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Spondylolisthesis

spondylolisthesisThe building blocks of a human spine are bones called vertebra. A human spine is made up of 33 vertebrae; 24 are mobile and 9 are fused.

A spondylolisthesis is the forward or backwards displacement of one of these mobile vertebrae, in relation to the one below.

Forward slippage of one vertebra on another is referred to as anterolisthesis, while backward slippage is referred to as retrolisthesis. The most common level for a spondylolistheis in the spine is the fifth and lowest lumbar vertebra.

The most widely used classification system of spondylolisthesis was developed by Wiltse et al in 1976. This system described five distinct types of spondylolisthesis:

  1. Dysplastic spondylolisthesis: Caused by a defect in the formation of part of the vertebra called the facet that allows it to slip forward. This is a condition that a patient is born with (congenital).
  2. Isthmic spondylolisthesis: In Isthmic spondylolisthesis, there is a defect in a portion of the vertebra called the pars interarticularis. If there is a defect without a slip, the patient has spondylolysis. Isthmic spondylolisthesis can be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions including gymnasts, and football linemen. Progression of an Isthmic spondylolisthesis rarely occurs after the age of 18.
  3. Degenerative spondylolisthesis: Occurs due to arthritic changes in the joints of the vertebrae due to cartilage degeneration. Degenerative spondylolisthesis is more common in older patients.
  4. Traumatic spondylolisthesis: Due to direct trauma or injury to the vertebrae. This can be caused by a fracture of the pedicle, lamina or facet joints that allows the front portion of the vertebra to slip forward with respect to the back portion of the vertebra.
  5. Pathologic spondylolisthesis: Caused by a defect in the bone caused by abnormal bone, such as from a tumour.

A sixth type of spondylolisthesis has been identified more recently; Iatrogenic spondylolisthesis, which is secondary to man-made intervention such as surgery.

The most common type of spondylolisthesis in the younger population is Isthmic, whereas in the older population the degenerative type is more common. Some individuals may have a spondylolisthesis, but with no symptoms and others may have low back pain, made worse by extension of the spine.

Congenital and pathologic types are very rare. Risk factors that increase the likelihood of a degenerative spondylolisthesis occurring are increased BMI, age, and the angle of the lumbar lordosis in females (but not males according to a study by Jacobsen et al 2007). Other risk factors include a history of repetitive trauma or hyperextension of the lower back or lumbar spine. Athletes such as gymnasts, weight lifters and football linesmen who have large forces applied to the spine during extension are at greater risk for developing isthmic spondylolisthesis as are Alaskan Eskimos (Yochum & Rowe, 2004).

What are the symptoms?
The most common symptom of a spondylolisthesis is lower back pain. This is often worse after exercise, especially with extension of the lumbar spine. Other symptoms include tightness of the hamstrings and decreased range of motion of the lower back. Some patients can develop pain, numbness, tingling or weakness in the legs due to the anterior slippage of the vertebra causing nerve compression. Severe compression of the nerves can cause loss of control over bowel or bladder function, or cauda equine syndrome, although this is extremely rare.

How is it diagnosed?
It is not common to see visible signs of a mild spondylolisthesis on physical examination of a patient, however some patients present with a palpable step defect which gives an indication of the possibility of a spondylolisthesis being present. Another visual indication is prominent, heart shaped buttocks. Spondylolistheses can often cause muscle spasms, or tightness in the hamstrings. Confirmation of a spondylolisthesis is done using X-ray examination.

X-ray examination gives the opportunity to grade a spondylolisthesis by severity into four groups. The grade of displacement of the vertebral body is given by dividing the vertebra below into quarters, and each quarter represents a grade. For example, a displacement of two quarters is a grade two spondylolisthesis.

What treatments are available?
Treatment varies depending on the severity of the condition. Most patients get better with strengthening and stretching exercises combined with activity modification, which involves avoiding hyperextension of the back and contact sports.

Nonsurgical treatments are usually recommended first. These may include:

Activities should be reduced or stopped until your symptoms reduce. In most cases, a gradual return to activity is ideal. Chiropractic treatments and physical therapy can evaluate and address postural and compensatory movement abnormalities such as hyperlordosis and hip flexor and lumbar paraspinal muscle tightness. Acupuncture may also be of benefit in reducing pain and muscle spasm.

Physical modalities such as thermal treatment, electrical stimulation and lumbar traction can help with reactive muscle spasm, but typically are of short therapeutic duration when done in isolation, and should be coupled with therapeutic exercise.

Epidural steroid injections, either interlaminal or transforaminal, performed under fluoroscopic guidance can help with severe radicular (leg) pain. Surgery to fuse the slipped disc may be needed if severe pain is present that does not get better with conservative treatment, a severe slip of the vertebra, or neurological changes. Prolotherapy injections are also used in the treatment of spondylolisthesis and the instability that is often associated with it. These dextrose injections strengthen the supporting ligaments to stabilise the intervertebral segment.

Conservative therapy for mild spondylolisthesis is successful in about 80% of cases. When necessary, surgery leads to satisfactory results in 85 - 90% of people with severe, painful spondylolisthesis.

by Shelley Doole DC MChiro


References

Jacobsen S, Sonne-Holme S, Rovsing H, Monrad H, Gebhur P.  Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study. Spine. 2007;32(1):120-125.
Rosenbaum RB, Ciaverella DP. Disorders of bones, joints, ligaments, and meninges. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J, eds. Neurology in Clinical Practice. 5th ed. Philadelphia, Pa: Butterworth-Heinemann; 2008:chap 77.
Spiegel DA, Hosalkar HS, Dormans JP. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 678.
Wiltse LL, Newman PH, Macnab I. "Classification of spondylolysis and spondylolisthesis." Clin Orthop Relat Res. 1976 Jun;(117):23-9
Yochum T, & Rowe L, Essentials of Skeletal Radiology. Lippincott Williams and Wilkins; 3rd Revised edition edition (1 July 2004)pgs 478-9