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anomaly may be accompanied by malformation of vertebral joints and usually induces pain only when aggravated by injury The neurologic aspects of defective fusion of the spine (dysraphism) are discussed in Chap 38 Many other congenital anomalies affect the lower lumbar vertebrae: asymmetrical facet joints, abnormalities of the transverse processes, sacralization of the fth lumbar vertebra (in which L5 appears to be xed to the sacrum), or lumbarization of the rst sacral vertebra (in which S1 looks like a sixth lumbar vertebra) are seen occasionally in patients with low back symptoms, but apparently with no greater frequency than in asymptomatic individuals The role of these anomalies in the genesis of low back derangement is unclear, but in the authors opinion they are rarely the cause of speci c symptoms Spondylolysis consists of a bony defect in the pars interarticularis (the segment at the junction of pedicle and lamina) of the lower lumbar vertebrae The defect is remarkably common; it is mainly a disease of children (peak incidence between 5 and 7 years of age) that affects approximately 5 percent of the North American population and is probably genetic The defect assumes great importance in that it predisposes to subtle fracture at this location, sometimes precipitated by slight trauma but often in the absence of injury Radiographically, the pars interarticularis defect is best visualized on oblique projections In some persons it is unilateral and may cause unilateral aching back pain that is accentuated by hyperextension and twisting It is not uncommon in athletes In the usual bilateral form, small fractures at the pars interarticularis allow the vertebral body, pedicles, and superior articular facets to move anteriorly, leaving the posterior elements behind This leads to an anterior displacement of one vertebral body in relation to the adjacent ones known as spondylolisthesis (the main cause of spondylolisthesis in adults is degenerative arthritic disease of the spine) It may cause little dif culty at rst but eventually becomes symptomatic The patient complains of limitation of motion and pain in the low back, radiating into the thighs Examination discloses tenderness near the segment that has slipped (most often L5, occasionally L4), a palpable step of the spinous process forward from the segment below, hamstring spasm, and, in severe cases (spondyloptosis), shortening of the trunk and protrusion of the lower abdomen (both of which result from the abnormal forward shift of L5 on S1) as well as compression of spinal roots by the displaced vertebrae resulting in paresthesias and sensory loss, muscle weakness, and re ex impairment These neurologic symptoms and signs tend not to be severe Sometimes, the fourth lumbar vertebra may slip forward on the fth, narrowing the spinal canal, without the presence of a defect in the pars interarticularis This is termed intact arch spondylolisthesis and occurs most often in middle-aged or elderly women This form of spondylolisthesis is probably due to degenerative disease of the inferior and superior facets It causes severe low back pain, made worse by standing or walking and relieved by bed rest Symptoms of root compression are common, as indicated in the review by Alexander and colleagues Patients with progressive vertebral displacement and neurologic de cits require surgery, usually posterolateral fusion and excision of the posterior elements Reduction of displaced vertebral bodies before fusion and direct repair of pars defects are possible in special cases Traumatic Disorders of the Low Back Traumatic disorders constitute the most frequent cause of low back pain In severe acute. barcode add in for word and excel pour windows Barcodes in Excel Tabellen - Barcode Software - ActiveBarcode
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