Spondylolisthesis

Definition
Spondylolisthesis is the anterior movement (anterolisthesis) of a vertebral body in relation to the segment immediately below it (Greek: spondylos = vertebra, listhesis = slippage). Many patients suffering from Spondylolisthesis will have some element of lumbar spine instability.
Types of Spondylolisthesis
Spondylolysis
Fatigue fracture through pars interarticularis.
Spondyloschisis
Spina bifida – non-union of spinous process.
Spondyloptosis
Complete slippage of a vertebra off the segment below (rare).

Clinical significance and symptoms may vary, with around 50% never developing lower back pain.

There are a number of different types of spondylolisthesis, the most common are:

Isthmic spondylolisthesis
Often found in young individuals, between the ages of 5 and 7 years old.
Degenerative spondylolisthesis
Most common in the elderly, which may lead to signs of stenosis.

Wiltse, Macnab & Newman Spondylolisthesis Classification

Type Name Definition
I Congenital Spondylolisthesis Congenital defect in neuro arch or sacrum, may allow for forward translation, producing undue stress on the pars, resulting in a fracture
II Isthmic Spondylolisthesis Caused by the development of a stress fracture of the pars interarticularis
III Degenerative Spondylolisthesis Intersegmental instability produced by facet arthropathy, in most cases, does not progress beyond a grade I spondylolisthesis
IV Traumatic Spondylolisthesis May result from acute stresses (trauma) to the facet or pars.
V Pathologic spondylolisthesis Occurs as a result of bone pathology (metastasis, Paget’s disease), may destabilise the facet mechanism. May also occur post surgery (facetectomy)

Aetiology

Causes are often unclear, however structural forces are thought to be fundamental to pathology, as stress fractures commonly develop.Interestingly, there is a 5%-7% prevalence in Caucasian populations, while there is a 40% prevalence in Eskimo populations.Often appears early in life, 5-7 years old and is more common in boys, but for most patients symptoms typically do not develop until adulthood. There is another spike in occurrence of lower back pain from spondylolisthesis in adolescence.Activities that require repetitive extension & flexion may increase incidence (eg. gymnastics, rowing and dead lifts)
Affected Segments
L5: 90%
By far most common affected segment.
L4: 5%
Most common with degenerative
L1-L3: 3%
Least common affected in lumbar spine.
C5-C7: 2%
Most affected in cervical spondylolisthesis .

History, Signs & Symptoms

Clinical findings often vary and are inconsistent as many patients are completely asymptomatic.

There is little or no correlation between degree of ‘slippage’ and clinical presentation or pain. This is to say, that even in server grades of anterior movement, symptoms may be minimal, while a smaller degree of movement for another patient may cause extreme symptoms and pain.

If lower back pain is present it may increase with extension.

Signs of stenosis may be presents in elderly patients with degenerative spondylolisthesis.

Patients may have, hyperlordosis of lumbar spine, hamstring tightness, hypertonic low back muscles.

Physical Exam

Palpation
Possible pronounced spinous process at involved segment, and/or depressed spinous process at the segment immediately above.
Active Movement
Possible ‘clicking’ sensation during trunk flexion or straight leg raise.
Neurological Exam
Usually within normal limits. May show non-dermatomal pain referral pattern, if leg pain is present (rare).

Imaging (X-ray)

Primary mode of diagnosis

  1. Lateral lumbar x-ray.
  2. The line of displacement in spondylolisthesis is called the Ullmann’s line
  3. The severity of spondylolisthesis is graded using the Meyerding Grading System, shown on the diagram.
  4. Oblique – the integrity of pars interarticularis must be evaluated, Scotty Dog Collar Sign may indicate fracture in the pars interarticularis
    Instability evaluation (lateral lumbar) may be performed with flexion/extension studies or distraction/compression studies.

Meyerding Grading System

Used in grading the severity of spondylolisthesis

Meyerding Grading System

Management

Physical & Rehabilitate Treatment

  1. Pain control: rest, ice, medications (NSAIDs, analgesics)
  2. Most spondylolisthese (grade 1) are stable & asymptomatic, with progressive slipping rarely occurring. Therefore focus in improving biomechanics of lower back as well as lower extremely joints. Use of osseous manipulation on above segments can improve biomechanics, but should be used with caution.
  3. There is a risk of progression in younger patients with isthmic or congenital spondylolisthesis, therefore, monitoring and rescanning should be considered one or twice a year to monitor progression
  4. Patients with grade 1 or grade 2 isthmic slips do well with conservative management
  5. Most common complication of any type of spondylolisthesis is nerve root impingement / radiculopathy at the level of slippage (stenosis & cauda equina syndrome may result when a significant slip has occurred), also disc degeneration occurs at the level of the spondylolisthesis faster than at other levels of the spine, increasing risk of discogenic pain.

Severe Spondylolisthesis

  1. With more severe spondylolisthesis (grade 3 or 4) alternate treatment & caution should be employed; consider bracing to help stabilize lumbar spine.
  2. Surgical consultation in severe cases or in the presence of neurocompressive radiculopathy is advice.