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

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cervical spondylolysis

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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

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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

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C3

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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.

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Cervical spondylolysis with spondylolisthesis. Case report.

The authors describe as case in which cervical spondylolysis was found at multiple levels with spondylolisthesis and associated neurological deficits...
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