Spondylolysis and Spondylolisthesis in the Skeletally Immature Patient

Abstract

Spondylolysis and spondylolisthesis are diagnosed in ambulatory children with low back pain. Spondylolysis is a defect of the vertebral pars interarticularis, and spondylolisthesis is the anterior translation of one vertebra relative to the adjacent caudal segment. The most common forms are isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions affecting the pars interarticularis. The typical patient is a child with an insidious onset of activity-related low back pain with associated hamstring tightness, without neurologic symptoms. Plain radiography and CT are useful in the diagnosis of this condition. Single-photon emission computed tomography is the single most valuable diagnostic test for spondylolysis in the presence of normal plain films. Spondylolysis and low-grade spondylolisthesis respond well to brief periods of activity modification, rest, immobilization, and physical therapy, in which case the deformity is not likely to progress. High-grade symptomatic spondylolisthesis is treated surgically, because many patients do not respond to nonsurgical treatment, and the natural history of the deformity is progressive. In situ posterolateral L5-S1 fusion is the treatment of choice for those patients with low-grade spondylolisthesis that is refractory to nonsurgical management. Pars interarticularis repair is effective for those patients with low-grade mobile spondylolisthesis or pars interarticularis defects cephalad to L5, and is considered for multilevel symptomatic spondylolysis. The optimal surgical treatment for high-grade spondylolisthesis remains controversial. Spinal fusion is recommended for patients with high-grade spondylolisthesis with or without symptoms. Traditionally, an in situ L4 through S1 fusion has been used to relieve back pain and neurologic symptoms, and to prevent continued slip progression. Reduction of the spondylolisthesis and fusion can correct sagittal spinal imbalance and permit more rapid rehabilitation. Instrumented reduction has been associated with higher rates of nerve root injury than has in situ fusion alone. The most common complications associated with surgical treatment of high-grade spondylolisthesis are pseudarthrosis and injury to the L5 nerve root.

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