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The space where the fracture was expands and the front and back part of the spine separate from each other and then the front part of the spine starts to come forward on S1. So here, L5-S1 you can see the anterior line comes down here then it jumps back to here. So the nerves are coming down out here and then draped over the back of S1. This is probably congenital because this looks like there may be some bone here thatís intact. This is a congenital spondylolisthesis, and these can be associated with pinching of the nerve roots here and can be very painful.

If we fuse these two together or these three together, the movement there and the pressure on the nerves will often end, the treatment we have to decide on, but this is one of the things you are looking for and the reason we get a lateral view is to see if the patient has this listhesis. Sometimes if the listhesis is bad enough, you will need surgery even if youíre not having a lot of symptoms because essentially you are guaranteed to get symptoms later on. Here is one thatís a little more subtle, but you can still see this comes down and then there is a step-off back to here. This is a grade I, this doesnít necessarily need surgery if itís a grade I, but it this slips 50% or more, then you have to fuse it, and can actually slide all the way out the front, and the operations to fix that are associated with a high degree of sexual dysfunction afterwards, so they are not very much fun and we try not to let them get that far. Again, 30% slip can we watched, 50% we fuse in situ and over 50% you have some reduction.

Here is an example of a spinal listhesis, and again, if you look for the Scottie dog, he not only has a collar, but the back of his neck is way up here instead of back here. The radiologists know about this and will usually pick this out and will be able to show you on the x-rays. This is another thing that can cause back pain, Shoremanís disease, this is that kyphosis that we saw earlier, three vertebrae wedged 5 degrees is the strict definition, it seems that patientís are painful because the muscles get tired of trying to hold the patient up when youíre bent over so far. If the patient still has growth to go, this is the one situation where the Milwaukee brace is nearly 100% effective in actually getting a person to grow straight and eliminate the pain. In people who are fully grown, it will eliminate the pain, but obviously they wonít grow straighter since they have already finished growing. We can also treat this with stretching exercises active and passive to try and get the patientís posture a little bit better.

Discitis. This is back pain that presents usually with normal x-rays, the pain can be present for months and can be a very low grade infection. Itís usually staph. The sed rate will usually be elevated, the bone scan is uniformly going to be hot if you have this. The first thing to do is get a sed rate, if itís normal, then it kind of makes it hard for it to be discitis. Here is an example, this is a little narrowed compared to the other one not noticed at the time but in retrospect it was a little narrowed compared to the one below it. It gets further narrowed as it eats up more of the disc, eventually it fuses together with the one below it. Once it fuses, then this is mechanically stable, patient can go back to playing football and doing all that sort of stuff. The treatment is antibiotics. Usually, itís a staph organism, we sometimes do needle biopsies of these, CT guided needle, we have had one kid that had pseudomonas, was diagnosed on that, did well and didnít have to have surgery. This is an osteoid osteoma which is a very small tumor that is extremely painful, more common at night time, night pain is very common, aspirin or Motrin will usually turn off the pain like a light switch. It has dramatic improvement with salicylates, more common the pain is at night. Itís a small tumor.