anterolisthesis L4 on L5 with no obvious spondylolysis
It may be compromised by a herniation of the L4- L5 and degenerative spondylolisthesis.
Degenerative Anterolisthesis L4 On L5 - Bing images
Debilitating pain - spondylysis - spondylolithesis 1. Pars fusion - painful spondylysis - minimal spondylolithesis 2. Fusion A. In situ v reduction - not required for grade 1 - 2 - consider if sagittal malalignment - associated with risk neurology especially L5 - controversial if should be performed in high grade slips B. Instrumented / non instrumented C. Levels - L5/S1 if grade I or II / 50% or less - L4/S1 if 50% for more D. Interbody cages - useful in long standing spondylolithesis presenting in adulthood - degenerative disc disease - nerve root pain from interforaminal compression - improves nerve root space - improves healing rate E. Posterior v circumferential - circumferential approaches may improve fusion rates and outcome in high grade slips Indication - normal discs and facets - pain relieved by pars injection - failure brace / non operative treatment - minimal slip Technique - lesion identified / debrided / iliac crest bone graft Options ORIF 1. Screw across lytic defect - unilateral defect 2. Pedicle screw + laminar hook - bilateral defect 3. TBW spinous process and transverse process Results Kakluchi et al JBJS Am 1997 - 16 patients with failure non operative treatment bilateral pars defect - pain relieved by pars injection with LA - pedicle screw + lamina hook - nerve root decompression where required - union in all 16 - 3 patients only had occasional back pain A. Wiltse Lateral Mass Fusion in situ Concept - in situ fusion via a paraspinal muscle splitting approach - no reduction or instrumentation Indication - for L5/S1 with minor slip in young patient - rarely done these days - most surgeons perform instrumented fusion Technique - midline incision - two paramedian incisions in lumbodorsal fascia 4.5cm lateral to midline - paraspinous muscle splitting approach 2 fingerbreadths lateral to midline - split sacrospinalis using finger to dissect through muscle - don't go anterior to TP or risk damage to nerve root - decorticate TP / Sacral ala / facet / famina and add crest graft / allograft / BMP Post-op - spica 3/12 with 1 leg incorporated - activity modification for 6/12 Instrumented fusion in situ without reduction Indications - slip grade 1 or II - grade III or IV with no sagittal malalignment Levels instrumentation - L5 / S1 grade I or II - L4 / S1 grade III or IV Options 1. Pedicle screw instrumentation 2. PLIF / interbody cage 3. Bohlman procedure - interbody fusion with fibula strut - augmented with decompression and PLF 4.
Acute traumatic fractures only involving the pars are rare, and certain disease processes which weaken the bone such as Osteopetrosis can cause spondylolysis. The most widely used classification is described by Wiltse, Newman and Macnab. Associated with a congenital abnormality of the upper sacrum or the neural arch of L5. There is usually no defect of the pars. Subtype A :A fatigue fracture of the pars interarticularis. Subtype B :There is elongation of the pars interarticularis without a defect. Subtype C :Rare, due to severe hyperextention leading to acute pars fractures. Also known as degenerative spondylolisthesis with an intact neural arch ie non spondylolytic spondylolisthesis. This is 10 times more common at L4, and no greater than 25% anterior displacement occurs. It is rare under 50 years of age, it is 6 times more common in females over 60 years of age, 3 times more common in blacks as in whites, and is 4 times more likely if associated with a sacralized L5. The mechanisms of displacement are thought to involve arthrosis of the zygapophyseal joint, disc degeneration, and remodeling of the articular process and pars. Can occur as an acute fracture of a portion of the neural arch other than the pars interarticularis ie a hangman’s type fracture of C2.(note this type is different from the pars fracture – Isthmic subtype C) Generalised or systemic disorders may affect the neural arch of the spine and cause spondylolysis and subsequent spondylolisthesis. Some of the more common forms are Paget’s disease, metastastatic disease, and Osteopetrosis. Radiological evaluation is the definitive method of confirming the presence of spondylolysis and spondylolisthesis. A complete plain film series of the lumbar spine and sacrum are recommended, and should include the following views.
Grade 1 anterolisthesis of l3 on l4 - …
Degenerative 2° to Facet OA - L4/L5 - > 40 years old - associated with DM - F>M - compared with lytic the disc tends to be preserved
Isthmic 50 % Pars Discontinuity / Defect - L5 /S1 80% - unilateral or bilateral - can have a pars defect at L4/5 - typically adolescent - due to repetitive stress with fracture - increased in competitive sports eg gymnastics, football - is a genetic predisposition due to increased pelvic incidence - tend to be mild and non progressive Tend to present in 2 groups - some present in young patient - some present in adulthood when the disc degenerates and foramina compressed 3 types A Stress fracture B Elongated type C Acute fracture
Degenerative Anterolisthesis Of L4 On L5 10+ 0.01 0.06
Sagittal orientation of facet joints obviates restraining effect Boden JBJS 1996 - facet joint angle L4 or L5 >45° to coronal plane - 25x more likely to have degenerate spondylolisthesis 3.
Lumbar Degenerative Disc Disease Video.
Grade 1 degenerative anterolisthesis - Things You …
exercises for anterolisthesis of l4 on l5 papers on organizational therapeutic relationships in nursing essay behavior
Degenerative about facet joints L4-5 and L5-S1
DEGENERTATIVE SPONDYLOLISTHESIS L4-5 - …
Back Neck and Spine
"I have always been impressed by the quick turnaround and your thoroughness. Easily the most professional essay writing service on the web."
"Your assistance and the first class service is much appreciated. My essay reads so well and without your help I'm sure I would have been marked down again on grammar and syntax."
"Thanks again for your excellent work with my assignments. No doubts you're true experts at what you do and very approachable."
"Very professional, cheap and friendly service. Thanks for writing two important essays for me, I wouldn't have written it myself because of the tight deadline."
"Thanks for your cautious eye, attention to detail and overall superb service. Thanks to you, now I am confident that I can submit my term paper on time."
"Thank you for the GREAT work you have done. Just wanted to tell that I'm very happy with my essay and will get back with more assignments soon."