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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 
           umbilicus.

- 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