter top, piece of furniture, or shopping cart are common ways to alleviate (reduce) the symptoms. Spasm is also common in the low back muscles. The hamstring muscles on the back of the thighs may become tight. The pain can be from mechanical causes. Mechanical pain is caused by wear and tear on the parts of the spine. When the vertebra slips forward, it puts a painful strain on the disc and facet joints.

Slippage can also cause nerve compression. Nerve compression is a result of pressure on a nerve. As the spine slips forward, the nerves may be squeezed where they exit the spine. This condition also reduces space in the spinal canal where the vertebra has slipped. This can put extra pressure on the nerve tissues inside the canal. Nerve compression can cause symptoms where the nerve travels and may include numbness, tingling, slowed reflexes, and muscle weakness in the legs.

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Nerve pressure on the cauda equina (mentioned earlier), the bundle of nerve roots within the lumbar spinal canal, can affect the nerves that go to the bladder and rectum. When this happens, bowel and/or bladder function can be affected. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle.

Diagnosis
How do doctors diagnose the problem? Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. Your doctor will also want to know what positions or activities make your symptoms worse or better. Next the doctor examines you by checking your posture and the amount of movement in your low back. Your doctor checks to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Doctors will usually order X-rays of the low back. The X-rays are taken with your spine in various positions. They can be used to see which vertebra is slipping and how far it has slipped. If more information is needed, your doctor may order computed tomography (a CT scan). This is a detailed X-ray that lets the doctor see slices of the body's tissue. If you have nerve problems, the doctor may combine the CT scan withmyelography. To do this, a special dye is injected into the space around the spinal canal, the subarachnoid space. During the

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CT scan, the dye highlights the spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the nerves. Your doctor may also order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It can help in the diagnosis of spondylolisthesis. It can also provide information about the health of nerves and other soft tissues.

Treatment
What treatment options are available?

Nonsurgical Treatment
Studies have not been done yet to determine the best treatment for this condition. Conservative care is preferred, especially when the vertebra hasn't slipped very far. Most patients with symptoms from degenerative spondylolisthesis do not need surgery and respond well to nonoperative care. Medications may be prescribed to help ease pain and muscle spasm. In some cases, the patient's condition is simply monitored to see if symptoms improve. Your doctor may ask that you rest your back by limiting your activities. This is to help decrease inflammation and calm muscle spasm. You may need to take time away from sports or other strenuous activities to give your back a chance to heal.

If your doctor diagnoses an acute pars fracture that has the potential to heal, it may be recommended that you wear a rigid back brace for two to three months. This

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usually occurs in children and teenagers who begin having back

pain and see their doctor early on. X-rays may show a fresh fracture of the pars area of the vertebra on one, or both, sides. A CT scan or bone scan may be recommended to determine if the fracture is likely to heal. If so, a brace is recommended. X-rays or a CT scan may be ordered in six to eight weeks to see if the fracture is healing. IF not, the brace will be discontinued.

Some patients who continue to have symptoms are given an epidural steroid injection (ESI). Steroids are powerful antiinflammatories, meaning they reduce pain and swelling. In an ESI, medication is injected into the space around the lumbar nerve roots. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren't working. But ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief. Patients often work with a physical therapist. After evaluating your condition, your therapist can assign positions and exercises to ease your symptoms. Your therapist can design an exercise program to improve flexibility in your low back and hamstrings and to strengthen your back and abdominal muscles.

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The use of a stationary bike can promote aerobic conditioning and puts you in the optimal position to open the spaces where the nerve roots exit. This type if exercise program can aid in reducing the painful symptoms.

Surgery
Surgery is used when the slip is severe and when symptoms are not relieved with nonsurgical treatments. Symptoms that cause an abnormal walking pattern, changes in bowel or bladder function, or steady worsening in nerve function require surgery. Deterioration of symptoms is common in patients with a history of significant neurologic symptoms who don't have surgery to correct the problem. If a reasonable trial of conservative care (three months or more) does not improve things and/or your quality of life is significantly reduced, then surgery may be the next best solution. The main types of surgery for spondylolisthesis include

laminectomy (decompression) posterior fusion with or without instrumentation posterior lumbar interbody fusion

Laminectomy

When the vertebra slips forward, the nearby nerves that exit the spine can become pinched or irritated. In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal. To fix this, the lamina of the bony ring is removed to ease pressure on the nerves. The procedure to remove the lamina and release pressure on the nerves is called laminectomy.

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Decompression alone is usually not advised. Studies show much better results when the operation is combined with a fusion of the involved vertebrae (see below). Posterior Fusion with Instrumentation

A spinal fusion is normally done immediately after laminectomy for spondylolisthesis. The fusion procedure is designed to fuse the two vertebrae into one bone and stop the slippage from worsening. The fusion is used to lock the vertebrae in place and stop movement between the vertebrae, easing mechanical pain. When combined with laminectomy surgery (mentioned earlier), fusion helps relieve nerve compression. In this procedure, the surgeon lays small grafts of bone over the

back of the problem vertebrae. Sometimes fusion is done just with bone graft material. This is a fusion without fixation (non-instrumentation).Instrumentation is the use of metal plates or screws to stabilize the segment during healing. Most surgeons combine fusion with instrumentation to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster. Outcomes are improved when decompression is combined with fusion (compared with decompression alone). Fusion and functional improvement are even better when spinal instrumentation is used. There are fewer long-term problems with

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pain and pseudoarthrosis(formation of movement or false joints within the fusion).
SOURCE: http://www.eorthopod.com

Spondylolisthesis
Spondylolisthesis is the displacement of one vertebra on top of another. This displacement can occur when there is significant acute damage to the area, from a contact sports injury say, or as a result of more chronic issues such as cervical degenerative disc disease, osteoarthritis, and other cervical spinal issues. Unchecked, degenerative spondylolisthesis can lead to cervical spinal stenosis (Kalichman, 2008). Physicians usually classify spondylolisthesis according to its cause, with the most common being degenerative spondylolisthesis. This is caused by chronic degenerative changes in the ligaments, facet joints, bones, and cartilage that hold the spinal/vertebral column in position. This degeneration can lead to spondylolisthesis as the vertebral column loses its ability to stay together and the vertebrae slip out of position. Isthmic spondylolisthesis is the result of spondylolysis; a defect in the pars interarticularis (part of the vertebrae) most commonly caused by repetitive microtrauma in childhood through activities such as gymnastics, diving, soccer, football, and wrestling (Standaert, 2000).

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Traumatic spondylolisthesis is due to direct trauma inflicted upon the vertebrae causing a fracture of the pedicle, lamina, or facet joints and allowing the front of the vertebrae to move forward. Cervical spondylolysis can lead to spondylolisthesis by altering the normal structure of the vertebral column and causing vertebral displacement. Congenital abnormalities of the facet joints can lead to spondylolisthesis, as the vertebrae are allowed to slip out of place. The condition is referred to as dysplastic spondylolisthesis. A further classification is pathological spondylolisthesis, where a defect of the bone, or a tumour causes the slip to occur. Understanding the cause means that the correct treatment can be applied, such as adequate rest from the microtrauma-inducing sport, analgesics, anti-inflammatories, physical therapy, or surgery in cases where significant damage has occurred and conservative treatment has proved ineffective. Spondylolysis normally does not require surgical intervention, unless it progresses into spondylolisthesis. The use of a brace may be helpful in reducing neck pain in the meantime. Identifying the exacerbating activity is key to preventing future occurrences of the condition, meaning that correct posture, and core muscle strengthening, along with neck strengthening exercises are key to a positive outcome. In the case of lumbar or cervical spine surgery, typically a spinal fusion is the procedure used to correct spondylolisthesis.

Causes of Spondylolisthesis

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There are five major types of spondylolisthesis, all with different causes. The most common is degeneration of the components of the vertebral column and spine - degenerative spondylolisthesis. These structures, when healthy, maintain the spines correct position, allowing for strength and flexibility of movement. As these components degrade, through chronic wear and tear they lose their ability to stay supple and strong, making shifts in the spinal structure more likely, including the slippage of the vertebrae as occurs in spondylolisthesis. Cartilage calcification and degeneration, ligaments stretching and tearing, bone spurs or osteophyte growth, and changes in the shock absorbing and cushioning qualities of the intervertebral discs means that the vertebra can slide forward (or backward in the case of retrolisthesis), and cause deformity of the spine, with associated pain, paraesthesia, pinched nerves, numbness, muscle weakening, and impaired mobility.

Degeneration with age is not, however, the only cause of spondylolisthesis. Congenital abnormalities such as misshapen bones in the spinal column, or problems with the pelvic incidence (tilt), can also

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cause excess pressure on the spinal column leading to slippage of the vertebrae and spondylolisthesis (Labelle, 2004). This is known as dysplastic spondylolisthesis. Isthmic spondylolisthesis is a further classification, used to describe the condition that results from spondylolysis. This is a condition where repetitive microtrauma causes defects in the pars interarticularis, a specific part of the vertebrae, which may develop into spondylolisthesis if the vertebrae slip forward due to this defect. Spondylolysis is commonly caused in adolescents and children by activities such as gymnastics, football, wrestling, and diving. With appropriate rest and possible use of a brace it should correct itself without developing into spondylolisthesis. Specific injury or damage to the vertebrae through complications of surgery, epidural injections, assault, or accidents, such as whiplash, can cause traumatic spondylolisthesis. These types of injury can result in fractures of the lamina, facet joints, or pedicle, and allow the vertebrae to slide forward. The final class is pathologic spondylolisthesis. This is where the vertebrae slip forward due to an abnormal growth such as a tumour or bone growth. The specific pathology of the spondylolisthesis requires careful diagnosis in order to apply appropriate treatment.

Symptoms of Spondylolisthesis
In some cases the patient may be asymptomatic and only discover the spondylolisthesis by chance when having an x-ray conducted for an unrelated reason. Many cases involving children cause no, or few, symptoms. Other patients suffer extreme

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symptoms, involving persistent, severe neck pain, back and spine, with radiating pain down the legs and arms. Pain may be worsened when hyperextending (arching) the back, making some activities such as yoga or pilates potentially unsuitable for those with spondylolisthesis. In general, however, these activities would be excellent for maintaining back and neck health. Some patients may experience neurological symptoms, such as intermittent claudication or vesicorectal disorder; in most cases these patients will require spine surgery to correct the slippage and compression on spinal structures. Pinched nerves in the cervical spine may lead to weakness and numbness in the arms and shoulders, along with paraesthesia. Pain in neck and head can occur, depending on the location of the slippage and which nerves are being impinged upon. Symptoms of spondylolisthesis may share commonalities with symptoms of bulging or herniated discs, spinal stenosis, and cervical arthritis, as well as the issues found with severe osteophyte growth in the spine. If the patient experiences numbness in the genital area, or loses bladder or bowel control then they should seek medical help immediately as they may be signs of cauda equina syndrome which is considered a medical emergency.

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As there are numerous blood vessels in the cervical area, including the arteries and veins leading up to the head, it is possible that spondylolisthesis can cause compression of these blood vessels. This may occur upon movement, with patients experiencing light-headedness upon rotation or flexion of the neck and head. If this occurs it is essential to seek medical assistance immediately as it may lead to blackouts, falls, and accidents as circulation to the brain is impaired. Physical signs of the slippage of the vertebrae can, in extreme cases, include deformity of the back and neck, with stiffness of the neck, pain on rotation, flexion, and extension, and an abnormal tilt to the posture. Those with spondylolisthesis of the lumbar area may experience tightness in their hamstrings, sciatic nerve pain, and numbness in the legs and buttocks; the latter is a sign of cauda equina syndrome and

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should be thoroughly investigated.

Diagnosis of Spondylolisthesis
In general it will not be possible for a physician to observe outward signs of spondylolisthesis upon examining a patient. Taking a history of symptoms, and a detailed record of trauma and activities such as contact sports, the physician will recommend further tests and scans as they see fit. They may also ask patients to conduct some simple stretches, rotation or flexion of the neck, and to apply resistance during gentle pressure on their hands, shoulders, and head from the physician. The production, or relief, of pain from these physical tests can be enlightening as to the aetiology of their spine condition, and also make it easier for the physician to estimate the specific area which is damaged so as to scan that area. Common symptoms of spondylolisthesis, such as tight hamstrings, muscle spasms, and pain, may overlap with other conditions, such as muscle strain,disc herniation, spinal stenosis, and diabetic neuropathy, making it extremely important to obtain the correct diagnosis prior to commencing treatment.

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Grades of Spondylolisthesis
X-rays taken from the side (lateral) can identify slippage of vertebra relative to the adjacent vertebrae. The degree of slippage can be calculated and is graded as follows: Grade 1 is a slip of up to 25%, grade 2 is a slip of 26%50%, grade 3 is a slip of 51%-75%, and grade 4 76%-100%. Grade 5 is known as spondyloptosis and is where the vertebra has slipped off the next vertebra completely. MRI or CT scans can be helpful in identifying any stenosis of the spine that may be causing neck, back, and shoulder pain, and radiating pain to the extremities. Paraesthesia, numbness, and weakness indicate nerve problems, possibly with a pinched nerve such as can occur in disc herniation. If a spinal fusion surgical procedure is being considered then a PET scan can ascertain whether the defective bone site has active bone growth occurring. This will affect the likely healing of the patients spine post-surgery, making

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decisions about the effectiveness of certain treatments simpler.

Treatment of Spondylolisthesis
Conservative Treatment
Conservative treatment is the usual therapeutic course for patients with spondylolisthesis. In small children, where the slip is normally quite minor, the usual therapeutic plan is simple observation and restriction of boisterous activities. More significant slips pose a threat of progressive complication and justify the use of more invasive treatment methods. NSAIDs and analgesics are likely to be used, alongside physical therapy, and the condition will be monitored closely. If treatment is unsuccessful after six months or so, or if an acute exacerbation occurs, then surgery may be required. If intermittent claudication and other neurological symptoms are present then the need for surgical intervention is more likely. Favored treatment plans for minor cases involve the use of analgesics and NSAIDs, or alternative supplements for those concerned with the potential side-effects of pharmaceutical medications. Epidural steroid injections and selective nerve root blocks may be used to provide relief from the condition and break the cycle of inflammation often found in spondylolisthesis. If the patient has adequate rest and refrains from any exacerbating activities, it is possible that the combination of anti-inflammatories, physical therapy and flexion strengthening exercises can alleviate, or even correct, the problem. Exercises to strengthen the core abdominal muscles are also likely to benefit a patient with spondylolisthesis as these may

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help correct underlying postural issues and alleviate some pressure on the spine. The use of a hyperextension brace may also assist those with isthmic spondylolisthesis as it can help to extend the lumbar spine and promote healing.

Surgical Treatment
Surgery varies depending on the type of spondylolisthesis. Isthmic spondylolisthesis patients are likely to have repair work done on the portion of the vertebrae that is defective, most notably the pars interarticularis. Healthy post-surgical healing is likely to occur if an MRI or PET scan reveals active bone at the defective site. In this procedure the scar tissue will be removed and a bone graft put in place with screws to hold it across the defect, thus encouraging the re-knitting of the bone. Those patients with neurological symptoms will likely undergo a decompression procedure to make the foramina through which the nerves exit the spine more spacious. Decompression surgery is often conducted alongside fusion to reposition the vertebrae correctly and hold them in place with plates. In some cases the vertebrae are fused in the position they have moved to, to prevent further slippage. This is done in cases where moving the vertebrae back has an increased risk of further nerve damage.
Source: http://www.painneck.com

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Spondylolisthesis -Degnerative
Spondylolisthesis occurs when one vertebra slips forward over the vertebra below. Degenerative spondylolisthesis often affects the lumbar (low back) spine, often at L4-L5 (4th and 5th lumbar vertebral levels). Degenerative changes in vertebral structure may cause joints between vertebrae to slip forward creating a spondylolisthesis. Sometimes spinal stenosis develops with spondylolisthesis. Degenerative spondylolisthesis is more common in older female patients over age 60.

Symptoms
Some people with spondylolisthesis are symptom-free. Spondylolisthesis may be discovered when the patient has a lumbar xray for back pain or another problem. Symptoms may include: Low back pain Sciatica Muscle spasms Leg weakness Tight hamstring muscles Irregular gait or a limp An accurate diagnosis of spondylolisthesis can be made by a physician with expertise in spinal disorders. This may include the following steps.

Medical history The doctor asks you about your symptoms, severity, treatments tried, and the results. Physical examination The physician examines you for movement limitations, balance problems, and pain. He tests your reflexes,

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evaluates muscle weakness, sensation, and signs of neurological injury. Diagnostic tests Spondylolisthesis is detected on a lateral (side) lumbar x-ray. If necessary, a CT scan or MRI may be ordered obtain information about your anatomy in greater detail.

Classifaction of Spondylolisthesis
Information from your imaging studies is used to grade the degree of vertebral slippage from mild to severe. Doctors use the Meyerding Grading

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System to classify the degree of vertebral slippage. This system is easy to understand. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below.

Grade I: 1-24% Grade II: 25-49% Grade III: 50-74% Grade IV: 75 %-99% slip. Grade V: Complete slip (100%), known as spondyloptosis Treatment is based on the degree of slip and factors, such as intractable pain and

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neurological symptoms. Most instances of degenerative spondylolisthesis are Grade I or II. In general, the more severe the slip (Grades III and above), the more likely surgical intervention will be required.

Non-operative Treatment
Treatments include:

Often degenerative spondylolisthesis is treated without surgery.

Short-term bed rest Activity restriction Over-the-counter or prescription pain medication Anti-inflammatory medication Muscle relaxants Steroid injections (i.e., lumbar epidural steroid injection) Physical therapy Bracing

Degenerative spondylolisthesis can be progressive. This means the spondylolisthesis worsens over time. Follow up with your doctor to monitor reatment progress and spondylolisthesis is important for recovery.

Surgery
If your degenerative spondylolisthesis progresses or causes neurologic problems, such as incontinence, surgery may be recommended. Spinal instrumentation (i.e., rods, screws) and fusion (bone graft) are common procedures to stop slip progression and stabilize the spine. There are different types of instrumentation, bone graft and graft products, as well as procedures (some minimally invasive) to surgically treat degenerative spondylolisthesis. Your surgeon will discuss the types of surgery and risks and benefits.

Conclusion

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Higher grades of degenerative spondylolisthesis can be serious. However, many safe and effective treatment options are available. Many patients resond well to non-surgical therapies.
Source: http://www.agingspinecenter.com

Spondylolisthesis-Isthmic
Isthmic spondylolisthesis is a spinal condition in which one vertebra slips forward over the vertebra below. It is caused by a defect, or fracture, of the pars interarticularis; a bone connecting the upper and lower facet joints. The defect may be congenital and a fracture can be caused by the accumulative affects of spinal stress. Sometimes isthmic spondylolisthesis affects young athletes. *Isthmic spondylolisthesis most often occurs at L5-S1, the fifth lumbar vertebra and first sacral segment.

Symptoms

Although isthmic spondylolisthesis can cause spinal instability, not all patients find the condition painful. Symptoms of isthmic spondylolisthesis may include:

Low back pain Sciatica Muscle spasms Leg weakness Tight hamstring muscles Irregular gait or limp

Causes
Isthmic spondylolisthesis may result from failure of bone to form properly. Accumulated physical stresses to the spine may cause weak or insufficiently formed vertebral structures (i.e., pars interarticularis) to break. Repeated heavy lifting, stooping over, or twisting may cause small fractures to occur and lead to a vertebral

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slip. Weightlifters, football players, and gymnasts may suffer from this disorder because of considerable spinal stress.

Diagnosis
Isthmic spondylolisthesis must be diagnosed by an expert physician.

Medical history Physical examination

The doctor asks you about symptoms, their severity, treatments you have already tried.

The physician examines you for limitations of movement, balance problems, and pain. He tests your reflexes, and evaluates muscle weakness, loss of sensation, and other signs of neurologic problems.

Diagnostic tests

Most doctors start with x-rays. Isthmic spondylolisthesis may be seen on a lateral (side) lumbar x-ray. If necessary, a CT scan or MRI may be ordered to see the spines tissues in greater detail.

Classification of Isthmic Spondylolisthesis

Information from your medical file and imaging studies is used to grade the degree of vertebral slippage from mild to severe. The grade of your spondylolisthesis is explained to you along with what it means. Doctors use the Meyerding Grading System to classify the degree of vertebral slippage. This system is easy to understand. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below.

Grade I: 1-24% Grade II: 25-49% Grade III: 50-74% Grade IV: 75%-99% slip. Grade V: Complete slip (100%), known as spondyloptosis

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When considering treatment, the degree of slip is taken into account as well as your pain and neurological symptoms (if any). Most cases of isthmic spondylolisthesis are Grade I or II. In general, the more severe the slip (Grades III and above), the more likely a surgical intervention will be required.

Non-operative Treatment
Most cases of isthmic spondylolisthesis are treated without surgery.

Short-term bed rest Activity restriction Over-the-counter or prescription pain medication Anti-inflammatory medication Muscle relaxants Oral steroids Steroid injections Physical therapy Bracing

Isthmic spondylolisthesis can be progressive. This means the spondylolisthesis worsens with time. This is why it is important to follow-up with your doctor to monitor your treatment progress and spondylolisthesis.

Surgery
If isthmic spondylolisthesis progresses or causes neurologic problems, such as incontinence, surgery may be recommended. Spinal instrumentation (i.e., rods, screws) and fusion (bone graft) are common procedures performed to stop slip progression and stabilize the spine. There are different types of instrumentation, bone graft and graft products, as well as procedures (some minimally invasive) to surgically treat isthmic spondylolisthesis. The surgeon will explain surgical options if you are an appropriate candidate, along with associated risks and benefits.

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Conclusion
Isthmic spondylolisthesis is a serious condition but it is one that can be safely and effectively treated. Many patients are able to recover fully and enjoy healthy, pain-free, and active lifestyles. There are many treatment options for isthmic spondylolisthesis but not all people are candidates for every treatment. An expert in spinal conditions should diagnose the condition and can then provide advice as to the best treatment options for an individual case.

Isthmic Spondylolisthesis
By: Peter F. Ullrich, Jr., MD

Fig. 1: X-ray of Isthmic Spondylol-isthesis

The spine condition called isthmic spondylolisthesis occurs when one vertebral body slips forward on the one below it because of a small fracture in a piece of bone that connects the two joints on the back side of the spinal segment.

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The fracture in this small piece of bone, called the pars interarticularis, is caused by stress to the bone. While the fracture tends to occur most commonly when an individual is young (around 5 to 7 years old), for most people symptoms typically do not develop until adulthood. There is another spike in occurrence of lower back pain from spondylolisthesis in adolescence. It is estimated that 5 to 7% of the population has either a fracture in this small piece of bone (a fracture of the pars interarticularis) or a spondylolisthesis (slipped vertebral body)1, but in most cases there are no symptoms. It has been estimated that 80% of people with a spondylolisthesis will never have symptoms, and if it does become symptomatic, only 15 to 20% will ever need surgical correction.

Spondylolisthesis Causes

The pars interarticularis (latin for bridge between two joints) connects the facet joint above to the one below. It is a thin piece of bone with a poor blood supply, which makes it susceptible to stress fractures. There also can be a fracture of the pars interarticularis without a vertebral slip. The fracture itself is known as a spondylolysis. The pars interarticularis may also be referred to as the isthmus. When this small bone fractures it usually does not cause pain or other symptoms. Trauma is not a common reason for fracturing. The fracture is usually due to cumulative stress, analogous to taking a paper clip and bending it multiple times. It will

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eventually break apart after enough stress. Isthmic spondylolisthesis occurs most commonly in the L5-S1 level of the spine, the lowest level of the lumbar spine. It does happen rarely above this level, at L4-L5 or L3-L4, but at these levels trauma (rather than cumulative stress) is a more common cause of the fracture.

Spondylolisthesis Symptoms
For patients with symptomatic isthmic spondylolisthesis, the most common symptoms include:

Low back pain, often described as a deep ache in the lower back Pain that radiates into the buttocks and back of the thighs, (also calledradicular pain) Pain that is worse when standing, walking, or any type of activities that involves bending backwards Pain that feels better with sitting, especially sitting in a reclining position A tired feeling in the legs, and possibly leg numbness or tingling, especially after walking Pain that radiates below the knee and possibly into the foot. In addition to the above pain-related symptoms, most patients with isthmic spondylolisthesis have tight hamstrings the large muscle that runs down the back of the thigh making it difficult for them to touch their toes.

Isthmic Spondylolisthesis During Adolescence

Isthmic spondylolisthesis is a common cause of back pain in adolescents.

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It is suspected that spondylolysis, the fracture in the lower back that can lead to spondylolisthesis, occurs most frequently in young athletes who are involved in sports that involve repeated hyperextension of the lower back (bending backwards), such as gymnastics. The most common symptom is back and/or leg pain that limits a patient's activity level. In cases of a more advanced slip, such as a grade 2 or more spondylolisthesis, the patient may have a noticeable forward curve or sway back in their lower back. Development of either neurological problems or paralysis is possible but exceedingly rare.

Adolescent Spondylolisthesis Treatment

Adolescents involved in sports can develop back pain from their activity. If a spondylolisthesis is noted on x-ray, generally it is recommended that the athlete refrain from sports until he or she is free from pain. The typical range of non-surgical treatments may be employed to manage pain, including:

Pain medications - NSAIDs and acetaminophen are good options Ice and/or heat therapy both are good options to relieve flare-ups of pain Physical Therapy - Physical therapy can be useful, especially to stretch the hamstring muscles. The condition causes the hamstrings to tighten, and as they tighten they contribute to extra stress across the disc and the fracture. Stretching of the hamstrings interrupts the cycle of pain causing hamstring spasm leading to further back pain.

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Pain from Isthmic Spondylolisthesis in Adults
An isthmic spondylolisthesis may also become symptomatic in adults, most typically when people are in their thirties and forties.

How Spondylolisthesis Causes Pain

There are two primary forces at work with isthmic spondylolisthesis in adults. Disc Degeneration The most common reason for low back pain in this situation is that the disc will start to wear out. Without a posterior tether connecting the facet joints, the disc space is forced to withstand shear forces. Normally thefacet joints in the back of the spine protect the disc from shear as they act to limit the shear force. When there is a pars interarticularis fracture the facet joints cannot limit shear. Discs work well as a shock absorber but they are susceptible to being damaged if they have to resist shear. The associated cumulative stress leads the disc to breakdown and eventually become painful.

Spondylolisthesis Treatment
Non-surgical treatment for adult patients with an isthmic spondylolisthesis is similar to that for patients with low back pain and/or leg pain from other conditions and may include one or a combination of: Medications Pain medications, such as acetaminophen, and/or NSAIDs (e.g. ibuprofen, COX-2 inhibitors) or oral steroids to reduce inflammation in the area

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Heat and/or ice application Heat and/or ice application, to reduce localized pain. Generally, ice is recommended to relieve pain or discomfort directly after an activity that has caused the pain. Heat application is recommended to relax the muscles, and promote blood flow and a healing environment. Physical Therapy Stretching is recommended, beginning with hamstring stretching and progressing over time. In addition, special attention should be paid to stretching the hamstrings twice daily in order to alleviate stress on the low back. The exercise program should be controlled and gradually increase over time. Manual manipulation Chiropractic manipulation, or manual manipulation from osteopathic doctors, physiatrists or other appropriately trained health professionals, can help reduce pain by mobilizing painful joint dysfunction. Epidural steroid Injections If the patient is having severe pain, injections can be useful. Epidural injections can help decrease inflammation in the area. The pars fracture itself can be injected with lidocaine and steroids for a diagnostic study. If the patients pain is relieved after a lidocaine injection it can be assumed that the pars fracture is the source of the patients pain. The steroid can be useful to reduce inflammation in the pars interarticularis, helping to relieve the pain and allow the patient to progress with physical therapy and non-surgical treatment Spondylolisthesis Surgery In most cases non-surgical treatment is successful in relieving the patients pain, but if not surgery may be considered.

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Spinal fusion surgery for spondylolisthesis is generally quite effective, but because it is a large procedure with a lot of recovery, it usually is not considered until a patient has failed to find pain relief with at least six months focused on a range of non-surgical treatments. A posterior fusion with pedicle screw instrumentation is generally considered the gold standard form of lumbar spinal fusion. The surgeon may also recommend a spinal fusion done from the front of the spine at the same time. The type of spinal fusion that is recommended by a surgeon is based largely on a surgeons preference and experience, as well as the patients clinical situation.

Spondylolisthesis-Isthmic Spondylolisthesis occurs when one vertebral body slips forward over the one beneath it. Isthmic spondylolisthesis is one type. Isthmic refers to the tube-shaped bone called the pars interarticularis, or simply the pars. Each of your spines joints (facet joints) contains pars. The pars connect the upper and lower facet joints and help stabilize the joint. Isthmic spondylolisthesis happens when the pars breaks. Spondylolisthesis is more common in the lumbar spine (low back).

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Causes The pars defect may be congenital (at birth), result from improper bone formation, or become damaged or broken by the accumulative effects of spinal stress. Repeated heavy lifting, stooping over, or twisting may cause small fractures to occur and lead to a vertebral slip. Weightlifters, football players, and gymnasts may suffer from this disorder because of considerable spinal stress. Symptoms Although isthmic spondylolisthesis can cause spinal instability, not all patients experience pain. Typical symptoms include:

Back pain (low back or neck) Sciatica Muscle spasms Leg, arm weakness Tight hamstring muscles (legs) Irregular gait or limp Bowel or bladder dysfunction (rare)

Accurate diagnosis Vertebral slip associated with isthmic spondylolisthesis can progress and worsen. Consult an expert about your back pain with or without extremity pain, pre-existing or changing spinal disorder. An accurate diagnosis is essential to an effective and successful treatment plan.

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Your medical history and physical and neurological examinations are very important. You and your doctor discuss your symptoms, when they started and treatments tried. The doctor tests your reflexes and evaluates you for muscle weakness, loss of feeling, and signs of neurological injury.

Diagnostic testing helps the doctor confirm your diagnosis. A simple spinal x-ray can show a spondylolisthesis. Typically, several x-rays are taken: side (lateral), standing (front and back), bending forward (flexion) and bending backward (extension). The flexion/extension studies help your spine specialist to evaluate your range of motion and spinal stability.

Other diagnostic imaging studies may include a CT or MRI series. A MRI study is of particular use to assess nerve and/or spinal canal (cord) compression. Your doctor will explain the purpose of these and other tests.

Classifying Isthmic Spondylolisthesis The Meyerding Grading System is used to determine the degree or severity of the vertebral slip. All of your imaging studies, including information from your medical file, are considered in the assessment of your spondylolisthesis and its characteristics. Meyerding Grading System

Grade I: 1-24% Grade II: 25-49% Grade III: 50-74% Grade IV: 75%-99% slip

Grade V: Complete slip (100%, spondyloptosis)

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Most cases of isthmic spondylolisthesis are Grade I or II. Grades III and above are more severe and may require surgical treatment. Treatment options Many isthmic spondylolisthesis cases are treated without surgery. Your doctor may combine more than one therapy to maximize the success of your treatment plan.

Short-term bed rest Activity modification (restrict spinal stress, flexion, extension) Non-steroidal anti-inflammatory drugs (NSAIDs) Pain medication Muscle relaxants Spinal injections Physical therapy Bracing Acupuncture

Isthmic spondylolisthesis can be progressive. This means the spondylolisthesis worsens with time. This is why it is important to follow up with your doctor to monitor your treatment progress and spondylolisthesis.

When your surgeon may discuss surgical treatment

Spinal instability (slip progression) Bowel or bladder dysfunction Neurologic dysfunction

Unrelenting pain, symptoms

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Non-operative treatment fails

Surgical treatment Surgical treatment of isthmic spondylolisthesis aims to reduce (decompress) nerve compression and stabilize the spine (stop the slip). You may be a candidate for aminimally invasive spine surgical procedure to alleviate neurological dysfunction. Spinal stabilization and fusion stops the slip, movement, and holds the spine stable as you heal. Outlook Many patients fully recover and enjoy healthy, pain-free, and active lives. We hope this information about isthmic spondylolisthesis has answered your immediate questions. Remember, your doctor is your most valuable source to answer yourquestions about symptoms and your healthcare.

Isthmic Spondylolisthesis
Spondylolisthesis is a condition of spinal instability, in which one vertebra slips forward over the vertebra below. Isthmic spondylolisthesis, the most common form of this condition, is caused by a bony defect (or fracture) in an area of the pars interarticularis, an area located in the roof (laminae) of the vertebral structure. This bony defect occurs in approximately 4% of the population, and results from a genetic failure of bone formation. The condition most commonly affects the fourth and fifth lumbar vertebrae (L4 and L5) and the first sacral vertebra (S1). It is interesting to note that the condition is

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not always painful.

Slip of L5 vertebra on sacrum Symptoms of Isthmic Spondylolisthesis Symptoms of isthmic spondylolisthesis may include the following:

Pain in the low back, thighs, and/or legs especially after exercise that radiates into the buttocks Muscle spasms Leg pain or weakness Tight hamstring muscles Irregular gait

Some people are symptom free and only discover the disorder when seeing a doctor for another health problem. In severe cases, the condition may cause swayback and a protruding abdomen, a shortened torso, and a waddling gait. What Causes Isthmic Spondylolisthesis? Isthmic spondylolisthesis can be the result of a genetic failure of bone formation in the spinal vertebrae. Usually physical stresses to the spine then break down the weak or insufficiently formed vertebral components. Repeated heavy lifting, stooping, or twisting can cause small fractures to occur in the vertebral structure and lead to the slippage of one vertebra over another. Weightlifters, football players, and gymnasts often suffer from this disorder due to the considerable stress placed on their spines. How is Isthmic Spondylolisthesis Diagnosed? To make an accurate diagnosis, the physicians at CCSI will conduct a careful and rigorous diagnostic process, including:

Medical history. We will talk to you about your symptoms, how severe they are, and what treatments you have already tried. Physical examination. You will be carefully examined by one of our spine specialists for limitations of movement, problems with balance, and pain. During

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this exam, we will also look for loss of reflexes in the extremities, muscle weakness, loss of sensation or other signs of neurological damage. Diagnostic tests. Generally, we start with plain x-rays, which allow us to rule out other problems such as tumors and infections. We may also use a CT scan or MRI to confirm the diagnosis. In some patients we may need a myelogram. This is a test that involves the use of a liquid dye that is injected into the spinal column to show the degree of nerve compression and slippage between involved vertebrae.

X-Ray showing lumbar spondylolisthesis Treatment of Isthmic Spondylolisthesis There are several methods used to "grade" the degree of slippage ranging from mild to most severe. Your surgeon will discuss with you the extent of your spondylolisthesis and how the severity indicates the type of treatment that is needed. In general, the physicians at CCSI use the Meyerding Grading System for classifying slips. This is a relatively easy to understand system. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below. Thus a Grade I slip indicates that 1-24% of the vertebral body has slipped forward over the body below. Grade II indicates a 25-49% slip. Grade III indicates a 5074% slip and Grade IV indicates a 75%-99% slip. If the body completely slips off the body below it is classified as a Grade V slip, known as spondyloptosis. Your physician will consider the degree of slip, and such factors as intractable pain and neurological symptoms, when deciding on the most suitable treatment. As a general guideline, the more severe slips (especially Grades III and above) are most likely to require surgical intervention. For most cases of isthmic spondylolisthesis (especially Grades I and II), treatment consists of temporary bed rest, restriction of the activities that caused the onset of

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symptoms, pain/ anti-inflammatory medications, steroid-anesthetic injections, physical therapy and/or spinal bracing. Surgery is rarely needed unless the case is severe (usually Grade III or above), neurological damage has occurred, the pain is disabling, or all non-operative treatment options have failed. The most common surgical procedure used to treat spondylolisthesis is called a laminectomy and fusion. In this procedure, the spinal canal is widened by removing or trimming the laminae (roof) of the vertebrae. This is done to create more space for the nerves and relieve pressure on the spinal cord. The surgeon may also need to remove all or part of the vertebral disc (discectomy) and then also fuse vertebrae together. If fusion is done, various devices (like screws or interbody cages) may be implanted to enhance fusion and to support the unstable spine.

Post-operative X-ray showing corrective implants Prevention is Key While it may not be possible to prevent all spine problems, there are things you can do to help keep your spine healthy. The most important prevention method is to avoid or limit those work or recreational activities that cause considerable stress to your spine. At CCSI we will work closely with you in establishing healthy lifestyle habits that can help keep your back healthy. For example, losing weight, starting a regular exercise regimen, not smoking, and learning proper body mechanics can all help reduce the risk of further back problems.

SOURCE: http://www.coloradospineinstitute.com

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Posterior Lumbar Interbody Fusion (PLIF) Surgery

As with all spinal fusion surgery, a posterior lumbar interbody fusion (PLIF) involves adding bone graft to an area of the spine to set up a biological response that causes the bone to grow between the two vertebral elements and thereby stop the motion at that segment.

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Unlike the posterolateral gutter fusion, the PLIF achieves spinal fusion in the low back by inserting a cage made of either allograft bone or synthetic material (PEEK or titanium) directly into the disc space. When the surgical approach for this type of procedure is from the back it is called a posterior lumbar interbody fusion (PLIF). A PLIF fusion is often supplemented by a simultaneous posterolateral spine fusion surgery.

Posterior Lumbar Interbody Fusion Surgery Description

First, the spine is approached through a three-inch to six-inch long incision in the midline of the back and the left and right lower back muscles (erector spinae) are stripped off the lamina on both sides and at multiple levels. After the spine is approached, the lamina is removed (laminectomy) which allows visualization of the nerve roots. The facet joints, which are directly over the nerve roots may then be undercut (trimmed) to give the nerve roots more room. The nerve roots are then retracted to one side and the disc space is cleaned of the disc material. A cage made of allograft bone, or posterior lumbar interbody cages withbone graft, is then inserted into the disc space and the bone grows from vertebral body to vertebral body.

PLIF Potential Advantages and Disadvantages

Doing a pure PLIF surgery has the advantage that it can provide anterior fusion of the disc space without having a second incision as would be necessary with an anterior/posterior spine fusion surgery. However, it has some disadvantages:

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Not as much of the disc space can be removed with a posterior approach (from the back). An anterior approach (an ALIF, from the front) provides for a much more comprehensive evacuation of the disc space and this leads to increase surface area available for a fusion. A larger spinal implant can be inserted from an anterior approach, which provides for superior stabilization. In cases of spinal deformity (e.g. isthmic spondylolisthesis) a posterior approach alone is more difficult to reduce the deformity. There is a small but finite risk that inserting a cage posteriorly will allow it to retro pulse back into the canal and create neural compression. PLIF surgery has a higher potential for a solid fusion rates than posterolateral fusion rates because the bone is inserted into the anterior portion (front) of the spine. Bone in the anterior portion fuses better because there is more surface area than in the posterolateral gutter, and also because the bone is under compression. Bone in compression heals better because bone responds to stress (Wolff's law), whereas bone under tension (posterolateral fusions) does not see as much stress.

PLIF Potential Risks and Complications

The principal risk of a PLIF is that a solid fusion will not be obtained (nonunion), and further back surgery to re-fuse the spine may be necessary. Fusion rates for a PLIF should be as high as 90-95%. Nonunion rates are higher for patients who have had prior spine surgery, patients who smoke or are obese, patients who have had a multiple level fusion surgery, and for patients who have been treated with radiation for cancer. Not all patients who have a nonunion will need to have another spine fusion procedure.

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As long as the joint is stable, and the patient's symptoms are better, more back surgery is not necessary. Other than nonunion, the risks of a spinal fusion surgery include infection or bleeding. These complications are fairly uncommon (approximately 1% to 3% occurrence). In addition, there is a risk of achieving a successful spine fusion, but the patient's pain does not subside.
Source: http://www.spine-health.com

Posterior Lumbar Interbody Fusion (PLIF): Spinal Stabilization

Introduction Posterior Lumbar Interbody Fusion (PLIF) involves the surgical stabilization and bone grafting of one or more lumbar intervertebral disc spaces using a posterior (from behind) approach. It may be carried out for a variety of indications and there are now many different techniques. PLIF is particularly useful in the correction of degenerative lumbar deformity such as spondylolisthesis, scoliosis or disc space collapse and in the management of associated of neurological compression.

(Left) Pre-operative (Right) Post-operative x-ray of a spondylolisthesis

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First described in the 1940's, PLIF has a number of theoretical advantages over other fusion techniques such as posterior or posterolateral (rear/side) fusion. Nevertheless, the technical demands, variable results and complications associated with the early techniques did not lead to its widespread uptake by surgeons. The newer techniques however, in conjunction with technological advances in interbody implants have made PLIF surgery much more attractive. They have improved the surgical ease and safety while retaining the biomechanical and other advantages of PLIF surgery. History Posterior Lumbar Interbody Fusion (PLIF) was first described by Briggs and Milligan in 19445 using laminectomy bone chips. In 1946, Jaslow7 described posterior interbody fusion, using an excised portion of spinous process, rotated into position within the intervertebral space. It was Cloward however, in the 1950's using impacted blocks of iliac crest (pelvis), who initially popularized PLIF surgery. While some surgeons reported favorably on their early experience with PLIF, difficulties with inconsistent fusion rates and complications related to blood loss, dural/neural injury, graft extrusion, and arachnoiditis (inflammation of a specific spinal cord membrane) limited its appeal.

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Its popularity rose in the 1990's with the advent of supplementary interbody implants (cages) to support and stabilize the disc space while bone graft, placed within the cages, united the bone of the vertebral end-plates (1,4,11). The first of these was the threaded cylindrical fusion cage, initially used by Bagby in horses (13). As with previous PLIF techniques, these implants used the principle of compression-distraction to achieve spinal stabilization. Fusion rates improved with many authors reporting successful fusion in up to 90-95%. Ray (11) reported a 96% fusion rate at 2 year follow-up with 86% satisfactory relief of back or radicular leg pain. More recently, newer and more streamlined impacted implants made of titanium, plastic PEEK polymers (Polyetheretheketone) or allograft bone (donor bone) has gained popularity. In a recent article by Barnes et al (2) they found significantly lower nerve root injury rates with the use of impacted allograft wedges when they compared their earlier experience with allograft cylindrical threaded fusion cages (0% vs. 13.6% respectively). The Insert and Rotate technique of implant placement (see below) is also gaining popularity. Some surgeons are now starting to perform PLIF procedures through minimal access (keyhole) approaches using either impacted or insert and rotate techniques, aided by advances in image-guided / computer assisted technology. Khoo et al (8) have recently written an excellent article on this approach. These minimal access techniques utilize the principles developed for minimal access laminectomy surgery and for image guided pedicle screw stabilization. Advantages The Posterior Lumbar Interbody Fusion (PLIF) procedure has a number of theoretical advantages over other forms of stabilization / fusion surgery:

Intervertebral distraction (separation) enables the restoration of three dimensional spinal alignment / balance and indirect neurological decompression of the neural foraminae (nerve

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passageways) and lateral recesses.

The interbody implants / graft subsequently maintain the disc space height and spinal alignment by supporting the load center.

The intervertebral graft is placed under dynamic compression with potential load sharing depending upon the type of supplementary implants / technique used. The surface area for bone graft healing is maximized (again, depending upon the type of supplementary implants / technique used). Several studies have shown the importance of anterior column structural support following deformity correction, especially of low and high grade spondylolisthesis (3,6,10,11,12). Posterolateral fusion alone in this setting will frequently fail due to the biomechanical stresses placed upon the instrumentation as well as placing the graft under tension rather than compression. In a series of 76 patients undergoing decompression and fusion for spondylolisthesis, Suk (12) found hardware failure in 2 and non-union in 3 out of 40 (7.5%) patients undergoing posterolateral fusion but no nonunion in the 36 patients undergoing PLIF. In the posterolateral group, the mean postoperative correction of the slip was 46.5% but this had reduced to 28.3% at final follow-up. In the PLIF group, mean postoperative correction was 51.6% and was 41.6% at final follow-up. Indications Principal indication: The principle indication for Posterior Lumbar Interbody Fusion (PLIF) surgery is in the stabilization and fusion of the spine following correction of adult spinal deformity. Degenerative deformity is a common and often missed cause of neurological compression. Foraminal stenosis in particular, associated with disc space narrowing, spondylolisthesis (vertebra slips forward), retrolisthesis (vertebra slips backward) or scoliosis may be difficult to relieve without correction of the associated deformity (Figure 1).

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Figure 1. Foraminal stenosis and L5 nerve root compression associated with Lumbosacral (lumbar and sacrum) spondylolisthesis. Secondary indications include:

Surgery for lumbar disc herniation, especially recurrent, lateral or massive disc herniations Failed previous fusions by other techniques Discogenic low back pain

Posterior Lumbar Interbody Fusion (PLIF): Surgical Techniques

The current main techniques of Posterior Lumbar Interbody Fusion (PLIF) surgery all incorporate a supplementary intervertebral implant: Threaded cylindrical cages made of titanium, cortical allograft (donor bone) or synthetic bone. Impacted cages made of titanium, carbon-fiber reinforced or plain PEEK polymer (Polyetheretheketone).

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Impacted wedges made of carbon-fiber reinforced PEEK, plain PEEK polymer or cortical allograft. Inserted and rotated wedges made of carbon-fiber reinforced PEEK or plain PEEK polymer. They all involve an initial laminectomy and a variable amount of removal of the facet joints (medial facetectomy). The latter, which may require complete removal of the facet joints, will depend upon the choice and size of implant, as well as the surgical level. Following decompression of the spinal canal, intervertebral disc space spreaders are used to correct coronal plane deformity (scoliosis) and restore disc space and foraminal height (Figure 2).

Figure 2. Restoration of disc space height with intervertebral spreaders usually reduces slip by ~ 50% Supplementary pedicle screw instrumentation may then be used to complete the correction of any spondylolisthetic deformity (spondylolisthesis) (Figures 3 and 4).

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Figure 3. Spondylolisthesis reduction using a screw thread to apply a powerful posterior translation force.

Figure 4. Complete reduction and PLIF in a 15 year old boy with Grade III spondylolisthesis Most modern techniques rely on supplementary pedicle screw instrumentation to assist the stabilization / deformity correction although some surgeons still regard the distraction (separation)/ compression stabilization achieved by the implants to be satisfactory. In the case of threaded cylindrical cages, bilateral holes are then made, centered upon the disc space and removing several millimeters of the adjacent vertebral end plates. The holes are tapped and the implants, filled with bone graft are screwed into the holes. Care must be taken to avoid injury to the adjacent nerve roots during preparation of

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the holes and implantation of the cages as these devices. With impacted cages / wedges, the posterior disc space is usually overdistracted (separated) to enable an implant of sufficient anterior height to be inserted. A broach (a surgical instrument) may be used to prepare a path through the posterior disc space. The disc space contents and cartilaginous end plates are removed to facilitate fusion. In the case of impacted wedges, bone graft is after loaded into the disc space beside the wedges. The Insert and Rotate technique is similar to the Impacted wedge technique but does not require over-distraction (separation) or involve the cutting of any channel through the posterior end plates. It separates the load bearing and stabilization role from the fusion role. The bone graft is after loaded and placed to either side of the implants. The implant may be made quite lordotic to facilitate restoration of Lordosis (natural inward spinal curvature), especially of the lumbosacral (lumbar / sacrum) segment. Care must be taken to preserve the vertebral end plates upon which the implant will rest. It requires minimal dural / neural retraction (Figure 5). Supplementary pedicle screw instrumentation must be used.

Figure 5. Schematic representation of the difference in the neural retraction required for Threaded Cylindrical, Impacted and Insert and Rotate implant techniques. Both the Impacted and Insert and Rotate techniques are suitable for use with minimal access techniques. Conclusion There seems to be little doubt that if the decision is taken to reduce spinal deformity such as spondylolisthesis, it should be accompanied by anterior column support.

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Modern implants and techniques have improved the ease of Posterior Lumbar Interbody Fusion (PLIF) surgery and greatly reduced the surgical risks. The clinical results have become more reliable with many surgeons now reporting good and excellent results in over 85% of patients. As minimal access techniques and fusion bio-technology continue to develop we can expect to see the clinical outcomes continue to improve. References 1. Bagby G, Kuslich S. Arthrodesis of the lumbar spine utilizing a rigid housing containing bone graft. The BAK interbody fusion method. In: Thalgot J, ed. Manual of Internal Fixation. New York, NY: Raven Press; 1994. 2. Barnes B. Rodts GE Jr. Haid RW Jr. et al. Allograft implants for posterior lumbar interbody fusion: results comparing cylindrical dowels and impacted wedges. Neurosurgery Nov 2002; 51(5):1191-98. 3. Boos N, Marchesi D, Zuber K, Aebi M. Treatment of severe spondylolisthesis by reduction and pedicular fixation. A 4-6 year follow-up study. Spine 1993; 18: 1655-61. 4. Brantigan J, Steffee A, Geiger J. A carbon fiber implant to aid interbody lumbar fusion. Mechanical testing. Spine 1991; 16:S277-82. 5. Briggs H, Milligan P. Chip fusion of the low back following exploration of the spinal canal. J Bone Joint Surg (Am) 1944; 26:125-130. 6. Hu SS, Bradford DS, Transfeldt EE, Cohen M. Reduction of high-grade spondylolisthesis using Edwards instrumentation. Spine 1996; 21:367-71. 7. Jaslow IA. Intercorporal bone graft in spinal fusion after disc removal. Surg Gyn Obstet 1946; 82:215-218. 8. Khoo LT. Palmer S. Laich DT. Fessler RG. Minimally invasive

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percutaneous posterior lumbar interbody fusion. Neurosurgery Nov 2002; 51 S2:166-181. 9. Molinari R, Bridwell K, Lenke L et al. Complications in the surgical treatment of pediatric high-grade isthmic, dysplastic spondylolisthesis: a comparison of three surgical approaches. Spine 1999; 24: 1701-17. 10. Molinari RW. Bridwell KH. Lenke LG. Baldus C. Anterior column support in surgery for high-grade, isthmic spondylolisthesis. Clinical Orthopaedics & Related Research. 2002; 394:109-20. 11. Ray CD. Threaded Titanium cages for lumbar interbody fusions. Spine 1986; 11: 601-606. 12. Suk S, Lee C, Kim W et al. Adding posterior lumbar interbody fusion to pedicle screw fixation after decompression in spondylolytic spondylolisthesis.Spine 1997; 22: 210-219. 13. Wagner PC, Grant BD, Bagby GW: Evaluation of cervical spinal fusion as a treatment in the equine "wobbler" syndrome. Vet Surg 1979; 8: 84-89.
SOURCE: http://www.spineuniverse.com

Spine Surgery: Lumbar Interbody Fusion

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Posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) decompression spine surgery to alleviate back pain
A variety of techniques exist for fusing lumbar spine vertebrae to help alleviate back pain, including posterior, transforaminal, anterior, and lateral lumbar interbody fusion (PLIF, TLIF, ALIF, and LLIF, respectively). The animations below allow an inside view of each of these surgeries.

Posterior Lumbar Interbody Fusion (PLIF)

A posterior lumbar interbody fusion (PLIF) is performed to remove a disc that is the source of back or leg pain and fuse spinal vertebrae with bone grafts. It is called a posterior procedure because the spine is approached through an incision on the back. Instrumentation is used to provide space for placing the grafts and to help stabilize the spine.

Minimally Invasive PLIF

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In patients with spinal instability, instrumentation is used to provide space for placing the grafts and to help stabilize the spine. Using a technique known as minimally invasive surgery, posterior lumbar interbody fusion can, in some patients, be done with a much smaller incision than traditional open spinal surgeries and avoids damaging the low back muscles.

Transforaminal Lumbar Interbody Fusion (TLIF)

As in the posterior lumbar interbody fusion (PLIF) procedure, a bone graft is used to fuse the spinal vertebrae after the disc is removed. However, the TLIF procedure places a single bone graft between the vertebrae from the side, rather than two bone grafts from the rear, as in the PLIF procedure. Inserting the graft from the side where the facet joint has been removed is an effort to avoid moving or damaging nerve roots during the procedure.

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Minimally Invasive TLIF
In patients with spinal instability, instrumentation is used to help stabilize the spine during the bone graft fusion. Using minimally invasive surgery, transforaminal lumbar interbody fusion can be done in certain patients with a much smaller incision than traditional open spinal surgeries, decreasing damage to the low back muscles.

Anterior Lumbar Interbody Fusion (ALIF)

This surgery is performed to remove a large portion of a degenerated disc that is frequently the source of back or leg pain. This procedure makes space between the vertebral bodies, relieving pressure and creating more room for spinal nerves to exit. It is called an anterior procedure because the spine is approached from the front. Unlike posterior approaches (from the back), the anterior approach avoids damage to the low back muscles. The removed disc portion is replaced with implanted bone grafting materials, and adjacent vertebral bodies fuse to provide support.

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Lateral Lumbar Interbody Fusion (LLIF)

This procedure, also known as lateral access spine surgery, is a minimally invasive surgery that accesses the spine from incisions on the side of the body. This procedure avoids separating the low back muscles, cutting bone, or moving aside blood vessels as required for other minimally invasive spine fusion procedures (PLIF, TLIF, ALIF). Lateral access spine surgery can treat a variety of conditions including herniations, asymmetric disc degeneration (degenerative scoliosis), nerve impingement, certain tumors, and as discussed in this animation, instability and pain resulting from disc degeneration.

SOURCE: http://www.hss.edu

Posterior Lumbar Interbody Fusion

Introduction

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Posterior lumbar interbody fusion (PLIF) is a procedure used to treat problems such as disc degeneration, disc herniation, and spine instability. In this procedure, the surgeon works on the spine from the back (the posterior) and removes a spinal disc in the lower (lumbar) spine. The surgeon inserts bone graft material into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage. The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone (known as a fusion). A fusion creates a rigid and immovable column of bone in the problem section of the spine. This guide will help you understand

what surgeons hope to achieve what happens during surgery what to expect as you recover

Anatomy
What parts of the spine and low back are involved? This surgery is done through an incision in the low back. The incision reaches to the spinous processes, the bony projections off the back of the vertebrae. A large block of bone, called the vertebral body makes up the front section of each vertebra.

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The vertebral bodies are separated by a soft cushion called an intervertebral disc. On the back of the vertebral body, the lamina and pedicle bones form a protective ring around the spinal canal. The spinal nerves are enclosed in the spinal canal and exit through small openings on the sides of each vertebral pair, one on the left and one on the right. These passageways are called the neural foramina. (The

term neural foramen describes a

single passageway).

Rationale
What do surgeons hope to achieve?

This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate, or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc begins to collapse, and the space decreases between the vertebrae. When this happens, the openings around the spinal nerves (the neural foramina) narrow and may put pressure on the nerves. The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may even buckle and put pressure on the spinal nerves.

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Pain from disc degeneration can come from a tear in the outer portion of the disc, from chemical inflammation inside the disc, or from a herniated disc that pushes on a nearby spinal nerve. Mechanical pain can also occur from excess movement within the problem part of the spine. Discectomy is the removal of the disc and any fragments between the vertebrae that are to be fused. Taking out the painful disc is intended to relieve symptoms. It also provides room for placing a graft that will allow the two vertebrae to fuse together.

Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make room to implant bone graft material. Bone graft is commonly taken from the rim of the pelvis and packed in a special case, called a fusion cage. Bone taken from your own body is called autograft. Bone substitutes are also being used and avoid the need for taking bone from your pelvis. Another option is to use a wedge of hard, cortical bone taken from preserved human bone. This source of bone graft is called allograft. During the PLIF procedure, the cage or bone wedge is implanted into the interbody space. The PLIF method provides a large surface area for fusion to occur.

The graft creates a solid spacer to separate and hold the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina,

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taking pressure off the spinal nerves that pass through these openings. Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don't buckle into the spinal canal. The surgeon also fixes the bones in place using pedicle screws. Thisinstrumentation (or hardware, as it is sometimes called) holds the vertebrae together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. The use of instrumentation has increased the success rate of spinal fusions considerably.

During the PLIF procedure, surgeons also commonly add bone graft material along the back sides of the spine. This step is calledposterolateral bone grafting. When combined with instrumentation, this approach helps fuse a large surface area on the back (posterior column) of the spine. In a successful fusion, the vertebrae that are fused together no longer move against one another. The fusion creates one solid bone. No movement happens within the bones that are fused. Instead, they move as one unit. This helps stop the mechanical pain that was coming from the moving parts of the back. Fusion also prevents additional wear and tear on the spinal segment that was fused. By fusing the bones together, surgeons hope to reduce future problems at the spinal segment.

Preparations
How will I prepare for surgery?

Inside Me..
The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon. Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation. On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn't eat or drink anything after midnight the night before.

Surgical Procedure
What happens during the operation? Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs. During surgery the patient usually kneels face down on a special operating table. The special table supports the patient so the abdomen is relaxed and free of pressure. This position reduces blood loss during surgery. It also gives the surgeon more room to work. Two measurements are made before surgery begins. The first measurement ensures that the surgeon chooses a fusion cage or bone wedge that will fit inside the disc space. To correctly size the fusion cage or bone wedge, the surgeon uses an X-ray image to measure the disc space in a healthy disc, above or below the problem segment. Second, to size the length of the pedicle screws, a CT scan is used to measure the length of the pedicle bone on the back of the vertebrae to be

Inside Me..
fused. The CT scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices.

To begin the procedure, an incision is made down the middle of the low back. The tissues just under the skin are separated. Then the small muscles along the sides of the low back are moved aside, exposing the back of the spinal column. Next, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct vertebrae. The bone graft is prepared. When autograft (bone taken from your body) is used, the same incision made at the beginning of the surgery can be used. The surgeon reaches through the first incision and opens the tissues that cover the back of the pelvis. Anosteotome is used to cut the surface of the pelvis bone. An instrument is used to gather a small amount of the pelvis bone. The graft material is prepared and will later be packed into the fusion cages. The tissues covering the pelvis bone are sutured.

Then the surgeon prepares to implant bone graft into the space between the vertebral bodies. The surgeon removes the lamina bones that cover the back of the spinal canal. Next, the surgeon cuts a small opening in theligamentum flavum, an elastic ligament separating the lamina bones and the spinal nerves. Removing the ligamentum flavum allows the surgeon to see inside the spinal canal. The nerves are checked for tension where they exit the spinal canal. If a nerve root is under

Inside Me..
tension, the surgeon enlarges the neural foramen, the opening where the nerve travels out of the spinal canal. The surgeon locates the spot where the pedicle screws are to be placed. A fluoroscope is used to visualize the pedicle bones. A fluoroscope is a special type of X-ray that allows the surgeon to see an X-ray picture continuously on a TV screen. The surgeon uses the fluoroscope to guide one screw through the back of each pedicle, one on the left and one on the right. The nerve roots inside the spinal canal are then pulled aside with a retractor so the problem disc can be examined. With the nerves held to the side, the surgeon is able to see the disc where it sits just in front of the spinal canal.

A hole is cut into the rim of the back of the disc. Forceps are placed inside the hole in order to clean out disc material within the disc. Reamers and scrapers are used to open up and remove additional disc material. The surgeon prepares the disc space where the fusion cages or bone wedges are to be inserted. Special spreaders hold the two vertebral bodies apart. A layer of bone is shaved off the flat surfaces of the two vertebrae, causing the surfaces to bleed. Bleeding stimulates the bone graft to heal the bones together. Adequate room is needed to get the bone graft implants through the spinal column and into the disc space. The nerve roots must be pulled as far to the side as possible to open up enough space. With the disc space held apart by the spreaders, the surgeon has enough room to place the bone graft between the two vertebral bodies. For the fusion cage method, the

Inside Me..
surgeon packs two cages with bone taken from the pelvis bone or with a suitable bone substitute. Two cages are inserted, one on the left and one on the right. When allograft bone wedges are used, the surgeon inserts the wedges and aligns them within the disc space.

The surgeon uses a fluoroscope to check the position and fit of the graft.

The spreaders used to hold the disc space apart are released. Then the doctor tests the graft by bending and turning the spine to make sure the graft is in the right spot and is locked in place.

Some surgeons add strips of bone graft along the back of the vertebrae to be fused. This is calledposterolateral fusion. The bones that project out from each side of the back of the spine are calledtransverse processes. The back surface of the transverse processes are shaved, causing the surfaces to bleed. Small strips of bone, usually taken from the pelvis bone at the beginning of the surgery, are placed over the transverse processes. The

Inside Me..
combination of this graft material with the pedicle screws helps hold the spine steady as the interbody fusion heals. A drainage tube may be placed in the wound. The muscles and soft tissues are then put back in place. The skin is stitched together. The surgeon may place you in a rigid brace that straps across the chest, pelvis, and low back to support the spine while it heals.

Complications
What might go wrong? As with all major surgical procedures, complications can occur. Some of the most common complications following PLIF include

problems with anesthesia thrombophlebitis infection nerve damage problems with the implant or hardware nonunion ongoing pain

This is not intended to be a complete list of possible complications. Problems with Anesthesia Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don't expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist. Thrombophlebitis (Blood Clots)

Inside Me..
Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can happen after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, andembolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include pressure stockings to keep the blood in the legs moving medications that thin the blood and prevent blood clots from forming Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin's surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine. Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the

Inside Me..
nerve, or from the formation of scar tissue. The nerve roots inside the spinal canal are especially at risk during the PLIF procedure. Retractors are used to hold the nerves aside and may cause muscle weakness and a loss of sensation to the areas supplied by an injured nerve. Pressure on the nerves that supply the bowels and bladder can cause incontinence. However, these types of nerve problems after PLIF usually go away soon after surgery. Problems with the Implant or Hardware Fusion surgery with cages requires bone grafting. The graft is commonly taken from the top rim of the pelvis (autograft). There is a risk of pain, infection, or weakness in the area where the graft is taken. These risks are avoided when a bone graft substitute is used in place of an autograft. After the interbody implant is placed, the surgeon checks the position of the fusion cage or bone wedge before completing the surgery. However, the implant may shift slightly soon after surgery to the point that it is no longer able to hold the spine stable. If the implant migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align or replace the implant. Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues. Also, the metal plates can sometimes break. If this happens, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem. Nonunion

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Sometimes the bones do not fuse as planned. This is called a nonunion, orpseudarthrosis. (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. (Fusion of more than one level means two or more consecutive discs are removed and replaced with bone graft.) If the joint motion from a nonunion continues to cause pain, the patient may need a second operation. In the second procedure, the surgeon usually adds more bone graft. Additional instrumentation may also be needed to rigidly secure the bones so they will fuse together. Ongoing Pain PLIF is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, patients should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

Afterward
What happens after surgery? Patients are sometimes placed in a rigid body brace after surgery. The surgical drain is removed within one to two days. Patients usually stay in the hospital after surgery for three to five days. During this time, patients work daily with a physical therapist. The therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help control pain and avoid problems. Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in

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order to give the fusion time to begin healing. Patients are cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy is usually started a minimum of six weeks after the date of surgery.

Rehabilitation
What should I expect as I recover? Rehabilitation after PLIF can be a slow process. Many surgeons prescribe outpatient physical therapy beginning a minimum of six weeks after surgery. This delay is needed to make sure the graft has time to begin to fuse. You will probably need to attend therapy sessions for two to three months. You should expect full recovery to take up to eight months. At first, treatments are used to help control pain and inflammation. Ice and electrical stimulationare commonly used to help with these goals. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain. Active treatments are slowly added. These include exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and use of a stairclimbing machine are helpful in the later phases of treatment. Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back.

Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions

Inside Me..
you use when sitting, lying, standing, and walking. You'll also work on safe body mechanics with lifting, carrying, pushing, and pulling. As your condition improves, the therapist tailors your program to prepare you to go back to work. Some patients are not able to go back to a job that requires strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job or to do alternate forms of work. You'll learn to do these tasks in new ways that keep your back safe and free of strain. Before your therapy sessions end, your therapist will teach you ways to avoid future problems.
SOURCE: http://www.eorthopod.com

Posterior Lumbar Interbody Fusion

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Introduction
Posterior lumbar interbody fusion (PLIF) is a procedure used to treat problems such as disc degeneration, disc herniation, and spine instability. In this procedure, the surgeon works on the spine from the back (the posterior) and removes a spinal disc in the lower (lumbar) spine. The surgeon inserts bone graft material into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage. The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone (known as a fusion). A fusion creates a rigid and immovable column of bone in the problem section of the spine.

Inside Me..
This guide will help you understand

what surgeons hope to achieve what happens during surgery what to expect as you recover

Anatomy
What parts of the spine and low back are involved? This surgery is done through an incision in the low back. The incision reaches to thespinous processes, the bony projections off the back of the vertebrae. A large block of bone, called the vertebral body makes up the front section of each vertebra. The vertebral bodies are separated by a soft cushion called an intervertebral disc.

Inside Me..

On the back of the vertebral body, the lamina and pedicle bones form a protective ring around the spinal canal. The spinal nerves are enclosed in the spinal canal and exit through small openings on the sides of each vertebral pair, one on the left and one on the right. These passageways are called the neural foramina. (The term neural foramendescribes a single passageway).

Rationale
What do surgeons hope to achieve? This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate, or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc

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begins to collapse, and the space decreases between the vertebrae. When this happens, the openings around the spinal nerves (the neural foramina) narrow and may put pressure on the nerves. The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may even buckle and put pressure on the spinal nerves. View animation of degeneration Pain from disc degeneration can come from a tear in the outer portion of the disc, from chemical inflammation inside the disc, or from a herniated disc that pushes on a nearby spinal nerve. Mechanical pain can also occur from excess movement within the problem part of the spine. Discectomy is the removal of the disc and any fragments between the vertebrae that are to be fused. Taking out the painful disc is intended to relieve symptoms. It also provides room for placing a graft that will allow the two vertebrae to fuse together. Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make room to implant bone graft material. Bone graft is commonly taken from the rim of the pelvis and packed in a special case, called a fusion cage. Bone taken from your own body is called autograft. Bone substitutes are also being used and avoid the need for taking bone from your pelvis. Another option is to use a wedge of hard, cortical bone taken from preserved human bone. This source of bone graft is called allograft. During the PLIF procedure, the cage or bone

Inside Me..
wedge is implanted into the interbody space. The PLIF method provides a large surface area for fusion to occur. The graft creates a solid spacer to separate and hold the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through these openings. Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don't buckle into the spinal canal. View animation of creating a spacer The surgeon also fixes the bones in place using pedicle screws. This instrumentation (orhardware, as it is sometimes called) holds the vertebrae together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. The use of instrumentation has increased the success rate of spinal fusions considerably. During the PLIF procedure, surgeons also commonly add bone graft material along the back sides of the spine. This step is called posterolateral bone grafting. When combined with instrumentation, this approach helps fuse a large surface area on the back (posterior column) of the spine. In a successful fusion, the vertebrae that are fused together no longer move against one another. The fusion creates one solid bone. No movement happens within the bones that are fused. Instead, they move as one unit. This helps stop the mechanical pain that was coming from the moving parts of the back. Fusion also prevents additional wear and tear

Inside Me..
on the spinal segment that was fused. By fusing the bones together, surgeons hope to reduce future problems at the spinal segment. Preparations How will I prepare for surgery? The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon. Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation. On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn't eat or drink anything after midnight the night before.

Surgical Procedure
What happens during the operation? Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

Inside Me..
During surgery the patient usually kneels face down on a special operating table. The special table supports the patient so the abdomen is relaxed and free of pressure. This position reduces blood loss during surgery. It also gives the surgeon more room to work. Two measurements are made before surgery begins. The first measurement ensures that the surgeon chooses a fusion cage or bone wedge that will fit inside the disc space. To correctly size the fusion cage or bone wedge, the surgeon uses an X-ray image to measure the disc space in a healthy disc, above or below the problem segment. Second, to size the length of the pedicle screws, a CT scan is used to measure the length of the pedicle bone on the back of the vertebrae to be fused. The CT scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices. To begin the procedure, an incision is made down the middle of the low back. The tissues just under the skin are separated. Then the small muscles along the sides of the low back are moved aside, exposing the back of the spinal column. Next, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct vertebrae. The bone graft is prepared. When autograft (bone taken from your body) is used, the same incision made at the beginning of the surgery can be used. The surgeon reaches through the first incision and opens the tissues that cover the back of the pelvis. Anosteotome is used to cut the surface of the pelvis bone. An instrument is used to gather

Inside Me..
a small amount of the pelvis bone. The graft material is prepared and will later be packed into the fusion cages. The tissues covering the pelvis bone are sutured. Then the surgeon prepares to implant bone graft into the space between the vertebral bodies. The surgeon removes the lamina bones that cover the back of the spinal canal. Next, the surgeon cuts a small opening in the ligamentum flavum, an elastic ligament separating the lamina bones and the spinal nerves. Removing the ligamentum flavum allows the surgeon to see inside the spinal canal. The nerves are checked for tension where they exit the spinal canal. If a nerve root is under tension, the surgeon enlarges theneural foramen, the opening where the nerve travels out of the spinal canal. The surgeon locates the spot where the pedicle screws are to be placed. A fluoroscope is used to visualize the pedicle bones. A fluoroscope is a special type of X-ray that allows the surgeon to see an X-ray picture continuously on a TV screen. The surgeon uses the fluoroscope to guide one screw through the back of each pedicle, one on the left and one on the right. The nerve roots inside the spinal canal are then pulled aside with a retractor so the problem disc can be examined. With the nerves held to the side, the surgeon is able to see the disc where it sits just in front of the spinal canal. A hole is cut into the rim of the back of the disc. Forceps are placed inside

Inside Me..
the hole in order to clean out disc material within the disc. Reamers and scrapers are used to open up and remove additional disc material. The surgeon prepares the disc space where the fusion cages or bone wedges are to be inserted. Special spreaders hold the two vertebral bodies apart. A layer of bone is shaved off the flat surfaces of the two vertebrae, causing the surfaces to bleed. Bleeding stimulates the bone graft to heal the bones together. Adequate room is needed to get the bone graft implants through the spinal column and into the disc space. The nerve roots must be pulled as far to the side as possible to open up enough space. With the disc space held apart by the spreaders, the surgeon has enough room to place the bone graft between the two vertebral bodies. For the fusion cage method, the surgeon packs two cages with bone taken from the pelvis bone or with a suitable bone substitute.Two cages are inserted, one on the left and one on the right. When allograft bone wedges are used, the surgeon inserts the wedges and aligns them within the disc space. The surgeon uses a fluoroscope to check the position and fit of the graft. The spreaders used to hold the disc space apart are released. Then the doctor tests the graft by bending and turning the spine to make sure the graft is in the right spot and is locked in place.

Inside Me..
Some surgeons add strips of bone graft along the back of the vertebrae to be fused. This is called posterolateral fusion. The bones that project out from each side of the back of the spine are called transverse processes. The back surface of the transverse processes are shaved, causing the surfaces to bleed. Small strips of bone, usually taken from the pelvis bone at the beginning of the surgery, are placed over the transverse processes. Thecombination of this graft material with the pedicle screws helps hold the spine steady as the interbody fusion heals. A drainage tube may be placed in the wound. The muscles and soft tissues are then put back in place. The skin is stitched together. The surgeon may place you in a rigid brace that straps across the chest, pelvis, and low back to support the spine while it heals.

Complications
What might go wrong? As with all major surgical procedures, complications can occur. Some of the most common complications following PLIF include

problems with anesthesia thrombophlebitis infection nerve damage problems with the implant or hardware nonunion

Inside Me..

ongoing pain This is not intended to be a complete list of possible complications. Problems with Anesthesia Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don't expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can happen after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

pressure stockings to keep the blood in the legs moving

Inside Me..

medications that thin the blood and prevent blood clots from forming

Infection
Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin's surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage
Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. The nerve roots inside the spinal canal are especially at risk during the PLIF procedure. Retractors are used to hold the nerves aside and may cause muscle weakness and a loss of sensation to the areas supplied by an injured nerve. Pressure on the nerves that supply the bowels and bladder

Inside Me..
can cause incontinence. However, these types of nerve problems after PLIF usually go away soon after surgery.

Problems with the Implant or Hardware

Fusion surgery with cages requires bone grafting. The graft is commonly taken from the top rim of the pelvis (autograft). There is a risk of pain, infection, or weakness in the area where the graft is taken. These risks are avoided when a bone graft substitute is used in place of an autograft. After the interbody implant is placed, the surgeon checks the position of the fusion cage or bone wedge before completing the surgery. However, the implant may shift slightly soon after surgery to the point that it is no longer able to hold the spine stable. If the implant migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align or replace the implant. Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues. Also, the metal plates can sometimes break. If this happens, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Nonunion
Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. (Fusion of

Inside Me..
more than one level means two or more consecutive discs are removed and replaced with bone graft.) If the joint motion from a nonunion continues to cause pain, the patient may need a second operation. In the second procedure, the surgeon usually adds more bone graft. Additional instrumentation may also be needed to rigidly secure the bones so they will fuse together.

Ongoing Pain
PLIF is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, patients should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.
SOURCE: http://www.orthogate.org

Posterior Lumbar Interbody Fusion When fusion surgery is needed for mild spondylolisthesis (up to 50 percent slippage), posterior lumbar interbody fusion may be considered. In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back). Combining fusion of both portions of the spine increases the fusion surface area and improves the fusion rate. The surgeon works from the back of the spine and removes the disc between the problem vertebrae. Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage that spreads and holds the vertebrae apart. Surgeons usually apply some form of instrumentation (described above) on the back of the vertebrae. In some cases, additional strips of bone graft are placed along the

Inside Me..
back surfaces of the vertebrae to be fused. This increases the mechanical strength of the spine. Fusion with Biologics New materials for fusion are being developed and tested. For example, bone morphogenetic proteins (BMP) mixed with bone graft in a putty is under investigation. This substance may help reduce the need for instrumentation with fusion. BMP helps promote faster and more bone growth in the unstable spinal segment. Studies of safety and effectiveness of this material have been very favorable so far. Without the need to harvest bone graft and place instrumentation, surgical time is much less with BMP putty. And the fusion rate is much higher with BMP alone compared with fusion alone or fusion with fixation. Motion-Sparing Technologies The Food and Drug Administration (FDA) is reviewing the use of devices inserted without invasive surgery to limit vertebral motion. For example, a special titanium implant has been designed to fit between the spinous processes of the vertebrae in your lower back. These motion-sparing devices are currently used with patients who have spinal stenosis(narrowing of the spinal canal or foramen). With spondylolisthesis, the goal is to reduce the load on the disc and facets while increasing the space inside the spinal canal and foramen, thus relieving your symptoms. The vertebral segment is stabilized enough to prevent further progression of the spondylolisthesis.

Rehabilitation
What should I expect as I recover?

Nonsurgical Rehabilitation

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Back pain associated with spondylolisthesis will gradually improve in up to one-third of all patients. Slippage of one vertebra over the other does not increase in this group. Worsening of symptoms is not expected in patients who don't have neurologic symptoms at the time of diagnosis. Nonsurgical treatment for spondylolisthesis commonly involves physical therapy. Your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care. The first goal of treatment is to control symptoms. Your therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulationmay be used to calm pain and muscle spasm. Patients are shown how to stretch tight muscles, especially the hamstring muscles on the back of the thigh. As patients recover, they gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move easier and lessens the chances of future pain and problems.

A primary purpose of therapy is to help you learn how to take care of your symptoms and prevent future problems. You'll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also describe strategies you can use if your symptoms flare up.

After Surgery

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Rehabilitation after surgery is more complex. Patients who have surgery for spondylolisthesis usually stay in the hospital for a few days afterward. Some surgeons require patients to wear a rigid brace or cast for up to four months after fusion surgery for spondylolisthesis. Patients who've had fusion surgery for a severe slip may also be required to stay off their feet for four months. After lumbar fusion surgery for spondylolisthesis, patients must normally wait four months before beginning a rehabilitation program. This delay is needed to give the fusion a chance to start healing. Patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take at least 12 months. Ideally, patients are able to return to their previous activities. However, some patients may need to modify or discontinue certain activities to avoid future problems. When your treatment is well under way, regular visits to the therapist's office will end. The therapist will continue to be a resource for you. But you will be in charge of doing your exercises as part of an ongoing home program.
SOURCE: http://www.eorthopod.com

Special Thanks To.. Mr Fazli, Orthopaedic Surgeon HTJS Mr Raof, Head department of Orthopaedic Clinic Orthopaedic 3B Ward, HTJS Orthopaedic Clinic, HTJS