Case 15 Spndylolisthesis


Case 15
                                                Spndylolisthesis
Age –Young                           What happened ?                    Any history of trauma ?
                                               
Symptoms –                            Gait disturbances , Numbness in lower extremities , Cauda Equina , Muscle weaknesses


Introduction ownself
Exposure – whole body
Hand scrubbing
Look- Standing Patient

Comment on Lumbar Corset
Attitude of the body
Look
Alignment       -           Front        Both shoulders and Pelvis are leveled,
                                                     No wasting of Quadriceps muscles
                                                      Patella facing forward and at equal height
Leg, foot and toes look normal with normal        
overlying skin
                                    Side           Elbows straight overlying greater trochanter
                                                       Transverse Loin Creases
     Knee Straight
      Foot Arches maintained  
                                    Back               
Short Kyphosis present at LS junction
Lumbar spine scoliosis due to paraspinal muscle spasm / Lumbar spine flattened / lumbar spine too short
Prominent Buttocks
 Stepping at L5 –S1 + ,
 Normal overlying skin on back with no dimpling , tuft of hair
  and swelling
  Calf symmetrical with normal overlying skin
  Heel has – Normal varus
 Feel
Temperature – Normal
Superficial Palpation – Paraspinal Muscle spasm +
Bony Palpation – Stepping L 5 – S 1
Tenderness at 5th Lumbar Spine
Movement – Global Reduction in movement

Gait                                         Normal / Foot Drop Gait , Disturbance +
Tip toe , heel walking ,

Squating                                  heel at the same level

Standing –      Special tests -Trendelenburg test

Lie down Patient
SLR – decrease to < 60 degrees bilaterally not true nerve root sign                                                
Movement                               Hip / Knee / Ankle / Toes                   
LLD
                                   
Neurovascular Assessment

Sensory Examination             L 2 – S 5   
Motor Examination  -               Global muscle weakness
Power of the Muscles –                      
                                    Supine             Quadriceps ,
TA / EHL /EDC / TP / Peronei
                                                Lateral             Abductor /Adductor
Prone               Gastrosoleus / FHL/FDC /Hamstring/Gluteal Maixums /Medius/Minimus


Reflexes

Vascular Examination – DPA / PTA on supine position












Investigations
Radiographs
CT Scan
MRI


Discussion
Types – Wiltse, Newman and Mc Nab
1)Congenital – Dysplasia S1 Superior Facet
                      a)Lytic – Fatigue Fractura Pars articularis
                      b)Elongated But intact      Pars articularis
                      c)Acute Fracture
2)Degenerative – Facet Arthrosis leading to Subluxation of L 4 – 5
3)Traumatic – patient don’t survive usually
4)Pathological – degenerative or localized bone disease
5)Post Surgical

Myerding Classification
Based on quartiles
Radiographs –
Slip angle is Measured
Scottie dog appearance can be observed .
Risk factors for progression
Young age
Female
Presence of Spina Bifida
Wedging of Vertebral Body
Round anterior dome of Sacrum
Hyperlordosis



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