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Spondylolysis/Spondylolisthesis, Emergency Medicine

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Spondylolysis/Spondylolisthesis, Emergency Medicine

Basics

Description

Unknown; theories include congenital pars anomalies, alterations in bone density, and recurrent subclinical stress injury. é á

Vigorous attempts at traction should not be pursued. é á

Close follow-up is mandatory. é á

  • Spondylolysis:Bony defect at the pars interarticularis (the isthmus of bone between the superior and inferior facets)Can be unilateral or bilateralBilateral form has a much higher likelihood of slippage or spondylolisthesis than the unilateral form.
  • Spondylolisthesis:The slipping forward of 1 vertebra upon anotherSpondylolysis can contribute to spondylolisthesis, which is noted in ó ł ╝5% of the population. It is 2 " ô4 times more common in males.Of those with spondylolysis, 50% will have some degree of spondylolisthesis develop during their lifetime, and 50% of those will be symptomatic:Literature does not associate athletic activity with increased slippage.Spondylolisthesis predisposes to nerve root impingement and frequently sciatica.
  • Classification:Type 1 " ödysplastic: Congenital defect of the neural arch or intra-articular facets is often associated with spina bifida occultaType 2 " öisthmic: Stress fracture from repetitive microtrauma through the neural archType 3 " ödegenerative: Long-standing segmental instabilityType 4 " ötraumaticType 5 " öpathologic: Generalized or focal bone diseaseSpondylolisthesis is divided into 4 grades based on degree of slippage (Meyerding grading system):Grade I: Up to 25% of the vertebral body widthGrade II: 26 " ô50% of vertebral body widthGrade III: 51 " ô75% of vertebral body widthGrade IV: 76 " ô100% of vertebral body widthThe most common location for spondylolisthesis is L5 displaced on the sacrum (85 " ô95%), followed by L4 on L5.
  • Bony defect at the pars interarticularis (the isthmus of bone between the superior and inferior facets)
  • Can be unilateral or bilateral
  • Bilateral form has a much higher likelihood of slippage or spondylolisthesis than the unilateral form.
  • The slipping forward of 1 vertebra upon another
  • Spondylolysis can contribute to spondylolisthesis, which is noted in ó ł ╝5% of the population. It is 2 " ô4 times more common in males.
  • Of those with spondylolysis, 50% will have some degree of spondylolisthesis develop during their lifetime, and 50% of those will be symptomatic:
  • Literature does not associate athletic activity with increased slippage.
  • Spondylolisthesis predisposes to nerve root impingement and frequently sciatica.
  • Type 1 " ödysplastic: Congenital defect of the neural arch or intra-articular facets is often associated with spina bifida occulta
  • Type 2 " öisthmic: Stress fracture from repetitive microtrauma through the neural arch
  • Type 3 " ödegenerative: Long-standing segmental instability
  • Type 4 " ötraumatic
  • Type 5 " öpathologic: Generalized or focal bone disease
  • Spondylolisthesis is divided into 4 grades based on degree of slippage (Meyerding grading system):Grade I: Up to 25% of the vertebral body widthGrade II: 26 " ô50% of vertebral body widthGrade III: 51 " ô75% of vertebral body widthGrade IV: 76 " ô100% of vertebral body width
  • The most common location for spondylolisthesis is L5 displaced on the sacrum (85 " ô95%), followed by L4 on L5.
  • Grade I: Up to 25% of the vertebral body width
  • Grade II: 26 " ô50% of vertebral body width
  • Grade III: 51 " ô75% of vertebral body width
  • Grade IV: 76 " ô100% of vertebral body width
  • Spondylolysis is one of the most common causes of serious low back pain in children, although it is most often asymptomatic.
  • Symptoms most often present during adolescent growth spurt from age 10 " ô15 yr.
  • Seen commonly in athletic teens; particularly in sports involving back hyperextension (e.g., gymnastics, diving, football).
  • Acute symptoms are related to trauma.

Etiology

Diagnosis

Signs and Symptoms

  • Onset often gradual, unless traumatic
  • Often associated with feeling of stiffness or spasm in paravertebral muscles
  • Pain in the back and proximal legs aggravated by standing and walking
  • Sitting or forward bending relieves pain.
  • Pain occurs after varying amounts of exercise, with standing, or with coughing:Aggravating factors can include repetitive hyperextending movements.Alleviating factors can include rest, although the course is variable and slow and usually requires sitting or stooping positions.
  • Systemic/neurologic symptoms: Minimal, unless there is significant trauma or "slip. " Ł
  • Aggravating factors can include repetitive hyperextending movements.
  • Alleviating factors can include rest, although the course is variable and slow and usually requires sitting or stooping positions.
  • Hyperlordotic posture:Trunk may appear shortened.Rib cage approaches iliac crests.
  • Hamstring tightness:Knees flexed to allow patient to stand upright
  • Only "typical " Ł finding is 1-legged hyperextension:Standing on 1 leg and leaning backward reproduces pain on ipsilateral side.
  • Palpation may reveal step-off with a prominent spinous process of L5 in significant spondylolisthesis.
  • Neurologic exam is usually normal:If abnormal, pain and sensorimotor loss is in a dermatomal distribution.Consider herniation or spondylolisthesis.
  • Trunk may appear shortened.
  • Rib cage approaches iliac crests.
  • Knees flexed to allow patient to stand upright
  • Standing on 1 leg and leaning backward reproduces pain on ipsilateral side.
  • If abnormal, pain and sensorimotor loss is in a dermatomal distribution.
  • Consider herniation or spondylolisthesis.
  • Spondylolysis in a child <10 yr is rare; these patients should be watched for the following:Constant pain lasting several weeksPain occurring spontaneously at nightPain that interferes repeatedly with school, play, or sportsPain associated with marked stiffness, limitation of motion, fever, or neurologic signsPain at the lumbosacral junction
  • Constant pain lasting several weeks
  • Pain occurring spontaneously at night
  • Pain that interferes repeatedly with school, play, or sports
  • Pain associated with marked stiffness, limitation of motion, fever, or neurologic signs
  • Pain at the lumbosacral junction

Diagnosis Tests & Interpretation

  • Lumbosacral spine radiographs:Lateral and oblique radiographs of spine most helpful.Spondylolysis will manifest as a radiolucent defect in the pars interarticularis, visible as a "collar " Ł or "broken neck " Ł on the oblique view "Scottie dog " ŁSecondary radiographic signs may include sclerosis of the contralateral pedicle and spina bifida occulta at the level of the spondylolysis.Majority (80 " ô95%) found at L5 " ôS1 level, 15% at L4 " ôL5.Spondylolisthesis will manifest as forward slipping of one vertebral body on another (seen on lateral view).
  • Single photon emission computed tomography (SPECT) " öbetter specificity for linking back pain to spondylolysis.
  • CT scan:Pathology more clearly demonstrated than on plain filmsCan identify other spinal pathologyPlays an important role for orthopedics in management decisions through identification of new stress fractures and healing of old stress fractures.If a CT scan is obtained in the ED, sagittal reconstructions should be performed and the CT scanner should be at minimum a 16-slice scanner.Outpatient evaluation unless history of recent trauma.
  • MRI " öexact role not yet clarified in literature:Useful for defining nerve root impingement and central canal and neuroforaminal narrowing.May be useful in the assessment of acuity of abnormality.Can identify alternate pathologic diagnoses.
  • Lateral and oblique radiographs of spine most helpful.
  • Spondylolysis will manifest as a radiolucent defect in the pars interarticularis, visible as a "collar " Ł or "broken neck " Ł on the oblique view "Scottie dog " Ł
  • Secondary radiographic signs may include sclerosis of the contralateral pedicle and spina bifida occulta at the level of the spondylolysis.
  • Majority (80 " ô95%) found at L5 " ôS1 level, 15% at L4 " ôL5.
  • Spondylolisthesis will manifest as forward slipping of one vertebral body on another (seen on lateral view).
  • Pathology more clearly demonstrated than on plain films
  • Can identify other spinal pathology
  • Plays an important role for orthopedics in management decisions through identification of new stress fractures and healing of old stress fractures.
  • If a CT scan is obtained in the ED, sagittal reconstructions should be performed and the CT scanner should be at minimum a 16-slice scanner.
  • Outpatient evaluation unless history of recent trauma.
  • Useful for defining nerve root impingement and central canal and neuroforaminal narrowing.
  • May be useful in the assessment of acuity of abnormality.
  • Can identify alternate pathologic diagnoses.
  • Lower threshold for ordering imaging studies.
  • Progressive slipping more likely to occur than in adults.

Differential Diagnosis

  • Tuberculosis (Pott disease)
  • Discitis
  • Bone or spinal cord tumor
  • Pyelonephritis
  • Retroperitoneal infection
  • Injury to muscles or joints of back
  • Congenital hip dislocation
  • Rickets
  • Ruptured intervertebral disc
  • Vascular claudication
  • Osteomyelitis
  • Osteoid osteoma
  • Aortic aneurysm

Treatment

Pre-Hospital

Initial Stabilization/Therapy

Ed Treatment/Procedures

  • Pain control and muscle relaxants as clinically needed
  • Supportive therapy if symptoms are mild
  • Restrict activities if repetitive trauma is likely aggravating cause (e.g., sports) for 3 " ô6 wk, followed by reintroduction of activity when asymptomatic.
  • Consider antilordotic braces (controversial) or physical therapy.
  • Orthopedic consult or referral if symptoms are moderate to severe or unresponsive to supportive care
  • Surgical intervention typically consists of spinal fusion in the flexed position:50% of symptomatic patients with spondylolisthesis may require surgery.
  • All symptomatic patients with grade III or IV spondylolisthesis should probably undergo surgery.
  • Exercises are not of proven benefit.
  • 50% of symptomatic patients with spondylolisthesis may require surgery.
  • Activity restriction is not necessary if minimal or no symptoms.
  • Literature suggests good outcome for young athletes with conservative treatment.

Medication

  • Muscle relaxants:E.g. " ömethocarbamol: 1,000 " ô1,500 mg PO QID (peds: Safety and effectiveness for children <12 yr of age not established)Diazepam: 2 " ô10 mg PO TID " ôQIDCyclobenzaprine: 5 " ô10 mg PO TID (peds: Safe for ages >15 yr old)
  • NSAIDs:E.g. " öibuprofen: 200 " ô800 mg PO TID " ôQID (peds: 5 " ô10 mg/kg PO q6h)
  • Opioids (doses can vary on oral medications):Example " ömorphine sulfate: 0.1 mg/kg up to 2 " ô4 mg increments IV.Acetaminophen/hydrocodone: 5/500 mg 1 " ô2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)Acetaminophen/oxycodone: 5/325 mg 1 " ô2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)Acetaminophen/codeine: 300/30 mg 1 " ô2 tabs PO QID (peds: 0.5 " ô1 mg/kg codeine PO q4 " ô6h; max. 60 mg/dose codeine; 1 g/dose, 75 mg/kg/d up to 4 g/d >3 yr old); do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)
  • E.g. " ömethocarbamol: 1,000 " ô1,500 mg PO QID (peds: Safety and effectiveness for children <12 yr of age not established)
  • Diazepam: 2 " ô10 mg PO TID " ôQID
  • Cyclobenzaprine: 5 " ô10 mg PO TID (peds: Safe for ages >15 yr old)
  • E.g. " öibuprofen: 200 " ô800 mg PO TID " ôQID (peds: 5 " ô10 mg/kg PO q6h)
  • Example " ömorphine sulfate: 0.1 mg/kg up to 2 " ô4 mg increments IV.
  • Acetaminophen/hydrocodone: 5/500 mg 1 " ô2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)
  • Acetaminophen/oxycodone: 5/325 mg 1 " ô2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)
  • Acetaminophen/codeine: 300/30 mg 1 " ô2 tabs PO QID (peds: 0.5 " ô1 mg/kg codeine PO q4 " ô6h; max. 60 mg/dose codeine; 1 g/dose, 75 mg/kg/d up to 4 g/d >3 yr old); do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " ô15 mg/kg acetaminophen in 24 hr)

Follow-Up

Disposition

  • Inability to walk
  • Inability to cope at home due to pain or social situation
  • New or progressive neurologic deficit
  • Orthopedic follow-up arranged
  • Social support system in place
  • Pain control
  • Patient education

Additional Reading

  • Clifford é áR, Wheeless é áIII. Wheeless Textbook of Orthopaedics. Spondylolysis/Spondylolisthesis. Accessed on April 25, 2012.
  • Congeni é áJ, McCulloch é áJ, Swanson é áK. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med. 1997;25(2):248 " ô253.
  • Iwamoto é áJ, Takeda é áT, Wakano é áK. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports. 2004;14(6):346 " ô351.
  • Tsirikos é áAI, Garrido é áEG. Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010;92(6):751 " ô759. doi:10.1302/0301-620X.92B6.23014.

Codes

ICD9

  • 738.4 Acquired spondylolisthesis
  • 756.11 Spondylolysis, lumbosacral region
  • 756.12 Spondylolisthesis

ICD10

  • M43.00 Spondylolysis, site unspecified
  • M43.10 Spondylolisthesis, site unspecified
  • M43.16 Spondylolisthesis, lumbar region
  • Q76.2 Congenital spondylolisthesis

SNOMED

  • 240221008 spondylolysis (disorder)
  • 274152003 Spondylolisthesis (disorder)
  • 307138004 Spondylolisthesis L5/S1 level (disorder)
  • 80712009 Congenital spondylolysis of lumbosacral region (disorder)
  • 13131000 Spondylolisthesis, grade 3 (disorder)
  • 13236000 congenital spondylolisthesis (disorder)
  • 203681002 acquired spondylolisthesis (disorder)
  • 3472009 Spondylolisthesis, grade 4 (disorder)
  • 44494000 Spondylolisthesis, grade 1 (disorder)
  • 62620001 Spondylolisthesis, grade 2 (disorder)