Talk:Spondylolisthesis

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[edit] Old discussion

I'm copying an old discussion that is relevant to this page.

[edit] Spondylolisthesis

Hi there: thank you for the improvements. One point: while it is unquestionably true that the development of a spondylolisthesis may be an immediate sequal of trauma, many orthopaedic specialists would say that this is a manifestation of a previously un-disrupted spondylolysis. Proof is difficult in that most people with no spinal pathology do not have either oblique x-rays or MTI or CT scans, so that the demonstration of the pre-existence of a defect in the pars interarticularis is difficult to achieve. It is of course a recognised fact that most disruptions ot the dorsal arch caused by gross trauma occur posterior to both superior and inferior articular processes, not between them. I cannot tell from your userpage; do you have orthopaedic experience?--Anthony.bradbury 20:20, 13 August 2006 (UTC)

Your further edit is wholly accurate and I have, of course, not altered it. When I wrote the article I was trying to keep it reasonably simple!--Anthony.bradbury 18:52, 14 August 2006 (UTC)
Good evening Doc! Tony, sorry I haven't replied earlier. I've had a very busy day at the clinic, but here goes:
I'm a Physiotherapist, so I have the clinical experience angle. I'm also an anti-quackery activist.
As a physician you may well know more about this subject from your experience, so you are more than welcome to revise the article and make it more precise.
As I understand it, the most common spot for an isthmic spondylolysis to occur is in the pars interarticularis of a vertebra, right between the superior and inferior articular processes. This allows the vertebral body to gradually move forward in relation to the vertebral body below it. When this happens we have a true spondylolisthesis. There isn't any true "slip" (in the sense of "sliding" or "gliding"), because the intervertebral disc is still intact and grown together with both vertebrae, but the relative position between the two vertebral bodies does change in the sagital plane. This will usually limit the size of the intervertebral foramen, thus compromising the nerve roots. In the worst cases it can cause spinal stenosis and cauda equina syndrome:
Here is a good flash illustration with two animations of the two major types of sp.:
Some other thoughts:
  • The use of the word "centrum" is confusing to me. I would usually say vertebral "body" or use the Latin "corpus vertebra," but I know there are terminology differences between various English speaking countries, and also here in Denmark. (I'm an American living here with my Danish wife - also a PT - and our two children.)
  • We need to describe the two types - degenerative and isthmic - and point out that only the last involves a spondylolysis (whether congenital or fracture)
  • It would strengthen all the anatomical articles if the Latin (or Greek where relevant) terminology is used concurrently with the English. This would make this aspect of Wikipedia truly international, since Latin is still the universal (and esoteric) language of medicine.
  • Example: Spondylolisthesis (Latin: spondylos=vertebra; olisthesis=slippage)
  • The decisive difference between a spondylolysis and a spondylolisthesis is not the lack of fusion (or the fracture) between bony structures, but the actual slippage. If there is no slippage, then there is no spondylolisthesis. Thus, in the case of degenerative spondylolisthesis, it can occur in the absence of any fracture, simply occurring because the integrity of the facet joints has been so seriously compromised as to make the movement segment unstable.
The "slipped disc" article was originally a scandal, with a very misleading image from the Hughston Clinic, so I contacted them and got permission to remove the image from the article. They could see it was very inaccurate. It was an image worthy of any chiropractor (maybe the medical illustrator had been brainwashed by one?), since they consistently try to get their patients to believe that they can "push it back in place." Hogwash! In fact, the presence of a spondylolisthesis would be a contraindication to spinal manipulation, but you won't get many chiros to admit that.
Actually there is some good information on the talk page there, which might be usable in this article.
BTW, you could add the category Physician to your user page:
  • [Category:Physicians|Bradbury, Anthony]
This article is an important addition, thanks to you, and it can be developed with time.


Regards,
Paul Lee, PT
You can contact me by email:

[edit] Informative

Just wanted to say great article. I was diagnosed with grade 2 of the L5 back in September after years of back back. Let me tell you, it was nice to at least have a reason for my own piece of mind. Some parts are a bit frightening such as the section on escalation into paralysis of the lower limbs. How rare is this? --MWillMS 21:52, 13 February 2007 (UTC)

[edit] Concern about recent edits

While the anonymous edits on April 26, 2007 (comparison) added much substance to the treatment section, I am concerned that:

  • These edits deleted the only references to MEDLINE, including an attempted meta-analysis (PMID 1531550) and two other references.
  • The new content, while noting authors names, is not linked with references
  • The content is pretty dense without topic sentences to help the reader through the long paragraphs.
  • The author cites an older version of PMID 10870149. I added the long term follow-up of this study (PMID 15653083).
  • I am not clear on the intent of the paragraph that starts 'The success of stand-alone posterolateral fusion...' It appears to cite studies of fusion alone for patients with both back and radicular symptoms. As the randomized controlled trial in its preceding paragraph included such patients and the two studies the author cites are uncontrolled case series, I proposed this paragraph be deleted. A comment from the author would help in case I misunderstood the intent. For now I have prepended this paragraph so it starts with 'Uncontrolled studies have focused on the role of fusion in patient with both back pain and radicular pain.' I have isolated this edit so it can be reverted.

Badgettrg 14:18, 3 May 2007 (UTC)

[edit] Addressing your concerns

  • The intent of the paragraph that starts 'The success of stand-alone posterolateral fusion...' was to give the readers some background as to why several different authors, including Eugene Carragee and de Loubresse, chose to study the difference between decompression with posterolateral fusion (PLF) to PLF alone. Given both existing practice patterns and the prevailing theories on the causes of radiculopathy in cases of isthmic spondy, it may seem counterintuitive that several authors chose to study laminectomy with PLF vs PLF alone expecting that PLF alone would result in better outcomes. This paragraph attempts to give some of the background that led to this interesting finding, but I agree that it may be confusing to some readers.
  • As I am new to wikipedia, I inadvertently deleted some citations while typing the article, I apologize for this. However, the attempted meta-analysis was centered on spinal stenosis with some reference to degenerative spondylolisthesis and does not effectively review the literature on isthmic spondylolisthesis.
  • Also, I will attempt to begin adding references besides the bibliography that follows the article. Is there a quicker way to add citations besides manually typing the code?
  • With respect to citing PMID 10870149 vs PMID 15653083, I cited the earlier study in my article and not the longer-term study (originally) for a few reasons. I have not been able to obtain a full version of PMID 15653083 and without in-depth evaluation of the article, it is difficult for me to accurately interpret their findings. Also, factors such as patient attrition, regression towards the mean, and possibly, the natural history of the disorder may have diminished the measured differences in outcome, even if a difference persists. Also, the short-term differences were highly significant and something of a landmark study for isthmic. I feel these results deserve mention. Finally, some of the descriptions within the abstract of PMID 15653083, such as deterioration in DRI scores, but not ODI scores raises questions about the reliability of the findings. Nevertheless, 15653083 does have some validity and I feel that the results of both studies should be mentioned.
  • I agree that the article is very dense and is aimed towards those with a medical background. I believe that the topic is difficult to address accurately without this density, especially in the light of evolving controversies and the numerous unknowns concerning this interesting disorder. I will attempt to simplify portions of it, especially the section of High-grade isthmic.
  • Finally, I retained very little of the old arcicle because almost nothing withn the article was accurate. I also feel that it painted a rather sinister picture for isthmic spondylolisthesis and led many readers to believe that surgery is a must when very few patients with this disorder have surgery. The risk of paralysis from isthmic spondylolisthesis is such a rare event that instances would require a case report (except for Hangman's fracture) and very, very few case reports of this complication have been published.
  • Thank you for your feedback. Nicholas Pirnia MD - Orthopaedic surgery resident

nicholas.pirnia@gmail.com

[edit] Great article- if the reader happens to be a physician or chiropractor

This article makes no sense to the typical layman. It reads like something out of a medical journal. No, even THAT'S not true; even I have been able to read articles from a medical journal. This article is not the kind of article that one would ever find in an encyclopedia. An encyclopedia is supposed to be something that is readable by all people. This article is EXLUSIVE. Slater79 19:11, 30 May 2007 (UTC)

Although most of us want clear language in articles we read, I doubt that you really want articles written at the level of a 12 year old. Such simplistic articles can be easily found with a Google search and read like the pamphlets you find in MD's waiting rooms. A Wiki article on spondylolisthesis using simple language would have a title such as "lower back pain" and not spondylolisthesis. Anybody searching or clicking on "spondylolisthesis" will be seeking more advanced concepts and will already have some knowledge of spinal anatomy, physiology, pathology, and the jargon that goes with it such as "anterior" instead of "front". To replace technical words with simple words in the present article would destroy it and will be reverted. However, it might be useful to have a "See also" article that uses simple concepts and language. You could reference it with the words: "For an explanation in simple words, see ----". Greensburger 22:37, 30 May 2007 (UTC)