Gayani Lalique Gunawardana
What is Spondylolisthesis?
The word spondylolisthesis refers to the anterior slippage of one vertebral body with relation to the one below it. The word is derived from two parts - 'spondylo' means spine and listhesis means slippage.1 A common reason for this type of slippage is weakness or fracture of the portion of the neural arch that connects the lamina with the pedicle, facet joints, and transverse process. This area is the isthmus or pars interarticularis (area between the bony protrusions which articulate to form the joint). As the bridging element between spinal vertebral bodies, these protruding joints are key to the integrity of spinal segments. isthmic spondylolisthesis results from a spondylolisthetic defect in the pars interarticularis, which may lead to the subluxation of a vertebral body.2
How is the degree of spondylolisthetic severity measured?
The diagram to the left (Source: http://www.spinepainny.com/spondylolisthesis.php) illustrates how spondylolisthesis is commonly graded. The arrow inside the vertebral body indicates its width, the other indicates the amount of slippage that has occurred. Together these arrows represent the measurements needed to calculate the ratio of slippage to vertebral-body width, which is then converted to a percentage.
The most common grading system for spondylolisthesis is the Meyerding grading system for severity of slip. The system categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This distance is then reported as a percentage of the total superior vertebral body length:
Grade 1 is 0–25%
Grade 2 is 25–50%
Grade 3 is 50–75%
Grade 4 is 75–100%
Over 100% slippage is also named spondyloptosis, when the vertebra falls completely off the supporting vertebrae beneath it.
With a documented spondylolysis incidence rate as high as 4.4 % at age six,1 with 28% of that number progressing to spondylolisthesis1, while 80% remained asymptomatic 2 spondylolisthesis is a serious concern, often manifested in the teen years when the rate of bone growth outstrips the rate of muscle growth. Spondylolysis and spondylolisthesis are common diagnoses in adolescent athletes who perform repetitive compression in extension, repetitive hyperextension across the lumbar spine, experience repetitive trauma, and/or have a genetic predisposition 3. Athletes who require central control of body motion in extension/hyperextension include gymnasts, football linemen, dancers, oarsmen, divers, and tennis players. 4,5,6
As a result of their sport related muscle hypertrophy, there is an especially high incidence of spondylolysis and spondylolisthesis in athletes, which coaches can be educated about as well. There should be serious watchfulness for spondylolysis leading to spondylolisthesis.
Approximately 90% of spondylolytic defects occur at L5, with L4 being the next most commonly affected vertebral level.6 Slippage is most commonly seen in association with an L5 lesion resulting in an L5-S1 spondylolisthesis.7 A defect in the pars interarticularis is 2 times more common in males. However, females are more prone to high-grade spondylolisthesis.8
McTimoney and Micheli, et al,9 report that spondylolysis occurs with a prevalence of 4% to 6% in the general population. Although the etiology of this lesion is still unclear, it has been shown to have both hereditary and acquired risk factors, with an increased prevalence in men and athletes participating in certain high-risk sports. Spondylolisthesis has also been found to occur in a significant proportion of individuals with bilateral spondylolysis. Predicting risk factors for progression of the slip in spondylolisthesis has proven difficult. Multiple imaging techniques are helpful in the diagnosis of spondylolysis and spondylolisthesis, with recent research addressing the utility of magnetic resonance imaging in the diagnosis and management of pars lesions. The management guidelines have remained largely unchanged since early recommendations. Recently, the addition of a bone growth stimulator to the management of difficult cases has shown promise. —-
III. Evaluation: Indications, clinical manifestations, signs, and symptoms typically seen upon examination
Patients usually present with
- back pain
and/or instability caused by spasming muscles trying to provide stability in a lengthened position (due to their being pulled anteriorly by the olisthesis) usually at L5-S1,
- what is termed the "step" deformity — the vertebra below the one that is slipping anteriorly forward sticks out and creates this bump that looks and feels like a "step"
- or alteration in gait "pelvic waddle" & hamstring spasm;
- Kyphosis of lumbosacral junction w/ or w/o palpable step off;
- severe slips may be assoc w/ radicular findings (L5);
- this occurs from compression between the superior end plate of the caudad
vertebrae and the inferior facet of the cephalad vertebrae;
- Since there will be back pain with extension and sometimes radiation of the same pain down the leg with such testing, PTs should attempt to be cautious about pushing and keeping the patient in positions of discomfort.
Why should health professionals and coaches be made more aware of spondylolisthesis?
As a result of age and sport-related muscle hypertrophy pulling on bone, there is an especially high incidence of spondylolysis and spondylolisthesis in athletes. Athletes who require central control of body motion in extension/hyperextension include gymnasts, football linemen, dancers, oarsmen, divers, and tennis players.
In the above mentioned sports, spondylolysis leading to spondylolisthesis are common diagnoses.
This is information on which coaches can be educated about as well. As with growing awareness of the etiology of ACL tears due to Astroturf, there should be serious awareness and monitoring of back pain in adolescent athletes who perform repetitive compression in extension, repetitive hyperextension across the lumbar spine, experience repetitive trauma, and/or have a genetic predisposition. Based on the above, the following Youtube educational video demonstrates some approaches for athletes to become aware of and prevent spondylolysis and spondylolisthesis by following the exercise regime below. (As a word of caution, if a patient has a diagnosed spondylolysthesis it is advisable to avoid any position of back extension, even for brief moments. In the presence of a spondylolysthesis, patients attempting to get into a plank position or a push-up position should move from a quadruped position and not from a prone lying position as is shown in the video below.)
There are different types of spondylolisthesis:
Congenital – this type of slippage is caused by abnormal bone development at birth, which predisposes the vertebrae to slip.
- Isthmic – in this case, there is breakage of the bony elements (pars interarticularis) supporting the joints, which in turn are responsible for keeping the vertebrae in place. This breakage is called spondylolysis.
- Therefore there is also a spondylolytic etiology
- Degenerative – degeneration of the discs and facet joints leads to slippage of the vertebrae.
- Traumatic – trauma can lead to a fracture of the stabilizing complex that houses the intervertebral joint and this in turn leads to the slippage.
- Post-surgical – overzealous decompressions of the lumbar spine during surgery can lead to instability and the inability of the intervertebral joints to stop slippage from occurring.
- Pathologic – this is when the bone is weakened by a pathological process such as a tumor, infection, bone disease or osteoporosis.
Conservative treatment options
Bracing (as illustrated by those below) and bone growth stimulation in addition to flexion/extension exercises, have been found to speed bone healing in the adolescent athlete.6
If total separation has not occurred, but the patient still has pain, it is likely due to nerve inflammation as they exit the spine. This inflammation can cause the same type of symptoms commonly seen with pinched nerve conditions. When a nerve is compressed, it may cause symptoms of numbness, tingling, burning and achy soreness along the nerve path. Extension of the spine will exacerbate spondylolisthesis, as the vertebrae is pushed further forward. As flexion of the spine will often alleviate the symptoms of spondylolisthesis, part of a normal physical therapy (PT) treatment regimen should include flexion exercises to take the pressure off the back of the vertebrae.
Spondylolisthesis PT treatment commonly also includes traction and vertebral adjustment procedures, manual therapy to help the muscles loosen up and thereby lessen the pain, and minimizing inflammation as necessary. The above listed therapies, products and activities section provides more information on how to alleviate the condition, however, as each spondylolisthesis is different, it is advisable to consult a physician to determine what treatment is right for the particular patient and their situation.
Surgical treatment options
There are a few Surgical Options available to those with grades of 3 or higher spondylolisthesis.
One such example is the single-level instrumented mini-open transforaminal lumbar
interbody fusion (or TLIF) that has been found beneficial in the elderly population per the 'Spine' Journal of Neurosurgery in 2008.
Below is an artist’s illustration of mini-open TLIF. After bilateral facetectomy and decompression of neural structures
via bilateral paraspinal routes, cages filled with graft materials were inserted into the disc space. B: Postoperative CT
scan demonstrating preservation of the midline posterior structures.
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