Traumatic spondylolisthesis of the lumbar spine

Journal of Orthopaedic Surgery ����������������
2009;17(3):361-5
Traumatic spondylolisthesis of the lumbar
spine: a report of three cases
Chin Tat Lim, Hwan Tak Hee, Gabriel Liu
Department of Orthopaedic Surgery, National University Hospital, Singapore
INTRODUCTION
ABSTRACT
Traumatic spondylolisthesis of the lumbar spine is
uncommon and can result in canal narrowing and
spinal cord injury. Early decompression promotes
recovery of neurological function. We report 3 such
cases: one in the lumbosacral joint and 2 in the lumbar
spine. The former patient had an open fracturedislocation and underwent (delayed) posterior
decompression and instrumentation without
interbody fusion. The connecting rods broke at 3 years
and the patient had a residual neurological deficit.
We recommend early decompression with posterior
instrumentation and interbody fusion for maximum
recovery of neurological function and stability of the
spine.
Key words: lumbar vertebrae; spinal fractures; spinal fusion;
spondylolisthesis
Only 8 cases of traumatic spondylolisthesis (from the
cranial to lumbosacral joint) have been reported to
date.1–6 Recovery of neurological function is dependent
on the time of decompression and stabilisation.6–8
We highlight the effects the difference in the time
to decompression and surgical technique have on
neurological recovery and implant durability.
CASE REPORTS
Case 1
In December 2005, a 48-year-old Chinese man was
hit by a 100-kg barrel and injured his head, chest and
abdomen. He complained of weakness and patchy
sensory loss over both lower limbs, but was alert and
conscious. A step-like deformity and 0.5 cm puncture
wound were noted in his lumbosacral region and
Address correspondence and reprint requests to: Dr Chin Tat Lim, Department of Orthopaedic Surgery, National University
Hospital, 5 Lower Kent Ridge Road, Singapore 119074. E-mail: chintat_lim@yahoo.com.sg
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CT Lim et al.�
his pelvis was unstable. A neurological examination
demonstrated grade-3 power in both lower limbs,
except for big toe flexion and extension that were
grade 4. His perianal sensation was intact, but his
anal tone was lax.
Plain radiographs showed anterolisthesis of L5
on S1 and an open-book pelvic fracture (Fig. 1a).
Computed tomography (CT) demonstrated fractures
of the left L5 inferior articular process and the right S1
superior articular process with moderate (60%, grade
3) anterior subluxation of L5 on S1 (Fig. 1a). There
was severe canal narrowing (70%) at this level.
The patient was haemodynamically unstable and
an urgent external fixation of the pelvic fracture and
debridement of the open L5/S1 fracture-dislocation
was performed. Two days after injury, he underwent
internal fixation using the Monarch stabilisation
system (Depuy Spine, Raynham [MA], USA). An
incision was made through the open wound, and
pedicle screws were inserted bilaterally into L4, L5
and S1, as well as posteriorly into the iliac crests
(from the posterior to the anterior inferior iliac spine).
The pedicle screws were connected with rods and the
listhesis reduced to grade 1 from grade 3 (Fig. 1b).
Posterolateral fusion was also performed.
Postoperatively, his lower-limb power increased
to grade 4, but the right extensor hallucis longus
power decreased to grade 0. An urgent lumbosacral
CT scan confirmed that the pedicle screws were not
encroaching on the spinal nerves. The patient was
(a)
(b)
(c)
Figure 1 Patient 1: a computed tomographic scan and radiographs showing (a) grade-3 anterolislithesis of L5 on S1 and
severe canal narrowing, (b) reduction to grade 1 after decompression, and (c) breakage of both rods and progression of the
anterolisthesis of L5 on S1 at the 3-year follow-up.
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Traumatic spondylolisthesis of the lumbar spine����
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then discharged to a rehabilitation centre for mobility
exercises.
At the 18-month follow-up, the patient had
recovered fully and had no lower-limb neurological
deficit. He was lost to further follow-up but returned
3 years postoperatively with low back pain radiating
to his left lateral leg. The rods were found to be broken
(Fig. 1c), and the listhesis had progressed to grade 3
from from grade 1. He underwent revision surgery
and a L5/S1 transforaminal lumbar interbody fusion.
At the 42-month follow-up, he was well with no
neurological deficit.
(a)
Case 2
In November 2007, a 41-year-old Chinese man
presented with severe low back pain after a 600-kg
container fell onto his back. He was unable to ambulate
and urinate, but was alert and conscious with normal
vital signs. A step-like deformity was noted in the
lumbar region. A digital rectal examination revealed
lax anal tone with saddle anaesthesia. An abdominal
examination revealed a palpable bladder so a urinary
catheter was inserted. A neurological examination
graded power at his hip, knee and ankle joints at
grade 3, 4 and 2, respectively. His flexor and extensior
hallucis longus power level was grade 0 bilaterally.
He had bilateral lower limb hypertonia with
hyporeflexia of the knee and ankle reflexes and had
reduced sensation over his right lateral leg.
Plain
radiographs
showed
a
grade-2
spondylolisthesis of L4 on L5 and a fracture of the
left transverse process of L4 (Fig. 2a). Magnetic
resonance imaging (MRI) demonstrated an avulsion
fracture of the anterior-superior corner of L5
associated with a Chance-type fracture-dislocation
through the L4/5 disc space and bilateral perched
facets with grade 2 spondylolisthesis of L4 on L5 (Fig.
2a). The cauda equina was severely compressed. An
anterior epidural haematoma extending from the
L2/3 to L5/S1 level was identified.
Four hours after presentation, the patient
underwent urgent decompression and stabilisation
(Expedium, Depuy Spine, Raynham, MA). Pedicle
screws were inserted bilaterally into L4 and L5. The
right transforaminal lumbar interbody was fused
at the L4/5 level and the left lateral recess was
decompressed at the same level. The right L2/3 level
was then decompressed and a posterolateral fusion
was performed.
Postoperatively, the patient regained full power
of his hip, knees and ankles, although his urinary
retention persisted. His flexor and extensor hallucis
longi were found to have power grades of 4 and 2,
(b)
Figure 2 Patient 2: magnetic resonance images and
radiographs showing (a) a fracture-dislocation through
the L4/5 disc space, bilateral perched facets, grade2 spondylolisthesis of L4 on L5, an anterior epidural
haematoma extending from the L2/3 to the L5/S1 level
(arrows), and severe compression of the cauda equina at
the L4/5 level, and (b) reduction of the anterolisthesis after
decompression.
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CT Lim et al.�
respectively. He was able to tolerate ambulatory
physiotherapy and was discharged to a rehabilitation
centre for mobility exercises and bladder and bowel
training. At the one-year follow-up, he had regained
full urinary continence and had fusion at L4/5 (Fig.
2b).
(a)
Case 3
In December 2007, a 56-year-old Chinese man
presented with pain in his lower back, left hip and
left shoulder after falling from a height of 2 metres.
He had tenderness and bruising from L2 to L5 but no
step-like deformity. He had no neurological deficits
in his lower limbs. The left acromioclavicular joint
was tender with a step-like deformity.
Plain radiographs showed a grade-2 subluxation
of the left acromioclavicular joint and a comminuted
fracture of L5 and grade-1 anterolithesis of L4 on
L5 (Fig. 3a), with extensive marrow oedema at this
level. A sagittal MRI revealed high signal intensity in
the lumbar interspinous ligaments, indicating acute
injury (Fig. 3a).
24 hours after presentation, this patient underwent posterior decompression and stabilisation
(Expedium, Depuy Spine, Raynham [MA], USA).
Pedicle screws were inserted bilaterally into L3, L4,
L5 and S1, and a rod was inserted on the left for
temporary reduction. The right L4/5 transforaminal
lumbar interbody was then fused, and another rod
was inserted on the right side for complete reduction
(Fig. 3b). Posterolateral fusion was not performed.
The patient recovered without complications and
was discharged 5 days after surgery. At the one-year
follow-up, he remained well.
(b)
DISCUSSION
There are 5 types of spondylolisthesis: dysplastic,
isthmic, degenerative, traumatic, and pathologic.9
Traumatic spondylolisthesis is a fracture of
the posterior elements, rather than the pars
interarticularis, leading to instability and listhesis.9
Only a few cases of traumatic spondylolisthesis of
the lumbosacral joint have been reported.10–16
Early decompression promotes recovery of
neurological function. The timing of decompression
and the degree of spinal canal narrowing are the main
factors affecting neurological recovery.8 In patient 1,
decompression was delayed because of the need to
stabilise the pelvic fracture with external fixation. He
had persistent neurological deficits. Patients 2 and 3
underwent decompression within 24 hours and their
Figure 3 Patient 3: magnetic resonance images and
radiographs showing (a) a comminuted fracture of L5
associated with grade-1 anterolisthesis of L4 on L5, high
signal intensity on the interspinous ligament indicating acute
injury, and severe spinal canal narrowing, and (b) reduction
of the anterolisthesis.
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American Spinal Injury Association impairment scale
improved from B to D.
When decompression of the spinal cord was
performed at 24 hours in dogs, the improvement
in somatosensory evoked potentials was only
26%, compared to the 85% and 72% improvement
achieved when decompression was carried out
immediately and one hour after injury, respectively.17
This may be due to the persistent reduction in
blood flow seen in delayed decompression. The
blood flow through the injured spinal cord region
is inversely related to the duration of compression.7
In dogs with decompression performed 30 minutes
after injury, the spinal blood flow was 49.1±3.1
ml/100 g/min, compared to 19.8±6.2 ml/100 g/
min in those with decompression performed after
180 minutes. In dogs who had the same duration
of spinal cord compression, those who achieved
recovery of evoked potential conduction showed a
higher regional blood flow after decompression.
We postulate that the reason for impant failure
in patient 1, who had both connecting rods broken,
was the lack of interbody fusion for stabilisation.
Similarly, the use of Harrington and sacral rods
for reduction and posterior stabilisation without
fusing the concomitant L4/L5 complete fracturedislocation was also insufficient, and the L4 vertebra
was displaced 2 months postoperatively.2 Interbody
fusion provides a larger surface area for bone graft
incorporation, achieving an indirect reduction of
foraminal stenosis by using the graft to restore
the height of the intervertebral disc, improving
lumbar lordosis, and ablating the degenerated
disc.9 Interbody fusion is superior to posterolateral
fusion for preventing non-union, reducing slippage
and improving back pain using the Kirkaldy-Willis
criteria.18 Interbody fusion is more predictable for
maintaining correction and achieving union.19 We
recommend early decompression with posterior
instrumentation and interbody fusion for maximum
recovery of neurological function and stability of the
spine.
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