Spondylolysis and spondylolisthesis in regard to classification clinical presentation radiographic workup and treatment

CLASSiFiCATiON

Contemporary classifications (Wiltse, Marchetti, and Bartolozzi) do not distinguish between pediatric and adult patients with spondylolisthesis. However, the degenerative type of spondylolisthesis is seen only in adult patients. Degenerative spondylolisthesis is covered in this chapter while basic principles regarding spondylolisthesis with emphasis on isthmic spondylolisthesis are covered in detail in Chapter 38.

CLiNiCAL PRESENTATiON

In pediatric patients, back pain is the most common presenting symptom. Pain is directly related to instability at the site of spondylolysis/spondylolisthesis. Symptoms of hamstring spasm are not uncommon. Occasionally, L5 radicular symptoms occur. In pediatric high-grade developmental spondylolisthesis patients, spinal stenosis symptoms may develop including cauda equina-related symptoms. In contrast, adult patients frequently present with both back and leg pain symptoms. In adult patients, symptoms may be related either to the level of spondylolisthesis or to degenerative pathology (disc protrusion, stenosis, discogenic pain) at adjacent spinal levels. It is critical to precisely localize the pain generator in adult patients with spondylolisthesis because pain may not be related to the spondylolisthesis.

DiAGNOSTiC Workup

Standing spinal radiographs are the initial radiographic study for assessment of spondylolisthesis in both pediatric and adult patients. The degree of slip (Meyerding classification) and the slip angle are important for decision making in both patient groups. The need for additional diagnostic imaging is more frequent in adults to assess the cause of leg pain and status of the lumbar discs. Magnetic resonance imaging (MRI) is the standard for evaluating neural compression in both pediatric and adult patients. Computed tomography (CT) is the method of choice for assessing osseous anatomy in both groups. Discography is occasionally used in adult patients to assess whether a particular disc is a pain generator but has little role in pediatric patients. Technetium bone scans are sometimes used in pediatric patients to assess osseous activity related to spondylolysis and assess healing of pars defects. In adult patients, bone scans are of little value for assessment of spondylolysis because pars defects are typically inactive in adults.

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