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Anatomy of Spondylolisthesis

Most spondylolytic defects and cases of Spondylolisthesis are congenital. The prevalence of Spondylolisthesis in the general population is about 5% and is about equal in men and women. Spondylolysis and Spondylolisthesis most frequently involve L5, although L4 can also be affected and, rarely, more proximal levels.

Normally the inferior articular facets of the fifth lumbar vertebra prevent the body of this vertebra from being displaced anteriorly on the sacrum. Bilateral defects in the pars interarticularis make the neural arch a loose fragment, causing a loss in osseous continuity between the inferior articular facets and the body of the fifth lumbar vertebra, and allowing the body of the vertebra to gradually become displaced anteriorly. In addition, as the slip progresses, the foramen elongates and flattens, resulting in a foraminal stenosis. When the loose neural arch is removed, the reparative attempts by bone are evidenced in the hypertrophy of the cephalad pars stump. This overgrowth or elongation results in a "hook" that may rest directly on the nerve roots. This "hook" must be removed if the individual is to be relieved of radicular symptoms.

Spondylolisthesis by its nature causes instability of the spine. This instability has an adverse effect on the disc immediately below the displaced vertebra and can influence the development of degenerative changes to a moderate to severe degree.

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Spondylolisthesis has been classified into grades I, II, III, IV and V depending on the severity of the displacement of the vertebra above on the vertebra below. In severe cases involving the lumbar spine, cauda equina syndrome can occur.

The following is a classification of Spondylolisthesis and Spondylolysis according to cause:

Type I.  Dysplastic: This type results from congenital abnormalities of the upper sacral facets or inferior facets of the fifth lumbar vertebra that allow slipping of L5 on S1. There is no pars interarticularis defect in this type. The sacrum is not strong enough to withstand the weight and stress. Thus, the pars and inferior facets of L5 are deformed. If the pars elongates, it is impossible to differentiate it by x-ray from the isthmic (type II b) Spondylolisthesis. If the pars separates, it becomes impossible to differentiate it by x-ray from the isthmic lytic (type II a) Spondylolisthesis. This type is also associated with sacral and neural arch deficiencies. It has a familial tendency.

Type II.  Isthmic: This type results from a defect in the pars interarticularis that allows forward slipping of L5 on S1. Three types of isthmic spondylolistheses are recognized: a. a stress (fatigue) fracture of the pars interarticularis - lytic b. an elongated but intact pars interarticularis c. an acute fracture of the pars interarticularis The lytic (subtype a) results from the separation or dissolution of the pars. The incidence of this type of Spondylolisthesis increases from less than 1 percent in children 5 years of age to 4.5 percent in children 7 years of age. The remaining 0.8 to 1 percent increase occurs between the ages of 11 to 16 years, presumably because of stress fractures caused by athletic activity. Extension movements of the spine, with lateral flexion, can increase the shearing stress at the pars interarticularis and result in Spondylolysis. Although this subtype has a strong hereditary tendency, it makes up only half of the dysplastic group. The elongated pars (subtype b) is believed to result from micro fractures that heal with an elongated pars rather than from a lytic lesion. Acute pars fractures (subtype c) always result from significant trauma; these are rare and most frequently occur with Spondylolysis rather than with Spondylolisthesis.

Type III.  Degenerative: This lesion results from intersegmental instability of long duration with subsequent remodeling of the articular processes at the level of involvement. Multiple small compression fractures of the inferior articular process of the vertebra that slips forward also have been postulated as a cause. The articular processes change direction to a more horizontal position as the slip progresses. This lesion is 4 times more frequent in females than in males and is 6 times more likely to occur at L4-5 than at the adjacent levels. This lesion is generally not seen in individuals younger than 40 years of age.
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This information is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient.
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