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Spondylolisthesis

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• Spondylolistheses

Spondylolisthesis  (plural: spondylolistheses) denotes the slippage of one vertebra relative to the one below. 

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Terminology, epidemiology, clinical presentation, classification, radiology report, radiographic features, treatment and prognosis, history and etymology.

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Although etymologically, it is directionless (see below) and could be applied to both anterolisthesis and retrolisthesis, in practice, spondylolisthesis is used synonymously with anterolisthesis . Often, particularly in the lower lumbar spine, it is due to spondylolysis ( pars interarticularis defects) 6 . 

The incidence of spondylolisthesis in childhood is ~5%, mostly due to spondylolysis . Incidence increases in adulthood to ~12.5% (range 10-15%), mostly due to degenerative change 9 .

When symptomatic, patients present with low back pain , radiculopathy and/or neurogenic claudication 9 .

Spondylolisthesis can occur anywhere in the vertebral column but is most frequent in the lumbar spine, particularly when due to spondylolysis  at L5/S1 9 , and when due to degeneration at L4/5 7 . 

Wiltse classification : divides into types by etiology

Meyerding classification : grades by severity of the slip

To adequately describe a spondylolisthesis, the type and grade must be stated ref and the presence or absence of instability 4 .

Plain radiograph

On lateral lumbar spine x-rays , a "step" in the alignment of the posterior cortices can be visible and then graded by the Meyerding classification. The type of spondylolisthesis may also be able to determined. On flexion/extension views , translation >4 mm indicates instability 4 .

Indications for surgical management of spondlylolisthesis includes 9 :

symptomatic grade 1/2 slips refractory to non-operative management (usually 6 months)

grade 3 or higher slips

progressive slip > 1 grade

instability

Spondylolisthesis is from the Ancient Greek σπονδύλους (spondylous) meaning vertebra and ολίσθηση (olisthesis) meaning slippage 6 .  Carl von Rokitansky, (1804-1878), an Austrian pathologist, was the first to describe spondylolisthesis in 1839 8 .

Quiz questions

• 1. Schneider C & Melamed A. Spondyloysis and Spondylolisthesis; Case Report Clarifying the Etiology of Spondylolysis. Radiology. 1957;69(6):863-6. doi:10.1148/69.6.863 - Pubmed
• 2. Ravichandran G. A Radiologic Sign in Spondylolisthesis. AJR Am J Roentgenol. 1980;134(1):113-7. doi:10.2214/ajr.134.1.113 - Pubmed
• 3. Oakley R & Carty H. Review of Spondylolisthesis and Spondylolysis in Paediatric Practice. Br J Radiol. 1984;57(682):877-85. doi:10.1259/0007-1285-57-682-877 - Pubmed
• 4. Wiltse LL. Classification, Terminology and Measurements in Spondylolisthesis. Iowa Orthop J. 1981; 1: 52–57. Free text at pubmed - Pubmed citation
• 5. Lee J & Shin B. Current Concept on the Classification and Treatment of Spondylolisthesis. J Korean Soc Spine Surg. 2010;17(1):38. doi:10.4184/jkss.2010.17.1.38
• 6. Yochum TR and Rowe LJ "Essentials of skeletal radiology" Lippincott Williams & Wilkins, 2004. Google Books
• 7. Izzo R, Guarnieri G, Guglielmi G, Muto M. Biomechanics of the Spine. Part II: Spinal Instability. Eur J Radiol. 2013;82(1):127-38. doi:10.1016/j.ejrad.2012.07.023 - Pubmed
• 8. Schlenzka D. [The History of Spondylolisthesis. The Nineteenth Century: Early Case Reports, Terminology, Etiology and Pathogenesis]. Unfallchirurg. 2015;118 Suppl 1(S1):37-42. doi:10.1007/s00113-015-0079-7 - Pubmed
• 9. Koslosky E & Gendelberg D. Classification in Brief: The Meyerding Classification System of Spondylolisthesis. Clin Orthop Relat Res. 2020;478(5):1125-30. doi:10.1097/CORR.0000000000001153 - Pubmed

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Spondylolisthesis Imaging

• Author: Zubin Irani, MD, MBBS; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
• Sections Spondylolisthesis Imaging
• Practice Essentials
• Radiography
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S pondylolisthesis  is a condition leading to slippage of one vertebral body over the one below, resulting in spinal stenosis and producing neurogenic claudication, with or without low back pain. [ 1 ] The word "spondylolisthesis" is derived from the Greek words spondylo, meaning spine, and listhesis, meaning to slip or slide. Spondylolisthesis has many etiologies, all of which ultimately lead to loss of stability offered by the locking mechanism of articular processes of the vertebrae that allow the superior vertebrae to slide forward over the inferior vertebrae. Etiologies can be classified as congenital (dysplastic), spondylolytic (isthmic), degenerative, traumatic, pathologic, or iatrogenic (eg, postoperative). [ 2 ]  Spondylolisthesis is typically classified as isthmic or degenerative. Isthmic spondylolisthesis is classically precipitated by progressive spondylolysis, and degenerative spondylolisthesis is most commonly associated with progression of age. Degenerative spondylolisthesis is estimated to be about 6 times more common in females than in males. [ 3 ]

Prevalence of spondylolisthesis is age and gender specific. Other risk factors include a history of occupational driving, intense manual activity, and sedentary work. Diagnosis for patients with spondylolisthesis requires a detailed history, physical examination, and imaging attained through standing lateral radiography and magnetic resonance imaging (MRI). [ 1 ]

Etiologies are described below [ 2 ] :

• Congenital spondylolisthesis occurs when a baby’s spine does not form the way it should before birth. Misaligned vertebrae put the person at risk for slippage later in life.
• Isthmic spondylolisthesis occurs as a result of spondylolysis. A crack or a fissure weakens the bone.
• Degenerative spondylolisthesis is the most common type and occrus with age. Over time, disks that cushion the vertebrae lose water. As disks thin, they are more likely to slip out of place. This is more common after age 50 years and is seen more often in women than in men.
• Traumatic spondylolisthesis occurs when an injury causes vertebrae to slip.
• Pathologic spondylolisthesis occurs because of  disease such as osteoporosis or a tumor.
• Iatrogenic (postoperative) spondylolisthesis results from spinal surgery.

The spondylolytic type is the most common form of spondylolisthesis. [ 4 ] It affects the region of the pars interarticularis, which is roughly the region of the junction of the pedicle and the lamina, where articular and transverse processes of the vertebrae arise. A defect at this point functionally separates the vertebral body, the pedicle, and the superior articular process from the inferior articular process and remaining vertebrae. Thus, the defect cleaves the vertebra into 2 parts. The portion of the vertebra posterior to the defect remains fixed, and anterior portions are free to potentially slip forward relative to posterior structures and the spine below. Note that a bilateral pars defect is needed to allow slippage.

Degenerative spondylolisthesis is a common back pathology in the general adult population. Patients with this condition may present for epidural steroid injection, epidural blood patch, or epidural analgesia. Sindhi et al concluded that patients with degenerative spondylolisthesis may be at higher risk for dural puncture due to stretching of the dura and contraction of the epidural space at the translated spinal level. [ 5 ]

Most patients with symptomatic degenerative spondylolisthesis and absence of neurologic deficits should do better with conservative treatment, whereas those with neurologic symptoms are more prone to undergo progressive functional deterioration without surgery. [ 1 ]

​Imaging modalities

For diagnosis of spondylolisthesis, comprehensive evaluation with static, dynamic radiographic studies performed with the patient in a standing position and magnetic resonance imaging (MRI) are essential. Conservative treatment is first-line therapy and includes analgesics, anti-inflammatories, and physiotherapy. [ 6 ]

Flexion-extension functional radiographs are considered the gold standard for diagnosis of degenerative spondylolisthesis; a disc angle change greater than 10° or a change in translation greater than 3 mm is generally used as the cut-off. [ 7 ]  

Lateral and anteroposterior plain radiographs of the lumbar spine should be obtained in patients with complaints of back pain. The lateral view (shown in the image below) is useful for detecting spondylolisthesis; it may show the pars defect.

Bilateral oblique views are especially useful in visualizing the pars interarticularis defect, which has the appearance of a Scottie dog with a collar. An elongated pars also may be seen.

(See the images below.)

In addition, plain radiographs may show congenital types of spondylolisthesis and the changes of spondylosis. In the setting of trauma, fractures may be apparent. Note that other causes of the patient's symptoms may be identified such as osteoid osteoma, Paget disease, and osteolytic lesions. The grade of spondylolisthesis can be measured by using the lateral view (as shown in the images below).

Cross-sectional imaging should be considered next.

For patients with back pain and no clinical findings of nerve root involvement, computed tomography (CT) scanning of the lumbar spine yields information regarding spondylolisthesis and its cause, along with other possible conditions, such as disc disease, disc herniation, spondylosis, and spinal canal stenosis. Other associations, such as spina bifida, may also be seen. For patients with radiculopathy, CT myelography can yield information regarding nerve root impingement and its etiology, such as disc herniation, abscess, or neoplasm. CT scanning is more sensitive for detecting spondylolysis, but occasionally this condition may be missed because scanning occurs in the plane of the spondylolysis or as the result of volume averaging. Sagittal reconstruction images are of help in patients with these findings.

MRI offers the distinct advantage of imaging the spine in any plane without exposure to radiation. Typically, axial and sagittal planes are used, but images in the coronal plane can also be acquired easily, if needed. MRI reveals spondylolisthesis on sagittal views. Spondylolysis may not be readily apparent on MRI, especially if a mild degree of bony sclerosis is evident. Other sclerotic lesions in the pars interarticularis, such as osteoblastic metastases, may present with a similar appearance. [ 8 , 9 , 10 , 11 ]

Traumatic cervical spine fractures and dislocations are common in clinical practice, but high-grade traumatic cervical spondylolisthesis is rare. Total spondylolisthesis, or dislocation of a single cervical vertebra, can occur only with high-energy trauma, such as that seen in motor vehicle collisions, diving accidents, or severe falls. Detailed 3-dimensional (3D) reconstructive CT should be performed to evaluate fractures, subluxations, and dislocations. MRI can be used to analyze the spinal cord and ligamentous injuries, and CT angiography can reveal a vascular injury. [ 12 ]

(A grading system for spondylolisthesis is shown in the image below.)

Meyerding grading scale

The most common grading scale for spondylolisthesis was proposed by Meyerding and describes the degree of vertebral slippage, as follows [ 3 , 13 ] :

• Grade I is < 25% slippage. 
• Grade II is 25-50% slippage. 
• Grade III is 50-75% slippage. 
• Grade IV is 75-100% slippage.
• Grade V is complete slippage.

For patients with complaints of back pain, anteroposterior and lateral projection plain radiographs of the lumbar spine should be obtained, at the least. [ 11 , 14 , 15 ]

The lateral view is especially useful in detecting spondylolisthesis. Moreover, the grade of spondylolisthesis is measured on the lateral view (as shown in the images below). The pars defect may or may not be visualized on the lateral view.

Bilateral oblique views may be obtained to visualize the pars defect, which has the appearance of a Scottie dog with a collar (as shown in the radiographs below). An elongated pars may also be seen. Note that oblique views increase specificity, but not sensitivity, for pars defects. [ 16 ]

Congenital and degenerative types of spondylolisthesis also can be visualized on plain radiographs. Lumbar degenerative spondylolisthesis most commonly occurs at the L4–L5 level, followed in frequency by L3–L4, L5–S1, and L2–L3 levels. The slip occurs secondary to degenerative changes in the facet joints. A grade 1 slip is most common, followed by a grade 2 slip. The width of the lumbar canal can be directly measured on these films from the mid aspect of the vertebral body in front (anteriorly) to the dorsal (back) interlaminar line (line created by the laminae coming together to form the spinous process). Normal canal width is 20 mm. Smaller widths are considered spinal stenosis. [ 17 ]

In the setting of trauma, fractures may be apparent. Traumatic spondylolisthesis of the axis, also known as a hangman’s fracture, is caused by hyperextension of the neck. These fractures are classified according to degree of anteroposterior deviation, evidence of disruption of the posterior longitudinal ligament, position of the fracture line, and presence of a facet joint dislocation. [ 18 ]

Other causes of symptoms may be noted; these include osteoid osteoma, Paget disease, and osteolytic lesions.

In a study of lateral flexion-extension radiographs and MRI for degenerative cervical spondylolisthesis by Alvarez et al, of the 77 levels of spondylolisthesis, 17 levels (22.1%) were missed on neutral radiographs, 20 levels (26.0%) were missed when flexion-extension radiographs were used alone, and 29 levels (37.7%) identified on radiograph were missed by MRI. The authors concluded that flexion-extension radiographs should not be used in place of standard anteroposterior and lateral radiographs but that they can be a useful adjunct in identifying cervical spondylolisthesis when standard AP and lateral radiographs and MRI are not able to identify the source of neck and radicular pain. [ 19 ]

Kashigar et al conducted a multicenter study to assess whether flexion-extension radiographs add value in assessment of patients with degenerative spondylolisthesis and concluded that flexion-extension radiographs may play a limited role. Patients for whom flexion-extension views were most likely to provide value were those with smaller slips (< 7 mm) with no evidence of motion on standing radiography. [ 20 ]

Bredow et al identified surgical modification of pelvic tilt and sagittal rotation as the radiologic alignment parameters that can most accurately predict long-term clinical outcomes after lumbar interbody fusion surgery. [ 21 ]

Degree of confidence

Five-view plain radiography of the spine is the standard for a plain radiographic evaluation.

Visualization of spondylolisthesis on standard radiographs, particularly lateral plain radiographs, confirms the presence of the condition. The etiology may not be readily evident, and other modalities may be needed for elucidation. CT scanning is perhaps the most valuable cross-sectional modality used to achieve this.

In the setting of trauma in a child, a pseudosubluxation of the vertebra in the cervical spine may be observed; such a finding may cause some confusion with traumatic spondylolisthesis. Clinical correlation may be helpful because focal tenderness at that level may require further evaluation clinically and/or radiologically; CT scanning may be needed.

No normal variants that mimic spondylolysis or degenerative changes have been identified.

For patients with back pain and no clinical findings of nerve root involvement, computed tomography (CT) scanning of the lumbar spine yields information regarding spondylolisthesis and its cause, along with other possible conditions, such as disc disease, disc herniation, spondylosis, and spinal canal stenosis. Other associations, such as spina bifida, also may be revealed. For patients with radiculopathy, CT myelography can provide information regarding nerve root impingement and its etiology, such as disc herniation, abscess, or neoplasm.

CT scanning of the spine can be performed with or without intrathecal contrast enhancement. Axial images are obtained in a plane parallel to disc spaces at each level imaged. Sagittal reconstruction images (shown below) are obtained by using post-acquisition processing software. Bone window (eg, 1500/300 HU) and soft tissue window (eg, 300/30 HU) settings are used.

Thin sections should be used to avoid problems such as volume averaging. (Contiguous images also reduce such problems.) Indeed, if sections are too thick and if a gap is present between sections, spondylolysis can be missed. In such cases, sagittal reconstructions may be of help in showing spondylolysis.

With spondylolysis , CT is performed as close as possible to an angle that is 90° to the level of interest. CT scans typically reveal a horizontally oriented defect in the pars, which interrupts the normally complete bony ring of posterior elements.

Spondylolisthesis is evaluated best on lateral topography, but it can be suggested for patients with spinal stenosis in the absence of disc pathology, posterior hypertrophic changes, or a congenitally narrow spinal canal. One typically looks for an elongated spinal canal (as shown in the images below).

CT scans can reveal findings of congenital/dysplastic and degenerative types of spondylolisthesis. Abnormalities of vertebral body or of articular processes may be present.

Changes in spondylosis deformans (degenerative changes) are apparent on CT scans. Degenerative disease of the spine has a characteristic appearance involving loss of disc space height with or without the presence of a vacuum phenomenon, narrowing of the facet joint space, subchondral sclerosis, osteophyte formation, and subchondral cysts. Some or all of these changes may be noted and may cause altered alignment of the facet joint articular surface, leading to slippage. Spinal canal and/or intervertebral neural foraminal stenosis may be identified.

In traumatic spondylolisthesis, findings may include jumped facets and fractures of articular processes and/or laminae that result in spondylolisthesis.

Usually, CT findings confirm the presence of spondylolisthesis, its etiologies, and potential complications. MRI provides complementary imaging in some patients with traumatic spondylolisthesis for whom information regarding ligamentous and spinal cord integrity is required. One of the limitations of CT scanning is that it does not clearly show ligamentous injury.

Magnetic resonance imaging (MRI) offers the distinct advantage of imaging the spine in any plane. Typically, axial and sagittal planes are used, but images in the coronal plane can also be acquired easily, if needed. [ 8 , 9 , 22 , 23 , 24 ]

Spin-echo and fast spin-echo sequences are applied for image acquisition in these planes. A fat saturation technique can be used to minimize signal from fat and to bring out signal from fluid structures (eg, bone edema). Gradient-echo sequences can also be used; they provide the advantage of faster image acquisition, limiting problems related to motion. For a postoperative patient, consideration should be given to gadolinium enhancement with T1-weighted spin-echo sequences.

Spondylolisthesis is confirmed by visualization on MRI. Spondylolysis may be difficult to appreciate, and plain radiographs and/or CT scans may be complementary in this regard.

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). This disease has occurred in patients with moderate to end-stage renal disease after they were given a gadolinium-based contrast agent to enhance MRI or magnetic resonance angiography (MRA) scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

MRIs should be scrutinized for the presence of a spondylolisthesis or any abnormality of the pars interarticularis, pedicles, or facet joints. Nerve structures, including those exiting neural foramina, and the spinal canal should be evaluated.

Spondylolisthesis is best assessed on median sagittal images of the spine. The levels and the grade involved can be seen.

Spondylolysis pathologically can be a fibrous bridge or a pseudarthrosis, both of which have corticated/sclerotic margins in adjacent portions of the bony ring. Bony sclerosis and fibrous tissue appear as an area of low signal intensity in the region of the pars interarticularis on images obtained with all sequences. This finding may not be easily seen, which is a limitation of using MRI for spondylolysis.

Similar signal intensity changes in these areas may be seen with bony sclerosis, volume averaging with adjacent osteoarthritic facet joints, osteoblastic metastases, and even involvement of the pedicles with Paget disease. Even if one sees normal bone signal extending from the vertebral body to the pedicle and into the lamina, it is not possible to exclude spondylolysis because minimal sclerosis may have occurred in the bone and because its signal intensity is similar to that of posterior element bone. This is a limitation of MRI in detecting spondylolysis.

High signal intensity may be seen in the pars interarticularis with T2-weighted sequences. This finding indicates the presence of fluid, a pseudarthrosis, or bone edema from infection.

Degenerative disease can also be seen. [ 25 , 26 ] Narrowed disc space with disc desiccation (low T2 signal intensity) should be sought. This disc narrowing causes superoinferior subluxation of the facet joint at the level of disease, resulting in anterolisthesis or retrolisthesis. Reactive marrow changes should also be sought; these are seen in portions of vertebral body adjacent to discs and in marrow adjacent to facet joints and may result in abnormal signal intensity in the pars interarticularis.

Neoplastic disease involving the pars interarticularis or other parts of the vertebra typically yields low marrow signal intensity with all sequences. Infection may be evident as fluid signal intensity (bright on T2-weighted MRIs) from bone edema. Both disease processes show enhancement with a gadolinium-based contrast agent. Other diseases causing a sclerotic response (eg, Paget disease ) result in low signal intensity with all sequences.

Nuclear medicine has no role as a primary imaging modality in spondylolisthesis. Spondylolysis can be detected as areas of increased activity on bone scans, but its appearance is nonspecific, and such findings may be seen in other disorders (eg, neoplasms, infections). Usually, correlation with clinical and plain radiographic findings is helpful in narrowing the differential diagnosis.

Nuclear medicine imaging involves the use of diphosphonates labeled with technetium-99m ( 99m Tc). These are administered intravenously, and planar images of the whole body are acquired (as shown in the image below).

High-count (1000 k) spot views of the lumbar spine are also obtained. Single-photon emission CT (SPECT) scanning, used to produce the images below, is a more powerful way to detect areas of increased activity that may not be readily apparent on planar images.

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Huang KY, Lin RM, Lee YL, et al. Factors affecting disability and physical function in degenerative lumbar spondylolisthesis of L4-5: evaluation with axially loaded MRI. Eur Spine J . 2009 Dec. 18 (12):1851-7. [QxMD MEDLINE Link] .

• Spondylolisthesis. Diagram shows how to grade spondylolisthesis. The 2 arrows, one indicating vertebral body width and the other indicating the amount of slippage that has occurred, represent the measurements needed. The ratio of amount of slippage to vertebral body width is obtained as a percentage. Grade 1 is a ratio of 0 to 25%, grade 2 is 25% to 50%, grade 3 is 50% to 75%, and grade 4 is 75% to 100%.
• Spondylolisthesis. Straight lateral radiograph of the L4-S1 level of the spine shows lucency at the pars area (arrow). Bilateral pars defects must be present to visualize this in a lateral projection. Grade 1 spondylolisthesis is associated.
• Spondylolisthesis. Oblique projection radiograph shows the presence of bilateral pars defects (arrows) with an appearance resembling a Scottie dog with a collar. (The collar is the pars defect.)
• Spondylolisthesis. Diagram in the oblique projection shows components of the vertebrae that result in the appearance of a Scottie dog with a collar.
• Spondylolisthesis. The appearance of a Scottie dog with a collar has been outlined in the normal vertebra, with the pars defect (the collar) shown by the arrows.
• Spondylolisthesis. Axial CT image shows bilateral spondylolysis (arrows). Note elongation of the spinal canal at this level.
• Spondylolisthesis. Sagittal CT reconstruction image shows the pars defect along with grade 1 spondylolisthesis (arrow).
• Spondylolisthesis. Sagittal CT reconstruction image shows the pars defect along with grade 1 spondylolisthesis.
• Spondylolisthesis. Lateral lumbar spinal radiograph in a pediatric patient shows spondylolysis with grade 1 spondylolisthesis.
• Spondylolisthesis. Grade 4 traumatic spondylolisthesis.
• Spondylolisthesis. Planar image of lumbar spine in a 14-year-old with back pain. Note hot spots at L5 in the region where one would see the pedicles end-on on a plain radiograph.
• Spondylolisthesis. Axial single-photon emission CT (SPECT) image shows bilateral hot spots in the pars; these indicate spondylolysis.
• Spondylolisthesis. Coronal single-photon emission CT (SPECT) image shows bilateral hot spots in the pars; these indicate active spondylolysis.
• Spondylolisthesis. Sagittal single-photon emission CT (SPECT) image shows hot spots in the pars; these indicate active spondylolysis.

Contributor Information and Disclosures

Zubin Irani, MD, MBBS Clinical Staff, Vascular Interventional Radiology, Massachusetts General Hospital, Harvard Medical School Zubin Irani, MD, MBBS is a member of the following medical societies: American College of Surgeons Disclosure: Nothing to disclose.

Jehangir J Patel, MD Director, Musculoskeletal Radiology Service, Department of Radiology, Baystate Medical Center Jehangir J Patel, MD is a member of the following medical societies: American College of Radiology , American Roentgen Ray Society , International Society for Clinical Densitometry , Massachusetts Medical Society , Radiological Society of North America Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand Disclosure: Nothing to disclose.

William R Reinus, MD, MBA, FACR Professor of Radiology, Temple University School of Medicine; Chief of Musculoskeletal and Trauma Radiology, Vice Chair, Department of Radiology, Temple University Hospital William R Reinus, MD, MBA, FACR is a member of the following medical societies: Alpha Omega Alpha , Sigma Xi, The Scientific Research Honor Society , American College of Radiology , American Roentgen Ray Society , Radiological Society of North America Disclosure: Nothing to disclose.

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, University of Washington School of Medicine Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society , Association of University Radiologists , International Skeletal Society , Radiological Society of North America Disclosure: Nothing to disclose.

David S Levey, MD Radiologist, Neurospinal and Orthopedic MRI, Musculoskeletal Subspecialty; Medical Expert, MRI and Radiology Review - Second Opinion Services David S Levey, MD is a member of the following medical societies: International Society of Forensic Radiology and Imaging Disclosure: Nothing to disclose.

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Spondylolytic Spondylolisthesis of Cervical Spine

Jun-hyuk woo.

Department of Neurosurgery, Dong-A University Medical Center, Busan, Korea.

Hong-June Choi

Cervical spondylolytic spondylolisthesis is a rare congenital anomaly. It is often misunderstood as a result of trauma. However, most of them are congenital deformities. The vast majority of patients with radiographically proven cervical spondylolysis can be treated confidently with conservative measures. Cervical spondylolytic spondylolisthesis that cause symptoms requiring surgery is very rare. Surgical intervention should be reserved for those who fail non-operative management or exhibit neurologic compromise referable to an unstable spondylolytic defect. We report a case of cervical radiculopathy in a 45-year-old female patient who had been diagnosed with spondylolytic spondylolisthesis at the sixth verterba and treated with surgery.

INTRODUCTION

Cervical spondylolysis is defined as a cortical defect in pars interarticularis. It is a rare anomaly contrary to lumbar spondylolysis. Cervical spondylolytic spondylolisthesis that cause symptoms requiring surgery is even rarer. Cervical isthmic spondylolisthesis has been seldom reported. In ordinary cases, cervical spondylolysis is diagnosed accidently in minor trauma. Although there are some hypotheses about its pathophysiology and natural history, nothing is certain. We report a case of cervical radiculopathy in a 45-year-old female patient who had been diagnosed with the sixth vertebral spondylolytic spondylolisthesis and treated with surgery. We also reviewed current literature about cervical spondylolysis.

CASE REPORT

A 45-year-old female presented with posterior neck pain, numbness, and transient weakness on both arms. Her symptoms arose 6 months prior. One week ago after a light traffic accident, these symptoms were aggravated. She was a housewife. She did not have any medical or surgical history. She was involved in a bicycle traffic accident 5 years ago. However, she said it was not too severe.

On physical examination, she presented with weakness (grade IV) for her both grasping and radiculopathy through both the sixth vertebrae (C6) and the seventh vertebrae (C7) dermatome. Radiographic examination of the patient's cervical spine revealed a bilateral spondylolysis on C6 and spondylolisthesis at C6 on C7 ( FIGURE 1 ). On plain radiograph, flexion and extension lateral view showed instability between C6 and C7 ( FIGURE 2 ). On computed tomography (CT) scan, a bilateral defect between the pedicle and the lamina was revealed. The spina bifida occulta at C6 level was revealed on CT scan ( FIGURE 3 ). On magnetic resonance image (MRI), cord compression was not definitive. However, the bilateral neural foramen was compressed according to movement due to instability between C6 and C7 ( FIGURE 4 ). There was a neurologic symptom. Thus, we planned to perform anterior cervical discectomy and fusion on C6 and C7 with posterior decompression and fusion using C5 lateral mass–C7 pedicle screw fixation ( FIGURE 5 ). Postoperatively, the patient presented improved symptoms.

Cervical spondylolysis was first described in 1951 by Perlman and Hawes. 14) Isthmic spondylolysis on C2 by trauma is often found. However, unlike lumbar spondylolysis, pure non-traumatic subaxial cervical spondylolysis is very rare. Only about 100 cases have been reported in the literature Furthermore, very few patients have had surgery ( TABLE 1 ). 1)

ACDF: anterior cervical discectomy and fusion.

The cause of cervical spondylolysis is uncertain Trauma, congenital anomaly, and developmental problem can be possible causes. 18) Cervical spondylolysis by trauma is found in relatively young patients. Due to a clear history of trauma and discontinuation of cortical margin of a defect on X-ray, it can be easily diagnosed. There are often other anomalies such as spina bifida occulta in case of cervical spondylolysis by congenital anomaly that can cause a developmental problem. 12 , 17 , 18) Schwartz et al. 18) have reported that this condition is due to repetitive micro-trauma like lumbar spondylolysis. Cervical spondylolysis is most commonly found at C6, a transitional vertebra. Schwartz et al. 18) have emphasized that it is because C6 is more exposed to stress than other subaxial cervical spines.

Cervical spondylosis is found in all ages. 11) The 6th vertebra is the most commonly involved, account for 70% of the cases reported in the world literature. 2) As mentioned above, Schwartz et al. 18) have pointed out that it is because C6 is a transitional vertebra.

Cervical spondylolysis caused by congenital anomaly often includes cleft in the articular mass, dysplastic pedicle, spina bifida, and so on. It can be easily diagnosed by plain radiograph and CT. Compression of neural tissue can be seen by MRI. 8 , 10 , 13) Its characteristic radiographic findings include well-corticated margins at the defect, a characteristic “bow tie” deformity, and ipsilateral dysplastic facets. Compensatory hypertrophic changes of adjacent articular processes, spina bifida, and spondylolisthesis are frequently, but not always, seen in cervical spondylolysis. 15)

In our case, the patient did not have a history of any memorable trauma. There was a spina bifida occulta on her 6th vertebra and a clear cortical margin in the defected area ( FIGURE 3 ). Thus, we think that congenital anomaly is the cause of her cervical spondylolysis. In previously reported cases, treatment was based on symptoms and signs of the patient. If there was no neurologic deficit by instability or medically intractable pain, most of them were treated by conservative methods including medication and immobilization. Our patient underwent surgery because she had neurologic deficit and instability. Anterior and posterior access surgeries were performed (anterior cervical discectomy with fusion between C6 and C7, posterior fixation with C5 lateral mass screw and C7 pedicle screw). The reason for performing posterior fixation from the fifth vertebra, not the sixth vertebra, was that pedicles of the sixth vertebra were dysplastic. In addition, the screw shaft might stimulate the nerve root passing nearby.

Surgical treatments for cervical spondylolytic spondylolisthesis, which is caused by a congenital reason rather than trauma, are very rare. Since the 1950s, when such a case began to be reported, only about 12 such cases have been reported. Thus, the authors think that this case is worthy of reporting.

Cervical spondylolytic spondylolisthesis is a rare congenital anomaly involving mainly C6. Most patients present with mild posterior neck pain without a neurologic deficit. The vast majority of patients with radiographically proven cervical spondylolysis can be treated confidently with conservative measures. Surgical intervention should be reserved for those who fail non-operative management or exhibit neurologic compromise referable to an unstable spondylolytic defect.

Conflict of Interest: The authors have no financial conflicts of interest.

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• Diagnosing and Treating Spondylolisthesis
• Symptoms of Spondylolisthesis
• Surgery for Spondylolisthesis
• Doctors Who Treat Spondylolisthesis
• ALIF, TLIF, and LLIF for Spondylolisthesis
• Video: Navigating Away from Back Pain

Since there can be so many different causes of back pain, an accurate diagnosis is very important. People usually see their primary care physician or general practitioner first about their back pain; that doctor will probably perform a physical exam first and then order imaging tests to see what’s causing the pain.

X-ray: an X-ray can show which vertebrae have slipped out of place.

Computerized tomography (CT) is a noninvasive procedure that uses x-rays to produce a three-dimensional image of the spine, particularly of the bone. A CT shows more detail than an X-ray, and can identify any fractures of the bone.

Magnetic resonance imaging (MRI): An MRI uses magnetic fields and radio-frequency waves to create an image of the spine, and can reveal fine details of the spine, including nerves, tumors, and other details. An MRI scan can show details in the spine that can’t normally be seen on an X-ray or CT. Sometimes a contrast agent is injected into a vein in the hand or arm during the test, which highlights certain tissues.

Myelogram: This test uses a dye that is injected directly into the spinal column, and is used in conjunction with an X-ray or CT Scan.

Treatment Options

Treatments for spondylolisthesis vary depending on the grade of the slippage, severity of the condition, and the age and health of the patient. Non-invasive, conservative treatment options include:

• Avoiding heavy lifting or strenuous activities
• Non-steroidal medications such as ibuprofen to reduce milder inflammation and pain
• Steroid injections to reduce more serious inflammation and pain
• Bracing to stabilize the spine and reduce pain

Physical therapy to strengthen the core muscles surrounding the spine. Physical therapy is usually prescribed in approximately 8- to 12-week regimens.

Surgery: If conservative treatments offer no relief, then surgery may be required. The goal of surgery is to relieve nerve pain, stabilize the spine, and increase a person’s ability to move.

Spine surgery has advanced in recent years so that many procedures are minimally invasive. This type of minimal access surgery causes less trauma than older surgical methods and requires much less time in the hospital. The incision is smaller and avoids muscle trauma, which allows patients to resume regular activity within a short period of time. Surgery for spondylolisthesis is best performed at a major spine center with doctors trained and experienced in the most up-to-date, minimally invasive techniques.  Minimally invasive surgery means a quick recovery, less pain, and less scarring. (See Surgery for Spondylolisthesis .)

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Reviewed by:Paul Park, MD Last reviewed/last updated: April 2024

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Characteristic findings on imaging of cervical spondylolisthesis: Analysis of computed tomography and X-ray photography in 101 spondylolisthesis patients

Affiliations.

• 1 Department of Orthopaedic Surgery, Tokyo Dental College Ichikawa General Hospital, Tokyo, Japan.
• 2 Shiraishi Spine Clinic, Tokyo, Japan.
• 3 Department of Orthopaedic Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan.
• 4 Department of Orthopaedic Surgery, Murayama Medical Center, Tokyo, Japan.
• 5 Department of Orthopaedic Surgery, Saiseikai Tobu Yokohama Hospital, Kanagawa, Japan.
• PMID: 31440643
• PMCID: PMC6698550
• DOI: 10.22603/ssrr.2017-0017

Introduction: The characteristics of cervical spondylolisthesis are not currently fully understood, because of the shortage of reports covering the large population of patients with cervical spondylolisthesis. The purpose of this study was to elucidate the characteristics of cervical spondylolisthesis by examining a relatively large number of cases.

Methods: We analyzed 101 cases with more than 2 mm of vertebral listhesis as determined from X-ray or computed tomography (CT) images among 731 patients who underwent surgery at a single institute. We considered the C2-7 angle, range of motion, and C2-7 sagittal vertical axis on lateral X-ray images. From sagittal CT images, classifications into five grades based on the slipped disc and adjacent caudal levels were made. We examined the orientation of facet joints at the slipped level using axial CT images.

Results: Spondylolisthesis was recognized in 101 cases at 124 levels. Anterior and posterior spondylolisthesis were detected in 68 and 40 cases, respectively. Anterior spondylolisthesis developed predominantly at C3 or C4, usually at the level adjacent to the narrowed disc, or at C7, adjacent to the stiffened thoracic spine. The disc height was relatively preserved at the anterior slipped level. Posterior spondylolisthesis developed predominantly at the level of the significantly narrowed disc associated with advanced intervertebral osteoarthritis. At the segment with listhesis in the lower cervical spine, the direction of the facet joint in the axial plane tended to be posteromedial.

Conclusions: Cervical degenerative spondylolisthesis was classified into two types. The first and more common listhesis occurred adjacent to stiffened levels, and anterior slippage was common in this type. The second and less common listhesis occurred within progressively degenerated segments, and posterior slippage was prominent. We have uniquely described the morphological changes in orientation of the cervical facet joints at the slipped level in the transverse plane.

Keywords: CT; X-ray; cervical facet joint; imaging; spondylolisthesis.

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Conflict of interest statement

Conflicts of Interest: The authors declare that there are no conflicts of interest.

Classification of the orientation of…

Classification of the orientation of facet joints in the axial plane. We categorized…

Numbers of patients with anterior…

Numbers of patients with anterior and posterior listhesis classified by the level of…

Male to female ratio in…

Male to female ratio in anterior and posterior listhesis classified by the level…

Average disc height grade in…

Average disc height grade in the three groups.

Types of alignment and the…

Types of alignment and the numbers of cases of each alignment in the…

Direction of the facet joints…

Direction of the facet joints at the slipped level in the transverse plane…

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