What is Spondylolisthesis?

The incidence of lumbar spondylolisthesis varies in different regions and may be related to race and genetic inheritance. It is reported that it is 4 to 6% in Europe and about 4.7 to 5% in China; in all lumbar spondylolisthesis, the isthmus About 15% of spondylolisthesis caused by cracking, and about 35% of degenerative lumbar spondylolisthesis. In China, the incidence of lumbar spondylolisthesis is mostly 20-50 years old, accounting for 85%; males are significantly more than females, and the male to female ratio is 29: 1. The most common sites of lumbar spondylolisthesis are L4 ~ L5 and L5 ~ S1, and the incidence of lumbar 5 vertebrae is 82 ~ 90%. ^[1] ^[2]

Dong Jian

(Chief physician)

Department of Orthopaedics, Shanghai Zhongshan Hospital

Lumbar spondylolisthesis is due to congenital dysplasia, trauma, strain and other reasons that cause abnormal bone connection between adjacent vertebrae. The upper and lower vertebrae are partially or completely slipped. They are manifested as lumbosacral pain, sciatic nerve involvement, intermittent Sexual claudication and other symptoms.

Lumbar spondylolisthesis

Classification of lumbar spondylolisthesis

I. Congenital slippage

The congenital isthmus is stunted and cannot support gravity in the upper part of the body, with L5S1 spina bifida.

Second, isthmic slippage

The structure of the posterior vertebral body is basically normal, and the spondylolisthesis is caused by abnormalities in the isthmus. Divided into two types: a isthmus separation: isthmus fatigue fracture; b isthmus is only elongated without fracture, and still maintain continuity.

Third, degenerative spondylolisthesis

Caused by disc degeneration, more common in the elderly.

4. Post-traumatic slippage

Severe acute injury to the bony hook area with pedicle fracture.

Fifth, pathological slippage

Secondary to systemic disease, causing fractures or elongation of the facet joint.

Iatrogenic spondylolisthesis

More common after surgical treatment, caused by extensive laminectomy and facet joint decompression. ^[3]

Causes of lumbar spondylolisthesis

I. Congenital hypoplasia

During the development of the lumbar vertebra, there are ossification centers of vertebral bodies and vertebral arches. Each vertebral arch has two ossification centers. One of them develops the superior articular process and pedicle, and the other develops the inferior articular process, lamina and spinous process. Half of the cases, if there is no healing between the two, will cause the congenital isthmus to break apart and cause lumbar spondylolisthesis. In addition, slippage may occur due to abnormal development of the upper sacrum or L5 vertebral arch, but in this case, the isthmus is not cracked.

Trauma

Acute trauma, acute fractures caused by posterior trauma can lead to lumbar spondylolisthesis, which is more common in sports activities or labor porters.

Third, fatigue fracture or chronic strain

When the human body is standing, the lower lumbar spine bears a larger load, causing the forward force component to act on the relatively weak bone isthmus. Long-term repeated effects can lead to fatigue fractures and chronic strain injuries.

Fourth, degeneration factors

Due to prolonged lower lumbar instability or increased stress, the corresponding facet joints are worn out, degenerative changes occur, the joints are mutated to a level, and intervertebral disc degeneration, intervertebral instability, and anterior ligament relaxation are gradually caused by slippage, but the isthmus Still intact, also known as pseudo slippage, is more common in older people.

Fifth, pathological fracture

Mostly due to systemic or local tumors or inflammatory lesions, involving the vertebral arch, isthmus, and articular processes, the stability of the posterior vertebral body is lost, and pathological slippage occurs. ^[2] ^[4] ^[5]

Pathogenesis of lumbar spondylolisthesis

The spine has shearing force at any motion segment, and it is especially obvious in the lumbosacral region because the intervertebral space is inclined. Therefore, the previous vertebra has a tendency to slide forward and rotate toward the next vertebra. Under physiological weight load, maintaining the normal positional relationship of the lumbar spine depends on the articular process joints, the fibrous ring of the complete intervertebral disc, the peripheral ligaments, the contractility of the extensor dorsi muscles, and the normal spinal line of force. The weakening or loss of any one or more of the anti-shearing force mechanisms will lead to instability of the lumbosacral region and slippage over time. Spondylolisthesis can cause or aggravate spinal stenosis, stimulate or squeeze nerves, cause symptoms such as low back pain, lower limb pain, numbness of the lower limbs, and even dysfunction of the stool. In addition, the protective contraction of the lower back muscles after slippage can cause lower back muscle strain and lower back pain. ^[4] ^[5] ^[6]

Clinical manifestations of lumbar spondylolisthesis

Lumbar spondylolisthesis

1. Congenital slippage exists at birth, and can be seen in children, adolescents, and young people.

2. Trauma, pathology and iatrogenic spondylolisthesis can be seen in people of any age.

3. The age of onset of degenerative lumbar vertebrae is more than 20-50 years old, accounting for 85%; more men than women, the ratio of male to female is 29: 1.

Spondylolisthesis symptoms

The clinical symptoms caused by lumbar spondylolisthesis have great variability. Not all spondylolisthesis have clinical symptoms, and different patients may have different manifestations and severity of clinical symptoms. This is not only related to the compensatory ability of the structures around the spine, but also depends on the degree of secondary damage, such as joint hyperplasia, spinal stenosis, compression of the cauda equina and nerve roots.

The main symptoms include the following:

1. Pain in the lumbosacral region: mostly manifested as dull pain, very few patients can have severe coccygeal pain. Pain can occur after exertion or persist after a sprain. Aggravated when standing and bending, lightening or disappearing after bed rest.

2. Sciatic nerve involvement: manifested as radiating pain and numbness in the lower limbs. This is because the fibrous connective tissue or hyperplastic epiphysis at the isthmus rupture can compress the nerve root, and the nerve root is stretched during slippage. Most of the straight leg elevation tests are positive.

3. Intermittent claudication: Intermittent claudication often occurs if the nerve is compressed or with lumbar spinal stenosis.

4. Symptoms of pulling or compressing the cauda equina: In severe slippage, the cauda equina may be affected by symptoms such as lower limb weakness, numbness in the saddle area, and dysfunction of the stool.

5. Increased lumbar lordosis and kyphosis. Patients with severe slippage may experience depression in the waist, lordosis of the abdomen, and even shortened torso and sway while walking.

6. On palpation, a spinous process moves forward, a step is felt at the back of the waist, and the spinous process is tender. ^[3] ^[4]

Diagnosis and identification of lumbar spondylolisthesis

Lumbar spondylolisthesis examination

1. Anterior and posterior X-rays

"It is not easy to show isthmus lesions. Through careful observation, it may be found that there is a reduced density oblique or horizontal fissure under the shadow of the pedicle, most of which are bilateral. In patients with obvious spondylolisthesis, the spondylolisthesis tilts and the lower edge is blurred.

Second, X-ray film

Can clearly show the vertebral arch collapse. The fissures are located posteriorly and inferior to the pedicle, and between the superior and inferior articular processes, the edges often have signs of sclerosis. Lateral radiographs can show signs of lumbar spondylolisthesis, and can measure the index of spondylolisthesis. Meyerding classification is commonly used in China, that is, the upper edge of the lower vertebra is divided into 4 equal parts, and it is divided into I-IV degrees according to the degree of forward sliding of the vertebra relative to the lower vertebra.

: The vertebral body that slides forward no more than 1/4 of the sagittal diameter of the middle part of the vertebral body.

: Those exceeding 1/4, but not exceeding 2/4.

: Those exceeding 2/4 but not exceeding 3/4.

: Those who exceed 3/4 of the vertebral sagittal diameter.

Third, oblique X film

Can clearly show isthmus lesions. When the vertebral arch collapses, a band-like fissure may appear in the isthmus, called the Scotty dog neck rupture sign.

Fourth, power position X film

It can judge the mobility of the slip, which is of higher value for judging the presence or absence of lumbar instability. X-ray diagnostic criteria for lumbar instability include hyperextension, hyperflexion, or forward or backward displacement> 3mm or endplate angle change> 15 °.

Five, lumbar CT

The CT manifestations of lumbar spondylolisthesis are as follows: bilateral sign double-tube sign intervertebral disc deformation, that is, fibrous ring deformation at the level of spondylolisthesis, manifested by symmetrical soft tissue shadows at the posterior lower edge of the previous vertebra, and posterior lower edges of the next No intervertebral disc tissue. Gap fissures appear on the plane of the lower edge of the pedicle, the direction of travel is uncertain, and the edges are jagged. Three-dimensional CT or multiple reconstructions of the sagittal plane can clarify the degree of intervertebral foramen and spondylolisthesis.

Six, lumbar magnetic resonance

Magnetic resonance imaging (MRI) can observe the pressure of lumbar spinal nerve roots and the degree of degeneration of each intervertebral disc, which can help determine the extent of decompression and fusion.

Lumbar spondylolisthesis

Lumbar spondylolisthesis is often associated with other lumbar degenerative diseases, mainly including the following:

Lumbar disc herniation

2. Lumbar spinal stenosis

3. Lumbar Degeneration Scoliosis

4. Others ^[4] ^[7]

Treatment of Lumbar Spondylolisthesis

Conservative treatment of spondylolisthesis

Lumbar spondylolisthesis below I can be treated conservatively, including bed rest, back muscle exercises, waist circumference or braces; appropriate aerobic exercise can be used to reduce weight; activities that increase the weight of the waist, such as lifting weights, Bend over, etc. In addition, it can also be combined with physical therapy such as infrared and hyperthermia; if you have pain and other symptoms, you can take anti-inflammatory and analgesics such as celecoxib and feminide symptomatically.

Lumbar spondylolisthesis surgery

1. Indications for surgery include:

1. Lumbar spondylolisthesis below degree, with intractable low back pain, or the original symptoms of lower back pain aggravated, which are not effective through formal conservative treatment, which seriously affects the patient's life and work;

2. Accompanied by lumbar disc herniation or lumbar spinal canal stenosis, radiating pain in the lower limbs, intermittent claudication, or compression of the cauda equina;

3. The course of disease is long, and there is a tendency to gradually increase;

4. Severe lumbar spondylolisthesis above degree.

Second, the surgical method:

1. The main purpose of nerve decompression is to fully decompress the nerve roots. Decompression can be performed through unilateral or bilateral laminar opening. If laminectomy is unavoidable, spinal fusion must be added. If the symptoms of lumbar spondylolisthesis are caused by lumbar spinal instability without spinal canal stenosis, then only lumbar spine fusion and fixation are needed without decompression of the spinal canal. 2. The long-term stability of spinal fusion depends on strong biological fusion. There are many methods of spinal fusion. According to the site of bone grafting, they can be divided into: intervertebral fusion, posterolateral fusion, 360 ° fusion of the perivertebral body, etc. According to the surgical approach, intervertebral fusion can be divided into anterior intervertebral fusion and posterior fusion. Intervertebral fusion, transforaminal intervertebral fusion. At present, posterior TLIF surgery is the mainstream operation, that is, unilateral foraminal interbody fusion surgery.

3. The current mainstream view of lumbar spondylolisthesis is to reduce it if it can be reduced, because it can reconstruct the normal anatomical position of the lumbar spine and nerve root. However, it is not recommended to expand the operation to force a complete anatomical reduction, because the lumbar spondylolisthesis that has been formed for a long time has changed the surrounding structure correspondingly. It has the inherent stress of resisting traction and maintaining the spondylolisthesis. The forced reduction is not only difficult to completely reset, but also destroys the adapted anatomy. Relationship, easily lead to complications such as nerve root tension and nerve traction injury after surgery.

4. Spinal internal fixation mainly includes strong fusion internal fixation. 5. The direct repair of isthmus joints is the reconstruction of isthmus or direct repair of isthmus. Methods include screw fixation and laminar hooks. Suitable for young patients.

Although lumbar spine fusion surgery has been successfully tested for decades and millions of cases, it is still a complicated large-scale operation. The surgeon's surgical skills are very demanding. Often, patients are met at the clinic with symptoms that are worse than before the operation. "

Third, postoperative guidance

Patients undergoing fusion and internal fixation surgery can wear a brace to get up for three days after surgery, but should avoid premature and vigorous physical labor. Generally, they can drive for six weeks after surgery, and can ride bicycles and wash clothes after three months. Physical activity, but avoid heavy physical activities such as carrying loads and carrying objects. Patients need to continue to exercise the lumbar and back muscles, and increase the intensity of the exercise based on their physical strength based on the original exercise. Follow-up in the clinic to check the bone fusion and internal fixation.

Quitting smoking is very important and you can drink some red wine.

Lumbar spondylolisthesis complications

Lumbar spondylolisthesis is a very mature operation that has been tested by hundreds of thousands and millions of patients. But any operation has certain risks, and lumbar spondylolisthesis is no exception. Surgery-related complications include intraoperative bleeding, vascular injury, dural injury, cauda equina injury, and nerve root injury. Systemic complications such as shock, deep vein embolism, dyspnea, pulmonary infection and atelectasis, urinary tract infection, bloating and vomiting may occur during the perioperative period after surgery. It is necessary to closely observe the condition and detect abnormalities in time, and give correct treatment promptly.

In spite of the above risks, as long as the diagnosis is clear, sufficient preoperative preparation, careful intraoperative operation, close observation after surgery, and strict adherence to the diagnostic and treatment routines, for experienced doctors, the possibility of the above complications is extremely low, as far as the surgery is concerned Complications are even more rare. As for the paralysis caused by folk-to-people surgery, it is extremely rare.

If conservative treatment is not effective, surgery may be a safe and effective method.

First, back pain does not disappear

Especially in elderly patients, most of them have osteoporosis and lumbar muscle strain. After treatment of lumbar spondylolisthesis, only one problem that causes back pain is resolved, and other diseases still exist. So low back pain will still exist after surgery. Osteoporosis requires long-term medication, and lumbar muscle strain requires persistent exercise to be effective.

Second, postoperative infection

Mainly manifested as fever, redness and swelling of the incision, exudate, routine blood test for increased white blood cells and so on. Preventive measures include keeping wound dressings and bed sheets clean and dry, and replacing them when contamination is found. At the same time, we must pay attention to keeping the negative pressure of the wound flowing smoothly, and closely observe the wound for bleeding, exudate, color, amount of drainage fluid, temperature, blood, patient signs and other changes. Strictly aseptic operation during dressing change.

Cerebrospinal fluid leakage

Due to the serious adhesion between the meninges and the tissues of the hyperplastic compression nerves, it is difficult to separate during the operation; or it is caused by accidental damage to the dura. Closely observe the drainage fluid after surgery. If you find that there is a large amount of drainage fluid and the color is pale, you should consider the possibility of cerebrospinal fluid leakage. You can go to the supine position or prone position, and change the negative pressure drainage of the wound to ordinary drainage. Observe the patient for symptoms of dizziness and headache, such as severe symptoms such as high head and low feet, intravenous balanced salt solution, and antibiotics to prevent infection. If necessary, perform two tight sutures and apply local pressure bandaging. After these measures, they can usually heal.

Fourth, nerve root pulling stimulation symptoms

It is caused by the reduction of the stretched nerve during the operation, and the common manifestations include lower limb acidity, swelling, numbness, and pain. Generally, after intravenous infusion of dexamethasone and mannitol; after treatment with neurotrophic drugs and anti-inflammatory analgesics, the symptoms can gradually reduce or disappear completely. However, it is necessary to be vigilant for delayed neurological symptoms and lower limb movement disorders after operation, which may be caused by hematomas compressing nerve vessels due to postoperative bleeding at the surgical site. This situation requires reoperation.

Five, other

Complications such as deep venous thrombosis of the lower limbs, precipitating pneumonia, bedsores, and urinary tract infections guide patients and their families to turn over, pay attention to skin care and prevent bedsores; strengthen muscle contraction exercises to prevent wasteful atrophy; pay attention to sputum and deep breathing training Prevent fallout pneumonia; in addition, the catheter should be removed as soon as possible to prevent urinary tract infection. At the same time, it is extremely important to strengthen the joint activities of the limbs, actively contract the muscle tissue of the limbs, and wear elastic socks to prevent venous thrombosis of the lower limbs. Because lower extremity venous thrombosis can lead to pulmonary embolism, which is a rare but extremely serious complication after spine and other major surgery, once it occurs, it may be life-threatening and difficult to rescue; ^[2] ^[4] ^[8]

Lumbar spondylolisthesis prevention

Preventing lumbar spondylolisthesis from daily life

First, strengthen the functional exercise of the back muscles

The strength of the lower back muscles can increase the stability of the lumbar spine and antagonize the tendency of lumbar spondylolisthesis. There are two ways to exercise the lower back muscles. One is in a prone position, with both upper limbs abducted, raising their heads, raising their chests, and their upper limbs leaving the bed. The second is in a supine position, with both knees flexed, feet on the bed, chest and waist when inhaled, leaving the hips off the bed, exhaled to recover.

Restricted activities

Reduce excessive waist rotation, squatting and other activities to reduce excessive waist load. This can reduce excessive strain and degeneration of the facet joints of the lumbar spine, and avoid the occurrence of degenerative lumbar spondylolisthesis to a certain extent.

Third, lose weight

Especially reduce abdominal fat accumulation. Overweight increases the burden and strain on the lumbar spine, especially abdominal fat accumulation, and increases the tendency of the lumbar spine to slip forward on the sacrum. ^[3]

Lumbar spondylolisthesis care

Preoperative care of lumbar spondylolisthesis

1. Psychological nursing According to the different social backgrounds and mental states of patients, explain the purpose of surgery and precautions before and after surgery. Focus on giving emotional support and psychological comfort to reduce the psychological burden on patients and eliminate their nervousness.

2. Restricted activities To prevent aggravation of slippage, from the beginning of admission, patients are instructed to reduce unnecessary activities such as long standing and long trips, and rest in bed.

3. Respiratory function training Because the surgery requires a prone position, which has a greater impact on the patient's normal breathing, patients should be trained in breathing after admission. Common methods include balloon blowing and chest expansion.

4. Other preparations In addition to making routine preparations before orthopedic surgery, patients must also control other existing medical diseases and control the disease to a tolerable range of surgery. Simultaneously train bed defecation to meet the needs of bed defecation after surgery.

Postoperative care of lumbar spondylolisthesis

1. Monitoring of vital signs It is necessary to strengthen the observation of vital signs after operation, and continuously monitor heart rate, blood pressure, blood oxygen saturation and respiratory changes. Closely observe the patient's consciousness and urine output.

2. Observation of spinal nerve function Closely observe the muscle strength, sensory and motor functions, and sphincter function of both lower limbs.

3. The care of the incision drainage tube keeps the negative pressure ball in a negative pressure state. Avoid pulling the drain tube out, twisting or angling when turning over. Observe and record the amount, color, and properties of the drainage fluid.

4. After the position nursing, the patient is moved to the bed and turned to the side for 6 hours to reduce the anesthesia reaction and achieve the purpose of compression and hemostasis. Change the position once every 2 hours, you can lie on the left and right sides. Patients can usually get out of bed in three days after surgery to complete their own toilet and sanitation work. ^[1] ^[5]