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Pediatric Spondylolisthesis M43.10 738.4

 

synonyms:

Pediatric Spondylolysis ICD-10

Pediatric Spondylolysis ICD-9

  • 738.4 (acquired spondylolisthesis or spondylolysis)

Pediatric Spondylolysis Etiology / Epidemiology / Natural History

  • Spondylolysis = disruption of the pars interarticularis.
  • Generally from cyclic loading of the inferior articualr facet onto the inferior lamina and pars interarticularis. May be genetic risk factors.
  • Spondylolisthesis = anterior vertebral tanslation in relation to the caudal vertebra.
  • Slip progression occurs in 5% of pts, is more common in girls and is rare after skeletal maturity.
  • Asymptomatic incidence: spondylolysis = 6%; spondylolisthesis = 3% (Belfi LM, Spine 2006;31:E907).
  • Associated with football (lineman), gymnasts, ballet, figure skating, wrestlers, divers.
  • Etiology: dysplastic, congenital, isthmic, degnerative, traumatic, patholigc.
  • Risk factors: increasing age, obesity, lordotic angle, pelvic inclination (Sonne-Holm S, Eur Spine J 2007;16:821).

Pediatric Spondylolysis Anatomy

  • L5-S1 slip affects L5 nerve roots.

Pediatric Spondylolysis Clinical Evaluation

  • Low back pain aggravated by spine hyperextension. May have sciatic/radicular symptoms.
  • Pain reproduced with back hyperextended while standing and performing a single leg hyperextension on the ipsilateral side of the lesion.
  • Often have hip flexor and hamstring tightness.
  • Crouched gait.

Pediatric Spondylolysis Xray / Diagnositc Tests

  • A/P and Lateral views. Oblique views(30° ). Consider flexion/extension views. Xray findings (pars defect, vertebral slippage) do not correlate with clinical symptoms (Fredrickson BE, JBJS 1984;66A:699).
  • SPECT(single photon emission computerized tomography) is most sensitive in detecting early spondylolysis.
  • CT (3-mm reverse gantry): best defines lesion.
  • MRI: reverse angle oblique axial T1 images and dual echo steady state images best demonstrate lesion. (Udeshi UL, Clin Radiol 1999;54:615).

Pediatric Spondylolysis Classification / Treatment

  • Meyerding Grading
    -Grade 1:0-15%
    -Grade II; 26-50%
    -Grade III; 51-75%
    -Grade IV:76-100%
    -Grade V: >100% (spondyloptosis)
  • Lumbar corsets or rigid thoracolumbar braces. PT with abdominal strengthening, psoas and hamstring stretching. May consider electromagnetic stimulation for nonunions.
  • Most patients with spondylolysis or grade 1 spondylolisthesis do not need surgical treatment
  • pts who have persistent pain unresponsive to conservative measures, consider Posterolateral arthrodesis of two or more vertebrae or direct repair of the defect by bone grafting and internal fixation 
  • Grade IV: generally treated with posterior spinal fusion with or without instrumentation
  • Grade V: Spondylo-optosis, consider vertebrectomy
  • Surgery: indicated for intractable pain with ADLs, spondylolisthesis >50%, progressive slippage, neurolic deficit. Surgical options include instrumented or noninstrumented posterolateral fusion, interbody fusion. Slip reduction has not demonstrated long-term clinical benefits verses insitu fusion. Consider vertebral resection for Grade V spondylolisthesis (Gaines RW, Spine 2005;30:S66).

Pediatric Spondylolysis Associated Injuries / Differential Diagnosis

  • Spina bifida occulta
  • Tumor (malignancy/primary)
  • Infection
  • Facet arthrosis

Pediatric Spondylolysis Complications

Spondylolysis Follow-up Care

  • May return to sports when painfree with full ROM and strength.
  • @12% of patients with bilateral pars defects and minor slippage will shown progression.

Pediatric Spondylolysis Review References

  • Staendaert CJ, Br J Sports Med 2000;34:415
  • Pedersen AK, Hagen R: Spondylolysis and spondylolisthesis: Treatment by internal fixation and bone grafting of the defect. J Bone Joint Surg Am 1988;70:15-24.
  • Lenke LG, ICL 2003;52:525.
  • Lovell and Winter's Pediatric Orthopaedics 2012

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