Thread by @Retlouping

A new “old man shouting at clouds” tweetorial inspired by listening to a webinar last week which had the wrong information and assumptive reasoning regarding “Spondylolisthesis”. I propose people don’t know what they don’t know and spondylolisthesis is a good example.
Strap in...

And enjoy the ride. (Sorry if this is obvious to you, but I sense it’s not to most.)

There are five types of spondylolisthesis, (some may be saying sure I know that, but do you?) these are not the “grades” of slip these are the etiology always causes. See below. 👇

Most people learn the first type “Isthmic” (not the most common) at school then for some reason extrapolate this one type to all other types? Isthmic is the second most common, and this is a formative type, we know this because the incidence peaks in late teen years.

The prevelance is around 6-7% ncbi.nlm.nih.gov/books/NBK43076…
This type of spondylolythesis occurs as a result of a stress reaction of the boney junction between the superior and inferior articular pillars of the lumbar spine, commonly L5/S1 & L4/L5, the stres reaction “spondylolysis

If the stress reaction fractures this gives the potential for a slip of superiors vertebrae on inferior, rotational slip if one Pars (pars interarticularis) is involved or anterior slip if bilateral pars fracture.
This is seen as a broken neck in the oblique X-ray “Scotty dog”

Remember most slippage is classed as grade 1 upto 25% of inferior body, (see below) the spine above slips forward, it is important to remember it is slipped not “slipping” or unstable, the soft tissues of the spine are now the restraints, rather than bone at that level.

Studies have demonstrated that spondylolisthesis is stable and rarely progresses with age. See below

Common cause of Isthmic spondylolisthesis are heavy load sports into an extended position. High preveleance are seen in cricket fast bowlers, butterfly swimmers, gymnasts and high jumpers. It has been suggested that the pars defect is actually a formative process leading to...

A new syndesmosis joint between the pars defects, thus allowing greater functional extension for the desired sport. The question then arises, why treat with the intent to stop this process if there are no symptomatic or safety reasons? A study following spondylolysis....

And spondylolisthesis for 45 years, demonstrated that there was no worse incedence of back pain or increased issues over time compared to the normal population. Slippage actually stabalizer over time.

Commonly the best treatment is management through load modification, respecting symptoms and progressive return to loading.
The most common form of Spondylolisthesis is degenerative and increases rapidly after age 50. This type of slippage is not due to a pars defect....

It is due to multilevel degeneration fo the soft tissue liagaments and discal structures causing small multilevel slippage either anteriorly or posteriorly (retrolysthesis) this multilevel slippage in it’s self may cause no issue, but as described in my previous thread...

On stenosis can lead to narrowing of the spinal canal and development of neurogenic claudication. The diagram below shows how even a normal vertebral foramen can produc a narrow canal with multi-leve small slippage. ncbi.nlm.nih.gov/pmc/articles/P…

Traumatic spondylolisthesis is more common in the cervical spine that lumbar, commonly seen in high impact sports or motor vehicle accidents. Two common types are from the Jefferson fracture of C1 or adontoid fractures of C2. These slippages can produce life threatening injuries

It si possible to have severe slippage in the cervical spine without serious symptoms, this may depend on speed of slippage
nejm.org/doi/full/10.10…
Humans are adaptable and durable.

Pathalogic spondylolisthesis is as it says as a result of boney spinal pathology either from bone weakening disorders like osteoporosis, bone metastasis or other diseases. Even though osteoporosis commonly affects the thoracic spine, the ribs often prevent spinal slippage.

Congenital spondylolisthesis is as it says a congenital dysplasia occurance, often absence of restraining articular pillar of the z-joints, these can produce dramatic slippage (spondyloloptis) but not necessarily symptoms or disability.

In review: there are five types of spondylolisthesis degenerative being the most common type. Isthmic is a formative type caused by sport loading in extension, I propose this is a formative process, not a pathology, traumatic is commonly cervical but also lumbar, pathologic...

Follow a bone weakening disorder, congenital as the name suggests occur at birth and development.
It is important to note symptoms may occur in all five types, but one must be careful to reason if the slip is causative or a coincidental image finding.

As always thanks for reading, hope this makes sense. Stay safe.