Spondylolisthesis: Operation (When is it indicated?)

Behind this barbaric term " spondylolisthesis hides a fairly frequent affection of the spine, which can affect (in varying degrees) between 3 and 7% of the general population.

It is a pathological situation characterized by the slip of a vertebrate forward compared to the one directly below it.

Le spondylolisthesis, although it may sometimes remain asymptomatic, may manifest as a whole range of symptoms : chronic low back pain/cervical pain, stiffness of the spine, neurological symptoms (secondary to the compression of nerve elements by the displaced vertebra) ...

Its management generally involves treatments preservatives, including painkillers, physiotherapy and osteopathy.

However, if this conservative approach fails, a surgical intervention will be considered.

So what does this intervention consist of? Who to operate (indications) ? What is the duration of the intervention? How many days of hospitalization are necessary? What results to expect? These are the questions we will answer in this article.

What is spondylolisthesis?

The etymology of the term spondylolisthesis comes from the Greek « spondylo » which means « vertebrate », and « listhesis » meaning « slip ».

In medicine, the spondylolisthesis corresponds to a condition affecting the spine characterized by a sliding of a vertebra forward relative to the vertebra just below. You can also use the term “anterolisthesis” to insist that it is a slippage forward.

When the sliding of the vertebra is backwards, we rather speak of « retrolisthesis ».

Spondylolisthesis can affect any vertebra in the mobile part of the spine (cervical spine, dorsal or lumbar). However, the locations lumbar et cervical are much more frequent.

What causes spondylolisthesis ?

There are 3 main categories of spondylolisthesis: isthmic, degenerative et congenital.

1. Isthmic spondylolisthesis: the vertebrae are connected to each other at the back by a bony bridge called the isthmus. In the event of a fracture of this part, the vertebra is separated from the one below, so it can slide forward.

2. Degenerative spondylolisthesis : slippage is secondary to a degenerative disc disease (wear of a disk intervertebral) or osteoarthritis of the posterior vertebral joints (facet osteoarthritis).

3. Congenital spondylolisthesis: the slip results from a malformation in the spine at birth.

What are the symptoms of spondylolisthesis ?

Although there are forms asymptomatic, spondylolisthesis can manifest as many symptoms. These are the result of irritation and / or the compression of certain anatomical structures by the vertebra projected forward (mainly compression of the spinal cord and/or its nerve roots).

Here is a non-exhaustive list of the symptoms in question:

• Pain lumbar, cervical ou lumbar (depending on the site of the spondylolisthesis).
• Stiffness et reduced mobility and flexibility of the spine.
• signs neurological secondary to the compression of a nervous element: tingling, numbness, pain, motor disorders, urinary/faecal incontinence, etc. These are symptoms similar to those observed during a narrow lumbar canal.

For more details on the causes and symptoms of spondylolisthesis, do not hesitate to consult our article: spondylolisthesis.

What is the treatment for spondylolisthesis?

The management of spondylolisthesis depends on several settings, in particular the seat of the slip, its grade, the compressed nerve structures, the type of symptoms and their severity, the age of the patient, his general state of health, his desire…

After having precisely evaluated all these parameters, two therapeutic approaches are possible: The approach conservative (no surgery) and The approach invasive (surgery).

Treatment of spondylolisthesis: conservative approach

The conservative approach aims to limit the symptoms et prevent worsening of spondylolisthesis. It may involve treatments such as:

• Turnkey pharmaceuticals (anti-inflammatories, more or less powerful analgesics depending on the intensity of the pain, muscle relaxants, corticosteroid injections, certain antidepressants, etc.).

• De physiotherapy to tone the stabilizing muscles of the trunk, preserve the mobility of the spine and its flexibility...

• De the osteopathy with the realization of certain precise manipulations and adapted exercises. But be careful, no manual maneuver can “put the vertebra back in place”! Neither osteopathy, nor physiotherapy, nor any other non-surgical therapy.

• De occupational therapy to limit movements that put stress on the back and its support structures (adapt the patient's environment, use of a cane, etc.).

• Le temporary wearing of a lumbar corset ou cervical collar for temporary relief of acute pain.

Treatment of spondylolisthesis: invasive or surgical approach

In some cases, surgical treatment becomes the ultimate solution to relieve the patient's symptoms.

In which cases to operate a spondylolisthesis?

First of all, it should be borne in mind that all patients with spondylolisthesis should initially benefit from conservative treatment.

The latter is frequently found to be effective in managing the symptoms of spondylolisthesis, to some extent.

In addition, scientific studies have shown that even if conservative methods fail, the time elapsed in implementing it does not influence the results of surgical treatment.

In other words, there is nothing to lose and everything to gain by trying a conservative approach first !

In the vast majority of cases, patients with spondylolisthesis ask for surgery in the event of refractory pain, that is to say, resistant to all the conservative treatments implemented.

This indication is mainly based on the patient's feelings, on its ability to manage or bear pain (threshold of resistance to pain varies from one individual to another).

In this case (refractory pain), surgery is not an emergency, because there is no immediate risk that threatens the health of the patient. It can therefore be deferred to be carried out calmly after a precise evaluation of all the different parameters.

On the other hand, there are certain situations which require surgical treatment as soon as possible, before the aggravation of the symptoms. Here they are :

• cauda equina syndrome : urinary disorders such as incontinence, loss of sensation in the buttocks and genital area.
• Sciatica paralyzing: pain sciatica with motor disorders in the lower limb which can go as far as paralysis.
• Hyperalgesic sciatica: unbearable sciatic pain despite well-conducted medical treatment.
• Root distribution neurological deficit: loss of sensitivity, motor disorders or pain in an area innervated by a nerve root compressed by spondylolisthesis…

What does the intervention consist of?

The goal of spondylolisthesis surgery is to lift the compression exerted on the nervous elements before fuse the vertebrae to fix them in the correct position thanks a arthrodesis (lumbar arthrodesis, dorsal or cervical).

 

The union of the vertebrae can call upon a system of rods, de screw and / or cages (osteosynthesis), or to a graft bone (removal of a bit of bone, usually at the level of the patient's hip) which will fuse the vertebrae over time.

In some cases, the displaced vertebra can even be realigned with the rest of the spine.

Sometimes a laminectomies will be necessary to decompress a nervous element.

What is the duration of the intervention?

Surgery for spondylolisthesis is most often done under general anesthesia. It lasts between 1 a.m. and 5 p.m. depending on the techniques used, the complexity of the intervention, the extent of the compression...

For certain spinal procedures lumbar who last less than 2 hours, it is possible to carry out the intervention under spinal anesthesia.

The latter consists of injecting an anesthetic product into the cerebrospinal fluid via a lumbar puncture. This helps anesthetize the lower part of the patient's body. The latter therefore remains aware during the operation, but does not feel no pain.

What is the length of hospitalization?

It is necessary to count 3 to 4 days of hospitalization on average for spondylolisthesis surgery. This duration is obviously variable depending on the complexity of the procedure, the condition of the patient before and after the operation, the stability of the spine, the occurrence of any complications, etc.

What are the possible complications of the procedure?

In addition to classic complications inherent in any other surgery (infection, postoperative hematoma, deep vein thrombosis, pulmonary embolism, etc.), spondylolisthesis surgery can be complicated by:

• Breach of the dura mater: lesion of the envelope that surrounds the spinal cord and its roots with cerebrospinal fluid flow.

• Postoperative hematoma: generally without consequence. Sometimes it can compress the dural bag and its contents (spinal cord and nerve roots). In this case, it must be drained quickly to avoid neurological damage.

• Paralysis according to the operated spinal level: for example, in case of intervention at the level of the cervical rachis, there is a risk of paralysis of the 4 limbs (tetraplegia).

• Great vessel lesions : they are seen exceptionally when the intervention is done with an anterior approach (the surgeon goes through the stomach to reach the spine, the patient is then lying on his back).

• Damage to an abdominal organ(also anterior).

• Destabilization of osteosynthesis (the vertebrae are not well fixed by the rods/screws/bone graft).

Other complications are possible. Nevertheless, all precautions are taken to make these adverse events exceptional.

How is the recovery period going?

The patient generally sees his symptoms (low back pain, pain in the lower limbs, numbness, etc.) improve gradually in the days or weeks following the intervention.

Sessions of re-education will be necessary to help the patient regain better mobility and flexibility of the back.

He will be able to resume his professional activity after approximately 6 weeks (varies according to profession and condition).

References

[1] JW Ogilvie, “Complications in spondylolisthesis surgery”, spine, flight. 30, n^o 6S, p. S97-S101, 2005.

[2] TD Koreckij and JS Fischgrund, “Degenerative spondylolisthesis”, Clinical Spine Surgery, flight. 28, n^o 7, p. 236-241, 2015.

[3] JW Frymoyer, “Degenerative spondylolisthesis: diagnosis and treatment”, JAAOS-Journal of the American Academy of Orthopedic Surgeons, flight. 2, n^o 1, p. 9-15, 1994.

[4] CJ DeWald, JE Vartabedian, MF Rodts, and KW Hammerberg, “Evaluation and management of high-grade spondylolisthesis in adults,” spine, flight. 30, n^o 6S, p. S49-S59, 2005.

[5] RB Cloward, “Spondylolisthesis: treatment by laminectomy and posterior interbody fusion. », Clinical orthopedics and related research, N^o 154, p. 74-82, 1981.

[6] TL Schulte, F. Ringel, M. Quante, SO Eicker, C. Muche-Borowski, and R. Kothe, “Surgery for adult spondylolisthesis: a systematic review of the evidence”, European Spine Journal, flight. 25, n^o 8, p. 2359-2367, 2016.

[7] H. Möller and R. Hedlund, “Surgery versus conservative management in adult isthmic spondylolisthesis: a prospective randomized study: part 1”. LWW, 2000.

[8] JS Lombardi, LL Wiltse, J. Reynolds, EH Widell, and C. Spencer 3rd, “Treatment of degenerative spondylolisthesis. », spine, flight. 10, n^o 9, p. 821-827, 1985.