The Hip: Preservation, Replacement and Revision

Exam: Spondylolithesis

- See: Back Pain in Children

- Discussion:
    - results of exam may be normal in child w/ spondylolysis or mild (Grade-I or Grade-II) spondylolisthesis.

- Back:
    - tenderness to palpation in the low back;
    - splinting as well as guarding & restriction of side-to-side motion of low back, particularly if onset of symptoms is acute;
    - lumbar offset & lordosis may be severe, & they are usually accompanied by backward tilt of pelvis that may result from tight hamstrings;
    - when viewed from back, ilia appear flared & buttocks are heart-shaped and flattened;
    - distortion of pelvis & trunk begin to become clinically apparent in late stages of Grade-II spondylolysis & is usually present when slip
            reaches Grade III;
    - cephalad to 5th lumbar spinous process, there may be palpable step-off or depression, which is prominent while 4th lumbar spinous 
           process is carried forward w/ anterior displacement of vertebral bodies;

- Tight Hamstrings:
    - restricted flexion of hips due to tight hamstrings may be the only finding;
    - 80% of symptomatic pts have tight hamstrings;
    - tight hamstrings may be found in pts who have spondylolysis or any grade of spondylolisthesis;
    - tightness may be extreme, so that child cannot bend forward at hips or, during straight leg-raising test, examiner cannot lift foot more than a
            few cm from the examining table;

- Gait:
    - tight hamstrings cause peculiar gait (pelvic waddle) in children w/ Spondylolisthesis;
    - excessively tight hamstring muscles tilt the pelvis backward and do not permit the hip to flex sufficiently for a normal stride;
    - consequently, pt has stiff-legged & short-stride gait, & pelvis rotates with each step.
    - child may prefer to jog or run rather than walk, or to walk on the toes with the knees bent;

- Abdomen:
    - when viewed from front, lower part of pt's abdomen appears to be thrust forward, forming transverse abdominal crease at level of 

- Neurologic Findings: neurologic deficits are uncommon;
    - most often involves the L5 nerve root;
           - L5 neuroforamen is narrowed anteriorly and inferiorly by the S1 vertebral body, posteriorly by the L5 pedicle, and dorsally by the 
                  fibrous tissue around the L5 pars defect

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, August 30, 2011 12:02 pm