spondylolisthesis

脊椎すべり症

　

WordNet

1. a forward dislocation of one vertebra over the one beneath it producing pressure on spinal nerves

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/04/17 23:35:40」(JST)

wiki en

[Wiki en表示]

Not to be confused with spondylosis, spondylitis, or spondylolysis.

Spondylolisthesis
Classification and external resources
X-ray of the lateral lumbar spine with a grade III spondylolisthesis at the L5-S1 level.
ICD-10	M43.1, Q76.2
ICD-9	738.4, 756.12
OMIM	184200
DiseasesDB	12318
MedlinePlus	001260
eMedicine	radio/651
MeSH	D013168

Spondylolisthesis is the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. It was first described in 1782 by Belgian obstetrician, Dr. Herbinaux. He reported a bony prominence anterior to the sacrum that obstructed the vagina of a small number of patients. The term “spondylolisthesis” was coined in 1854 from the Greek σπονδυλος = "vertebra" and "ὁλισθος" = "slipperiness," "a slip." The variant "listhesis," resulting from misdivision of this compound word, is sometimes applied in conjunction with scoliosis. These "slips" (aka "step-offs") occur most commonly in the lumbar spine.

A hangman's fracture is a specific type of spondylolisthesis where the C2 vertebra is displaced anteriorly relative to the C3 vertebra due to fractures of the C2 vertebra's pedicles.

Signs and symptoms

Typical physical changes that occur in an individual with spondylolisthesis will be a general stiffening of the back and a tightening of the hamstrings, with a resulting change in both posture and gait. The posture will typically give the appearance that the individual leans forward slightly and/or that they are suffering from kyphosis. In more advanced cases, the gait of the individual may change to give the appearance of more of a "waddle" than a walk, where the individual rotates the pelvis more due to the decreased mobility in the hamstrings. A result of the change in gait is often a noticeable atrophy in the gluteal muscles due to lack of use.

MRI of L5-S1 Spondylolisthesis

An individual suffering from spondylolisthesis will typically experience generalized pain in the lower back, along with intermittent shocks of shooting pain beginning in the buttock traveling downward into the back of the thigh and/or lower leg via Sciatica nerve that runs from the lower back to the feet. Sometimes symptoms include tingling and numbness. Sitting and trying to stand up may be painful and difficult. Coughing and sneezing can intensify the pain. The individual may also note a "slipping sensation" when moving into an upright position. An increase in activity level, for an individual experiencing pain of this type, will likely cause the individual to experience an increase in pain levels in the day(s) following the activity due to inflammation of the soft tissues, which is alleviated with reduced activity and/or rest.

Low-grade isthmic

Patients with symptomatic low-grade (<50% slippage) isthmic spondylolisthesis typically present with activity related back pain and often with radicular symptoms as well, but despite the large number of individuals with radiographic evidence of isthmic spondylolisthesis, few of them become symptomatic or require treatment.

Additionally, the cause of pain in patients with isthmic spondylolisthesis remains unclear. The first theory of pain production was segmental instability with excessive forward translation during flexion. This notion was logical from the mechanical standpoint as the pars defect eliminated the vertebral body’s primary restraint to forward translation, the inferior facet joint. This theory has now been evaluated by multiple radiographic studies, none of which were able to demonstrate excessive forward translation as a common feature of isthmic spondylolisthesis. A more contemporary theory of pain generation is excessive tension on the annulus of the inferior disc and foraminal stenosis at the level of the slip. Excessive annular tension is also mechanically logical as without the restraint of the inferior facet joints; the disc has to both resist shear forces from the slip and compressive forces from the body’s mass. However, this theory does not explain why some patients have symptoms while so many others do not, since the inferior discs of all patients with isthmic spondylolisthesis are subjected to similar forces. Foraminal stenosis is also thought to play a role, but long-term studies on surgical outcome have shown that many patients have poor results following decompression alone. Since the mid-1950s, surgeons have been advocating the combination of decompression and fusion. A recent biomechanical study of flexion-extension X-rays in patients with isthmic spondylolisthesis and normal controls found paradoxical motion at the level of the slip in 46% of patients and 0% of controls without back pain. Paradoxical motion has not been previously reported in cases of spondylolisthesis, but its role in the symptomatic and asymptomatic patient is not clear

High-grade isthmic

X-ray of a grade 4 spondylolisthesis at L5-S1 with spinal misalignment indicated

High-grade isthmic spondylolisthesis and dysplastic spondylolisthesis are regarded as separate clinical entities from low-grade isthmic slips. High-grade slips are defined as those with greater than 50% forward displacement. These slips are also accompanied by a significant amount of lumbosacral kyphosis, which is forward bending of the L5 vertebral body over the sacral promontory. Rounding of the sacral body and trapezoidal deformation of L5 are also common features. High-grade slips are much rarer than low-grade slips, representing less than 10% of all isthmic slips, and the vast majority present during adolescence, most during the early teenage years.

Unlike low-grade slips, many patients present without pain. Instead symptoms like bodily deformity, neurologic abnormalities, tight hamstrings, and abnormal gait are often the reason for consultation. The natural history of high-grade spondylolisthesis is also quite different from those with low-grade slips. The majority of low-grade slips are asymptomatic and do not progress past a patient’s initial presentation. Prospective studies on children with low-grade slips have demonstrated that once a slip occurs, it rarely worsens, even after 40+ years of follow-up. However, high-grade slips do continue to progress in many cases and are much more likely to cause pain. One natural history study by a Swedish researcher, Saraste, found that roughly 60% of patients with slips greater than 15 mm (which is roughly a Meyerding grade 2 or greater) had persistent daily symptoms, including both back pain and radiculopathy. The low-grade slips in Saraste's study were symptomatic in only 10% of patients.

Some cases do eventually progress to complete spondyloptosis and prevention of progression is the primary focus of surgery for high-grade slips. Why low-grade slips tend not to progress and why certain slips ultimately become severe is not known. There have been few long-term follow-up studies on patients with high-grade spondylolisthesis who did not undergo surgery. Harris and Weinstein reported on eleven patients after a mean follow-up of 18 years, all of which had greater than 50% slip and did not have surgery. Thirty-six percent of patients were asymptomatic, 55% of patients had relatively mild symptoms, and only one (9%) was disabled. The patients with mild symptoms were all able to work and participate in recreational activities, although they did need to make modifications to their lifestyle. No patient developed fulminant cauda equina syndrome, severe neurologic symptoms, or incontinence. Forty-five percent of patients had some neurologic abnormalities on exam, including weakness, paresthesias, and diminished deep tendon reflexes. Patient symptoms were primarily related to mild to moderate neurologic symptoms, muscle weakness, especially abdominal muscles, inactivity/deconditioning, obesity, lack of spinal mobility, and the late development of degenerative scoliosis with lateral listhesis (a deformity associated with advanced osteoarthritis of the lumbar spine). The patients in this study were a group of 21 patients who had undergone classic posterior interlaminar fusion from L4 to S1 for their severe slip with. The surgically treated patients were less symptomatic with 57% reporting no symptoms and no limitations, 36% reporting mild symptoms, and 5% reporting severe symptoms12. It should also be noted that the outcomes of posterior interlaminar fusions were poorer than newer posterolateral and circumferential techniques now utilized. Patients with posterior-only fusions tend to have more progression of their spondylolisthesis following surgery and more pain as well.

Degenerative

Patients with isthmic spondylolisthesis almost universally have a neural arch defect, meaning widening of the central spinal canal at the level of the slip. In contrast, in degenerative spondylolisthesis the forward translation of the vertebral body also causes narrowing of the central spinal canal at the level of the slip. This narrowing of the canal has been termed the "napkin ring effect", an illustrative description as one imagines the spinal canal as a series of napkin rings with one of the rings slid forward in comparison to the others. The classic symptomology of patients with symptomatic degenerative spondylolisthesis are similar to those with symptomatic lumbar spinal stenosis; which can be either neurogenic claudication or radiculopathy (either unilateral or bilateral radiculopathy) with or without low back pain.

Neurogenic claudication is thought to result from central canal narrowing that is exacerbated by the listhesis (forward slip). The classic symptoms of neurogenic claudication are bilateral (both legs) posterior leg pain that worsens with activity, but is relieved by sitting or forward bending.

Pathophysiology

Developmental anatomy

In the late 1890s, several cadaver studies demonstrated the characteristic pars defect of isthmic spondylolisthesis, leading to many different theories concerning the etiology of the defect. The first theory proposed a failure of ossification during embryonic development, leading to a pars defect at birth, which then progressed to an isthmic slip after the infant began ambulating. Following the development of the Roentgenogram in 1895, population X-ray studies showed that isthmic spondylolisthesis is, in fact, quite common. A population study by Fredrickson, et al. demonstrated that the pars defect began to appear around age six and became progressively more common until age 16. After age 16, the incidence fell and rarely developed after adolescence. This study confirmed that the pars defect is the result of a defect in the cartilaginous anlage of a vertebra but not apparent at birth. It is currently thought that the defect develops from small stress fractures that fail to heal and form a chronic nonunion. There have been reports that the defect is more common among athletes who participate in sports with repeated hyperextension, such as gymnastics, ballet, and American football.

Spondylolysis also runs in families and is more prevalent in some populations, suggesting a hereditary component, such as a tendency toward thin vertebral bone. Spondylolysis is the most common cause of spondylolisthesis. The hereditary factor (mentioned above) is quite notable, since the frequency of spondylolisthesis among Inuit is 30–50%. (This statistic is controversial, however, because further anthropological studies have shown that the occurrence of spondylolysis in Inuit people living in Western-style communities is within the normal variancy at 7%. These people are hereditarily linked to the study group showing ~40%. It is theorized that the nomadic Inuit have a higher incidence of spondylolysis due to trauma acquired as infants by being carried in an amauti. While in an amauti, the baby is put into compressive extension with each step taken by the mother. Also, all other studies have shown a normal variance of spondylolysis within cultures of 6-10%, further suggesting that spondylolysis is an environmental abnormality and that a hereditary tie is very unlikely).

Pathology

Spondylolisthesis is officially categorized into five different types by the Wiltse classification system: Dysplastic, Isthmic, Degenerative, Traumatic, and Pathologic.

Dysplastic spondylolisthesis is a true congenital spondylolisthesis that occurs because of malformation of the lumbosacral junction with small, incompetent facet joints. Dysplastic spondylolisthesis is very rare, but tends to progress rapidly, and is often associated with more severe neurological deficits. It is difficult to treat because the posterior elements and transverse processes tend to be poorly developed, leaving little surface area for a posterolateral fusion.

X-ray picture of a grade 1 isthmic spondylolisthesis at L4-5

Isthmic spondylolisthesis is the most common form of spondylolisthesis. Isthmic spondylolisthesis (also called spondylolytic spondylolisthesis) is a common condition with a reported prevalence of 5%-7% in the U.S. population. The spondylolytic defect is usually acquired between the ages of 6 and 16 years, and that the slip often occurs shortly thereafter. Once the slip has occurred, it rarely continues to progress, although one study did find an association between disc desiccation and slip progression during middle age. It is thought that the vast majority of isthmic slips do not become symptomatic, but the incidence of symptoms is unknown. One very long-term prospective study by Fredrickson, et al. that followed a cohort of 22 patients from the development of their slip into middle age, reported that many of the patients experienced occasional back pain, but so does the vast majority of people without isthmic spondylolisthesis. One patient did undergo spinal fusion at the slipped level, but the study could not verify if the isthmic slip was the indication for surgery. Roughly 90% of isthmic slips are low-grade(less than 50% slip) and 10% are high-grade (greater than 50% slip).

The most common grading system for spondylolisthesis is the Meyerding grading system for severity of slip. The system categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This distance is then reported as a percentage of the total superior vertebral body length:

• Grade 1 is 0–25%
• Grade 2 is 25–50%
• Grade 3 is 50–75%
• Grade 4 is 75–100%
• Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.

Degenerative spondylolisthesis is a disease of the older adult that develops as a result of facet arthritis and facet remodeling. As the facets remodel, they take on a more sagittal orientation, allowing a mild slip to occur. These slips are very common: a study of osteoporosis found a 30% incidence among Caucasian women older than 65 years and a 60% incidence among African-American women older than 65 years. Most slips are asymptomatic but can worsen the symptoms of neurogenic claudication when associated with lumbar spinal stenosis. Degenerative spondylolisthesis with spinal stenosis is one of the most common indications for spine surgery among older adults, and current evidence suggests that patients have much better success rates and more clinical benefit with decompression and fusion than with decompression alone.

Traumatic spondylolisthesis is very rare and may be associated with acute fracture of the inferior facets or pars interarticularis. It is treated in the same manner as are other spinal fractures, and there are only a handful of case reports on this type.

Pathologic spondylolisthesis is the last type and is also very rare. This type can occur following damage to the posterior elements from metastases or metabolic bone disease. These slips have been reported in cases of Paget's disease of bone, tuberculosis, giant-cell tumors, and tumor metastases.

Treatment

The appropriate treatment of patients with isthmic spondylolisthesis is just as controversial as the cause of symptoms. Patients with isthmic spondylolisthesis are usually divided into two general classes for both treatment and for study: low grade isthmic spondylolisthesis (<50% slip) and high grade isthmic spondylolisthesis (>50% slip). Patients with low grade spondylolisthesis are usually young adults (90% adults and 10% adolescents) who present with low back pain and often with radiculopathy. High grade spondylolisthesis may also present with back pain, but may also present with cosmetic deformity, hamstring tightness, radiculopathy, abnormal gait, or it may be asymptomatic.

Conservative

Patients with symptomatic isthmic spondylolisthesis are initially offered conservative treatment consisting of activity modification, pharmacological intervention, and a physical therapy consultation. Anti-inflammatory medications (NSAIDS) in combination with acetaminophen (Tylenol) can be tried initially. If severe radicular component is present, a short course of oral steroids such as Prednisone or Methylprednisolone can be considered. Chiropractic treatments and physical therapy can evaluate and address postural and compensatory movement abnormalities such as hyperlordosis and hip flexor and lumbar paraspinal tightness. The majority of these patients also present with chronically tight hamstrings. Physical modalities such as thermal treatment, electrical stimulation and lumbar traction can help with reactive muscle spasm, but typically are of short therapeutic duration when done in isolation, and should be coupled with therapeutic exercise. Epidural steroid injections, either interlaminarl or transforaminal, performed under fluoroscopic guidance can help with severe radicular (leg) pain. Lumbosacral orthoses may be of benefit for some patients but should be used on a temporary basis to prevent spinal muscle atrophy and loss of proprioception.

Surgical

Low-grade isthmic spondylolisthesis

Surgical treatment is only considered after at least 6 weeks and often only after 6–12 months of non-operative therapy has failed to relieve symptoms. Several authors have noted that patients with only low-back pain are more likely to respond to non-operative therapy than patients with radiculopathy, but this has not been formally documented and likely reflects the weakness of our current diagnostic system.^{[citation needed]} Currently, there are no means of effectively differentiating a patient with low-back pain and an incidental finding of spondylolisthesis from a patient whose symptoms are the result of their spondylolisthesis. However, in cases of a bilateral radiculopathy in a dermatomal distribution that matches the patient’s segment with spondylolisthesis, as well as radiologic evidence of slip (listhesis) progression, the differential diagnosis is narrower and the diagnostic accuracy higher.^{[citation needed]}

Posterolateral fusion

Posterolateral fusion in adult lumbar isthmic spondylolisthesis results in a significant improvement in 2 year outcomes, but the difference between surgical and nonsurgical treatment narrows with time. There has been one randomized controlled trial for low-grade isthmic spondylolisthesis that compared non-operative therapy to surgery. The study evaluated the severity of pain and limitations of daily function in patients with 'lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severely restricted functional ability in individuals 18 to 55 years of age'. At two years follow-up, patients who underwent surgery had significantly better scores for both pain and daily function. The benefits were reduced after nine years. While the patients undergoing non-operative care did show some improvement in pain, their daily activities and physical function did not change during the follow-up period. The follow-up was relatively short, but the study clearly favored surgery and was the first prospective randomized trial for spondylolisthesis . This was also the first prospective trial demonstrating that surgery could be effective for the treatment of some types of low-back pain. Several other retrospective studies have found significant and reliable benefit for patients with isthmic spondylolisthesis, but none compared the results of surgery to natural history of the disorder^{[citation needed]}. Nevertheless, posterolateral fusion for isthmic spondylolisthesis has been one of the least controversial surgeries for spinal pathology and has consistently demonstrated good outcomes^{[citation needed]}.

The success of stand-alone posterolateral fusion for treating adolescent isthmic spondylolisthesis led several authors, including Dr Leon Wiltse and Dr Eugene Carriagee, to speculate about the effectiveness of posterolateral fusion without a decompression for adult patients with both back and leg pain. In 1989, Drs. Peek and Wiltse, et al. reported on eight cases of adults with high-grade spondylolisthesis who presented with back pain and severe radicular pain. These patients were all treated with an in situ uninstrumented posterolateral fusion and followed for an average of 5.5 years. At final follow-up, all eight patients reported complete relief of their back pain and leg pain, no patients were taking analgesics for back pain, and all patients were unrestricted with respect to work and recreational activities. The mean time to complete resolution of symptoms was 2.8 months and all patients achieved a solid fusion. No patients underwent subsequent surgery for either back pain or leg pain throughout the follow-up period. This was the first report of excellent relief of leg pain in cases of isthmic spondylolisthesis from posterolateral fusion without decompression. Another study by de Loubresse, et al. reported on 48 adults with low grade isthmic spondylolisthesis and radiculopathy, half treated by posterolateral fusion or posterolateral fusion and a Gill laminectomy . With respect to radicular pain during activity, 92% of patients treated by posterolateral fusion reported complete relief, while only 65% of those treated with fusion and decompression reported relief. Several natural history studies have also reported that foraminal stenosis is common among asymptomatic isthmic patients and does not correlate well with radiculopathy.

Fusion with decompression

The addition of decompression does not appear to improve clinical outcome in addition to fusion for the treatment of low-grade isthmic spondylolisthesis in patients without serious neurological deficit. A randomized controlled trial compared fusion with a decompression to fusion without a decompression in adult cases of isthmic spondylolisthesis . The study enrolled 42 patients, all of which had both leg pain and back pain, but no evidence of cauda equina syndrome or motor strength less than 5-. The mean post-operative follow-up was 4.5 years. Clinical success was evaluated by a series of visual analog scales (VAS) for leg pain, back pain, analgesic use, and overall function. Scores are numbered from 0–10 with lower scores meaning less pain. Success was defined as leg and back pain of three or less on the VAS scale with an analgesic score above six (meaning only sporadic use of NSAIDs or Tylenol) and functional score above six (meaning infrequent limitations of activity that does not affect employment or important recreational activities). All smokers received pedicle screw fixation to decrease the risk of pseudoarthrosis while non-smokers were not instrumented. The results showed no benefit to performing a decompression for isthmic spondylolisthesis; in fact, patients undergoing decompression had worse clinical outcomes and a higher rate of pseudoarthrosis. Of the patients managed without a decompression 96% of the reached clinical success (as defined above), patients who received a decompression had a clinical success rate of only 66%. Interestingly, the rate of persistent leg pain was much higher in the group managed with a decompression (average VAS for leg pain was 3.8 for patients after decompression versus 1.4 for those without). Although the number of enrolled patients was small the difference was statistically significant (p=0.01). The pseudoarthrosis rate among those who received a decompression was 22% compared to 0% for those without a decompression, pseudoarthrosis was strongly associated with persistent symptoms (p=0.0001). The results seem to strongly support the argument for fusion alone in the management of adults with isthmic spondylolisthesis. The majority of adults treated for isthmic spondylolisthesis are managed with an instrumented posterolateral fusion and a decompression, perhaps this represents improper management of the disorder. The results of Dr. Carriagee’s study should be verified with a large multi-center study with many more patients that hopefully can definitively answer the question of which approach is most effective.

High-grade isthmic spondylolisthesis

There are several forms of surgery that have been advocated for the treatment of high-grade isthmic spondylolisthesis, including posterior interlaminar fusion, in situ posterolateral fusion, in situ anterior fusion (ALIF), in situ circumferential fusion, instrumented posterolateral fusion, and surgical reduction with instrumented posterior lumbar interbody fusion (PLIF). Advocates of these different techniques all cite specific advantages of each approach, but they all have established risks and some are much more complication-prone than others.

The role of surgical reduction in the treatment of high-grade isthmic is a controversial topic. Advocates of surgical reduction state that fusion in situ leaves too much residual deformity and impairs the natural mechanics of the lumbar spine. Patients with high-grade isthmic tend to have hyper-lordosis of the lumbar spine that compensates for the lumbosacral kyphosis associated with the severe slip and many feel that this hyper-lordosis will lead to early arthritis and low back pain. Seitsalo, et al. reported on the largest, long-term cohort of adolescents operated on for high-grade isthmic spondylolisthesis with 87 patients and mean follow-up of 14 years. Of the patients, 54 had posterior interlaminar fusions, 30 had posterolateral fusion, and 3 had an anterior interbody fusion (ALIF). The authors did note an association between hyper-lordosis and back pain after fusion in situ, particularly when contact and/or sclerosis is noted between adjacent spinous processes, called “kissing spinous processes”. This pain tends to be worsened by hyperextension, but it does not usually cause much pain at rest or during normal activities. Overall, 63% of patients in the study were asymptomatic, 24% reported frequent back pain, but only 7% had taken analgesics for back or leg pain in the last month. The authors did note a significant progression of lumbosacral kyphosis in many of their patients. They also noted that patients undergoing single-level fusions had much worse outcomes (p<0.0001) and they recommend fusing patients to L4 in virtually all cases. The authors also concluded that the clinical outcome, while much better than prior to surgery, still left several patients with significant symptoms and progression of deformity. The authors felt that reduction may offer patients a better chance of excellent long-term outcomes.

Reduction became feasible with the development of pedicle screws, allowing the reduction to be maintained. Several authors have published the results of reduction with pedicle screws and posterior interbody fusion with posterolateral fusion. While the improvement in percent slipped and lumbosacral kyphosis is significant, many have noted a 10–20% rate of nerve root injury and a few cases reports of complete cauda equina, especially with complete reduction of the deformity. While many of these injuries improve, several patients are left with permanent deficits. The clinical outcomes after reduction and instrumentation do not appear to be significantly superior to fusion in situ using modern techniques, despite the higher complication rate. It should also be noted that recurrence of deformity is common after reduction and many patients will either bend their hardware or bend at the sacrum, which is often fully segmented during adolescence. These facts have tarnished the notion of reduction and instrumentation for high-grade slips, but the technique is still utilized with theoretical benefits and some authors, particularly Dr Harry Shufflebarger, has reported both low complication rates and good clinical outcomes. Dr. Shufflebarger currently performs reductions for all high-grade slips that are referred to him and is a leading advocate of the technique. It should also be noted that the use of pedicle screw fixation is much more extensive in the U.S. than other countries and that these surgeons are somewhat more inclined to reduce patients, at least partially, while instrumenting. The routine use of pedicle screws for one or two level pediatric fusions (not long fusions for correcting scoliosis) is without proven benefit in clinical outcome or fusion rate, but is associated with more blood loss, increased rate of nerve root injury, and more cases of reoperation.

Until very recently, there was no data comparing the long-term outcome of reduction with instrumented fusion to an uninstrumented in situ fusion. Poussa, et al. recently published the first long-term follow-up report comparing reduction with instrumented posterolateral fusion to uninstrumented circumferential fusion in situ with a mean follow-up of 14.8 years. There were two groups of eleven patients and the patients were not randomized. The patient selection process reflected the differing opinions of surgeons at the author’s institution. However the patients’ preoperative symptoms were the same and patient demographics were identical. There was a tendency for patients with a greater percentage of vertebral slip to receive reduction, but the degree of lumbosacral kyphosis was similar between the two groups. At final follow-up, patients also underwent physical exam and were asked to fill out an Oswestry Disability Index (ODI) and Scoliosis Research Society Questionnaire-22 (SRS-22).

Although the number of patients in the study was small, patient outcomes clearly favored the fusion in situ group. The average ODI score was 7.6 (range 0–20) in the reduction group and 1.6 (range 0–4) for the fusion in situ group (p<0.01). The SRS-22 similarly favored the fusion in situ with a total score of 103.9 (range 93–120) compared to an average of 90 (range 39–107) for the reduction group (p<0.05). The domains of pain and function differed most significantly between the two groups. Additionally, the radiographic measures did not differ as greatly between the two groups as the authors had expected. Many of the reduction patients experienced a recurrence of their deformity especially the lumbosacral kyphosis. At final follow-up, the average kyphosis measured 20 degrees in the reduction group and 23 degrees in the circumferential group. Finally, MRI studies demonstrated a higher incidence of disc degeneration and psoas muscle atrophy. The authors concluded that reduction and instrumented fusion resulted in poorer long-term outcome than fusion in situ and that the deformity tended to recur following reduction. The increased risks and more extensive surgery associated with reduction did not translate into better outcomes or permanent correction of deformity.

In addition to the ongoing debate of reduction versus fusion in situ, there is also new evidence emerging as to what form of fusion is most effect for eliminating symptoms and controlling deformity. This discussion of surgical technique has been much enhanced recently by the publication of a long-term follow-up study comparing three different techniques of fusion in situ for treating high-grade spondylolisthesis. The study by Helenius, et al. compared the outcomes for posterolateral fusion, anterior interbody fusion (ALIF), and circumferential fusion that is a combination of posterolateral and anterior fusion . Anterior fusion is a relatively new technique to spine surgery, emerging during the last two decades. It involves either a retroperitoneal or transperitoneal (through the abdomen) approach to the lumbosacral junction with mobilization of the iliac arteries and veins. The surgeon then performs a total discectomy and places a bone graft into the intervertebral space; the graft is usually either a tricortical iliac crest or a femoral ring allograft. For circumferential fusion, after completing the anterior fusion, the patient is turned and a one or two level posterolateral fusion without instrumentation is performed. Circumferential fusion can either be performed under one run of general anesthesia with patient repositioning or the procedure can be staged. Helenius, et al. followed 70 patients for a mean period of 17 years who had been treated by one of the above procedures. Patient selection for each procedure was not randomized, but represented an evolving technique at the Hospital for Invalid Children, in Helsinki, Finland. At last follow-up each patient underwent physical exam, lumbar spine X-rays, and completed several questionnaires including an Oswestry disability index (ODI), Scoliosis Research Society Questionnaire (SRS-22), and two 100 mm visual analog scales for leg and back pain. There were 21 patients treated with posterolateral fusion (PLF), 23 patients treated with anterior fusion (ALIF), and 26 treated with circumferential fusion (CIRC). No patient was intentionally reduced, although some reduction did take place during positioning and during placement of anterior grafts. There was no use of instrumentation. The patients in the circumferential group had the worst preoperative slip and lumbosacral kyphosis by an average of 9% and 10 degrees (p<0.05 and p<0.005). Otherwise, all patients had the same pre-operative symptoms and had very similar demographics.

At final follow-up, the patients in the circumferential group had the best scores for function and pain by a statistically significant margin. Mean VAS back pain score was 22.6 mm for PLF, 24.1 for ALIF, and 5.5 for CIRC. Mean VAS leg pain was 7.6, 16.1, and 2.0 for PLF, ALIF, and CIRC respectively. Total functional scores were also significantly better for the ODI (lower is better) and SRS-22 (higher is better), mean ODIs were 9.7, 8.9, and 3.0 for PLF, ALIF, and CIRC with SRS means of 89.7, 93.2, and 100. The standard deviations were also different with the range of scores much narrower for CIRC compared to PLF or ALIF. No CIRC patient reported back pain at rest or was taking analgesics for back or leg pain. Three patients in both the PLF and ALIF group reported back pain often at rest. The CIRC patients showed the least progression of deformity with both percent slip and kyphosis improving over the follow-up period, mostly the result of vertebral remodeling. Both the PLF and ALIF showed modest increases in kyphosis over the follow-up period. Finally, the complication rate for CIRC was not significantly higher than the other two techniques with a trend towards fewer complications in the CIRC group, which is surprising since the circumferential fusion represents the combination of the other two procedures. Nevertheless, the infection rate and blood loss were not significantly higher and both stages of the operation could be completed together for the majority of cases. Overall, the authors concluded that circumferential fusion provided the best long-term outcomes among the three techniques with excellent long-term outcomes and a low complication rate.

See also

• Spondylosis
• Failed back syndrome

References

• Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D (2003). "The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation". Spine 28 (10): 1027–35; discussion 1035. doi:10.1097/01.BRS.0000061992.98108.A0. PMID 12768144. 

• Bradford DS, Boachie-Adjei O (1990). "Treatment of severe spondylolisthesis by anterior and posterior reduction and stabilization. A long-term follow-up study". J Bone Joint Surg Am 72 (7): 1060–6. PMID 2384506. 

• Carragee EJ (1997). "Single-level posterolateral arthrodesis, with or without posterior decompression, for the treatment of isthmic spondylolisthesis in adults. A prospective, randomized study". J Bone Joint Surg Am 79 (8): 1175–80. PMID 9278077. 

• Cartlidge NE, McCollum JP, Ayyar RD (1972). "Spinal cord compression in Paget's disease". J. Neurol. Neurosurg. Psychiatr. 35 (6): 825–8. doi:10.1136/jnnp.35.6.825. PMC 494187. PMID 4647855. 
• de Loubresse CG, Bon T, Deburge A, Lassale B, Benoit M (1996). "Posterolateral fusion for radicular pain in isthmic spondylolisthesis". Clin. Orthop. Relat. Res. (323): 194–201. PMID 8625579. 

• Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT (1997). "Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation". Spine 22 (24): 2807–12. doi:10.1097/00007632-199712150-00003. PMID 9431616. 

• Floman Y (2000). "Progression of lumbosacral isthmic spondylolisthesis in adults". Spine 25 (3): 342–7. doi:10.1097/00007632-200002010-00014. PMID 10703107. 

• Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP (1984). "The natural history of spondylolysis and spondylolisthesis". J Bone Joint Surg Am 66 (5): 699–707. PMID 6373773. 
• Gill GG (1984). "Long-term follow-up evaluation of a few patients with spondylolisthesis treated by excision of the loose lamina with decompression of the nerve roots without spinal fusion". Clin. Orthop. Relat. Res. (182): 215–9. PMID 6692617. 

• Gill GG, Binder WF (1980). "Autoamputation of the first sacral nerve roots in spondyloptosis". Spine 5 (3): 295–7. doi:10.1097/00007632-198005000-00014. PMID 7394667. 

• Helenius I, Lamberg T, Osterman K, et al. (2005). "Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients". Spine 30 (3): 336–41. doi:10.1097/01.brs.0000152375.13316.6a. PMID 15682016. 

• Helenius I, Lamberg T, Osterman K, et al. (2006). "Posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation using the Scoliosis Research Society questionnaire". Spine 31 (2): 190–6. doi:10.1097/01.brs.0000194843.94071.09. PMID 16418639. 

• Henderson ED (1966). "Results of the surgical treatment of spondylolisthesis". J Bone Joint Surg Am 48 (4): 619–42. PMID 15580735. 

• Hu SS, Bradford DS, Transfeldt EE, Cohen M (1996). "Reduction of high-grade spondylolisthesis using Edwards instrumentation". Spine 21 (3): 367–71. doi:10.1097/00007632-199602010-00023. PMID 8742214. 

• Kim YJ, Bridwell KH, Lenke LG, Rinella AS, Edwards C, Edward C (2005). "Pseudarthrosis in primary fusions for adult idiopathic scoliosis: incidence, risk factors, and outcome analysis". Spine 30 (4): 468–74. doi:10.1097/01.brs.0000153392.74639.ea. PMID 15706346. 

• Kim YJ, Lenke LG, Bridwell KH, Kim KL, Steger-May K (2005). "Pulmonary function in adolescent idiopathic scoliosis relative to the surgical procedure". J Bone Joint Surg Am 87 (7): 1534–41. doi:10.2106/JBJS.C.00978. PMID 15995121. 

• Lamberg TS, Remes VM, Helenius IJ, et al. (2005). "Long-term clinical, functional and radiological outcome 21 years after posterior or posterolateral fusion in childhood and adolescence isthmic spondylolisthesis". Eur Spine J 14 (7): 639–44. doi:10.1007/s00586-004-0814-1. PMID 15690214. 

• Luhmann SJ, Lenke LG, Kim YJ, Bridwell KH, Schootman M (2005). "Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary?". Spine 30 (18): 2061–7. PMID 16166896. 

• McGuire RA, Amundson GM (1993). "The use of primary internal fixation in spondylolisthesis". Spine 18 (12): 1662–72. doi:10.1097/00007632-199309000-00015. PMID 8235847. 

• Molinari RW, Lenke LG (2003). "Pediatric Spondylolysis and Spondylolisthesis". In Wiesel, Sam W.; Frymoyer, John W.; Howard S., Md An; Scott D., Md Boden; William C., Md Lauerman; Lawrence G., Md Lenke; Robert F., Md McLain. The Adult and Pediatric Spine: Principles, Practice, and Surgery (3rd ed.). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-3549-1. 

• Möller H, Hedlund R (2000). "Surgery versus conservative management in adult isthmic spondylolisthesis--a prospective randomized study: part 1". Spine 25 (13): 1711–5. doi:10.1097/00007632-200007010-00016. PMID 10870148. 

• Möller H, Hedlund R (2000). "Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis--a prospective randomized study: part 2". Spine 25 (13): 1716–21. doi:10.1097/00007632-200007010-00017. PMID 10870149. 

• Osterman K, Lindholm TS, Laurent LE (1976). "Late results of removal of the loose posterior element (Gill's operation) in the treatment of lytic lumbar spondylolisthesis". Clin. Orthop. Relat. Res. (117): 121–8. PMID 1277661. 

• Peek RD, Wiltse LL, Reynolds JB, Thomas JC, Guyer DW, Widell EH (1989). "In situ arthrodesis without decompression for Grade-III or IV isthmic spondylolisthesis in adults who have severe sciatica". J Bone Joint Surg Am 71 (1): 62–8. PMID 2913004. 

• Poussa M, Remes V, Lamberg T, et al. (2006). "Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome". Spine 31 (5): 583–90; discussion 591–2. doi:10.1097/01.brs.0000201401.17944.f7. PMID 16508556. 

• Sailhan F, Gollogly S, Roussouly P (2006). "The radiographic results and neurologic complications of instrumented reduction and fusion of high-grade spondylolisthesis without decompression of the neural elements: a retrospective review of 44 patients". Spine 31 (2): 161–9; discussion 170. doi:10.1097/01.brs.0000194780.17528.6b. PMID 16418634. 

• Schneider G, Pearcy MJ, Bogduk N (2005). "Abnormal motion in spondylolytic spondylolisthesis". Spine 30 (10): 1159–64. doi:10.1097/01.brs.0000162400.06685.37. PMID 15897830. 

• Seitsalo S, Osterman K, Hyvärinen H, Schlenzka D, Poussa M (1990). "Severe spondylolisthesis in children and adolescents. A long-term review of fusion in situ". J Bone Joint Surg Br 72 (2): 259–65. PMID 2312566. 

• Shufflebarger HL, Geck MJ (2005). "High-grade isthmic dysplastic spondylolisthesis: monosegmental surgical treatment". Spine 30 (6 Suppl): S42–8. PMID 15767886. 

• Vogt MT, Rubin DA, San Valentin R, et al. (1999). "Degenerative lumbar listhesis and bone mineral density in elderly women. The study of osteoporotic fractures". Spine 24 (23): 2536–41. doi:10.1097/00007632-199912010-00016. PMID 10626317. 

• Vogt MT, Rubin D, Valentin RS, et al. (1998). "Lumbar olisthesis and lower back symptoms in elderly white women. The Study of Osteoporotic Fractures". Spine 23 (23): 2640–7. doi:10.1097/00007632-199812010-00020. PMID 9854764. 

• Weinstein SL (2000). "Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions. Natural history and outcomes of treatment". J Bone Joint Surg Am 82–A (7): 980–90. PMID 10901313. 

• Wiltse LL (1962). "The etiology of spondylolisthesis". J Bone Joint Surg Am 44–A: 539–60. PMID 14040287. 

External links

• Spondylolisthesis: Back Condition and Treatment
• Cervical spondylosis treatement
• Lumbar Spine Surgery
• Spondylolisthesis for health professionals

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 小児および青年のアスリートにおける脊椎分離症および脊椎すべり症：臨床症状、画像診断、および診断 spondylolysis and spondylolisthesis in child and adolescent athletes clinical presentation imaging and diagnosis
• 2. 亜急性および慢性腰痛：外科治療 subacute and chronic low back pain surgical treatment
• 3. 小児および思春期のアスリートにおける脊椎分離症および脊椎すべり症：マネージメント spondylolysis and spondylolisthesis in child and adolescent athletes management
• 4. 腰部脊柱管狭窄症：治療および予後 lumbar spinal stenosis treatment and prognosis
• 5. 小児および思春期における腰痛：原因の概要 back pain in children and adolescents overview of causes

English Journal

• Treatment of traumatic spondylolisthesis of the lower cervical spine with concomitant bilateral facet dislocations: Risk of respiratory deterioration.

• Ye ZW1, Yang SH1, Chen BJ1, Xiong LM1, Xu JZ2, He QY3.
• Clinical neurology and neurosurgery.Clin Neurol Neurosurg.2014 Aug;123:96-101. doi: 10.1016/j.clineuro.2014.04.010. Epub 2014 May 27.
• BACKGROUND: This study aimed to retrospectively examine 36 cases of bilateral cervical facet dislocations (BCFD) of the lower cervical spine who were at risk for respiratory deterioration.METHODS: The cases of 36 subjects with BCFD of the lower cervical spine who failed to achieve closed reduction w
• PMID 25012020

• 138 Effect of medicare eligibility on utilization of deferrable spine surgery.

• Aronson JP, Agha LS, Nahed BV.
• Neurosurgery.Neurosurgery.2014 Aug;61 Suppl 1:204-5. doi: 10.1227/01.neu.0000452412.61076.5e.
• INTRODUCTION: The high cost of spine surgery may lead uninsured and underinsured patients to defer surgical intervention. Health insurance coverage in the United States expands at age 65 as people become eligible for Medicare. This expansion has a significant impact on overall utilization of health
• PMID 25032589

• 109 Defining the effectiveness of lumbar spine surgery in a nationwide, prospective longitudinal quality of life registry: an analysis of variability in patient-reported outcomes and preliminary predictive models of treatment failure.

• Godil SS, McGirt MJ, Glassman SD, Knightly JJ, Mummaneni PV, Oetting G, Theodore N, Gottfried ON, Khairi S, Schmidt MH, Boakye M, Kalkanis SN, Rabin D, Ryken TC, Balturshot GW, Chadduck J, Fassett DR, Reeder RE, Miller CF, Briggs TB, Zhang D, Bambakidis NC, Shaffrey ME, Hadley MN, Karahalios DG, Angevine PD, Martin MD, Ewend MG, Bydon A, Kremer MA, Holly LT, Slotkin J, Kaakaji W, Powers AK, Griffitt WE, Tippett TM, Cozzens JW, Christiano LD, Grahm TW, Guthrie BL, Harrington JF, Shaffrey CI, Elowitz EH, Foley KT, Watridge CB, Asher AL.
• Neurosurgery.Neurosurgery.2014 Aug;61 Suppl 1:194-5. doi: 10.1227/01.neu.0000452383.18082.73.
• INTRODUCTION: Thirty percent of US healthcare expenditures support care that is ineffective in real-world (non-research) settings. Efficacious treatments in research settings often fail to prove effective at the individual-patient level when applied in everyday-care settings. Prospective patient-rep
• PMID 25032560

Japanese Journal

• 不安定性を有する症候性腰椎すべり症におけるtransforaminal lumbar interbody fusion(TLIF)の治療成績

• 高橋 敏行,花北 順哉,南 学,本多 文昭,倉石 慶太
• 脳神経外科ジャーナル 19(6), 484-489, 2010-06-20
• 不安定性を有する症候性腰椎すべり症に対し,transforaminal lumbar interbody fusion(TLIF)を施行し,最低1年以上経過観察可能であった症例の臨床成績,放射線学的骨癒合率,合併症発生頻度を検討した.症例は77例で,手術時平均年齢は64.3歳,変性すべり症が66例,分離すべり症が11例であった.全例椎弓根スクリューシステムを併用し,椎間腔に椎体間インプラントおよび …
• NAID 110007619766

Related Links

• Spondylolisthesis: MedlinePlus Medical Encyclopedia

In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury ...

• Spondylolisthesis

Spondylolisthesis is the medical condition wherein one of the vertebras of the patient’s spine shifts forward or backward in regards with the adjoining vertebras. This displacement can be of a single vertebra or the whole vertebral ...

Related Pictures

---

★リンクテーブル★

リンク元	「脊椎すべり症」「マイヤーディング分類」「腰椎変性すべり症」「listhesis」
拡張検索	「lumbar spondylolisthesis」「isthmic spondylolisthesis」

「脊椎すべり症」

　　[★]

英

spondylolisthesis

同

脊椎辷り症

定義

• 椎骨がその尾側の椎骨に対して前方に滑った状態の総称 (SOR.484)

分類

原因

• spondyloptosis：先天的な形成異常
• 変性脊椎すべり症 degenerative spondylolisthesis
• 脊椎分離すべり症 isthemic spondylolisthesis
• 外傷性すべり症 traumatic spondylolisthesis
• 病的脊椎すべり症 pathological spondylolisthesis

評価

• マイヤーディング分類 Meyerding分類

「マイヤーディング分類」

　　[★]

英

Meyerding classification

関

脊椎すべり症 spondylolisthesis

• 腰椎すべり症の程度の評価に用いられる。
• 滑りのある椎体後下縁が4等分した下位椎体上縁のどこにいちするかで1度～4度と表現する。

「腰椎変性すべり症」

　　[★]

関

脊椎すべり症 spondylolisthesis

• 腰椎にみられる変性脊椎すべり症 degenerative spondylolisthesis

「listhesis」

　　[★] =spondylolisthesis

• 例：xpにてL4 mild listhesis

「lumbar spondylolisthesis」

　　[★]

同

腰部椎体すべり症

「isthmic spondylolisthesis」

　　[★] 分離性脊椎すべり症