Pathology
- Two distinct pelvic orientations seen in patients:
- Pelvis with high sacral slope - results in shear strain on the vertebrae
- Pelvis with more horizontal sacral plate - called the "Nutcracker" type
- Ossification of the pars defect can cause the pars to appear intact but elongated in spondylolisthesis cases
- Gill Fragment:
- During a pars fracture, the inferior articular process can break off and become a separate fragment.
Radiology
- Recognise key radiographic features:
- Presence of sacral dome
- Elongated pars interarticularis
- Thin L5 pedicles
- Sacralisation of L5 vertebra
- Vertebra appears rectangular and wedged at the bottom
- This type is the most challenging surgically due to anatomical variants
Clinical Presentation and Physical Examination
- Spondylolisthesis is the most common cause of back pain in children
- Other signs and associated features:
- Poor posture
- Abnormal gait patterns
- Scoliosis (sideways spinal curvature)
- Physical exam findings:
- Generalized ligament laxity
- Lordotic posture (exaggerated lumbar curve)
- Anterior pelvic tilt
- Hamstring muscle tightness
Treatment of Low-Grade Spondylolisthesis
Nonoperative Management
- Mainstay therapy for symptomatic cases (~68% of patients)
- Focuses on:
- Activity restriction and modification to minimize symptoms
- Core muscle strengthening exercises
- Use of orthoses (braces) to provide support
Operative Management
- Surgical Decision Tips
- Pars repair is generally not indicated in adults
- Laminectomy without fusion is not recommended
- Surgical options involve fusion procedures rather than isolated decompression or repairs in adults
- Indicated when conservative treatment fails or symptoms worsen
- Surgical options include:
- Pars repair, primarily in young patients with reparable pars defects
- Posterior or posterolateral fusion, typically at a single spinal level
- Wiltse paraspinal sacrospinalis splitting approach for accessing the spine
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