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Isthmic Spondylolisthesis

- Discussion:
    - most common type seen in children & young adults;
    - occurs in about 5% of the population;
           - more common in Eskimos;
           - more common in yound white males involved in  hyperextension activities;
    - most common at ages 5-8 years;
    - results from shear stress at pars intra-articularis, and is more common in repetitive hyperextension activities;
    - associated conditions:
           - spina bifida occulta;
                  - those w/ more severe degrees of slipping early in life are most oftenfemale, and it is most often associated w/ Spina Bifida 
                          occulta and L5 to S1;
           - thoracic kyphosis;
           - Scheuermann's disease;

- Clinical Manifestations:
    - usually at L5-S1, usually presents w/ back pain (instability), deformities
          or alteration in gait "pelvic waddle" & hamstring spasm;
    - Kyphosis of lumbosacral junction w/ or w/o palpable step off;
    - severe slips may be assoc w/ radicular findings (L5);
          - this occurs from compression between the superior end plate of the caudad vertebrae and the inferior facet of the cephalad vertebrae
- Radiographs:
    - Grade I:
    - Grade II:
    - Grade III and IV:

- Treatment:
    - although most patients will develop isthmic spondylolithesis in childhood and adolescence, most patients (90%) who require 
          surgery are adults;
    - treatment is based on grade (I, II, III and IV) and clinical findings;
          - w/ high grade L5-S1 slip consider additional fusion to L4-5 (especially if MRI shows L4-L5 disc degeneration);
          - wide neuroforaminal decompression is also usually required;

- Gill Procedure:
    - of historical interest;
    - involves removal of the loosely attached arch of L5;
    - procedure was complicated by recurrence of pain and progression of deformity

Natural history of symptomatic isthmic low-grade spondylolisthesis in children and adolescents: a seven-year follow-up study.

Isthmic spondylolisthesis in symptomatic and asymptomatic subjects, epidemiology, and natural history with special reference to disk abnormality and mode of treatment.

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