A 66 year-old woman was admitted to our hospital for progressive weakness of both lower extremities since a month ago. Imaging study, based on plain X-ray, computed tomography and magnetic resonance image revealed spinal stenosis owing to anterior slipping of T10/11 segment. Degenerative spondylolisthesis is common in the lumbar spine and rarely occurs in the cervical spine2,5). But there was no report of degenerative spondylolisthesis in thoracic spine. The authors experienced a case of degenerative spondylolisthesis in the thoracic spine. And we achieved a satisfactory result with posterior decompressive laminectomy alone.ope

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Journal of Korean Neurosurgical Society

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IntroductionDegenerative spondylolisthesis in the lumbar spine is acommon disease in old age. But, to our knowledge,spondylolisthesis in the thoracic spine has not been reportedso far. In our spine center, there have been 84cases ofoperation for thoracic spinal stenosis since 1983, which wereossification of posterior longitudinal ligament, ossification ofligament flavum, thoracic disc herniation, and so on. Weencountered only one case of thoracic stenosis due to degen-erative spondylolisthesis. This is a very unique and interestingcase, because the thoracic spine is more fixed than cervicaland lumbar spine owing to several anatomical properties.Case ReportA66 year-old woman was admitted to our hospital due toprogressive weakness of both lower extremities since amonth ago. She had no events of spine trauma and previousspinal surgery. She had not experienced low back pain andleg pain. She had a few medical problems, such as essentialhypertension, ischemic heart disease and diabetes mellitus.Neurologic examination revealed that she had spastic para-paresis with Grade 4 motor weakness (MRC scale) withouturinary incontinence and sensory impairment. Plain X-rays ofthe thoracic spine showed Grade 1 (Meyerding classification)spondylolisthesis and reduced disc height of T10/11 segment(Fig. 1). Magnetic resonance(MR) image showed spinal cordcompression caused by spondylolisthesis and ligamentflavum thickening at T10/11 segment in sagittal view (Fig. 2).Total laminectomy and medial facetectomy of T10 and T11spine were performed using high-speed drill undermicroscopic view. We found a significant stenosis caused byspondylolisthesis, ligament flavum thickening and bilat-eral facet joint hypertrophy, but there was no defect of parsinterarticularis on operative findings. The previously com-pressed dural sacwas reexpandedafter decompress-ivesurgery.Thepo-sterior spinal fix-ation was not ne-eded after lami-nectomy and me-dial facetectomy,because it was notdeveloped posto-perative instabi-lity. She has beenfollowed up for 25months and sheimproved spastic-ity and motor wea-kness from Grade4 to Grade 5.Degenerative Spondylolisthesis in Thoracic Spine Eui  -  Hyun   Kim,   M.D.,1 Sung  -  Uk   Kuh,   M.D.,1Yong  -  Eun   Cho,   M.D.,1 Young  -  Soo    Kim,   M.D.2Department of Neurosurgery,1 Yonsei University College of Medicine, Seoul, KoreaDepartment of Neurosurgery,2 Kwanghye Spine Center, Seoul, KoreaA 66 year-old woman was admitted to our hospital for progressive weakness of both lower extremities since amonth ago. Imaging study, based on plain X-ray, computed tomography and magnetic resonance image revealedspinal stenosis owing to anterior slipping of T10/11 segment. Degenerative spondylolisthesis is common in thelumbar spine and rarely occurs in the cervical spine2,5). But there was no report of degenerative spondylolisthesis inthoracic spine. The authors experienced a case of degenerative spondylolisthesis in the thoracic spine. And weachieved a satisfactory result with posterior decompressive laminectomy alone.KEY WORDS :Degenerative spondylolisthesis·Thoracic spine·Spinal stenosis.Case Report䤎Received：July 26, 2004  䤎Accepted：October 29, 2004䤎Address for reprints：Sung-Uk Kuh, M.D., Department ofNeurosurgery, Yonsei University College of Medicine, 146-92Dogok-dong, Gangnam-gu, Seoul 135-270, KoreaTel：02)3497-3397, Fax：02)3461-9229E-mail： kuhsu@yumc.yonsei.ac.krVOLUME 37 April, 2005 313Fig.1. Plane lateral radiography of thoracic spineshows Grade 1 spondylolisthesis and reduceddisc height of T10/11 segment.J   Korean   Neurosurg   Soc   37 :  313-315, 2005K I S E PDiscussionSpondylolisthesis is anterior slipping of a uppervertebral body on the lower vertebral body. Spon-dylolisthesis may be caused by facet dysplasia, elongationor fracture of the pars interarticularis. Degeneration andsecondary instability of the facet joints, trauma, pathologiesinvolving bone including tumor, osteogenesis imperfecta, orprimary bone disorders9) can cause spondylolisthesis. It isknown that degenerative spondylolisthesis usually occursin the lumbar spine. But in the thoracic spine, spondylolist-hesis can not occur easily because of its reduced mobility, whichis due to several anatomical properties of the thoracic spine. First, the thoracic spine have their ribs, which serve torestrict the motion of the thoracic spine and provide a majordegree of stability. Andriacchi et al. studied the effect of therib cage on the thoracic spine and found that the rib cageincreases stiffness 2.64 times in extension and 2.14 timesin flexion1). Oda et al. investigated the biomechanical role ofthe costovertebral joint and rib cage through sequentialresection of the thoracic spinal column. They showedbilateral destruction of the costovertebral joints and rib cageresulted in instability of the thoracic spinal motion seg-ment, and concluded that the costovertebral joint and ribcage confer stability on the thoracic spine6,8). In addition tothese skeletal properties, the articular capsule and ligamentssuch as the radiate, costotransverse and intraarticularligaments connect the ribs to the posterolateral aspect of theadjacent two vertebrae and the intervertebral disc lyingbetween them7). Secondly, the facet joint orientation have an importantrole in the devel-opment of deg-enerative spond-ylolisthesis. Thefacet joint anglesvary throughoutthe whole spine.At the thoracicspine, the facetangles are orie-nted more in thecoronal plane, wh-ereas the facet an-gles are almost co-mpletely orientedin the sagittal pl-ane at the lumbarspine. In this case,the facet joint alsoshows coronal ori-entation(Fig. 3).Spondylolisthesiscan not occur easily,because the super-ior articular processof lower vertebraeis located in front ofthe inferior articu-lar process of uppervertebrae. The inc-reased sagittal pla-ne angulation andconsequent decre-ased coronal planeangulation dimi-nished the anat-omic resistance toshearing forcesand created a bio-mechanical env-ironment in which anterolisthesis could occur3,4). Both of fracture dislocation and degenerative spon-dylolisthesis could be possible mechanisms for the anteriorslipping of vertebral body. But fracture dislocation involvesall three columns, so the spinal column would be veryunstable and kyphosis would progress. In this case, she hadno major trauma history and her symptom had very insidiousonset. Moreover, there was no kyphosis on imaging study, so,the pathology of this patient is likely degenerative spondy-lolisthesis.Degenerative spondylolisthesis is not easy to develop in thispatient, because she had intact rib cage and normal coronallyplaned facet joint. But she was a heavy worker and this couldfacilitate degenerative change of the spinal column includingfacet loosening.ConclusionThe thoracic spine is less mobile than lumbar and cervicalspine due to their ribs and coronal-orientated facet joints.By these anatomical properties, the thoracic spine is protectedagainst shearing forces at the level of the intervertebral disc.But in spite of these conditions, spondylolisthesis can occur inthe thoracic spine, and we achieved a satisfactory result withonly posterior decompressive surgery.314 J  Korean Neurosurg Soc  37Spondylolisthesis   in   Thoracic   SpineFig. 3. The facet joint plane shows coronalorientation in T10/11. Fig. 2. T2-weighted sagittal magneticresonance images shows spinal cordcompression owing to spondylolisthesis atT10/11 level and ligament flavum thickeningat T11/12 level.VOLUME 37 April, 2005 315EH Kim, et al.References 1. Andriacchi T, Schultz A, Belytschko T, Galante J : A model forstudies of mechanical interactions between the human spine and ribcage. J Biomech 7 : 497-507, 19742. Deburge A, Mazda K, Guigui P : Unstable Degenerative spondyl-olisthesis of the cervical spine J Bone Joint Surg 77B : 122-125, 19953. Fitzgerald J, Newman PH : Degenerative spondylolisthesis. J BoneJoint Surg 58B : 184-192, 19764. Grobler LJ, Robertson PA, Novotny JE, Pope MH : Etiology ofspondylolisthesis. As assesment of the role played by lumbar facetmorphology. Spine 18 : 80-91, 19935. Kong DS, Park K, Cho BM, Kim JH : Congenital Spondylolisthesisof the Sixth Cervical Vertebra - Case Report - J Korean NeurosurgSoc 28 : 1639-1643, 19996. Oda I, Abumi K, Lu D, Shono Y, Kaneda K : Biomechanical role ofthe posterior elements, costovertebral joints, and rib cage in thestability of the thoracic spine. Spine 21 : 1423-1429, 1996 7. Panjabi MM, Hausfeld JN, White AA : A biomechanical study of theligamentous stability of the thoracic spine in man. Acta OrthopScand 52 : 315-326, 19818. Takeuchi T, Abumi K, Shono Y, Oda I, Kaneda K : Biomechanicalrole of the intervertebral disc and costovertebral joints in the stabilityof the thoracic spine. Spine 24 : 1414-1420, 19999. Wiltse LL, Newman PH, Macnab I : Classification of spondylolysisand spondylolisthesis. Clin Orthop 117 : 23-29, 1976

Degenerative Spondylolisthesis in Thoracic Spine

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Degenerative Spondylolisthesis in Thoracic Spine

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