What is the difference between l5 and l5 sd

Rarely, tumors and infections may affect the L4-L5 vertebrae and spinal segment. Referred pain from L4-L5 usually stays within the lower back and is typically felt as a dull ache. The back may also feel stiff. Common symptoms and signs include:. It is also possible for a stabbing pain or ache to be isolated to any of these dermatomal areas. While lumbar radiculopathy typically affects one leg at a time, sometimes, both legs may be affected together. See Lumbar Radiculopathy.

An injury to the cauda equina may cause severe pain, weakness, numbness, tingling, or paralysis in both legs. See Cauda Equina Syndrome. Nonsurgical treatments are often tried first for symptoms that stem from L4-L5. In rare cases, surgery may be considered. Lumbar Spine Anatomy and Pain. You are here Conditions Spine Anatomy.

Peer Reviewed. Waldman SD. Functional Anatomy of the Lumbar Spine. In: Pain Review. Elsevier; Cramer GD. The Lumbar Region. Kayalioglu G. The Spinal Nerves. In: The Spinal Cord. After 12 weeks, the analysis was repeated. The inter-observer reliability and intra-observer reproducibility of SDSG system were substantial with K values of 0. Lumbar degenerative spondylolisthesis DS is defined as anterior displacement of one vertebra over the subjacent vertebra caused by degenerative changes, without an associated disruption of defect in the vertebral ring, which is mainly manifested as lumbosacral pain, sciatic nerve involvement, and intermittent claudication.

Increasing patients are suffering from different degrees of low back pain and radicular symptoms [ 1 ]. However, the pathogenesis, symptoms, and imaging manifestations often differentiate in individuals, so treatment strategies remain controversial [ 2 , 3 ].

In the past decades, relevant classifications of the disease have emerged. In addition, classification such as Meyerding system [ 6 ] did not consider morphological parameters related to clinical outcomes, for example, disk height or spinopelvic balance. Thus, an appropriate classification of lumbar DS is essential.

Use of an appropriate classification is crucial to guide the surgical decision. With the further study of spine biomechanics and sagittal balance, the understanding of lumbar DS pathogenic factors and natural history has been increasingly comprehensive.

Nowadays, the correlation between pelvic incidence PI and morbidity of lumbar DS, as well as between spine sagittal balance and progression of lumbar DS has been clarified [ 7 ]. High-grade spondylolisthesis are defined as type 4 balanced sacro-pelvis , type 5 retroverted sacro-pelvis with balanced spine , and type 6 retroverted sacro-pelvis with unbalanced spine [ 8 ]. They suggested that for patients with balanced pelvis and spine, fusion can be performed either in situ or in reduction and fixation, while for those with unbalanced pelvis or spine, reduction should be emphasized in order to restore sagittal balance and provide a better biomechanical environment for fusion Fig.

High-grade spondylolisthesis: type 4 balanced sacro-pelvis , type 5 retroverted sacro-pelvis with balanced spine , and type 6 retroverted sacro-pelvis with unbalanced spine. In , Kepler et al. This classification takes both radiographic parameters and clinical manifestations into consideration, so as to provide a more comprehensive evaluation for surgical treatment Fig. However, any classification being widely used in clinical evaluation and treatment strategy decision-making should allow communication and easier consultation among specialists and needs multiple validations.

The study was conducted in accordance with the principles of the Declaration of Helsinki, and obtained institutional review board approval from our ethics committee.

Patients included in the study should have performed posteroanterior and lateral standing radiographs of the entire spine and pelvis showing both femoral heads including flexion and extension lumbar position.

Exclusion criteria were patients with a history or clinical signs of hip, pelvic, or lower limb disorders, and incomplete clinical data or imaging studies. All subjects were required to have complete and available clinical data including demographic characteristics, chief complaint, neurological function, complications, and treatment history.

Two physicians who collected the cases and treated these patients did not participate in the later statistics and analysis. Each evaluator was provided with essential original literature and pertinent information of cases for assessment [ 8 , 9 ]. Face-to-face meetings and evaluation sessions were performed before the agreement study and through which any controversies about the two classifications were discussed until all the observers came to a consensus. Standard imaging reports were available to observers as reference.

Inter-observer reliability was assessed by comparing the initial responses of the 5 observers. The intra-observer reproducibility was determined through a comparison between the two responses which were separated by a week interval, and all cases in the first and second acquisition sessions were displayed randomly so as to minimize the recall bias.

All data analyses were performed using Stata Version Higher values signified better agreement. This study totally involved consecutive patients, including 45 males and 72 females, with an average age of The overall inter-observer agreement of SDSG classification was substantial at In addition, at least 3 observers showed agreement on Besides, the inter-observer agreement of slip grade low-grade vs. Nevertheless, at least 3 observers showed agreement on 89 In addition, the K values of 3 items of CARDS system: disk space height, sagittal vertebral translation, and kyphotic alignment were 0.

The intra-observer agreement of slip grade low-grade vs. The K values of 3 items were 0. At present, the simplest classification of lumbar DS is Meyerding system [ 6 ], which is to grade according to vertebral translation. However, it cannot accurately describe the state and judge the severity of spondylolisthesis to further guide treatment and predict prognosis. Other traditional classification of lumbar DS mainly includes Wiltse and Marchetti classification [ 13 , 14 , 15 ].

These classifications have significant defects that they lack quantitative indexes and cannot determine the degree of spondylolisthesis, which makes them difficult to be evaluated and inferior in reproducibility. The abovementioned classifications all emphasizes on characteristics of slipped vertebrae or bony structures, without considering disk degeneration, spinal-pelvic sagittal balance and clinical symptoms which are regarded as key factors to judge whether lumbar DS will progress [ 16 , 17 , 18 ].

SDSG classification gives spine surgeons a clear definition of spinal-pelvic sagittal balance, and helps them to provide targeted treatment for patients [ 19 , 20 ]. There is always a dispute about whether severe spondylolisthesis needs reduction. According to current study of biomechanics, combined with SDSG classification, specialists have reached a consensus that for patients with imbalanced spine or pelvis, reduction should be emphasized to correct the imbalance as well as the external deformities, and provide a more favorable biomechanical environment for bone graft.

For patients with balanced pelvis and spine, either fusion in situ or fusion with reduction and fixation can be used. In these studies, the case scope of assessment of SDSG classification covered dysplastic, degenerative and isthmic spondylolisthesis.

Moreover, it is worth mentioning that the research has even better reliability of intra-observer reproducibility than those previous, for there is an only 1-day or 2-week interval between the 2 acquisition sessions in those studies, while too short interval will make observers in the second assessment tend to evaluate according to their recollections of the first assessment, and thus may reduce the reliability of results.

The week interval in our study may be a more appropriate choice. In addition, we analyzed the agreement of slip grade, and the results show that both inter- and intra-observer K values are high 0.

Therefore, we believe that low resolution and clarity of radiographs, and serious osteoporosis of elderly patients make it difficult to judge the bone structure and anatomic landmark, which leads to deviations of sagittal parameter measurements. As a more recent established one, CARDS system can provide a relatively ideal treatment plan for patients in comparison with other classifications.

For those without clinical symptoms type A0 , conservative treatment is recommended [ 18 ]. On the aspect of surgery, simple decompression can be performed on type A1 and A2 patients [ 23 ], while internal fixation and fusion is practical in type B or C patients. For cases of type D, internal fixation is needed to correct kyphosis deformity and interbody fusion cage is needed to reconstruct anterior column support, so that physiological lumbar lordosis and fusion rate can be improved as much as possible [ 24 ].

Whether the leg pain exists or not is regarded as the clinical index for subtypes, which is also helpful to guide surgical plan. A study published in recent years has confirmed that patients with leg pain as the main symptom before surgery have better postoperative effect than those with back pain as the main symptom [ 25 ]. Compare with the previous study by Kepler et al. Thus may lead to difference between the results. Firstly, the classification requires that any translation longer than 5 mm in neutral, flexion, or extension lateral radiographs should be classified as type C, while in the actual process, observers may have certain marking or measuring deviations.

Furthermore, with the multiple measurements, sometimes observers judging by subjective impression is also a factor, which leads to the relatively low agreement. Both classifications had substantial inter- and intra-observer agreement, while SDSG classification had better inter-observer reliability in comparison with CARDS classification.

With regard to sagittal balance parameters, SDSG classification can provide better reference value for surgical strategy. Nevertheless, it does not consider the changes on flexion and extension lateral radiograph, and the evaluation of lumbar instability is insufficient, which reduces the guiding value of surgical treatment, and that is the issue of SDSG classification.

Since the clinical symptoms are often the reasons for DS patients to see a doctor, CARDS classification takes leg pain into account, which makes evaluation of scientific and clinical study more convenient, and that is the advantage of CARDS classification. However, its morphological types are less and not precise enough, and that will lead to the relatively unclear boundaries between the various types. The current study has several limitations. Firstly, is the retrospective design.

It is easy to produce selection bias. Secondly, is the relatively small sample size. Expanding the sample population to include non-operative patients of a wider population, allowing for more meaningful statistical testing on the reliability and reproducibility of these parameters.

Thirdly, is the relatively low resolution and clarity of radiographs. We believe that it may be more accurate in the practical application to observe high resolution radiograph combining with computed tomography CT sagittal reconstruction image. Therefore, in future clinical work, high-quality, multicenter, large sample, and wide case scope studies should be conducted to provide spine surgeons with the best evidence-based information.

However, we still need more higher-quality, larger samples, and multicenter prospective studies in future work to evaluate whether these classification systems allow better decision-making or prognosis-prediction in individual patients. Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin N Am. Article Google Scholar. Lumbar multilevel degenerative spondylisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis.

J Spinal Disord Tech. Article PubMed Google Scholar. Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen osteoarthritis study. Spine Phila Pa Surgery in lumbar degenerative spondylolisthesis: indications, outcomes and complications.

A systematic review. Eur Spine J. Natural history of degenerative spondylolisthesis. Pathogenesis and natural course of the slippage. Meyerding HW. Surg Gynecol Obstet.