LBP DUE TO CASE REPORT

spondylolisthesis L5-S1 AGUSTUS 2016

ADVISORS
DR. ZULPAN ZULKARNAIN
DR. QARIAH MAULIDIAH

SUPERVISOR
DR. JAINAL ARIFIN, M.KES, SP.OT(K)SPINE

ORTHOPEDIC AND TRAUMATOLOGY DEPARTMENT

HASANUDDIN UNIVERSITY
 PATIENT IDENTITY

Name : Ny. M
Age : 56 years old
Sex : Female
Reg. Number : 767800
Date of Admission : On August 10th, 2016
 HISTORY TAKING

Chief complaint
Low back pain

History Taking
Suffered since 10 days ago and worsen since last 3 days.
Pain begin when fall in sitting position10 days a go.
Pain used to be intermittent and aggravated when
patient doing activity, decrease when patient rest. No
referred pain.
 History Taking
History of low back pain before (-)
Family history with same complaint (-)
History of chronic cough (-), night sweat (-), fever (-)
History of loss of body weight (-)
History of previous TB treatment (-)
Defecation and urination : normal
History of lump on the body (-)
History of trauma (+) 10days ago patient slippery when she was walking and
fall in sitting position

History of medication (+) 7 days ago patient got ibuprofen 3x1

History of previous operation (-)

History of hypertension and diabetes mellitus (-)
History of heavy lifting (-)
 PHYSICAL EXAMINATION

GENERAL STATUS

Poor nourished/Compos mentis

BP : 110/80 mmHg
Pulse : 80 x/m, regular
RR : 16 x/m, regular
Temperature : 37 oC (axilla)
 PHYSICAL EXAMINATION

LOCAL STATUS
Look deformity (-), swelling (-), hematome (-), gibbus (-), wound (-)

Feel Tenderness (+) as level as vertebrae L5-S1, Step-off (-)

PHYSICAL
EXAMINATION
2
2
2
2
2
2
2
2 SENSORY
2 2 2 2 KEY SENSORY POINTS
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2

56 56 112
56 56 112
PHYSICAL
EXAMINATION 5 5
5 5
5 5

MOTOR 5
5
5
5
KEY MUSCLES
25 25 50

5 5
5 5
5 5
5 5
5 5

25 25 50
 PHYSICAL EXAMINATION

REFLEXES
R L R L
Biceps (N) (N) Hoffman (-) (-)
Triceps (N) (N) Tromner
PHYSOLOGIS REFLEX

PATHOLOGIC REFLEX
Achilles (N) (N) Babinski (-) (-)
Patellar (N) (N) Chadock (-) (-)
Openheim (-) (-)
Clonus (-) (-)
 PHYSICAL EXAMINATION

SPECIAL TEST
Straight Leg Raise Test (-)
Laseque Test (-)
Patrick Test (-)
Contrapatrick Test (-)
 INVESTIGATION
LABORATORY FINDING
TEST RESULT REFERENCE
WBC 14,1 4,00-10,0
RBC 4,42 4,00-6,00
HGB 10,7 12,0-16,0
HCT 33,9 37,0-48,0
PLT 361 150-400
CT 800 4-10
BT 300 1-7
GDS 242 140
SGOT 26 <38
SGPT 31 <41
Ureum 27 10-50
Kreatinin 0,84 <1.3
HBsAg Non Reactive Non Reactive
 INVESTIGATION
RADIOLOGY FINDING
Thorax AP

Cardiomegaly with dilatation et elongation

INVESTIGATION
RADIOLOGY FINDING
V.Thoracal
 RADIOLOGY FINDING
V. Lumbosacral Lateral
Dynamic
RADIOLOGY FINDING
V. Lumbosacral Lateral
Dynamic
RADIOLOGY FINDING
V. Lumbosacral Lateral
Dynamic
RADIOLOGY FINDING
V. Lumbosacral Lateral
Dynamic
RADIOLOGY FINDING
MRI L-Spine
RADIOLOGY FINDING
MRI L-Spine
RADIOLOGY FINDING
MRI L-Spine
RADIOLOGY FINDING
MRI L-Spine
 RESUME

Women, 56 yo, admited to hospital with low back

pain that suffered since 10 days ago and worsening
since 3 days ago. Pain used to be intermittent and
aggravated when patient doing activity, decrease
when patient rest. No referred pain. History of
trauma (+) 10 days ago patient slippery when she
was walking and fall in sitting position. History of
medication (+) 4 days ago after trauma, patient got
ibuprofen 3x1
 RESUME

From physical examination, there was

tenderness as level as V. L V S I
From neurological examination, sensory and
motor were normal.
From radiological examination, from the thorax
xray can be found cardiomegaly with dilatation
and elongation aortae. From the vertebra xray,
there is Spondylolisthesis CV L5 to S1. From
MRI L-spine there is Spondylolisthesis CV L5
to S1
 DIAGNOSIS

Physical Diagnostic

History Taking Investigation

LOW BACK PAIN DUE TO SPONDYLOLISTHESIS L5-S1

 TREATMENT

TREATMENT
Life style modification
Bracing
Analgetic
DISCUSSION
 ANATOMY

Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

DENNIS CLASSIFICATION

The three columns of the spine, as proposed by Francis Denis. The anterior column (A)
consists of the anterior longitudinal ligament, anterior part of the vertebral body, and
the anterior portion of the annulus fibrosis. The middle column (B) consists of the
posterior longitudinal ligament, posterior part of the vertebral body, and posterior
portion of the annulus. The posterior column (C) consists of the bony and ligamentous
posterior elements. (Modified from Denis F. The three-column spine and its significance
in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817831.)

Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition, chapter 3. USA
Lippincot Williams & Wilkins.2010
 ANATOMY
Column vertebrae:

Bodies

Arch :

o Pedicles

o Laminae

Processes:

o Transverse

o Spinosus

Foramina

o Vertebral

o Neural

Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

 LIGAMENT

Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

 HISTORY TAKING

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
 McAfee expanded Deniss concepts and
classified thoracic and lumbar spine fractures into
six patterns based on CT scan analysis. Injury
patterns were determined based on the force
(compression, axial distraction or translation) that
disrupt the middle spinal column.

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
 Compression fractures represent an isolated
failure of the anterior spinal column due to a
combination of flexion and axial compression
loading

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012

 Stable Burst Fracture is fracture involves the
anterior and middle spinal columns with height
loss of the vertebral body is present.
Unstable Burst Fracture result from axial
compression forces that disrupt all three columns
of the spine.

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012

CLINICAL MANIFESTATION

Mild to severe acute back pain that feels better

with rest
Though rare, if the collapsed vertebra is
compressing one or more nerves, pain may
radiate down the path of the nerve, such as into
the arm or leg.
Other common symptoms of compression
fracture include pain when twisting or bending,
loss of height, and a hunched forward position
called kyphosis.
 RADIOLOGIC EXAMINATION
IN LUMBAL FRACTURE
Loss of vertebra height (more 50% suggest
possible porterior ligamentous injury)
Kyphotic deformity
Interpedicle distance
Pedicle shadow
Posterior vertebra body angle (>100 degree sign
of burst fracture)
CT-scan -> Spinal Canal Compromised

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012

 RADIOLOGICAL
EXAMINATION

Radiographs
obtain radiographs of entire spine (concomitant
spine fractures in 20%)
CT scan indications
fracture on plain film
neurologic deficit in lower extremity
inadequate plain films
MRI useful to evaluate for
injury to anterior and posterior ligament complex
spinal cord compression by disk or osseous material
cord edema or hemorrhage

Moore D. Thoracic & Lumbar Trauma Introduction. Orthobullets

 TREATMENT

Nonoperative indications
most thoracic and thoracolumbar fractures (burst and
compression) can be treated nonoperatively when the patient is
neurologically intact
treat in Thoraco Lumbal Sacral Orthosi (TLSO) is for 6 to 12 weeks
depending on degree of instability

Operative indications for surgery

Progressive neurological deficit
CT evidence of spinal canal compromise associated with
incomplete neurologic deficit
Burst fracture associated with significant disruption of the posterior
column-for example, facet subluxation, significant disruption of the
posterior ligamentous complex
Greater than 50% loss of vertebra body height
Kyphosis greater than 25-30 degree at level of fracture
Inability to immobilize the patient with a brace due to associated
injuries or body habitus

Moore D. Thoracic & Lumbar Trauma Introduction. Orthobullets

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
SPONDYLOLISTHESIS
 DEFINITION

Spondylolisthesis means forward

translation of one segment of the spine
upon another. The shift is nearly always
between L4 and L5, or between L5 and the
sacrum.
Normal discs, laminae and facets
constitute a locking mechanism that
prevents each vertebra from moving
forwards on the one below.
Forward shift (or slip) occurs only when this
mechanism has failed.
Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th
ed.London : Hodder Arnold; 2010.
 EPIDEMIOLOGY

Degenerative spondylolisthesis is observed more

frequently as the population ages and occurs
most frequently at the L4-L5 level. Up to 5.8% of
men and 9.1% of women are believed to have
this type of listhesis.

Vookshor A. Spondilolisthesis, spondilosis and spondylisis. Available at :

www.eMedicine.com. Accessed on July 16th, 2016.
 ETIOLOGY

The etiology of spondylolisthesis is multifactorial.

A congenital predisposition exists in types 1 and 2,
and posture, gravity, rotational forces, and high
concentration of stress loading all play parts in the
development of the slip.

Vookshor A. Spondilolisthesis, spondilosis and spondylisis. Available at :

www.eMedicine.com. Accessed on July 16th, 2016.
 CLASSIFICATION

Various classifications
have been suggested.
Basically
there are six types of
spondylolisthesis:

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th

ed.London : Hodder Arnold; 2010.
Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
 CLINICAL
MANIFESTATION

Rarely symptomatic
Backache is the usual presenting symptom; it is often
intermittent, coming on after exercise or strain.
Tenderness and spasms of the paravertebral muscles.
A step-off at the lumbosacral junction is palpable .
Motion of the lumbar spine is restricted
Sciatica may occur in one or both legs.
Hamstring tightness is evident on straight leg raising.
Adults may have objective signs of nerve root compression,
such as motor weakness, reflex change, or sensory deficit.

Spondylolisthesis and Spondylolysis Guidelines. Veterans affairs Canada. February 2005.

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th
ed.London : Hodder Arnold; 2010.
 RADIOLOGICAL
EXAMINATION

X-RAYS
Lateral views show the forward shift of the upper
part of the spinal column on the stable vertebra
below; elongation of the arch or defective facets
may be seen.
The gap in the pars interarticularis is best seen in
theoblique views.

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th

ed.London : Hodder Arnold; 2010.
 RADIOLOGICAL
EXAMINATION

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th

ed.London : Hodder Arnold; 2010.
 RADIOLOGICAL
EXAMINATION

CT-Scan
Patient with pars interarticulare defect is easy to
seen in CT scan. CT scan can show the
abnormality of the vertebra.

MRI
Can identify the bone and soft tissue (disk, canal,
neural fibre anatomy)

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th

ed.London : Hodder Arnold; 2010.
 GRADING

Severity of Slip
Percentage of slip of AP
diameter of vertebra
below (Meyerding
classification)
Grade I <25%
Grade II 25-50%
Grade III 50-75%
Grade IV 75-100%
Grade V >100%
(spondyloptosis)

Thompson JC, Netter Concise Orthopaedic Anatomy. 2nd ed. Philadelphia : Elsevier Saunders; 2010.
Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th ed.London :
Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012
GRADING
 TREATMENT

Conservative Operative
Lifestyle Decompr
modification ession

Bracing Fusion

Medication

Physiotherap
y
Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th
ed.London : Hodder Arnold; 2010.
 TREATMENT

Operative treatment is indicated:

(1) if the symptoms are disabling and interfere
significantly with work and recreational activities;
(2) if the slip is more than 50 percent and
progressing;
(3) if neurological compression is significant.

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th

ed.London : Hodder Arnold; 2010.
 PROGNOSIS

Dysplastic spondylolisthesis appears at an early

age, often goes on to a severe slip and carries a
significant risk of neurological complications.
Lytic (isthmic) spondylolisthesis with less than 10
percent displacement does not progress after
adulthood, but may predispose the patient to
later back problems.
Degenerative spondylolisthesis is rare before the
age of 50, progresses slowly and seldom exceeds
30 percent.

Solomon L, Warwick D, Nayagam S. Apleys System of Orthopaedics and Fractures. 9th

ed.London : Hodder Arnold; 2010.
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