Cervical spondylolysis with spondylolisthesis Case report
GEORGE R. PR1OLEAU, M.D., AND CHARLES B. WILSON, M.D.
Department of Neurological Surgery, University of California School of Medicine, San Francisco, California v, The authors describe a case in which cervical spondylolysis was found at multiple levels with spondylolisthesisand associated neurological deficits. Radiographic findings and the absence of history of trauma suggest a congenital etiology. KEY WORDS spina bifida
~
cervical spondylolysis
s
PONDYLOLYSIS with spondylolisthesis of the lumbar spine is found in approximately 5% of the general population. 7 It is observed most frequently at L-5, occasionally at L-4, but rarely above this level. Spondylolisthesis of the cervical spine was first reported by Perlman and Hawes in 19517 Six additional cases have since been reported; however, none of these patients had neurological deficits and all had defects at only one level. 1-4 We are reporting a case of multilevel defects of the pars interarticularis with spondylolisthesis and associated neurological deficits; we believe it is the first such case reported. Case Report
A 46-year-old woman was admitted with progressive neck pain radiating down her left arm, and pain on rotation of her neck. There was no history of trauma, and the medical history and general examination were nor750
9 spondylolisthesis
9
mal. Neurological examination revealed decreased strength of her left biceps and brachioradialis muscles with depression of associated reflexes. Pin perception was decreased over the left C-6 distribution. No pathological reflexes were demonstrated. Plain cervical spine films showed smooth, well-corticated bilateral defects at the bone margins of the pars interarticularis at the levels of C3-5 with spondylolisthesis of C-5 on C-6. Paravertebral soft tissues were normal, and spina bifida was not present (Figs. 1 and 2). Instability was demonstrated on flexion and extension films. No significant abnormality was revealed by cervical myelography or electromyography. The patient underwent anterior cervical disc removal with interbody fusion at C5-6 without complications. Discussion
Table 1 outlines the cases of cervical spondylolysis with spondylolisthesis reported in the English medical literature. Four patients
J. Neurosurg. / Volume 43 / December, 1975
Cervical spondylolysis with spondylolisthesis
FI~. 1. Radiographs of the cervical spine. Left: Anteroposterior view showing no evidence of spina bifida. Right." Lateral view. Defects of the pars interarticularis are noted at C3-5 (small arrows). The bone margins are smooth and well corticated. The height of the involved vertebral bodies is decreased. Spondylolisthesis is noted at C-5 on C-6 (large arrow).
FIG 2. Lateral tomograms of the cervical spine. Left." Smooth, well-corticated bone margins of the pars interarticularis defects can be seen at C3-5 on the right side (arrows). Right." Lateral tomogram of cervical spine shows smooth, well-corticated bone margins of the pars interarticularis defects at C3-5 on the left side (arrows).
J. Neurosurg. / Volume 43 / December, 1975
75]
e~
e~ e~
t~
1,0
",4
Clinical Findings Spondylolysis
11 F
15 M (twins)
34 M
Dawley, 1971
Cautilli, et al., 1972
Azouz, et al., 1974
38 M
45 F
41 M
Op Den Orth, et al., 1969
none
C-4
C-6
Spina Bifida
neck disno neurological bilateral C-6 C-6 comfort abnormalities when head held erect one noted spasm of right elongation of C-6 neck pain sternocleiC-6 pars interfollowing a domastoid and articularis, football trapezius (the radiogame muscles, pain on graphic findings rotationofneck, apply to both no neurological twins, neither abnormalities had neurological abnormalities) neck pain pain on rotation bilateral C-6 C-6 of neck, no neurological abnormalities neck pain pain on rotation unilateral C-6 C-6 of neck, no neurological abnormalities occipital no neurological unilateral C-4 C-4 headache abnormalities
25 M
Durbin, 1956
neck pain
Symptoms
palpable step-off bilateral C-6 between C-5 and C-6 spinous process; pain on rotation of neck neck pain and right torticollis, bilateral C-4 stiffness pain on rotation of neck neck and left no neurological unilateral C-6 shoulder abnormalities pain
Age, Sex
Perlman & 19 M Hawes, 1951
Author, Year
none
not mentioned
C-6 on C-7
C-6 on C-7
C-6 on C-7
not mentioned
C-4 on C-5
C-6 on C-7
Spondylolisthesis
not mentioned
not mentioned
none
not mentioned
C-6 on C-7
not mentioned
C-4 on C-5
not mentioned
Instability
Review of reported cases of cervical spondylolysis with spondylolisthesis
TABLE 1
free of symptoms after 6 yrs
Follow-up
not mentioned
not mentioned
not mentioned
skull traction for 2 wks
not mentioned
not mentioned
not mentioned
15 mos after diagnosis, radiographs unchanged, neurological examination negative
employed as brick layer 3 mos postoperatively cervical traction, not mentioned muscle relaxants, physical therapy anterior not mentioned interbody fusion
posterior spinal fusion
not mentioned
Treatment
o
C3
e~
3. o
9
Cervical spondylolysis with spondylolisthesis had bilateral spondylolysis, three had varying unilateral involvement, and two had only elongation of the pars interarticularis. The prevalent site of involvement appears to be C6 with only two cases involving another level, C-4. Most cases occurred in males (seven of nine patients). Although t r a u m a was a precipitating factor in several cases, the radiographs revealed well-corticated margins at the pars interarticularis defect. All cases with spondylolysis except one 5 were associated with spina bifida. N o neurological a b n o r m a l i t y was present in any of the reported cases. These findings suggest a congenital etiology, or at least the presence of the lesion from an early age. Patients with unilateral spondylolysis did not have spondylolisthesis. Patients with bilateral involvement and instability underwent spinal fusion and attained a satisfactory level of stability. Our case is unique in having bilateral defects in the pars interarticularis at levels C3-5, with neurological deficits manifested by motor and reflex changes. References
1. Azouz EM, Chan JD, Wee R: Spondylolysis of the cervical vertebrae. Report of three cases, with a review of the English and French literature. Radiology 111:315-318, 1974
J. Neurosurg. / Volume 43 / December, 1975
2. Cautilli RA, Joyce MF, Lin PM: Congenital elongation of the pedicles of the sixth cervical vertebra in identical twins. J Bone Joint Surg (Am) 54:653-656, 1972 3. Dawley JA: Spondylolisthesis of the cervical spine. Case report. J Neurosurg 34:99-101, 1971 4. Durbin FCL: Spondylolisthesis of the cervical spine. J Bone Joint Surg (Br) 38:734-735, 1956 5. Op Den Orth JO, Penning L, Kluft O: Unilateral spondylolysis of the sixth cervical vertebra. J Bone Joint Surg (Am) 51:1379-1382, 1969 6. Perlman R, Hawes L: Cervical spondylolisthesis. J Bone Joint Surg (Am) 33:1012-1013, 1951 7. Stewart TD: The age incidence of neural-arch defects in Alaskan natives, considered from the standpoint of etiology. J Bone Joint Surg (Am) 35:937-950, 1953
This work was supported in part by NINCDS Training Grant 5593. Address reprint requests to: Charles B. Wilson, M.D., Department of Neurological Surgery, University of California School of Medicine, San Francisco, California 94143.
753
GEORGE R. PR1OLEAU, M.D., AND CHARLES B. WILSON, M.D.
Department of Neurological Surgery, University of California School of Medicine, San Francisco, California v, The authors describe a case in which cervical spondylolysis was found at multiple levels with spondylolisthesisand associated neurological deficits. Radiographic findings and the absence of history of trauma suggest a congenital etiology. KEY WORDS spina bifida
~
cervical spondylolysis
s
PONDYLOLYSIS with spondylolisthesis of the lumbar spine is found in approximately 5% of the general population. 7 It is observed most frequently at L-5, occasionally at L-4, but rarely above this level. Spondylolisthesis of the cervical spine was first reported by Perlman and Hawes in 19517 Six additional cases have since been reported; however, none of these patients had neurological deficits and all had defects at only one level. 1-4 We are reporting a case of multilevel defects of the pars interarticularis with spondylolisthesis and associated neurological deficits; we believe it is the first such case reported. Case Report
A 46-year-old woman was admitted with progressive neck pain radiating down her left arm, and pain on rotation of her neck. There was no history of trauma, and the medical history and general examination were nor750
9 spondylolisthesis
9
mal. Neurological examination revealed decreased strength of her left biceps and brachioradialis muscles with depression of associated reflexes. Pin perception was decreased over the left C-6 distribution. No pathological reflexes were demonstrated. Plain cervical spine films showed smooth, well-corticated bilateral defects at the bone margins of the pars interarticularis at the levels of C3-5 with spondylolisthesis of C-5 on C-6. Paravertebral soft tissues were normal, and spina bifida was not present (Figs. 1 and 2). Instability was demonstrated on flexion and extension films. No significant abnormality was revealed by cervical myelography or electromyography. The patient underwent anterior cervical disc removal with interbody fusion at C5-6 without complications. Discussion
Table 1 outlines the cases of cervical spondylolysis with spondylolisthesis reported in the English medical literature. Four patients
J. Neurosurg. / Volume 43 / December, 1975
Cervical spondylolysis with spondylolisthesis
FI~. 1. Radiographs of the cervical spine. Left: Anteroposterior view showing no evidence of spina bifida. Right." Lateral view. Defects of the pars interarticularis are noted at C3-5 (small arrows). The bone margins are smooth and well corticated. The height of the involved vertebral bodies is decreased. Spondylolisthesis is noted at C-5 on C-6 (large arrow).
FIG 2. Lateral tomograms of the cervical spine. Left." Smooth, well-corticated bone margins of the pars interarticularis defects can be seen at C3-5 on the right side (arrows). Right." Lateral tomogram of cervical spine shows smooth, well-corticated bone margins of the pars interarticularis defects at C3-5 on the left side (arrows).
J. Neurosurg. / Volume 43 / December, 1975
75]
e~
e~ e~
t~
1,0
",4
Clinical Findings Spondylolysis
11 F
15 M (twins)
34 M
Dawley, 1971
Cautilli, et al., 1972
Azouz, et al., 1974
38 M
45 F
41 M
Op Den Orth, et al., 1969
none
C-4
C-6
Spina Bifida
neck disno neurological bilateral C-6 C-6 comfort abnormalities when head held erect one noted spasm of right elongation of C-6 neck pain sternocleiC-6 pars interfollowing a domastoid and articularis, football trapezius (the radiogame muscles, pain on graphic findings rotationofneck, apply to both no neurological twins, neither abnormalities had neurological abnormalities) neck pain pain on rotation bilateral C-6 C-6 of neck, no neurological abnormalities neck pain pain on rotation unilateral C-6 C-6 of neck, no neurological abnormalities occipital no neurological unilateral C-4 C-4 headache abnormalities
25 M
Durbin, 1956
neck pain
Symptoms
palpable step-off bilateral C-6 between C-5 and C-6 spinous process; pain on rotation of neck neck pain and right torticollis, bilateral C-4 stiffness pain on rotation of neck neck and left no neurological unilateral C-6 shoulder abnormalities pain
Age, Sex
Perlman & 19 M Hawes, 1951
Author, Year
none
not mentioned
C-6 on C-7
C-6 on C-7
C-6 on C-7
not mentioned
C-4 on C-5
C-6 on C-7
Spondylolisthesis
not mentioned
not mentioned
none
not mentioned
C-6 on C-7
not mentioned
C-4 on C-5
not mentioned
Instability
Review of reported cases of cervical spondylolysis with spondylolisthesis
TABLE 1
free of symptoms after 6 yrs
Follow-up
not mentioned
not mentioned
not mentioned
skull traction for 2 wks
not mentioned
not mentioned
not mentioned
15 mos after diagnosis, radiographs unchanged, neurological examination negative
employed as brick layer 3 mos postoperatively cervical traction, not mentioned muscle relaxants, physical therapy anterior not mentioned interbody fusion
posterior spinal fusion
not mentioned
Treatment
o
C3
e~
3. o
9
Cervical spondylolysis with spondylolisthesis had bilateral spondylolysis, three had varying unilateral involvement, and two had only elongation of the pars interarticularis. The prevalent site of involvement appears to be C6 with only two cases involving another level, C-4. Most cases occurred in males (seven of nine patients). Although t r a u m a was a precipitating factor in several cases, the radiographs revealed well-corticated margins at the pars interarticularis defect. All cases with spondylolysis except one 5 were associated with spina bifida. N o neurological a b n o r m a l i t y was present in any of the reported cases. These findings suggest a congenital etiology, or at least the presence of the lesion from an early age. Patients with unilateral spondylolysis did not have spondylolisthesis. Patients with bilateral involvement and instability underwent spinal fusion and attained a satisfactory level of stability. Our case is unique in having bilateral defects in the pars interarticularis at levels C3-5, with neurological deficits manifested by motor and reflex changes. References
1. Azouz EM, Chan JD, Wee R: Spondylolysis of the cervical vertebrae. Report of three cases, with a review of the English and French literature. Radiology 111:315-318, 1974
J. Neurosurg. / Volume 43 / December, 1975
2. Cautilli RA, Joyce MF, Lin PM: Congenital elongation of the pedicles of the sixth cervical vertebra in identical twins. J Bone Joint Surg (Am) 54:653-656, 1972 3. Dawley JA: Spondylolisthesis of the cervical spine. Case report. J Neurosurg 34:99-101, 1971 4. Durbin FCL: Spondylolisthesis of the cervical spine. J Bone Joint Surg (Br) 38:734-735, 1956 5. Op Den Orth JO, Penning L, Kluft O: Unilateral spondylolysis of the sixth cervical vertebra. J Bone Joint Surg (Am) 51:1379-1382, 1969 6. Perlman R, Hawes L: Cervical spondylolisthesis. J Bone Joint Surg (Am) 33:1012-1013, 1951 7. Stewart TD: The age incidence of neural-arch defects in Alaskan natives, considered from the standpoint of etiology. J Bone Joint Surg (Am) 35:937-950, 1953
This work was supported in part by NINCDS Training Grant 5593. Address reprint requests to: Charles B. Wilson, M.D., Department of Neurological Surgery, University of California School of Medicine, San Francisco, California 94143.
753
