Fig. 4.1
(a) Standing sagittal view of a patient with a high grade spondylolisthesis. Notice the flattened buttock (black arrow), flattened lumbar lordosis and the positive overall sagittal balance when standing with the knees straight. (b) A crouch stance and gait is used to improve the overall sagittal balance due to the spinal imbalance and tight hamstrings
Fig. 4.2
Coronal and sagittal view of an adolescent with a high grade spondylolisthesis. Notice the abdominal crease (white closed arrow) and flattening of the lumbar spine and buttock (white open arrow)
In some cases, when an Adam’s forward bend test is performed, scoliosis will be noted in the upper lumbar and thoracic region of the spine. McPhee and O’Brien have described three categories of scoliosis which are associated with spondylolisthesis [17]. The first is idiopathic scoliosis which is unrelated to the spondylolisthesis. The deformity has the typical appearance of thoracic or thoracolumbar idiopathic scoliosis, and is identified in about 5–10 % of patients with spondylolisthesis [2] (Fig. 4.3). The second type of scoliosis is a rotational deviation of the upper spine due to an asymmetric slippage of the spondylolisthesis, more on one side than the other. In the third category the scoliosis is due to pain or muscle spasm caused by the spondylolisthesis and resultant nerve root irritation. This scoliosis, termed olisthetic scoliosis, has an atypical appearance and is non-structural (Fig. 4.4). Treatment of this third category of scoliosis is often aimed at the spondylolisthesis with subsequent expected resolution of the scoliosis [17].
Fig. 4.3
AP and lateral radiograph showing a grade 1 L5–S1 spondylolisthesis and a 55° idiopathic scoliosis
Fig. 4.4
AP and lateral radiograph showing a grade 3 L5–S1 spondylolisthesis and a 25° olisthetic scoliosis
Palpation
Palpation of the spine in children with spondylolisthesis is typically unremarkable. Pain is usually not exacerbated with palpation of the lumbar spine in these patients, even those reporting back pain. The pain is usually exacerbated with range of motion of the spine, specifically hyperextension. Occasionally in thin patients with high grade spondylolisthesis a step-off is appreciated at the lumbosacral junction, especially when assessed during Adams’ forward bend test. This step-off correlates with the prominent posterior elements of the vertebral body immediately caudal to the level of the spondylolisthesis (Fig. 4.5).
Fig. 4.5
Lateral lumbosacral radiograph demonstrating the prominence of the posterior elements of the sacrum (white arrow) caudal to the spondylolisthesis. This area is easily palpated on exam due to prominence
Range of Motion
As is the case with many of the physical findings in a child with spondylolysis or spondylolisthesis, the range of motion of the spine can range from full and unaffected to severely limited. This motion is somewhat correlated to the degrees of displacement of the spondylolisthesis and the degrees of back pain and nerve root irritation. Flexion of the lumbar spine is typically unencumbered by the anatomic deformity of the spine, but may be limited by associated hamstring tightness. Extension is typically limited by pain in the lumbar spine. The rotation and lateral bending of the spine may also by limited by pain [7].
Tightness of the hamstrings is a classic physical finding associated with pediatric spondylolysis and spondylolisthesis. Originally described by Phalen and Dickson in association with spondylolisthesis, this is found in up to 80 % of symptomatic patients [4]. The etiology of this finding remains unclear. One leading theory is this tightness is due to irritation of the lower lumbar and upper sacral nerve roots which innervate the hamstring muscles and cause muscle spasticity. Some people believe this irritation is from stretching of the nerve roots due to the deformity while others believe it is caused by hypertrophic granulation tissue at the site of the pars defect which impinges on the traversing nerve roots. Others suspect the rotation of the pelvis leads to a mechanical tightness of the hamstrings. No one theory has been shown to be the definitive cause to this point [18, 19].
Gait
Evaluation of the gait of a patient with suspected spondylolisthesis is important. Many of the anatomic abnormalities found can lead to gait alterations. It is most helpful to have the child dressed in shorts, a bathing suit, or a small exam gown so the entire lower extremities and trunk can be evaluated. Shoes and socks are removed and the child is asked to walk back and forth down a long hallway. Often times it is helpful to have the child walk multiple times so different segments of the body can be watched, from the trunk to the pelvis and hip, to the knees and finally the feet. Additionally, in children with spondylolisthesis, it is helpful to evaluate the gait from the front and side of the child to assess both the coronal and sagittal plane.
As discussed above, severe spondylolisthesis typically results in a more vertically oriented sacrum, a forward displacement of the proximal spine and trunk, and tightness of the hamstrings. These deformities will lead to distinct gait abnormalities seen in these patients. In general, patients with significant spondylolisthesis will be found to have a shortened stride length due to the hamstring tightness. In extreme cases, this hamstring tightness and limited stride length can be so severe the child will need to walk sideways to move around effectively. As the spinal deformity, hamstring tightness and sacral malalignment worsen and a crouch alignment becomes more fixed, the child may begin to walk on their tip-toes to compensate for this flexed hip and knee deformity [20].
Neurologic Exam
A detailed neurologic exam is required when evaluating children with spondylolysis and spondylolisthesis. This exam should include documentation of a full lumbar root motor and sensory exam, evaluation of the deep tendon reflexes at the knee and ankle and the abdominal reflexes. Sacral root sensory testing and rectal exam are typically deferred to cases of severe deformity, pre-operative evaluation, and in those patients who complain of bowel or bladder dysfunction.
A complete evaluation of the lower extremity strength and sensation should be completed and documented in a systematic fashion. The typical root levels and exam findings are found in Table 4.1.
Table 4.1
Neurologic examination findings in the lower extremities
Nerve root | Motor distribution | Sensatory distribution | Deep tendon reflex |
|---|---|---|---|
L1 | Iliopsoas (hip flexion)
Related posts: Intraoperative Neuro-Monitoring During Spondylolisthesis Surgery
 Management of Traumatic Spondylolisthesis: Cervical and Lumbar
 Surgical Techniques: Management of High-Grade Spondylolisthesis Including Reduction Techniques
 Decompression and Spinal Fusion in Low Grade Spondylolisthesis
 Spondylolisthesis Associated with Scoliosis
 Management of Spondyloptosis
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