Spondylolisthesis
- Anterior displacement of a vertebra in relation to the segment below |
- Occurs mainly at L5 then L4 |
- Spondylolysis = Pars interarticularis break |
Imaging
- Only if: high degree of suspicion for pars defect |
- Patients who do not improve with short term treatment |
- MRI for suspected active spondy/neurological symptoms/disc lesions |
DDx
- F# |
- Infection |
- Neoplasm |
- Spondylolysis |
- Growth Plate F# |
- Scheuermanns |
- Degeneration |
- Disc lesions |
- Facet Syndrome |
- Sprain/Strain |
- Myofascial Pain syndrome |
- Hip/SI pathology |
- Viscerosomatic referred pain |
Classifications
- Type I : Dysplastic: Congenital abnormality of upper sacrum or neural arch of L5 |
- Type II : Isthmic: A: Fatigue F# of pars, B: Enlongated, intact pars C: Acute f# of pars |
- Type III: Degenerative: facet and disc degeneration |
- Type IV: Traumatic: F# of neural arch other than pars |
- Type V: Pathologic: Bone disease - Paget's osteoporosis, metastasis |
- Type VI: Iatrogenic: Above/below spinal fusion |
Type I:
- Rare, congenital thin pars
- Not present at birth
- Trapezoidal L5, dome shape S1
- Elongated Neural Arch (SP to posterior vertebra body)
Type II
Isthmic Spondylolisthesis |
Most Common is IIA: Stress f# |
Common in Athletes (Gymnast, Weight lifters, Divers) and Alaskan Indigenous People |
Younger skeletal immature (thinner pars, immature isthmus, decreased ability of the disc to resist shear stress) |
Usually due to repetitive microtrauma |
Clinical Features
Common in childhood/adolescence |
Further displacement rarely occurs after 18 years old |
Step Defect (gap) |
Hyperlordosis |
Tight Hamstrings |
Achy lumbrosacral pain with standing or slow walking |
Prominent Buttocks |
Waddling Gait (stiff, short stride) |
Prominence of the SP at the involved level |
+ve Stork Test |
Transverse Skin Fold - Advanced Slippage |
Insidious onset back pain |
Aggravated by activity - repetitive extension, rotation/axial rotation |
Spondy caused by pregnancy will notice increased symptoms |
Assess for CE |
ROM painful during ext |
+ve Kemps, +Ve Mcgills +ve Yeomans |
Lower Crossed signs |
Scleratogenous referral to theposterior thigh |
Radicular complaints that change side common in Type III |
Imaging
Arrow: Pars Defect
Active Spondy: developing stress f# of the pars, not yet broken.
S&S = Pain on palpation of the lumbosacral region, +ve stork's test, negative plain film
Management Boston overlap anti-lordotic brace, stop offending activity, Pain killers No NSAIDs, isometric contraction of muscles, pulsed Ultrasound, Electrical bone stimulators, physical rehab
Best imaging = MRI
Meyerding's grading
Grade V = Spondyloptosis
Method of Taillard
a/b X 100 = % of displacement
Unstable spondy = >4mm translation between flexion and extension
Inverted Napoleon's Hat Sign
Seen with >3 grade spondy
Type III
- Degenerative Spondy |
- Rarely passes Grade 1 and never passes grade 3 |
- 3 F's : Female, Fourth Lumbar Vertebra, Forty years or older |
- Cartilage degeneration - ligamentous laxity - tension on facet capsule, disc, ligaments, muscle instability |
- Can cause spinal stenosis/myelopathy |
- Common in L4/5 |
- Anatomical risk factors:
Facet tropism
Sagittaly orientated facet joints
Lx hyperlordosis
L5 sacralisation
Joint laxity |
Cervical Dysplastic Spondy
- Common at C6 |
- Associated with spina bifida |
- Congenital - hypoplastic neural arch |
- Usually asymptomatic |
- Flexion/Extension x-rays needed |
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Scheuerman's Disease
S&S |
- Adolescent onset (13-17) |
- More common in males |
- Mid and lower Tx affected |
- Pain, Fatigue + Defective posture |
- Increased kyphosis |
- Hyperlordosis of lx and cx |
- Protruberant Abdomen |
- Hypertonic Hamstrings, iliopsoas and pecs |
Imaging Features
- Kyphosis due to at least 3 contiguous segments
- Wedging of 5 degrees or more of each segment
- Irregular Endplates
- Loss of Disc Height
- Enlongated VB
- Schmorl's nodes in at least 4 segments
Management
- Explanation and reassurance |
- SMT (above and below spondy) and soft Tissue work of lumbar erectors, hip abductors and hip flexors |
- Flexion biased exercises |
- Strengthening of tx and lx extensors |
- Postural Correction |
- Stretching/Relaxing of Pecs and Hammies |
- Boston bracing for 3-6 months |
- If seriously deformed, consider referral for bracing/surgery |
- Stopping of aggravating activity for 2-6 months |
- NSAIDs |
- Flexion/distraction |
- Home exercises - knee to chest, posterior pelvic tilt, dead bug, piriformis stretching, abdominal strengthening (10 weeks) |
- Lifestyle advie: proper lifting, weight loss, aerobic exercise, mattress selection, sleep position, limit hyperextension movements and avoid wearing high heels |
- If conservative care fails, consider injections/surgical consultation |
- Criteria for surgical consultation: high- grade slip
slip progression
Neurological deficit
unresponsive to conservative care after 6 months |
Criteria
Grade I spondy can return to sport if: |
- Full pain free ROM |
- Normal strength |
- Appropriate aerobic fitness |
- Adequate spinal awareness of mechanics |
- Ability to perform sports related skills without pain |
- Avoid repetitive extension/loading |
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