RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES , …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES , BANGALORE , KARNATAKA

| ANNEXURE II |

|PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION |

| 1. |Name AND ADDRESS of the candidate |DR .AMIT SINGH |

| | |S/O MR. SHARAD SINGH |

| | |47 GOVARDHANDHAN DHAM |

| | |NAGAR UJJAIN -456010 MADHYA PRADESH |

| 2. |Name of the institution |KEMPEGOWDA INSTITUTE OF |

| | |MEDICAL SCIENCES AND RESEARCH CENTRE, |

| | |BANGALORE. |

| 3. |Course of study and subject |M.S. ORTHOPAEDICS |

| 4. |Date of admission to course |31.05.2012 |

| | | |

| |Title of the topic | |

|5. | |“FUNCTIONAL OUTCOME OF LUMBO-SACRAL SPONDYLOLISTHESIS - POSTERIOR |

| | |STABILIZATION WITH MOSS-MIAMI INSTRUMENTATION AND SPINAL FUSION” |

| | | |

| 6. |BRIEF RESUME OF INTENDED WORK: |

| |6.1 NEED FOR STUDY: |

| |Herbiniaux, a Belgian obstetrician is credited with having first described spondylolisthesis. The term spondylolisthesis was used by |

| |Kilian in 1854 and is derived from the Greek word spondylos, meaning “vertebra,” and olisthenein, meaning “to slip.” |

| |Spondylolisthesis is defined as anterior or posterior slipping of one segment of the spine on the next lower segment. |

| |The prevalence of spondylolisthesis in the general population is approximately 5% and about equal in men and women. Increased slipping |

| |usually occurs between the ages of 9 and 15 years and seldom after the age of 20 years. Recent studies shows increased prevalence of |

| |spondylolysis in community based population to 11.5%, nearly twice the prevalence of previous plain radiograph studies as compare to CT.|

| |Male to Female ratio for |

| |Spondylolysis is 3:1 |

| |Isthmic type of Spondylolisthesis is 2:1 |

| |And degenerative type of Spondylolisthesis is 1:3. |

| | |

| |Even though low back pain is common presentation in case of spondylolysis and spondylolisthesis, no significant association was found |

| |between spondylolysis, isthmic and degenerative spondylolysthesis on CT and low back pain. |

| |Patients usually present with a persistent dull low-back pain with radiculopathy, which increases with activity and decreases with rest,|

| |low-back stiffness, tight hamstrings and intermittent claudication. With more severe slips, the trunk becomes shortened and often leads |

| |to complete absence of the waistline. These children walk with a peculiar spastic gait, described as a “pelvic waddle” by Newman, |

| |because of the hamstring tightness and the lumbosacral kyphosis. |

| |The initial treatment is conservative, with rest, use of NSAIDs, physical therapy and the wearing of a body brace. Operative management |

| |for Lumbar-Sacral Spondylolisthesis is commonly performed via a posterior decompression, reduction and with poster spinal fusion of the |

| |slipped vertebra with spinal instrumentation. |

| |As surgical outcome of lumbo-sacral spondylolisthesis is better than conservative according to literature in accordance with stable |

| |reduction and early amelioration of symptoms, hence we wish to undertake this study and try to establish facts regarding surgical |

| |management of spondylolisthesis by moss-miami instrumentation and posterior spinal fusion. |

| |6.2 REVIEW OF LITERATURE: |

| |Spondylolysis is a descriptive term referring to a defect in the pars interarticularis. The defect may be unilateral or bilateral and |

| |may be associated with spondylolisthesis. Spondylolisthesis refers to the anterior displacement (translation) of a vertebra with respect|

| |to the vertebra caudal to it. This translation may also be accompanied by an angular deformity (kyphosis)1. |

| |With regards to progression, in patients with isthmic spondylolisthesis the incidence of a spondylolysis may be as high as 70%. The risk|

| |of progression from |

| |spondylolysis to spondylolisthesis is reported to be small 4% -5%. The risk factors that increase the likelihood of further slippage are|

| |younger age, female sex, presence of spina bifida, wedging of the vertebrae, rounding of the anterior sacral dome and hyperlordosis2. |

| |During a fifteen-year period a clinical, radiological and in some cases a surgical study has been made of 319 patients suffering from |

| |spondylolisthesis, the five etiological factors are described, and the cases are assigned to five groups according to the factor |

| |responsible for the slip. In every case slipping is permitted by a lesion of the apparatus which normally resists the forward thrust of |

| |the lower lumbar spine—that is, the hook of the neural arch composed of the pedicle, the pars interarticularis and the inferior |

| |articular facet engaging caudally over the superior articular facet of the vertebra below. |

| |In Group I - Congenital spondylolisthesis (66 cases) |

| |In Group II - Spondylolytic spondylolisthesis (164 cases) |

| |In Group III - Traumatic spondylolisthesis (3 cases) |

| |In Group IV - Degenerative spondylolisthesis (80 cases) |

| |In Group V - Pathological spondylolisthesis (6 cases)3. |

| |Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP performed a prospective roentgenographic study to determine the incidence of |

| |spondylolysis, spondylolisthesis, or both, in 500 unselected first-grade children from 1955 through 1957. |

| |The families of the children with spondylolysis were followed in a similar manner. The incidence of spondylolysis at the age of six |

| |years was 4.4 per cent and increased to 6 per cent in adulthood. The degree of spondylolisthesis was as much as 28 per |

| |cent, and progression of the spondylolisthesis was unusual. The data support the hypothesis that the spondylolytic defect is the result |

| |of a defect in the cartilaginous anlage of a vertebra. There is a hereditary pre-disposition to the defect and a strong association with|

| |spina bifida occulta. Progression of a slip was unlikely after adolescence4. |

| |A prospective study of spondylolysis and spondylolisthesis was initiated in 1955 with a radiographic and clinical study of 500 |

| |first-grade children. Objective was to determine the natural history of spondylolysis and spondylolisthesis. To conclude subjects with |

| |pars defects follow a clinical course similar to that of the general population. There appears to be a marked slowing of slip |

| |progression with each decade, and no subject has reached a 40% slip5. |

| |In the series of 500 children for who radiographs were made at three separate times during their growth. Of the 500 individuals, thirty |

| |eventually had a defect. An incidence of 6 per cent by adulthood. None of these had a progression beyond 30 degrees6. |

| |With mechanical equations it has been established, the pars interarticularis and the ligaments resist together the tensile and shear |

| |force, the bending moment if the pars interarticularis is uncracked. If the tensile stress in the pars interarticularis reaches its |

| |strength, crack occurs and the spondylolysis is developed. The cracked pars interarticularis is no longer capable of sustaining tension,|

| |the tensile force is transferred to the ligament. When the compressive strain of the pars interarticularis reaches its strain limit, the|

| |spondylolisthesis does not develop, because the vertebra cannot slip with the unbroken ligaments. If the loading on the pars |

| |interarticularis would be decreasing, the cracks close and the pars interarticularis can ossify. If the tensile stress in the ligament |

| |reaches its strength and the ligament breaks, the pars interarticularis cracks through, the vertebra slips and the spondylolisthesis |

| |develops7. |

| |Study conducted with 2 year follow up of patient treated with postero-lateral fusion had less pain and better functional outcome then |

| |patients treated with exercise programme8. |

| | |

| |A retrospective study of 14 patients with high-grade L5-S1 spondylolisthesis surgically treated with one-stage decompression and |

| |posterolateral and interbody fusion (technique of Bohlman and Cook) concluded that posterior decompression of the spinal canal combined |

| |with anterior and posterior arthrodesis performed at one stage through a posterior approach is a safe and effective technique for |

| |managing severe spondylolisthesis9. |

| |In a study among a total of 136 patients,129 cases developed solid fusion mass at 8 months post op with failed fusion in 7 cases and all|

| |129 patients that developed solid fusion after postero lateral fusion claimed to have relief of symptoms10. |

| | |

| | |

| |6.3 OBJECTIVES OF THE STUDY |

| |Objectives of the study are to evaluate the safety, efficacy and functional outcome of surgical management of spondylolisthesis with |

| |moss-miami instrumentation and posterior spinal fusion. |

| |MATERIALS AND METHODS |

| |7.1 SOURCE OF DATA |

| |All cases presenting at KIMS OrthopaedicsOPD and meeting the inclusion and the exclusion criteria as mentioned below, during the study |

| |period will be the subject of study. |

| | |

| |7.2 METHOD OF COLLECTION OF DATA |

|7. |INCLUSION CRITERIA: |

| |Patients of age group >20yrs - ................
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