Anatomy -
In our spine there are total 33 vertebrae ... those
are arranged one over the other like a building ... those are divided into four
anatomical segments ,
1.
Cervical
2.
Thoracic
3.
Lumbar
4.
Sacral
Functional unit
of spine -
Movements in spine occurs at functional unit of spine
. These are comprised of
-
Vertebra above ( Bone )
-
Intervertebral Disc
-
Vertebra below ( Bone or vertebral body )
-
Facet joints
-
Adjoining ligaments
Our spine is always under load and stress . When we
sit, stand and walk movements occurs at this functional unit . So this unit is
always under stress ...
Pars
Interarticularis - as
the name, its inter-articularis….. means it joins the facet joints in spine. It
is located between superior and inferior articular process of facet joint.
What is a
Listhesis ?
Listhesis means slipping of one vertebra over other
.... the above or upper vertebra slips over lower vertebra .
Classification for Listhesis
Type I: This
is also called dysplastic or congenital spondylolisthesis. Congenital means
that you're born with it. Type I spondylolisthesis, then, is a defect in the
articular processes of the vertebra (the part that's supposed to control the
movement of the vertebra; your facet joints are made of the articular
processes). It usually happens in the area where the lumbar spine and the
sacrum come together: the L5-S1 area. The defect allows the L5 vertebra (your
last vertebra in your lumbar spine) to slip forward over the sacrum.
Type II: Also
called isthmic, this is the most common kind of spondylolisthesis. With type II
spondylolisthesis, there's a problem with the pars interarticularis, a
particular region of your vertebra. Isthmic spondylolisthesis is divided
further:
Type II A:
Gymnasts, weight lifters, and football linemen are especially prone to this
kind of spondylolisthesis. It's caused by multiple micro-fractures on the pars
interarticularis—micro-fractures that occur because of hyperextension
(overarching) and overuse. The pars fractures completely in type II A.
Type II B: This
type is also caused by micro-fractures. The difference, though, is that the
pars don't fracture completely. Instead, new bones grow as the pars heals,
causing it to stretch. A longer pars can then cause the vertebra to slide
forward.
Type II C: Like
type II A, this type has a complete fracture. However, it's caused by trauma,
injury The impact in a car accident could fracture your pars, for example.
A pars fracture can lead to a mobile piece of bone;
the detached inferior articular process can actually move around. This bone fragment,
also called a Gill fragment, can pinch the exiting nerve root, so the bone may
need to be removed.
Problems with the pars interarticularis can also be
called spondylolysis. The word looks like spondylolisthesis, and they are
somewhat related. Micro-fractures in the pars interarticularis—the kind that
gymnasts, football linemen, and weightlifters are prone to—are a form of
spondylolysis. The fractures are called spondylolysis; if the vertebra slips
forward because it's not being held in place properly, it's called
spondylolisthesis.
Type III:
Aging can also cause spondylolisthesis. As you grow older, the parts of your
spine can degenerate; they can wear out. Usually your intervertebral discs
change first. The older you get, the less water and proteoglycan content the
discs have—and less fluid makes them less able to handle movement and shock.
Less fluid can also cause the disc to thin, and a thinner disc brings the facet
joints closer together. Without the disc acting as the cushion, the facets
can't control the spine's movement as well, and they become hypermobile.
Eventually, a vertebra can slip forward because the facets aren't holding it in
place effectively as the spine moves. Type III spondylolisthesis usually
happens at the L4-L5 region (the fourth and fifth vertebrae in your low back),
and it's more common in women older than 50 years old.
Type IV:
Similar to type II C, type IV involves a fracture. However, it's a fracture of
any other part of the vertebra other than the pars interarticularis. Your facet
joints, for example, can fracture, separating the front part of your vertebra
from the back part.
Type V:
Tumors on the vertebra can also cause spondylolisthesis because they weaken the
bones and can cause fractures that split your vertebra, leading to instability
and a potential slip.
Type VI: You
have this type of spondylolisthesis if surgery caused your vertebra to slip
forward. It's also known as iatrogenic spondylolisthesis, and it's caused by a
weakening of the pars, often as a result of a laminectomy (a typical back
surgery, but type VI spondylolisthesis isn't a typical result of the surgery).
Slip Grades
Using the lateral (side) x-ray, your doctor will grade
your spondylolisthesis. He or she will use a grade I through grade V scale that
describes how far forward your vertebra has slipped.
Grade I is a less than 25% slip.
Grade II is a 25% to 49% slip.
Grade III is a 50% to 74% slip.
Grade IV is a 75% to 99% slip.
Grade V is for a vertebra that has fallen off the
vertebra below it. (That's an extreme case of spondylolisthesis that has its
own name: spondyloptosis.)
Symptoms of Spondylolisthesis
1.
Back pain
2.
Lower limb pain / Leg pain
3.
Thigh pain
4.
Calf pain
5.
Tingling and Numbness
6.
Leg pain and numbness after standing for long time
7.
Back pain after sitting for long time
8.
Made to sit after standing for long time
9.
Pain and Numbness in legs after walking for some
distance, made to sir in between due to pain and Numbness
10.
Neurological claudication and decreasing distance day
by day
11.
Weakness in legs , either one or two
12.
Heaviness in legs , either one or two
13.
Difficulty in urine , frequent passing of urine ,
difficult to control urine
14.
Difficult to control motion
15.
Numbness in private parts
16.
Disturbed sleep due to pain
Signs -
1.
Tenderness in spine
2.
Facetal tenderness
3.
Slip palpable in high grade Listhesis
4.
SLR may be free for lower limbs
5.
Hamstring tightness
6.
Neurodeficit
Treatment
options
1.
Conservative – Medications like Pain killers, anti
inflammatory , Pregabalin medicaitons
2.
Pain
Block
Indications for surgery –
1.
Failed conservative treatment
for longer time
2.
Worsening of symptoms
3.
Decreasing claudication
distance
4.
Persistent back pain
5.
Back pain disturbing in sleep
6.
Weakness in one or two legs
7.
Difficulty in holding chappals
in legs or history of sleeping of chappals from legs
8.
Difficulty in passing urine or
motion
Surgery in the form of Lumbar Decompression
with or without stabilisation
