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CHAPTER 13

13 Low back pain and leg pain

About 90% of the population suffer from


Sciatica
low back pain at some time and 30% of these
will develop leg pain due to lumbar spine
Aetiology (Table 13.1)
pathology.
The critical factor in assessing patients with The most common cause of sciatica is a lumbar
low back pain is whether there are also features of disc prolapse causing nerve root compression.
lumbosacral nerve root compression, such as leg Sciatica-type pain may also occur as a result of
pain or focal signs of neural compression in the bony compression of the nerve root, usually by
lower limbs. In general, neurosurgeons are prin- an osteophyte, and is often associated with lum-
cipally concerned with lumbar spine pathology bar canal stenosis or spondylolisthesis. Narrow-
that causes nerve root compression. ing of the lateral recess of the spinal canal
Sciatica is the clinical description of pain in the may also occur in conjunction with lumbar canal
leg due to lumbosacral nerve root compression stenosis, and may cause compression of a nerve
which is usually in the distribution of the sciatic root. Sciatica may occasionally be caused by tu-
nerve. Sciatica was first mentioned in an Egypt- mours of the cauda equina or by pelvic tumours,
ian manuscript dated 25003000 BC. In 1934 such as spread from carcinoma of the rectum.
Mixter and Barr established that a prolapsed
lumbar intervertebral disc was commonly the
Anatomy and pathology
cause of sciatica.
Lumbar canal stenosis, a narrowing of the lum- Nearly 75% of the lumbar flexionextension and
bar spinal canal, is the other major spinal cause of of total spinal movement occurs at the lumbo-
leg pain. In 1949 Verbiest specifically defined the sacral junction, 20% of lumbar flexionextension
clinical significance of the narrow spinal canal occurs at the L4/5 level and the remaining 5% is
and the syndrome of intermittent neurogenic at the upper lumbar levels. Consequently, it is not
claudication of the legs. surprising that 90% of lumbar disc prolapses
A lumbar disc prolapse can occur at any age in occur at the lower two lumbar levels; the most
adults but is uncommon in teenagers. The symp- frequently affected disc is at the L5/S1 level.
toms of lumbar canal stenosis usually commence The lumbar disc consists of an internal nucleus
after the 5th decade. Although lumbar canal pulposus surrounded by an external laminar
stenosis and lumbar disc prolapse may be pre- fibrous container, the annulus fibrosus. A disc
sent in the same patient, they each produce a prolapse may consist of the nucleus pulposus
distinct clinical entity which will be described bulging, with the annulus being stretched but
separately. intact. Alternatively, the nucleus may rupture
through the annulus and sequestrate as a free
fragment under the posterior longitudinal liga-
ment or lie in the extradural space. Prolapse of

185
186 CHAPTER 13

Table 13.1 Causes of sciatica.

Prolapsed lumbar disc


Lumbar spondylosis (osteophyte)
Lumbar canal stenosis (lateral recess)
Lumbar spondylolisthesis
Cauda equina tumours (e.g. ependymoma)
Pelvic tumours (e.g. rectal carcinoma)
Spinal arteriovenous malformation (rare)

the disc is usually in a posterolateral direction, as


(a) (b)
the posterior longitudinal ligament prevents
Fig. 13.1 The diagram shows (a) a posterolateral
direct posterior herniation. Less frequently the
lumbar disc proplapse causing compression of lumbar
disc may herniate laterally to trap the nerve in
nerve root passing across the disc to enter the neural
the neural foramen. canal below the pedicle and (b) a lateral disc prolapse
A prolapsed intervertebral disc causes com- causing compression of the nerve root passing beneath
pression of the nerve which runs along the the pedicle above the disc prolapse.
posterior aspect of the disc and down under
the pedicle of the vertebra below (Fig. 13.1). Con-
sequently, an L4/5 posterolateral intervertebral may be present, the important feature is the pain
disc prolapse will usually compress the L5 nerve which radiates down the leg in the distribution of
root, which runs caudally across the disc to enter the affected nerve. The pain usually radiates into
the neural foramen below the L5 pedicle. Simi- the buttock, along the posterolateral aspect of the
larly, a lumbosacral (L5/S1) disc prolapse will thigh and calf into the foot (S1 nerve root); it may
usually affect the S1 nerve root. The less common extend into the dorsum of the foot and great toe
lateral disc prolapse will cause compression of (L5 nerve root). An L3/4 disc herniation may pro-
the nerve root at one level higher than expected duce pain in the posterior thigh but, as with an
(e.g. L4 nerve root compression due to L4/5 L2/3 disc prolapse, the pain is frequently along
lateral disc prolapse). In the case of a large disc the anterior aspect of the thigh. L4 root pain fre-
prolapse, there may be evidence of more than quently radiates into the anterior aspect of the
one nerve root compression. lower leg. Depending on the degree of nerve root
Cauda equina compression may result if the compression, the patient may complain of senso-
disc herniation is sufficient to rupture the pos- ry disturbance such as numbness or tingling in
terior longitudinal ligament and produce a pos- the leg or foot, and weakness may be present. The
terior central disc prolapse. history must include an assessment of sphincter
function, as a large disc prolapse may cause
cauda equina compression.
Patient assessment
The patient suffering from sciatica will be in ob-
Examination features
vious discomfort, which will be reflected by
movements and posture when lying supine. The Lumbar back movements may be restricted and a
patient lies tilted, usually to the side opposite to scoliosis may be seen, usually concave to the side
the sciatica, with the affected hip and knee of the affected leg. Straight leg raising (Lasegues
slightly flexed taking pressure off the stretched test) will be restricted on the affected side and, in
nerve. The pain is worse on movement, cough- severe cases, pain in the affected leg will be re-
ing, sneezing or straining. Although back pain produced when the opposite leg is raised.
LOW BACK PAIN AND LEG PAIN 187

Table 13.2 Segmental innervation of lower limb musculature.

L1 Psoas major; psoas minor


L2 Psoas major; iliacus; sartorius; gracilis; pectineus; adductor longus; adductor brevis
L3 Quadriceps; adductors (magnus, longus, brevis)
L4 Quadriceps; tensor fasciae latae; adductor magnus; obturator externus; tibialis anterior; tibialis
posterior
L5 Gluteus medius; gluteus minimus; obturator internus; semimembranosus; semitendinosus; extensor
hallucis longus; extensor digitorum longus and peroneus tertius; popliteus
S1 Gluteus maximus; obturator internus; piriformis; biceps femoris; semitendinosus; popliteus;
gastrocnemius; soleus; peronei (longus and brevis); extensor digitorum brevis
S2 Piriformis; biceps femoris; gastrocnemius; soleus; flexor digitorum longus; flexor hallucis longus;
some intrinsic foot muscles
S3 Some intrinsic foot muscles (except abductor hallucis; flexor hallucis; brevis; flexor digitorum brevis;
extensor digitorum brevis)

Examination of the neurological disability


Table 13.3 Segmental innervation of lower limb
should proceed in an ordered fashion. Initially a
joint movements.
search is made for wasting in specific muscle
groups, particularly the quadriceps, calf muscles,
Hip Flexors, adductors, medial L1, 2, 3
extensor digitorum brevis muscle and the small rotators
muscles of the foot. The patient is then examined Extensors, abductors, lateral L5, S1
for weakness in each of the muscle groups (Tables rotators
13.2 and 13.3). Weakness of dorsiflexion of the
Knee Extensors L3, 4
foot and extension of the great toe (extensor
Flexors L5, S1
hallucis longus) is most commonly caused by
a prolapsed L4/5 intervertebral disc with in- Ankle Dorsiflexors L4, 5
volvement of the L5 nerve root; severe cases may Plantar flexors S1, 2
result in a complete foot drop. Foot Invertors L4, 5
Plantar flexion weakness is caused by com- Evertors L5, S1
pression of the S1 nerve root, usually due to a Intrinsic muscles S2, 3
prolapsed lumbosacral disc. However, plantar
flexion is a very strong movement and any weak-
ness may be difficult to elicit unless tested by ask-
ing the patient to stand on the toes of the affected
side. A large prolapsed disc at the L4/5 level may
result in some plantar flexion weakness because Sensation should be tested in the foot and leg
of compression of the S1 nerve root, and simi- (Fig. 13.2).
larly a large lumbosacral disc prolapse may be At the end of the examination the patient
associated with dorsiflexion weakness due to L5 should be turned prone so that the buttocks can
nerve root compression. be inspected for atrophy of the gluteal muscles,
The deep tendon reflexes should be carefully sensation can be tested along the back of the legs
tested as they provide objective evidence of and in the perianal region, and anal tone can be
nerve root compression. The ankle jerk is de- assessed. A rectal examination should be per-
pressed or absent when the S1 nerve root is com- formed if there are clinical features suggestive of
pressed, usually by a lumbosacral disc prolapse. a pelvic tumour.
188 CHAPTER 13

L3/4 prolapsed intervertebral disc


Pain in the anterior thigh
S4 L2 Wasting of the quadriceps muscle
L1
Ventral Weakness of the quadriceps function and dor-
S3
axial siflexion of foot
line
L2 Diminished sensation over anterior thigh,
knee and medial aspect of lower leg
S2
Dorsal Reduced knee jerk.
axial
L3 L3 line
Extension Management
forwards L4
from dorsal Most patients with sciatica achieve good pain
axial line
L5 relief with simple conservative treatment and
L4
L5 less than 20% will require surgery. The likelihood
of symptomatic relief without surgery is related
to the pathology of the disc prolapse. A bulging
disc is likely to settle with simple conservative
S1 measures, but sciatica due to a nucleus pulposus
L5 S1 that has herniated out of the disc space and se-
L5
questrated outside the annulus will probably
need surgery for satisfactory relief of symptoms.
Fig. 13.2 Segmental distribution of nerves of the
lumbar and sacral plexuses to the skin of the anterior Conservative treatment
and posterior aspect of the lower limb. Most patients achieve good pain relief following
bed rest, usually for a period of about 710 days,
and the use of simple analgesic agents and
non-steroidal anti-inflammatory medication. Al-
Summary of clinical features
though traction is sometimes recommended it
Clinical localization of the disc prolapse should probably has only limited benefit and may result
be possible in the majority of patients with scia- in lower leg complications. Resolution of the
tica. The following features are typical (but not pain is probably due to a combination of some
invariable) of disc herniation. resorption of the prolapsed disc material, the
oedema of the nerve decreasing and possible
L5/S1 prolapsed intervertebral disc adaptation of the pain fibres to pressure. Spinal
Pain along the posterior thigh with radiation to manipulation is not recommended and the con-
the heel cept that a disc prolapse can be reduced by ma-
Weakness of plantar flexion (on occasion) nipulation is a myth. Initially, the only necessary
Sensory loss in the lateral foot investigations are a plain lumbar spine X-ray and
Absent ankle jerk. an erythrocyte sedimentation rate (ESR). The
lumbar spine X-ray will diagnose an associated
L4/5 prolapsed intervertebral disc spondylolisthesis which may contribute to the
Pain along the posterior or posterolateral thigh sciatica, and it also helps to exclude sinister
with radiation to the dorsum of the foot and great pathology, such as metastatic tumour involving
toe the spinal vertebrae. The ESR will also exclude
Weakness of dorsiflexion of the toe or foot systemic disease.
Paraesthesia and numbness of the dorsum of Some clinicians advocate the use of high-dose
the foot and great toe corticosteroids in the conservative management
Reflex changes unlikely. of sciatica due to lumbar disc prolapse. Whilst
LOW BACK PAIN AND LEG PAIN 189

steroid therapy may help to give transient pain mobilizing despite adequate relief with bed rest.
relief, the limited benefit is probably outweighed In this group of patients physiotherapy and a
by the possible complications of corticosteroid limited trial of a spinal brace might be tried, but
treatment. they usually have only limited success.
Chemonucleolysis has, in the past, been advo-
cated as a treatment for lumbar disc prolapse. It Neurological deficit. A significant weakness or in-
involves the intradiscal injection of a proteolytic creasing amount of weakness is an indication for
enzyme, such as chymopapain, which dissolves early investigation and surgery.
disc material. Chymopapain was first isolated in
1941 and has been used intermittently since 1963 Central disc prolapse. Patients with bilateral sciati-
in clinical studies. There is a small risk of serious ca or other features indicating a central disc
anaphylactic reaction following intradiscal injec- prolapse, such as sphincter disturbance and di-
tion. Although chymopapain dissolves the nor- minished perineal sensation, should be investi-
mal nucleus pulposus it has a high failure rate in gated promptly. An acute central disc prolapse
the treatment of prolapsed disc, as it fails to affect may lead to acute, severe, irreversible cauda
the extruded disc material, and further nerve equina compression and should be investigated
compression may occur following chemonucle- and treated as an emergency.
olysis from the disc dissolving and collapsing, re-
sulting in narrowing of the intervertebral neural Tumour. Surgery is indicated if the clinical fea-
foramen. The procedure is not recommended for tures suggest that a tumour could be the cause of
use at this time. sciatica.

Indications for surgery


Investigations
Pain. The most common indication for surgery in
patients with disc prolapse is pain in the follow- Lumbar myelography (Fig. 13.3) was the time-
ing situations. honoured investigation for lumbar disc prolapse.
Incapacitating pain despite 710 days of bed The use of water-soluble non-ionic contrast
rest. material avoids the risk of the postmyelogram
Continuing episodes of recurrent pain when arachnoiditis previously seen with the oil-based

(a) (b)
Fig. 13.3 Lumbar myelogram using water-soluble contrast medium showing (a) posterolateral L4/5 disc
prolapse and (b) complete block due to a large central L5/S1 disc protrusion.
190 CHAPTER 13

mediums. Although myelography is now much


safer, there is a very small risk of reaction to the
contrast medium, particularly epileptic seizures.
Some patients suffer headaches following the
myelogram. These are due to the lumbar punc-
ture (Chapter 2) and/or the effects of the contrast
material.
High-quality computerized tomography scan-
ning (Figs 13.4 and 13.5) and magnetic resonance
imaging (Fig. 13.6) have largely superseded
myelography for the diagnosis of lumbar disc
prolapse. The MRI is especially helpful in show-
ing the size, configuration and position of the disc
prolapse, as well as any associated nerve root or
thecal compression. In addition the MRI will also
demonstrate pathology at other discs, such as de-
generative changes as evidenced by decreased
signal in the disc on the T2-weighted scans.

Operative procedure for lumbar disc prolapse


The operation involves excision of the disc pro-
lapse with decompression of the affected nerve
root.
In the past the operation usually entailed a (a)
complete or partial laminectomy, identification
of the compressed nerve root, its mobilization off
the disc prolapse and excision of the herniated
disc. However, with improvements in instru-
mentation and magnification, e.g. the operating
microscope, most disc prolapses can be excised
with minimal disturbance to the normal bony
anatomy and with the removal of only a small
amount of bone, usually from the adjacent lami-
nae on the side of the prolapse.
A full laminectomy may occasionally be neces-
sary prior to the disc excision of a large central
disc prolapse causing cauda equina compression. (b)
A percutaneous lumbar discectomy to remove Fig. 13.4 (a) CT scans of lumbar spine showing
the nucleus pulposus is sometimes advocated for posterolateral disc prolapses. (b) CT scan of left
the bulging lumbar disc. However, if the disc is posterolateral disc prolapse after intrathecal contrast.
bulging the sciatica will nearly always settle
with conservative treatment and surgery is not
Postoperative mobilization
necessary. A percutaneous discectomy of the in-
tradiscal contents will fail to relieve the sciatica if Most patients commence walking the day after
the disc has ruptured through the annulus, be- surgery and are discharged from hospital on day
cause it will not remove the herniated disc mate- 2 or 3 following the operation. A gently graduat-
rial causing the nerve root compression. ed mobilizing programme should be carefully
LOW BACK PAIN AND LEG PAIN 191

and straining for the first 4 weeks. A graduated


active exercise programme can commence after
the first month.

Prognosis following surgery


The results following lumbar disc surgery are
directly related to the accuracy of the preopera-
tive clinical evaluation. Excellent results can be
achieved if:
there is a good history of sciatica
there are good signs of nerve root irritation
the investigations show evidence of a
Fig. 13.5 CT scan of left lateral disc prolapse. herniated disc
at surgery the nerve root is stretched by a disc
prolapse
the patient is well motivated.
If any of the above criteria are absent the results
following surgery are disappointing.
Recurrent sciatica following surgery occurs in
about 10% of cases and is usually due to further
disc prolapse, either at the same level or at
another level. The principles of management are
similar to those described for the initial treatment
of sciatica. Recurrent sciatica is sometimes due to
adhesions developing around the nerve root
causing perineural fibrosis. The treatment is con-
servative, with judicious use of bed rest followed
by gentle mobilizing exercises, simple analgesic
medication and non-steroidal anti-inflammatory
agents. Surgery to excise the adhesions is suc-
cessful in relieving the pain in less than 60% of
patients.
Rarely, recurrent sciatica is due to intradural
arachnoiditis. Treatment is conservative and
surgery to divide the intradural adhesion is
rarely successful.

Lumbar canal stenosis


The patient with lumbar canal stenosis usually
complains of pain radiating diffusely into the
Fig. 13.6 MRI of lumbar disc prolapse. legs, particularly when standing or walking. The
pain may be a diffuse ache, or is sometimes de-
explained to the patient, often with the help of a scribed as having a burning quality; it is usually
physiotherapist. Gentle back strengthening exer- relieved with sitting and patients often adopt a
cises commence after 10 days, and the patient posture of bending the body forward when walk-
should avoid prolonged periods of sitting, lifting ing to help relieve the discomfort. The pain may
192 CHAPTER 13

be similar to that described by patients with vas-


cular occlusive disease, although a key feature is
the presence of pain when standing only.
On occasions there may be features of sciatica-
like pain in association with the diffuse pain of
lumbar canal stenosis due to entrapment of a
nerve root by an osteophyte or within the lateral
recess of the canal.
The patient often complains of a subjective
feeling of weakness and of a diffuse numbness
and tingling radiating down the legs. Sphincter
difficulties may occur if the stenosis is particul-
arly severe.

Examination findings Fig. 13.7 CT scan of lumbar spine showing severe


lumbar canal stenosis.
The examination of the lower limbs and back
often reveals little or no abnormality. Focal wast-
ing may occur in the lower limbs if the compres-
sion is severe, and the ankle jerks may be usually straightforward, but it should be con-
depressed or absent. Definite sensory disturbance firmed by radiological investigations. High-
or weakness occur only in the most severe cases. quality CT scanning (Fig. 13.7) and MRI (Fig.
The peripheral pulses should be checked as the 13.8) have replaced the need for myelography
symptoms may mimic those due to peripheral (Fig. 13.9). All these radiological studies demon-
vascular disease. strate the canal stenosis. The myelogram will
show marked indentation of the contrast column
and, if the stenosis is severe, there may be a com-
Pathology and anatomy
plete block to the flow of contrast. The MRI will
The stenosis of the lumbar canal may involve re- show the extent and severity of the stenosis as
duction of the sagittal diameter of the canal, nar- well as other pathology related to the lumbar
rowing of the lateral recess and stenosis of the discs such as degenerative disease and prolapse.
neural foramen. The pathology is frequently due The clinical features of lumbar canal stenosis
to a combination of congenital canal stenosis and do not respond favourably to conservative treat-
degenerative pathology, such as lumbar spondy- ment, and surgery is almost invariably successful
losis with hypertrophy of the facet joints and in relieving the symptoms. The operation con-
ligamentum flavum, osteophyte formation and sists of a decompressive lumbar laminectomy
thickening of the laminae causing further nar- extending over the whole region of the stenosis
rowing of the canal and bulging of the discs such with decompression of the lumbar theca and
that the space for the neural elements becomes nerve roots.
compromised. The patient can be mobilized promptly after
The most frequently affected levels are L4/5 the operation and a course of gently graduated
and L3/4. The lumbosacral level may be in- active exercises prescribed, usually with the help
volved, but this is less common. The stenosis may of a physiotherapist.
also be related to a degenerative spondylolisthe-
sis, particularly at the L4/5 level.
Back pain
Low back pain without leg pain or signs of nerve
Management
root compression is a common problem. The
The clinical diagnosis of lumbar canal stenosis is usual presentations are:
LOW BACK PAIN AND LEG PAIN 193

Fig. 13.8 MRI showing severe canal stenosis.

acute low back pain, often following minor


trauma
chronic or recurrent low back pain.
Acute sudden-onset back pain, following a rec-
ognized episode of trauma, is usually due to soft Fig. 13.9 Lumbar myelogram showing lumbar canal
tissue strain. If the injury was severe it may have stenosis.
caused a fracture or disc herniation. The manage-
ment of patients with an acute onset of back pain
following trauma involves:
history and examination to exclude symptoms
and signs of nerve root compression
194 CHAPTER 13

radiological evaluation to exclude fracture or clinician to the possibility of a more sinister basis
disc herniation (if severe trauma) for the back pain.
conservative management with initial bed rest Intra-abdominal pathology should also be con-
followed by gentle mobilization and simple anal- sidered in patients presenting with back pain,
gesic medication. especially:
Most of the pain and stiffness should settle pancreatic disease pancreatitis or tumours
after a few days, although mild discomfort may aortic aneurysm
linger for some weeks. renal disease calculus, infection or tumour.
The more difficult problem is chronic or recur- Lumbar spondylosis, a degenerative disease
rent back pain, where the patient gives a history involving the vertebral column, is the most
of less severe or even trivial trauma. In some common demonstrable cause of low back pain.
cases no pathological cause will be found. The The arthritic process may involve any of the
most common aetiology is degenerative disease spinal joints and be associated with degenera-
which includes: tive disc disease. Low back pain, without fea-
lumbar spondylosis tures of sciatica, is only rarely caused by disc
spondylolisthesis prolapse, and then only if the prolapse is large
degenerative disc disease. and central.
Other uncommon but important causes of low
back pain which, in the early stages, may present
Spondylolisthesis
without pain radiating into the legs or radicular
signs, include: Spondylolisthesis is a subluxation of one verte-
spinal tumours (Chapter 15) bral body on another, usually involving the L4 or
thoracic disc prolapse (Chapter 15) L5 levels, and may be due to congenital defects
spinal abscess (Chapter 15) involving the neural arch or to degenerative
arteriovenous malformation (Chapter 15). changes. Spondylolysis describes a defect in the
These serious but unusual causes may present pars interarticularis, often the precondition for
with acute or chronic back pain but nearly always spondylolisthesis (Fig. 13.10).
have other features, e.g. symptoms or signs of Various classifications have been used to
nerve root involvement, which would alert the categorize spondylolisthesis; most subdivide the

(a)

Fig. 13.10 Lumbar spondylolysis with bilateral defects in the


(b)
pars interarticularis.
LOW BACK PAIN AND LEG PAIN 195

Table 13.4 Classification of spondylolisthesis.

Congenital
Dysplastic Congenital deficiency of superior facet of sacrum or inferior facet of 5th lumbar vertebra
Isthmic Lesion in pars interarticularis
Lytic fatigue fracture
Elongated but intact pars
Acute fracture
Degenerative In adults, usually at L4/5; a cause of lumbar canal stenosis

Traumatic

Pathological Pagets disease, neoplastic, osteogenesis imperfecta and achondroplasia

forms into those of congenital and those of de-


generative origin (Table 13.4).
The congenital dysplastic variety results from
congenital deficiencies of the superior facets of
the sacrum or the inferior facets of the 5th lumbar
vertebra. The lumbosacral junction is incapable
of withstanding the truncal forces imposed by
the erect stance and there is gradual forward slip-
page of the 5th vertebral body. This is frequently
associated with spina bifida occulta of L5 or S1.
The congenital isthmic category involves a defect
of the pars interarticularis, either a lytic fatigue
fracture or, rarely, when the interarticularis frac-
ture occurs following severe trauma. Fig. 13.11 CT scan showing lumbar spondylolisthesis
A further subtype is when the pars is elongated
but intact.
Degenerative spondylolisthesis, also known as
pseudospondylolisthesis, results from severe pain, which may radiate into the buttocks, but
localized arthritis of the facets (apophyseal patients often complain of a tight feeling in the
joints) of the slipped vertebrae. upper thighs. Symptomatic children and adoles-
Radiological investigations, including plain X- cents often have a gait disturbance, the so-called
rays, CT scan and MRI, will show the type of tight hamstring syndrome.
spondylolisthesis, the amount of slippage and The vertebral slippage may produce compres-
the associated narrowing of the neural canals sion of the lumbar nerve roots in the neural fora-
(Fig. 13.11). The degree of subluxation is com- men. This causes sciatica, the symptoms of which
monly described by the percentage of slip (Tail- may be indistinguishable from those due to disc
lard method) or assigned a grade (IIV) based on prolapse. Narrowing of the bony canal may
the number of quarters of the adjacent body result in clinical symptoms of lumbar canal
spanned by the slip. stenosis.

Clinical presentation Treatment


The presenting features involve back pain and Children and adolescents
leg pain. The initial symptom is usually back In the majority of children and adolescents
196 CHAPTER 13

symptomatic spondylolisthesis responds to con- conservative treatment, where the radiological


servative treatment. The following indications findings show a relative absence of degenerative
are guidelines for lumbar fusion. disease as a cause for the pain. This is an uncom-
Pain unrelieved by conservative measures. mon situation since, in most cases, it is not possi-
Progression of subluxation on serial radiologi- ble to identify that the spondylolisthesis is the
cal studies. sole cause of the back pain.
Subluxation of greater than 30%. Documented progressive subluxation. This is
Tight hamstring gait. uncommon in adults but is a definite indication
The usual surgical procedure is a spinal fusion. for spinal fusion.
Only rarely is a laminectomy necessary, and it In general, the treatment of symptomatic grade
should never be performed unless the spine is I spondylolisthesis by fusion and fixation re-
fused as there will be a progressive slip. mains controversial and should be considered on
an individual basis. Symptomatic patients with a
Adults grade II slip usually benefit from surgery, and
In most patients conservative therapy involving symptomatic patients with grade III or IV benefit
short periods of bed rest during exacerbations of greatly.
discomfort, gentle mobilizing exercises, simple
analgesic medication and non-steroidal anti-in-
Further reading
flammatory medication will be sufficient. If some
pain persists following bed rest a period with a Bogduk N (2004) Management of chronic low back
properly fitted lumbar brace may be of value. pain. Medical Journal of Australia 180 (2), 7984.
Surgery involves either a laminectomy to decom- Branch CL, Handley EN, Ducker T (1995) Treatment of
press the neural structures and/or a spinal lumbosacral spondylolisthesis. In: Al-Mefty O, Orig-
itano TC, Harkey HL, eds. Controversies in Neuro-
fusion to prevent instability. The indications for
surgery. Thieme, New York.
laminectomy include:
Hardy RW (1982) Lumbar disc disease. Seminars in Neuro-
symptomatic spinal canal stenosis (that is, logical Surgery. Raven Press, New York.
symptoms of lumbar canal stenosis) Kaye AH, Black P McL (2000) Operative Neurosurgery.
clinical features of nerve root compression Churchill Livingstone, London, New York,
(e.g. sciatica) unrelieved by conservative therapy. Edinburgh.
A laminectomy decompresses the lumbar Maroon JC, Young P, Tarlov E, Haines SJ (1995) Treat-
theca and nerve roots, usually with satisfactory ment of lumbar disc protusion, percutaneous discec-
relief of lower limb symptoms. However, a tomy, microdiscectomy, conservative treatment. In:
laminectomy may increase the instability and Al-Mefty O, Origitano TC, Harkey HL, eds. Contro-
some surgeons prefer to combine a decompres- versies in Neurosurgery. Thieme, New York.
Mixter W, Barr J (1934) Rupture of the intervertebral
sive laminectomy with a spinal fusion. An
disc with involvement of the spinal canal. New Eng-
intertransverse fusion between the transverse
land Journal of Medicine 211, 210214.
processes has been the traditional method of Sherman FC, Rosenthal RK, Hall JE (1979) Spine fusion
fusion, but more recently internal pedicle screw for spondylolysis and spondylolisthesis in children.
fixation and/or interbody cages placed in the Spine 4, 5967.
emptied disc space between the vertebral bodies Vierbiest H (1954) A radicular syndrome from develop-
have become the preferred method. mental narrowing of the lumbar vertebral canal.
Spinal fusion, without laminectomy, is occa- Journal of Bone and Joint Surgery 36B, 230237.
sionally indicated and should be considered in Wiltse LL, Newman PH, MacNab I (1976) Classification
patients with the following conditions. of spondylolysis and spondylolisthesis. Clinical Or-
Incapacitating low back pain unrelieved by thopaedics 177, 2329.