IntroductionSpondylolysis is nowadays considered to be an acquired lesion originating in early childhood, and is not found in infants [1,10,12,14,15]. It affects the fourth and fifth lumbar vertebrae in more than 95% of cases [12]. Wiltse et al. classified spondylolistheses into four types [16], of which the isthmic variety is the most common, especially in children and adolescents, and is thought to be acquired in origin [15]. Spondyloptosis indicates any slip greater than 100% [5], and this has only ever been observed in the dysplastic type [6].The association between spondylolysis and spondylolistheses is well known, but there has been no previous report, to the best of our knowledge, of as many multiple defects in one patient as the case we present here.
Case reportA 15-year-old female student presented with an 8-year history of chronic lower back pain, with radiation into the left lower limb during the last 2 years. The pain was aggravated by activities and there was no history of precipitating events. The parents of the girl were close relatives.The girl walked with a waddling gait. There was an obvious lumbar hyperlordosis with lumbosacral kyphosis. She had limitation of flexion of lumbar spine. Straight leg raising was limited to 70°bilaterally, which was due to hamstring muscle tightness. She had no neurological deficit. The mother was found to have isthmic spondylolisthesis of L5/S1.Radiographs showed bilateral spondylolyses at L2, 3 and 4, with grade I isthmic spondylolisthesis at the L3/4 level. There was also a spondyloptosis at L4/5, with domed L5 and elongated pars interarticularis. L5 was sacralized with vertical sacrum below it (Fig. 1). (Sacralization of L5 was confirmed by radiographs taken of the chest and thoracic vertebrae). The myelogram revealed complete obstruction of the thecal sac with compression and narrowing of the thecal sac at the L4/5 level (Fig. 2).The patient was managed surgically by a three-stage operation. The first stage was through a posterior approach, where posterior decompression and laminectomy at the L4/5 level was done. This included excision of the elongated pars down to the pedicles of L4. The second stage was a retroperitoneal corpectomy of L4, and was performed 1 week after the first. Through a flank incision, L4 was approached after mobilization of the vessels medially and ligation of the left iliolumbar vessels. The discs above and below were completely excised, the lower one was in front of and above the domed L5. L4 was then excised using an osteotome and rongeurs.Abstract An unusual case of a combination of multiple bilateral spondylolyses (L2, 3 and 4), spondylolisthesis at L3/4, spondyloptosis at L4/5 and sacralization of L5 in a teenage female is described. The patient had severely increasing lower back pain radiating to the left lower limb. Radiography identified the abnormalities and myelography revealed complete obstruction and compression of the thecal sac at the L4/5 level. The case was treated surgically by posterior decompression, corpectomy and fu...
