An oblique x-ray of the patient's right L4 spondylolysis.
Spondylolisthesis Imaging - Medscape Reference
oblique x-rays are not upto the mark.
Forspondylolysis and low grade spondylolisthesis the first line treatment isnonsurgical and most of the time it works very nicely. This is mostly rest/bracing, nonsteroidalinflammatory medications. According toat least one study bracing doesn't really change the outcome, so rest andnonsteroidal antiinflammatories and after that starting a strengthening coreand pelvic stabilization exercises seems to work for almost 85% of thesepatients including grade I spondylolisthesis. Healing of the defect is not necessary and as I said in a year typicallyspeaking 80, 85% of these kids will be pain free and they will be able to goback to their preinjury activity level. If it's spondylolysis or low grade level grade I spondylolisthesis youcan let them go back to whatever they used to do without any limitations once theyare comfortable and you don't need to look for a healing pars fracture, itdoesn't really change anything.
Ifyou look at the natural history, natural history is important to decide on treatmentdecisions. So there are multiplestudies. This spondylolisthesis has been a reason for argument between spinesurgeons, pediatric orthopedic surgeons and pediatric spine surgeons, whichones to treat, how to treat it, or should we do surgery at all. But if we look at the studies mostly fromadult world and also from adolescents it appears like the slip angle whichshows you a lumbosacral kyphosis basically and the grade of slip, thepercentage of slip are related to progression. So high grade slips over 50% of slippage and the higher slip angles over50 degrees according to a couple of studies including this one by Boxall andBradford shows that over 50 degrees of slip angle those spondylolisthesisprogresses despite solid fusion, so in situ fusion. So for those ones actually they back in 1979,they recommended reduction, at least partial reduction or correction of thelumbosacral or the slip angle.
Oblique lumbar spine X-ray also known as Scotty-dog view
Andon the physical examination you will see that the patient has a heart shapedbuttocks, that's how they say in the textbooks typically but their pelvis ispretty much tilted this way forward. Sotheir butt actually flattens out as if like a flat back you see in adult spineworld. You might see an abdominal creaseright in the front or right below the umbilicus right around here. Again it's very high grade slips orspondyloptosis which is a grade V slip. And there might be some neural symptoms, typically in isthmic spondylolysis not typically but in isthmicspondylolisthesis even in high grade there may be no neural symptoms whatsoeverbecause the posterior elements are separated there may not be really too muchstretch on the nerves or not too much compression. /So the symptoms might range from sensorysymptoms to Cauda equina. So you have tolook for it. Typically if there is no objective motor symptoms you do notnecessarily need to do a decompression. And hamstring tightness is still not known if it's coming from thestretch or irritation of the nerve roots or the retroverted position of thepelvis. But typically it responds to afusion in situ. Even in situ fusionshows the hamstring tightness.
Ifwe look at the x-rays and MRIs typically the plain films and MRI helps you foryour decision making. CT scans is reallyrarely required for spondylolisthesis. On the x-rays you will see the pars defect along with a translation forspondylitic spondylolisthesis and on theAP x-rays you will see - you might see a small scoliosis. This might get worseover time and it's - the difference with olisthetic scoliosis than idiopathicscoliosis is the most amount of rotation will be up to the level of L5 insteadof the apex of the scoliosis. So that'ssomething that differentiates between idiopathic scoliosis plusspondylolisthesis from olisthetic scoliosis. You will see lumbosacral kyphosis especially prominent in high gradespondylolisthesis. The sacrum might bevertical and pelvis retroverted as we mentioned. And on the MRI scans you might see the L4-L5root compression or disc herniation at the level of L5-S1, typically it'ssmall.
Oblique x rays help to delineate the pars defect more clearly
Clinicalfindings are quite typical for high grade spondylolisthesis. In spondylolysis and low gradespondylolisthesis big back pain is typically what you see or they might becompletely asymptomatic. In high gradespondylolisthesis typically the gait disturbances are more prominent than backpain. The Phalen-Dickson sign is quitetypical appearance in kids with high grade spondylolisthesis and spondyloptosisand Phalen and Dickson described it as restriction of straight leg raisingwhich shows hamstring spasm basically, and inability to bend the trunk forwardand a peculiar gait. If it's very highgrade and flexion contractures along with hamstring and hip flexioncontractures are severe actually they might walk as if they are walking side toside instead of going forward because of the inability to extend theirknees. One other thing is theretroverted pelvis and on the x-rays you can see it as a more vertically positionedsacrum as we can see right here.
Inchildren even low grade spondylolisthesis may progress during the adolescentgrowth spurts or prepubertal growth spurts. In adults lower grade slips typically do not get worse over time, theystay stable and you can completely forget about those. But in children if there is a low gradespondylolisthesis in a child less than10 years old you have to watch for it, you have to monitor it because there isa risk that it might progress up to 5%. And some of those children may require surgical treatment of those lowgrade spondylolisthesis. Having saidthis though, I said in adults typically it doesn't progress but there are somecase reports showing that even spondylolysis turned into high gradespondylolisthesis in an adult, there are a few of those reports in theliterature and I have actually seen one during one of my spine fellowships backin San Francisco. And L-4 spondylolysisin a matter of 3 months or so actually did progress into spondyloptosis. So it was a very heavy set 35 year old woman,but it might happen. I guess anythingmight happen.
Lumbar Spondylolisthesis as seen on X-Ray Films
Lumbar Spondylolisthesis-Pars Defect As Seen on X-Rays ..
13/04/2017 · Most people find out they have spondylolisthesis when they have an x-ray ..
Understanding X-Rays of the Neck | Cervical Spine …
A spondylolisthesis is diagnosed from an xray though the astute clinician may be able to palpate it
X-Ray of an Oblique View of a Normal Lumbar Spine …
cause pain and is called "isthmic spondylolisthesis" which is diagnosed by simple X Rays of the lumbo ..
X-rays are the best way to diagnose spondylolisthesis
Andthe best way to look for spondylolysis is a lateral lumbar x-ray and if thereis high suspicion you can get a thin cut CT scan as you can see here the defectright there and break the collar of the Scotty dog. And if you look at the Scotty dog which partis what look at this picture in right here, the neck is the parsinterarticularis, the eye is the pedicle, the ear is the superior facet, thenose is the transverse process. And asyou can see the tail is the superior facet. So try to like imagine that picture if you are looking at an obliquex-ray. But there are two recent studieswhich show that if you don't see anything on the lateral x-rays it's veryunlikely to see anything additional from oblique x-rays. There might be some value of getting obliquex-rays if there is very high clinical suspicion still to look for a unilateralisthmic defect; however as I said it is very unlikely to see anything in the oblique if you don't see anything n thelateral view. So some people actuallystopped doing oblique views.
Your doctor may also order an oblique x-ray.
Spondylolysisis unlike spondylolisthesis you can't really do too much classification forspondylolysis because it's either a stress fracture or a developmental defect inthe Pars of L3, L4 or L5. Most commonlyyou see it at L5 level. This is thoughtto be a result of a bipedal posture because it hasn't shown in nonambulatorychildren and by quadripedal animals either. The earliest age, there are reports in the literature of going down to 4or 2 1/2 years old but nothing below that so the likelihood of this developingis more in gymnasts or football linemen or people who continuously extend theirlumbar spine. So that's why it's thoughtto be a stress fracture as well but also it is about 6% in the wholepopulation. So it could be a stressfracture, it could be traumatic but there is a very strong reason to believethat this is also genetic as well because it has been shown in the families,appearing more commonly in the families.
therefore oblique and flexion/extension x-rays are usually obtained.
Soif we look at this, these x-rays have most of the findings. So as you can see there is a small scoliosisup here and this is a high grade III spondylolisthesis. As you can see the sacrum is quite verticalinstead of having this nice sacral slope. This kid's spine is pretty well balanced overall though. So lumbar lordosis increases once you havehigh grade spondylolisthesis and thoracic kyphosis flattens out. And very high grades, grade IV andspondyloptosis, those children might actually have a positive spinal balancewith a C7 plum line falling in front of the femoral head. And here are the CT scan, there is the CTscan changes in the sacral dome. And theMIR, if you look at the MRI so this is a nerve root here, this is L4 nerveroot. As you can see it's covered nicelyby fat here and here again and this is - that's your L5 nerve root here. You see how it's squished and impinged here,it's right here again.
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