Vertebral arch isthmus spondylolysis

　　1, The vertebral column begins to appear four cartilage nuclei (two vertebral bodies, one on each side of the vertebral arch) in the seventh week of embryonic development. The four cartilage nuclei continue to grow and unite to form a cartilaginous vertebral column. After about the tenth week of embryonic development, three primary ossification nuclei also appear, contained within the primary cartilage nuclei, grow chronically, and remain separate at birth. Around 1 to 2 years after birth, the vertebral arch begins to fuse, and spinous processes appear. After 3 to 6 years, the vertebral bodies and vertebral arch ossification nuclei fuse.

　　2, A fully grown vertebral column can be divided into vertebral bodies, vertebral arches, vertebral plates, superior and inferior articular processes, transverse processes, and spinous processes. There is a narrow area between the superior and inferior articular processes, known as the vertebral arch root isthmus. If ossification in this area is incomplete or there is a potential cartilage defect, congenital isthmus spondylolysis may occur. The defect area is located between the superior and inferior articular processes, and this vertebral body has no bony connection with the posterior vertebral plate, and is only connected to the adjacent vertebral body by soft tissue. If this area is weakly developed, combined with some degree of trauma or fatigue, it can also lead to a fracture of the weak isthmus. The mechanism is similar to that of fatigue fracture.

　　Patients have significant lumbar lordosis, slight forward tilt of the trunk, and the costal margin is close to the iliac spine. The buttocks are posteriorly突出, the abdomen is下垂, the lumbosacral region is concave, and the spinous process of the fifth lumbar vertebra is significantly posteriorly突出. Walking is difficult, with a swinging gait. The lumbar muscles are spasmodic, and function is limited, especially when bending forward. There is marked tenderness at the spinous process of the fifth lumbar vertebra. Women with obvious anterior spondylolisthesis have a reduced distance from the anterior edge of the lumbar vertebra to the symphysis pubis, resembling a flat pelvis, which affects the child's entry into the pelvis during childbirth.

　　The clinical manifestations of this disease can be divided into the following situations:

　　1. True spondylolisthesis is anterior spondylolisthesis caused by spondylolysis of the pedicle, which is the most common type.

　　2. Pseudospondylolisthesis has no spondylolysis, but is caused by mild anterior displacement of the vertebral body due to vertebral or intervertebral disc degenerative changes, or other causes, and is more common.

　　3. Posterior spondylolisthesis is less common.

　　The common symptoms of the three types of spondylolisthesis mentioned above are chronic lumbar and leg pain. Simple spondylolysis does not usually show obvious clinical symptoms, but due to poor stability of the lumbosacral region, local soft tissues are prone to fatigue, and symptoms become obvious in adults after spondylolisthesis occurs. The main symptoms are lumbar and leg pain, with different pain locations and nature, which can be continuous or intermittent, or only felt when overexerted. The pain can be localized to the lumbosacral region, or radiate to the hip, coccygeal region, or lower limb, such as sciatica, spinal stenosis, etc. In cases where cauda equina palsy occurs, pain is relatively mild after lying down, but worsens when getting up from a lying position, and there is occasional movement sensation internally when the waist is moved.

　　1. The affected joints should be protected, joint load reduced, weight loss, adequate rest, and avoiding long-term weight-bearing and poor posture. Use canes, walkers, and other aids.

　　2. Pay attention to keeping the affected joints warm in daily life. You can use hot water bottles, hot towels, and other hot compresses. Try to avoid direct wind from air conditioners and fans blowing on the joints during hot summer days.

　　3. Appropriate exercise is very helpful in protecting and improving joint mobility and alleviating pain. Beneficial exercises are gentle movements with minimal joint impact, including swimming, walking, Tai Chi, jogging, cycling, supine straight leg raising or resistance training, and extension and flexion activities of joints without weight-bearing. Swimming should be a good exercise method. Harmful exercises are those that increase joint torque or excessive load on the joint surface, such as climbing or squatting activities.

　　1. Imaging examination

　　1. It is difficult to diagnose vertebral collapse and mild spondylolisthesis clinically, and X-ray examination is required. The commonly used projection positions are anteroposterior, lateral, and oblique.

　　2, Anteroposterior view: In the anteroposterior view, it is often not easy to show the vertebral arch disintegration. If there is a significant isthmus defect, when the plane of the fissure is parallel to the X-ray, a low-density slanting shadow can be seen under the annular shadow. If there is significant spondylolisthesis, the lower margin of the slipped vertebral body overlaps with the lower vertebral body, showing a crescent-shaped dense thickening, and the transverse process of the fifth lumbar vertebra overlaps with the anterior edge of the vertebral body.

　　3, Lateral view: On the lateral view, there is a slanting bone density reduction shadow between the posterior inferior part of the pedicle root and the superior and inferior articular processes. The posterior part is higher than the anterior part. If the defect is unilateral, it is not easy to see.

　　4, If there is spondylolisthesis, the vertebral body moves forward, but the degree is not equal. There are cases where the entire vertebral body moves forward completely, and there are cases where the forward movement is very slight. Most spondylolisthesis is about 1/3 to 1/4, and the intervertebral disc has degenerative changes, resulting in narrowing of the intervertebral space.

　　Two, measurement methods of position measurement of spondylolisthesis

　　1, Draw a vertical line from the anterior margin of the first sacral vertebra. This line should pass through the anterior inferior margin of the fifth lumbar vertebral body. If the fifth lumbar vertebra slips forward, this line will pass through the vertebral body (Ullman line).

　　2, If there is a suspected forward spondylolisthesis of the fifth lumbar vertebra, a straight line can be drawn from the posterior superior and inferior margins of the fifth lumbar vertebra to the posterior superior margin of the first sacral vertebra. The two lines can intersect or be parallel. Normally, the angle of intersection of the two lines is not greater than 2°, and it is below the inferior margin of the fourth lumbar vertebra. If the two lines are parallel, the distance is not greater than 3mm (Ullman line). In the case of spondylolisthesis, the intersection points are all above the inferior margin of the fourth lumbar vertebra. The degree of spondylolisthesis can be divided into three degrees according to the size of the angle of intersection or the distance between the parallel lines.

　　Three,Method of grading lumbar spondylolisthesis

　　1, The degree of spondylolisthesis is parallel to the angle of intersection and the distance between the parallel lines. Mild: 3°-10°, 4-10mm; Moderate: 11°-20°, 10-20mm; Severe: 21°, 21mm and above.

　　2, Divide the superior margin of the first sacral vertebra into four equal parts. Normally, the vertebral body of the fifth lumbar vertebra and the posterior margin of the first sacral vertebra form a continuous arc. In the case of spondylolisthesis, the fifth lumbar vertebral body moves forward. Moving forward 1/4 is 1°, 2/4 is 2°, 3/4 is 3°, and complete spondylolisthesis is 4°.

　　3, The lateral view can distinguish true and false spondylolisthesis in the lateral view. The former increases the anterior and posterior diameter of the spine; the latter remains unchanged, and degenerative changes such as narrowing of the intervertebral space, ossification of adjacent vertebral body edges, or marginal hyperplasia can be seen.

　　4, The oblique view at 45° oblique position is the best position to show the isthmus. Normally, the pedicle appendage is shaped like a hound, the dog's mouth represents the same-side transverse process, the dog's eyes represent the pedicle root, the dog's ears represent the superior articular process, the dog's neck represents the isthmus, the dog's body represents the vertebral plate, the front and back legs of the dog represent the upper and lower articular processes on the same side and the opposite side, and the dog's tail represents the opposite transverse process.

　　5, If the isthmus is not connected, a strip-like low-density shadow can be seen in the neck, resembling a hound wearing a neck collar, which is the bony non-union of the pedicle. If there is a spondylolisthesis, the superior articular process and transverse process move forward with the vertebral body, like the neck of a severed dog's head.

　　6, CT, MRI: Defect in the bony part of the pedicle, intervertebral disc protrusion, neural foramen, spinal canal deformation, pedicle fracture, asymmetrical spinous process leaning to one side, 'double tube' sign may appear on CT.

　　1. What foods are good for the body for those with spina bifida

　　It is best to supplement folic acid, collagen, spirulina milk calcium in daily life, and pay attention to a light and nutritious diet, eat more vegetables and fruits such as bananas, strawberries, and apples. Because they are rich in nutrients, eat more foods that enhance immunity such as propolis. This can enhance personal resistance to diseases. In daily life, it is also necessary to reasonably match the diet and pay attention to adequate nutrition.

　　2. What foods are bad for the body for those with spina bifida

　　Avoid smoking and drinking, spicy foods, greasy foods, and smoking and drinking. Avoid cold foods to prevent recurrent attacks of the disease.

　　1. For patients with simple isthmic spondylolysis without spondylolisthesis or obvious clinical symptoms, it is advisable to avoid overexertion, regularly perform exercises such as supine sit-ups to strengthen the abdominal muscles, reduce lumbar lordosis, prevent spondylolisthesis, or use a corset or brace for protection.

　　2. For patients with no spondylolisthesis but with lower back and leg pain, or with minimal spondylolisthesis without nerve compression symptoms, bone graft fixation surgery can be performed after 3 to 4 weeks of bed rest.

　　3. For adolescents with obvious anterior spondylolisthesis and nerve compression symptoms, or patients with spondylolisthesis not exceeding one year, the patient should be instructed to flex both hips and lie on their back for 2 to 4 weeks, wait for the vertebral body to self-reduce, and then perform bone graft fixation surgery after the nerve symptoms subside.

　　4. If there is no significant improvement in the symptoms of spondylolisthesis and nerve symptoms after bed rest, manual reduction can be attempted. Reduction should be under anesthesia, with the patient lying on their back, both hips and knees flexed and suspended, lifting the buttocks with the weight of the trunk to reduce the spondylolisthesis.

　　5. Or let the patient lie on their stomach, gently pull the lower limbs downwards, so that the pelvis is off the bed, then flex both hips, and the operator presses the back of the pelvis with their palm, gently exerting downward pressure to move the sacrum forward and correct the spondylolisthesis.

　　6. If the symptoms of spondylolisthesis and nerve symptoms recover or improve after bed rest or manual reduction, bone graft fixation surgery can be performed. Fix the pedicle of the affected vertebra, the joints between the superior and inferior articular processes, the vertebral plate, and the spinous process.

　　7. If the symptoms of spondylolisthesis and nerve compression still exist after bed rest or manual reduction, anterior spinal fusion should be performed. After the operation, bed rest for 3 to 4 months is required, and if the symptoms of nerve compression have not subsided after the bone graft has healed, vertebral plate resection decompression surgery can be performed.