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Spondylolysis and spondylolytic spondylolisthesis

A review of current concepts on pathogenesis, natural history, clinical symptoms, imaging, and therapeutic management

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Résumé

Cet article se propose de faire une rvue analytique des concepts actuels au sujet de la spondylolyse et du spondylolisthésis par lyse isthmique. Ces deux affections, directement apparentées, résultent d'un trouble du développement des vertèbres lombo-sacrées, étroitement lié à la station érigée bipède spécifique de l'Homme. Cette perturbation dépend de facteurs intrinsèques déterminants d'ordre génétique, et de facteurs extrinsèques favorisants. La lyse isthmique survient habituellement au cours de la première enfance. Le primum movens des malformations lombo-sacrées du spondylolisthésis est représenté par le glissement et ses conséquences biomécaniques sur les vertèbres en croissance. La plupart des cas sont asymptomatiques, mais parmi les cas symptomatiques, certains sont très invalidants. Les principaux signes cliniques sont rappelés ici, ainsi que les paramètres radiographiques habituellement utilisés pour l'évaluation. La plupart des cas symptomatiques ne nécessitent pas le recours à la chirurgie. Cependant les méthodes chirurgicales ont été largement développées au cours des soixante dernières années, pour faire face aux formes rebelles aux traitements conservateurs. Elles sont présentées ici dans un ordre logique, allant de la plus physiologique à la plus radicale. La reconstruction des isthmes est une méthode fiable, mais exige des conditions locales très strictes. La résection de l'arc mobile n'est plus guère indiquée de manière isolée, surtou s'il s'agit d'un patient jeune. Les arthrodèses en place sont largement employées, en particulier par voie postérieure; mais en raison des conditons biomécaniques précaires, un taux non négligeable de pseudarthroses est rapporté, ainsi que de progression du glissement chez les sujets jeunes. L'addition d'une ostéosynthèse est souhaitable. La réduction du spondylolisthésis associée à l'arthrodèse, remet le rachis dans des conditions mécaniques optimales pour l'obtention d'une fusion stable. Differentes méthodes sont rapportées, procédant par une ou par plusieurs étapes. La double arthodèse, antérieure et postérieure, associée à la réduction semble donner les meilleurs résultats, malgré quelques rares cas d'atteinte neurologique transitoire. La résection de la vertèbre olisthésique, associée à la réduction et à l'arthrodèse, est une alternative thérapeutique qui peut être proposée dans les formes très graves du sujet jeune. Des indications éclectiques sont données à la fin de la discussion, sur la base des procédés actuellement en usage, en fonction du type lésionnel et de la catégori du patient.

Summary

The purpose of this paper is to review the current concepts on spondylolysis and spondylolytic spondylolisthesis. The two are very closely connected, and bothe result from a growth disturbance of the lumbosacral vertebrae, linked to the human biped standing position, and depending on genetic and environmental factors. Pars defect occurs usually in early childhood. The primum movens of lumbosacral deformities in spondylolisthesis is the slippage and its biomechanical consequences for the growing vertebrae. Most cases are asymptomatic but symptomatic cases can be very disabling. Major clinical symptoms are presented here, as are the roentgenographic parameters usually required for the assessment. Most cases do not require surgery. However, surgical procedures have been widely developed in the last 60 years for the cases resistant to non-operative treatments. They are presented here in a logical order, from the most physiological to the most aggressive. Isthmic repair is reliable but requires very strict local conditions. Excision of the loose arch alone should no longer be practised especially in young patients. Fusions in situ are widely used, especially by the posterior approach, but owing to unfavourable biomechanical conditions, a significant amount of pseudarthrosis is reported as well as slip progression in young patients. Additional internal fixation is recommended. Associated reduction allows placement of the spine in the best mechanical conditions for a stable fusion. Several procedures have been reported, involving either single or staged approaches. Either anterior and posterior fusion associated with reduction seems to give the best results, in spite of some few cases of transitory neurological involvement. Resection of the olisthetic vertebra associated with reduction and fusion is a therapeutic alternative in very severe case in young people. Elective indications are given at the end of the Discussion on the basis of current procedures, according to the type of lesion and the category of patient.

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    S. Nazarian

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Nazarian, S. Spondylolysis and spondylolytic spondylolisthesis. Eur Spine J 1, 62–83 (1992). https://doi.org/10.1007/BF00300931

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