Spondylolisthesis: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==
[[File:Spondylolisthesis grading.jpg|right|frameless|331x331px]]
Spondylolisthesis is the slippage of one vertebral body with respect to the adjacent vertebral body causing mechanical or radicular symptoms or pain. It can be due to congenital, acquired, or idiopathic causes. Spondylolisthesis is graded based on the degree of slippage (Meyerding Classification) of one vertebral body on the adjacent vertebral body.<ref name=":1">Tenny S, Gillis CC. [https://www.ncbi.nlm.nih.gov/books/NBK430767/ Spondylolisthesis]. InStatPearls [Internet] 2019 Mar 27. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK430767/ (last accessed 26.1.2020)</ref>


The term spondylolisthesis is derived from the Greek words spondylo = vertebra, and listhesis = translation.<ref>D. Winkel, orthopedische geneeskunde en manuele therapie: de wervelkolom deel 2. (Level of evidence 5)</ref>Spondylolisthesis is defined as a translation of one vertebra over the adjacent caudal vertebra. This can be a translation in the anterior (anterolisthesis) or posterior direction (retrolisthesis) or, in more serious cases, anterior-caudal direction<ref name=":0">Amir Vokshoor et al., Spondylolisthesis, Spondylolysis, and Spondylosis. Medscape, updated Sep 10, 2014, Consulted on Oct 20, 2014 (Level of evidence 2A)</ref><ref name=":1">Tebet, M.A., Currents concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia, 2014, 49 (1), 3-12. (Level of evidence 1A)</ref>.It is classified on the basis of etiology into the following six types by Wiltse: Dysplastic (congenital), isthmic, degenerative, traumatic, pathologic and iatrogenic spondylolisthesis.<ref name=":0" /><ref name=":2">O’sullivan RCT + Iguchi T. et al., Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis, J Spinal Disord Tech. 2002. Apr;15(2):93-9 (Level of evidence 1B)</ref><u></u><sub></sub><sup></sup><br>
== <u></u><sub></sub><sup></sup> Clinical Anatomy ==
 
Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the [[Cervical Anatomy|cervical]] spine and rarely, except for trauma, in the thoracic spine.<ref name=":1" />
http://www.spine-health.com/video/degenerative-spondylolisthesis-video


== Clinically Relevant Anatomy ==
'''Spondylolisthesis''', regardless of the type, is mostly common preceded by [[spondylolysis]]. This pathology involves
* A fractured pars interarticularis of the [[Lumbar Anatomy|lumbar]] vertebrae, also called the isthmus.
* This affects the supporting structural integrity of the vertebrae, which could lead to slippage of the corpus of the vertebrae, called spondylolysthesis.
* In turn, leads to one of the most obvious manifestations of lumbar instability.
* Slippage can occur in 2 directions- most commonly in anterior translation, called anterolisthesis, or a backward translation, called retrolisthesis.<ref name=":2">Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K. [https://journals.lww.com/jspinaldisorders/fulltext/2002/04000/lumbar_multilevel_degenerative_spondylolisthesis_.1.aspx Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis.] Clinical Spine Surgery. 2002 Apr 1;15(2):93-9.</ref>
A study of Dai L.Y. analysed the correlation between disc degeneration and the age, duration and severity of clinical symptoms and grade of vertebral slip. The disc degeneration on sub segmental level was significantly related to age and duration of clinical symptoms, although it was not related to the severity of clinical symptoms or the grade of vertebral slip<ref>Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K. [https://journals.lww.com/jspinaldisorders/fulltext/2002/04000/lumbar_multilevel_degenerative_spondylolisthesis_.1.aspx Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis.] Clinical Spine Surgery. 2002 Apr 1;15(2):93-9.
</ref>.


<br><br>Spondylolysthesis, regardless of the type, is mostly common preceded by spondylolysis. This pathology involves a fractured pars interarticularis of the lumbar vertebrae, also called the isthmus. This affects the supporting structural integrity of the vertebrae, which could lead to slippage of the corpus of the vertebrae, called spondylolysthesis. This, in turn, leads to one of the most obvious manifestations of lumbar instability. This slippage can occur in 2 directions: most commonly in anterior translation, called anterolisthesis, or a backward translation, called retrolisthesis.<ref name=":2" /> In addition, ligamentous structures, including the iliolumbar ligament, between L5 and the sacrum, are stronger than those between L4 and L5, by which the vertebral slip commonly develops in L4<ref name=":1" /> A study of Dai L.Y. analysed the correlation between disc degeneration and the age, duration and severity of clinical symptoms and grade of vertebral slip. The disc degeneration on subsegmental level was significantly related to age and duration of clinical symptoms, although it was not related to the severity of clinical symptoms or the grade of vertebral slip<ref>Iguchi T. et al., Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis, J Spinal Disord Tech. 2002. Apr;15(2):93-9 (Level of evidence 2B)
=== Epidemiology ===
</ref>.
* Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese.
* Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males.
* Dysplastic spondylolisthesis is more common in the pediatric population, with females more commonly affected than males. Current estimates for prevalence are 6 to 7% for isthmic spondylolisthesis by the age of 18 years, and up to 18% of adult patients undergoing MRI of the lumbar spine. 
* Grade I spondylolisthesis accounts for 75% of all cases.  
* Spondylolisthesis most commonly occurs at the L5-S1 level with anterior translation of the L5 vertebral body on the S1 vertebral body.
* The L4-5 level is the second most common location for spondylolisthesis.<ref name=":1" /> 


<br><br>
== Etiology ==


[[Image:Scottie dog.png]]
* Repetitive stress to the pars interarticularis
* Decreased strength of the neural arch at a young age predisposes children and adolescents to a higher risk of fracture.
* Traumatic accidental injuries
* Microtrauma in sports
* Pathological causes - Neoplasm, connective tissue disease, etc.
* Iatrogenic - After laminectomy
* Adolescents and children also have more elastic intervertebral disks which cause increased stress to be placed on the pars interarticularis


Figure 1: Scottie dog <ref name="Foreman">Foreman P. et al, L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus, Childs Nerv Syst. 2013;29(2):209-16 (Level of evidence 1B)</ref>&nbsp;
== Classification ==


== Epidemiology  ==
There are different classification systems regarding the etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment.<br>'''A'''. '''Wiltse Classification''' <ref name=":4">Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. [https://www.sciencedirect.com/science/article/pii/S0972978X18300308 Spondylolysis and spondylolisthesis: a review of the literature.] Journal of orthopaedics. 2018 Jun 1;15(2):404-7.</ref> is one of the most commonly used classification systems to convey the etiology of spondylolisthesis (see table below). It has five major etiologies: degenerative, isthmic, traumatic, dysplastic, or pathologic.[[File:Scottie_dog.png|right|'''Scottie dog .png'''<ref name="Foreman">Foreman P. et al, L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus, Childs Nerv Syst. 2013;29(2):209-16 (Level of evidence 1B)</ref>]]
The incidence of spondylolisthesis varies considerably depending on ethnicity, sex,&nbsp;family history, relevant disease and sports activity.<ref name=":3">Sakai T, Sairyo K, Suzue N, Kosaka H, Yasui N.Incidence and etiology of lumbar spondylolysis: review of the literature. Journal of orthopedic sience,2010 May;15(3):281-8. (Level of evidence: 1A)
# Dysplastic spondylolisthesis (Type 1) is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment.  In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation.
</ref> Several epidemiological studies have revealed that the incidence of symptomatic spondylolisthesis in Caucasian populations varies from 4 to 6% <ref name=":5">Mc Timoney, C.A. et al, Current evaluation and management of spondylolysis and spondylolisthesis. Current Sports Medicine Reports, 2003, 2, (1), 41–46. (Level of evdidence: 2A)</ref><ref>Taillard, W.F., Etiology of spondylolisthesis. Clinical Orthopaedics and Related Research, 1976, 117, 30–39. (Level of evidence: 2A)
# Isthmic spondylolisthesis results from defects in the pars interarticularis. The cause of isthmic spondylolisthesis is undetermined, but a possible etiology includes microtrauma in adolescence related to sports such as [[Spondylolysis in Young Athletes|wrestling, football, and gymnastics]], where repeated lumbar extension occurs. Type II is isthmic and is separated into Type IIA and Type IIB. Type IIA is caused by a stress fracture of the pars interarticularis (spondylolysis) that results in anterior slippage of the vertebrae. Type II B is caused by repetitive fractures and subsequent healing which results in lengthening of the pars interarticularis leading to anterior slippage of the vertebrae.<ref name=":4" />
</ref>, but rises as high as 26% in secluded Eskimo populations<ref name=":6">Stewart, T., The age incidence of neural arch defects in Alaskan natives, considered from the standpoint of etiology. The American Journal of Bone and Joint Surgery, 1953, 35, 937–950. (Level of evidence: 2A)
# Degenerative spondylolisthesis (Type 3) occurs from degenerative changes in the spine without any defect in the pars interarticularis. It is usually related to combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body relative to the adjacent vertebral body. Arthritis of facet joint which in turn causes weakness of ligamentum flavum leads to anterior slippage of vertebra.
</ref> and varies from 19 to 69% among first-degree relatives of the affected patients.<ref>Lonstein, J.E., Spondylolisthesis in children Cause, natural history, and management. Spine, 1999, 24, (24), 2640–2648. (Level of evidence: 2A)</ref><br>
# Traumatic spondylolisthesis (Type 4)occurs after fractures of the pars interarticularis or the facet joint structure and is most common after trauma.
 
# Pathologic spondylolisthesis (Type 5) can be from systemic causes such as bone or connective tissue disorders or a focal process, including infection, neoplasm.
== Etiology ==
# Iatrogenic spondylolisthesis (Type 6)  is a potential sequela of spinal surgery. Frequently, these patients will have undergone prior laminectomy
 
Additional risk factors for spondylolisthesis include a first-degree relative with spondylolisthesis, [[scoliosis]], or [[Spina Bifida]] at the S1 level<ref name=":1" />  
There are different classification systems regarding the etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment.<br>  
 
'''A'''. '''Wiltse Classification''': It is one of the most commonly used classification systems to convey the etiology of spondylolisthesis. 


[[Image:Wlitse.jpg]]  
[[Image:Wlitse.jpg]]  


<span>&nbsp;</span>• '''Type 1: Congenital spondylolisthesis'''<br>An elongation of the pars interarticularis can be seen in congenital spondylolisthesis, in which the pars lesion is due to a congenital anomaly of the L5-S1 facet articulation. As the slip progresses, the pars elongates in response to the deformity. Therefore, with an elongated pars, it is important to evaluate the lumbosacral facets to properly classify the lesion.<ref name=":4">Wiltse LL. Classification, Terminology and Measurements in Spondylolisthesis. Iowa Orthop J. 1981; 1: 52–57. (Level of evidence: 2A)</ref>The symptoms usually develop during the adolescent growth period.<ref name=":7">Frymoyer, J.W.,Degenerative spondylolisthesis. In: Andersson GBJ, McNeill TW (eds) Lumbar spinal stenosis. Mosby Year Book, St Louis, 1992 (Level of Evidence: 5)</ref>


<br>• '''Type 2: Isthmic spondylolisthesis'''<br>It is due to a lesion of the pars interarticularis and is a common source of pain and disability in both pediatric and adult population. The basic lesion in isthmic spondylolisthesis is in the pars interarticularis and mainly appears at the lumbosacral level (L5-S1).<ref name=":8">Kalichman L. et al, Diagnosis and conservative management of degenerative lumbar spondylolisthesis, Eur Spine J, 2008; 17:327-335 (Level of evidence 2B)
The Myerding classification defines the amount of vertebral slippage on X-ray in reference to the caudal vertebrae.4 There are five grades of spondylolisthesis in the Myerding classification. Grade I is less than 25 percent slippage, grade II is 26–50% slippage, grade III is 51–75% slippage, grade IV is 76–100% slippage, and grade V is over 100% slippage and is referred to as spondyloptosis<ref name=":4" />.
</ref> It is characterized by high lordosis angles and lordotic wedging of the affected vertebra (L5) and very high L4-5 intervertebral disc wedging.<ref>Been E. et al, Geometry of the vertebral bodies and the intervertebral discs in lumbar segments adjacent to spondylolysis and spondylolisthesis: pilot study, Eur Spine J, 2011; 20:1159-1165 (Level of evidence 3B)</ref><ref>Labelle H. et al., Spino-pelvic alignment after surgical correction for developmental spondylolisthesis, Eur. Spine J, 2008; 17:1170-1176 (Level of evidence 2B)
</ref> Isthmic spondylosithesis is typically considered as a pediatric condition.<ref>Steven, S.A. et al, (20mc10). Contemporary management of isthmic spondylolisthesis: pediatric and adult. The Spine Journal, 2010, 530-543. (Level of evidence: 1A)
</ref><br>Spondylolisthesis is most often caused by spondylolysis. Spondylolysis is considered a stress fracture caused by an excessive amount of mechanical stress that affects the isthmus. This part of the vertebrae forms the connection between the corpus and the facet joints, at the back of the vertebrae. Therefore, a load for the facet joints results in a stressor for the isthmus. The stress on the pars interarticularis is the highest with extension and rotation. Anterior pelvic tilt, abdominal muscle weakness and hamstring tightness magnify these biomechanical forces.<ref>Standaert C.J., Herring S.A., Cole A.J., and Stratton S.A.The lumbar spine and sports. The low back pain handbook, 2003, 385-404.) (Level of evidence 2A)
</ref>  Wiltse et al. divided this category into three subtypes:
* ''The lytic lesion of the pars (Type II-A'') is the most common cause of spondylolisthesis and is termed spondylolysis. This defect is present in 6% of the population by young adulthood.
* ''The elongation of the pars interarticularis (Type II-B)''&nbsp;is thought to be due to repetitive microfractures with subsequent healing in an elongated position. Elongation of the pars can also be seen in congenital spondylolisthesis.
* ''An acute fracture of the pars (Type II-C), ''the third subtype,&nbsp;resulting from a single traumatic episode. Wiltse et al. suggested that this type of isthmic spondylolisthesis could also be classified as traumatic spondylolisthesis. Isthmic spondylosithesis is typically considered as a pediatric condition,<ref name=":10">Agabegi SS, Fischgrund JS. Contemporary management of isthmic spondylolisthesis: pediatric and adult. The Spine Journal, 2010, 530-543. (Level of evidence: 1A)
</ref> but Saraste (1987) demonstrated that the onset of symptoms tends to occur after childhood, with a mean age at presentation of 20 years.
<br>• '''Type 3: Degenerative spondylolisthesis'''<br>Degenerative spondylolisthesis is most common in adults.<ref>Gille O, Challier V, Parent H, Cavagna R, Poignard A, Faline A, Fuentes S, Ricart O, Ferrero E, Ould Slimane M; French Society of Spine Surgery (SFCR). Orthop Traumatol Surg Res. 2014 Oct;100(6 Suppl)</ref> In this type, the L4–L5 vertebral space is affected 6 to 9 times more commonly than other spinal levels.<ref>Dai LY et al., Disc degeneration in patients with lumbar spondylolysis. J Spinal Disord. 2000 Dec;13(6):478-86 [2B]
</ref><ref name=":3" /> It is characterized by a significant constriction of the cauda equina, combined with a diminished cross-sectional area of the vertebral canal, thickening and buckling of the ligamentum flavum and hypertrophy of adjacent facet joints.<ref>Kalichman, L., Kim, D., Li, L., Guermazi, A., Berkin, V., & Hunter, D. (2009). Spondylolysis and spondylolisthesis: Prevalence and association with low back pain in the adult community‐based population. ''Spine'', 34(2), 99–205.</ref> It is also a common condition in the elderly (&gt;50 years). The main causes are<ref>Sheng-Dan, J. et al, Degenerative cervical spondylolisthesis: a systematic review. International Orthopaedics (SICOT), 2011, 35, 869-875. (Level of evidence: 3A)
</ref><ref>Vibert, B.T. et al, Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment. Clinical Orthopaedics and Related Research, 2006, 443, 222–227. (Level of evidence: 5)
</ref><ref>Sengupta, D.K. et al, Degenerative spondylolisthesis: review of current trends and controversies. Spine, 2005, 30(Suppl), S71–S81. (Level of evidence: 1A)
</ref>: <br>• Disc degeneration;<br>• Facet joint arthrosis;<br>• Malfunction of the ligamentous stabilizing component;<br>• Ineffectual muscular stabilization.<br>Degenerative spondylolisthesis is believed to result from chronic intersegmental instability. Degenerative changes to both the facet joints and the intervertebral disk cause the slip. Sagittal orientation of the facet joints and facet tropism also have been related to the development of degenerative spondylolisthesis. <ref name=":4" />  


<br>• '''Type 4: Traumatic spondylolisthesis'''<br>Traumatic spondylolisthesis is caused by a fracture in a region other than the pars. This fracture leads to slippage of the vertebrae.<ref name=":4" />
== Clinical Presentation ==
 
'''Symptoms and findings in spondylolisthesis''' <ref>Wicker A. [https://journals.co.za/doi/abs/10.10520/EJC48630 Spondylolysis and spondylolisthesis in sports: FIMS Position Statement.] International SportMed Journal. 2008 Jan 1;9(2):74-8.  
<br>• '''Type 5: Pathological spondylolisthesis'''<br>Pathological spondylolisthesis is due to generalized or localized musculoskeletal processes affecting the posterior elements and causing instability.<ref name=":4" /><br>Diffuse or local disease compromises the usual structure integrity that prevents slippage.<ref name=":11">Leonidou, Andreas, et al. "Treatment for spondylolysis and spondylolisthesis in children." Journal of Orthopaedic Surgery 23.3 (2015): 379. (LE:3A)
</ref>
</ref>  
* Patients typically have low back pain which mimics radiculopathy for lumbar spondylolisthesis and localized/radiating neck pain for cervical spondylolisthesis.
 
* Pain is exacerbated by extending at the affected segment, as this can cause mechanic pain from motion, leading to diminished ROM (spine). Pain decreases as the patient assumes flexed posture which reduces stress on the nerve being impinged.
<br>• '''Type 6: Iatrogenic spondylolisthesis'''<br>Iatrogenic spondylolisthesis results from excessive removal of the posterior elements after laminectomy.<ref name=":4" />
* Pain may be exacerbated by direct palpation of the affected segment.  
 
* Pain can also be radicular in nature as the exiting nerve roots become compressed due to the narrowing of nerve foramina as one vertebra slips on the adjacent vertebrae, the traversing nerve root (root to the level below) can also be impinged through associated lateral recess narrowing, disc protrusion, or central canal stenosis.  
Potential risk factors are<ref>N.J. Rosenberg. Degenerative spondylolisthesis. Predisposing factors. The journal of Bone and Joint Surgery (1975) 57:467-474. (level of evidence 1C</ref>: <br>• Increasing age;<br>• Female sex;<br>• Pregnancies;<br>• African-American ethnicity;<br>• Generalized joint laxity<u></u><sub></sub><sup></sup><br>• anatomical predisposition (sagitally oriented facet joints, hyperlordosis, high pelvic incidence)&nbsp;
* Pain can sometimes improve in certain positions such as lying supine. This improvement is due to the instability of the spondylolisthesis that reduces with supine posture, thus relieving the pressure on the bony elements as well as opening the spinal canal or neural foramen.
 
* Spondylolisthesis can also present as an acute or acute-onchronic episode with the patient having severe exacerbation of pre-existing back pain, neurological deficits, hamstrings spasm and a crouched gait.<ref name=":5">Mataliotakis GI, Tsirikos AI. [https://www.sciencedirect.com/science/article/pii/S1877132717301070 Spondylolysis and spondylolisthesis in children and adolescents: current concepts and treatment.] Orthopaedics and Trauma. 2017 Dec 1;31(6):395-401.</ref>The patient develops a crouched gait (Phalen-Dickson sign) due to the vertical position of the sacrum, lumbosacral kyphosis, compensatory lordosis of the proximal spine and flexion of the knees and hips, which may be present regardless of the degree of slippage.
'''B. Marchetti-Bartolozzi Classification'''
 
[[Image:Marchetti.jpg]]
 
C. '''Myerding Classification'''<ref>Niggemann et al. Spondylolysis and isthmic spondylolisthesis: impact of vertebral hypoplasia on the use of the Meyerding Classification, The British Journal of Radiology, 85 (2012), 368-362 (LOE: 2C)
</ref>
 
[[Image:Meyerdig.jpg]]
 
== Characteristics/Clinical Presentation  ==
 
[[Image:Stress lumbar vertebra.png|388x391px]]
 
Figure 2: Highest stress during various lumbar motions is found at the pars interarticularis, as shown in a threedimensional finite element moedel <ref name="Mays">Mays, S. (2006). Spondylolysis, spondylolisthesis, and lumbo-sacral morphology in a medieval English skeletal population. American Journal of Physical Anthropolgy, 131, 352–62. (Level of evidence: 2B)</ref>&nbsp;
 
Symptoms and findings in spondylolisthesis are<ref>Antony Wicker et al; Spondylolysis and spondylolisthesis in sports; International SportMed Journal, Vol. 9 No.2, 2008 pp.74-7 (level of evidence 2B)
</ref>:
 
*Low-back pain
*Pain radiating down the leg
*Neurological symptoms (possible evolution towards cauda equine syndrome)
*Atrophy of the muscles,&nbsp;muscle weakness  
*Atrophy of the muscles,&nbsp;muscle weakness  
*Tense hamstrings,&nbsp;hamstrings spasms  
*Tense [[hamstrings]],&nbsp;hamstrings spasms  
*Diminished ROM (spine)
*Disturbances in [[Coordination Exercises|coordination]] and [[balance]], difficulty walking
*Disturbances in coordination and balance<br>
*Rarely loss of bowel or bladder control.<ref name=":1" /><br>  
 
Spondylolisthesis can occur with other disorders and seems to have a link with some of them
Patients usually report that their symptoms vary as a function of mechanical loads (such as in going from supine to erect position) and pain frequently worsens over the course of the day. Radiation into the posterolateral thighs is also common and is independent of neurological signs and symptoms. The pain could be diffuse in the lower extremities, involving the L5 and/or L4 roots unilaterally or bilaterally, but generally bilaterally&nbsp;<ref name=":7" />
*[[Spina Bifida]] <ref name="Mays">Mays S. [https://onlinelibrary.wiley.com/doi/abs/10.1002/ajpa.20447 Spondylolysis, spondylolisthesis, and lumbo‐sacral morphology in a medieval English skeletal population.] American Journal of Physical Anthropology: The Official Publication of the American Association of Physical Anthropologists. 2006 Nov;131(3):352-62.</ref>&nbsp; <ref name="Sairyo">Sairyo K, Goel VK, Vadapalli S, Vishnubhotla SL, Biyani A, Ebraheim N, Terai T, Sakai T. [https://www.nature.com/articles/3101867 Biomechanical comparison of lumbar spine with or without spina bifida occulta. A finite element analysis]. Spinal Cord. 2006 Jul;44(7):440-4.</ref>&nbsp;<ref name="Burkus">Burkus JK. [https://europepmc.org/article/med/2205929 Unilateral spondylolysis associated with spina bifida occulta and nerve root compression.] Spine. 1990 Jun 1;15(6):555-9.</ref>;
 
*[[Cerebral Palsy Introduction|Cerebral Palsy]] <ref name="Sakai">Sakai T, Yamada H, Nakamura T, Nanamori K, Kawasaki Y, Hanaoka N, Nakamura E, Uchida K, Goel VK, Vishnubhotla L, Sairyo K. [https://journals.lww.com/spinejournal/Fulltext/2006/02010/Lumbar_Spinal_Disorders_in_Patients_With_Athetoid.23.aspx Lumbar spinal disorders in patients with athetoid cerebral palsy: a clinical and biomechanical study.] Spine. 2006 Feb 1;31(3):E66-70.</ref>; A number of studies proved the association between cerebral palsy and spondylolysthesis, certainly in athetoid cerebral palsy (60%)
Symptoms decrease with sitting or standing with lumbar flexion and with lying. As symptoms worsen patients are more and more limited in their activities and walking distance. This relationship is known as neurogenic intermittent claudication<ref name=":12">Phalen GS. et al, Spondylolisthesis and tight hamstrings. J Bone Joint Surg, 1961, 43:505–512 (Level of evidence 1B)</ref> <br>
*[[Scheuermann's Kyphosis|Scheuermanns Disease]]
 
*[[Scoliosis]]<ref name="Toshinori">Sakai T, Sairyo K, Suzue N, Kosaka H, Yasui N. [https://www.sciencedirect.com/science/article/pii/S0949265815309556 Incidence and etiology of lumbar spondylolysis: review of the literature.] Journal of orthopaedic science. 2010 May 1;15(3):281-8.</ref>
Spondylolisthesis can occur with other disorders and seems to have a link with some of them:
*[[Rheumatoid Arthritis|Rheumatoid arthritis]]
 
*[[Spinal Stenosis|Spinal stenosis]]<ref>Andersen T, Christensen FB, Langdahl BL, Ernst C, Fruensgaard S, Østergaard J, Andersen JL, Rasmussen S, Niedermann B, Høy K, Helmig P. [https://www.hindawi.com/journals/bmri/2013/123847/ Degenerative spondylolisthesis is associated with low spinal bone density: a comparative study between spinal stenosis and degenerative spondylolisthesis.] BioMed research international. 2013 Jan 1;2013.
*[[Spina Bifida Occulta]] <ref name="Mays" />&nbsp; <ref name="Sairyo">Sairyo, K., Goel, V.K., Vadapalli, S., Vishnubhotla, S.L., Biyani, A., Ebraheim, N. et al. (2006). Biomechanical comparison of lumbar spine with or without spina bifida occulta: a finite element analysis. Spinal Cord, 44, 440–4. (Level of evidence: 2C)</ref>&nbsp;<ref name="Burkus">Burkus, J.K. (1990). Unilateral spondylolysis associated with spina bifida occulta and nerve root compression. Spine (Phila Pa 1976), 15, 555–9. (Level of evidence: 3B)</ref>; Several studies support a positive association between spina bifida occulta and spondylolysthesis <ref name="Toshinori">Toshinori, S, Koichi, S., Naoto, S., Hirofumi, K., Natsuo, Y. (2010). Incidence and etiology of lumbar spondylolysis: review of the literature. Journal of Orthopaedic Science, 15, 281-288. (Level of evidence: 2A)</ref>. This high association may not be due to mechanical factors but to genetic factors <ref name="Sairyo" />.
</ref> <u></u><sub></sub><sup></sup>
 
*[[Cerebral Palsy Introduction|Cerebral Palsy]] <ref name="Sakai">Sakai, T., Yamada, H., Nakamura, T., Nanamori, K., Kawasaki, Y., Hanaoka, N. et al. (2006). Lumbar spinal disorders in patients with athetoid cerebral palsy: a clinical and biomechanical study. Spine (Phila Pa 1976), 31, E66–70. (Level of evidence: 2B)</ref>; A number of studies proved the association between cerebral palsy and spondylolysthesis, certainly in athetoid cerebral palsy (60%)  
 
*[[Scheuermanns Disease]] <ref name="Ogilvie">Ogilvie, J.W., Sherman, J. (1987). Spondylolysis in Scheuermann’s disease. Spine (Phila Pa 1976), 12, 251–3. (Level of evidence: 2B)</ref><ref name="Greene">Greene, T.L., Hensinger, R.N., Hunter, L.Y. (1985). Back pain and vertebral changes simulating Scheuermann’s disease. Journal of Pediatrics Orthopedics, 5, 1–7. (Level of evidence: 2B)</ref>; Ogilvie and Sherman reported a 50% incidence of spondylolIsthesis in 18 patients with Scheuermann’s disease <ref name="Ogilvie" />. Greene et al. found spondylolIsthesis (grade I or II) at L5-S1 in 32% of patients with Scheuermann’s disease <ref name="Greene" />.
 
*[[Scoliosis]]<ref name="Toshinori" />: Fisk et al. reported that the incidence in 539 patients with ideopathic scoliosis was 6.2%, which corresponded to that found in the general population <ref name="Fisk">Fisk JR, Moe JH, Winter RB. Scoliosis, spondylolysis, and spondylolisthesis: their relationship as reviewed in 539 patients. Spine (Phila Pa 1976) 1978;3:234–45. (Level of evidence 2B)</ref>. But the relation between scoliosis and spondylolisthesis has not been clarified<ref name="Toshinori" />&nbsp;
 
*&nbsp;Spinal stenosis<ref>Anderson T. et al, Degenerative spondylolisthesis is associated with low spinal bone density: a comparative study between spinal stenosis and degenerative spondylolisthesis, Biomed Res Int. 2013; 123847 (Level of evidence: 2A)
</ref><br><u></u><sub></sub><sup></sup>
== Differential Diagnosis  ==
== Differential Diagnosis  ==


#[[Spondylolysis|<font color="#0066cc">Spondylolysis</font>]] <ref name="Tsirikos">Tsirikos AI, Garrido EG. Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010 Jun;92(6):751-9. doi: 10.1302/0301-620X.92B6.23014 (Level of evidence 1A)</ref>&nbsp; <ref name="Thein-Nissenbaum">Thein-Nissenbaum J, Boissonnault WG. Differential diagnosis of spondylolysis in a patient with chronic low back pain. J Orthop Sports Phys Ther. 2005 May;35(5):319-26. (Level of evidence 4)</ref>&nbsp;  
#[[Spondylolysis|<font color="#0066cc">Spondylolysis</font>]] <ref name="Tsirikos">Tsirikos AI, Garrido EG. [https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.92B6.23014 Spondylolysis and spondylolisthesis in children and adolescents.] The Journal of bone and joint surgery. British volume. 2010 Jun;92(6):751-9.</ref>&nbsp; <ref name="Thein-Nissenbaum">Thein-Nissenbaum J, Boissonnault WG. [https://www.jospt.org/doi/abs/10.2519/jospt.2005.35.5.319 Differential diagnosis of spondylolysis in a patient with chronic low back pain.] Journal of Orthopaedic & Sports Physical Therapy. 2005 May;35(5):319-26.</ref>&nbsp;
#[[Skeletal Metastases|<font color="#0066cc">Metastatic disease</font>]] <ref name="Kalichman" />&nbsp;  
#[[Skeletal Metastases|<font color="#0066cc">Metastatic disease</font>]] <ref name="Kalichman">Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3793342/ Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population]. Spine. 2009 Jan 15;34(2):199.</ref>&nbsp;
#[[Low Back Pain|<font color="#0066cc">Low back pain</font>]] <ref name="Metzger">Metzger R, Chaney S. Spondylolysis and spondylolisthesis: what the primary care provider should know. J Am Assoc Nurse Pract. 2014 Jan;26(1):5-12. doi: 10.1002/2327-6924.12083. (Level of evidence 1C)</ref>  
#[[Low Back Pain|<font color="#0066cc">Low back pain</font>]] <ref name="Metzger">Metzger R, Chaney S. [https://onlinelibrary.wiley.com/doi/abs/10.1002/2327-6924.12083 Spondylolysis and spondylolisthesis: What the primary care provider should know.] Journal of the American Association of Nurse Practitioners. 2014 Jan;26(1):5-12.</ref>
#[[Osteoarthritis]] <ref name="Metzger" />&nbsp;  
#[[Osteoarthritis]] <ref name="Metzger" />&nbsp;  
#Neuroforaminal stenosis <ref name="Metzger" />&nbsp;  
#Neuroforaminal [[Lumbar Spinal Stenosis|stenosis]] <ref name="Metzger" />&nbsp;  
#[[Spinal Stenosis|<font color="#0066cc">Spinal Stenosis</font>]] <ref name="Metzger" />
#[[Spinal Stenosis|<font color="#0066cc">Spinal Stenosis</font>]] <ref name="Metzger" />


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


According to Jerrad MD. et al., an early diagnosis, i.e. in the first month after the first symptoms increase the likelihood of the formation of a bony callus. Panteliadis et al. concluded that the formation of a bony unit is not inevitable for a good clinical outcome of therapy. As it happens a fibrocartilaginous callus can also be sufficient for normal functioning and pain reduction, and can meet the requirements of an athlete.<ref>Garet M, Reiman MP, Mathers J, Sylvain J. Non-operative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review, Sports Health, 2013 May; 5(3):225-32 (Level of evidence 3A)
=== Physical Examination ===
</ref> [4) Radiographic examination provides the best diagnostic information when spondylolisthesis is suspected. Standard lumbar anteroposterior and lateral views are needed, but oblique views are essential to visualize the pars interarticularis directly. These views may demonstrate a pars interarticularis abnormality, which is depicted as a defect in the collar of the ‘‘Scotty dog.’’ Radiographic evaluation should not be an isolated clinical examination. It should be correlated with further examination such as history and physical examination.<ref>Nissenbaum J. et al, Differential diagnosis of spondylolysis in a patient with chronic low back pain. J Orthop Sports Phys Ther. 2005 May;35(5):319-26. (Level of evidence 4)</ref><br><br>Radiological assessments are required in order to make the diagnosis clear and to determine the grade and prognosis of spondylolisthesis.<ref>Kalpakcioglua B. et al; Determination of spondylolisthesis in low back pain by clinical evaluation; Journal of Back and Musculoskeletal Rehabilitation 22 (2009) 27–32 ( level of evidence 2B)</ref>  Most commonly used clinical imaging is X-ray, CT and MRI.<ref>Tsirikos AI et al, Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010 Jun;92(6):751-9. doi: 10.1302/0301-620X.92B6.23014 (Level of evidence 1A)
[[File:Step off sign.jpg|thumb|Step off sign]]
</ref>  Although guidelines for spondylolisthesis concerning X-ray, MRI and CT remain elusive<ref name=":13">Sinaki M. et al. Lumbar spondylolisthesis: retrospective comparison and three year follow-up of two conservative treatment programs. Arch Phys Med Rehabil 1989 70:594-598. (level of evidence 1B)
* Step off Sign-A noticeable Step off sign is palpated at the Lumbo sacral area due to slippage of the vertebrae.
</ref> . The following recommendations were drafted by The North American Spine Society (NASS) concerning the diagnosis of adult isthmic spondylolisthesis.<ref name=":5" /><br><br>1. There is insufficient evidence to make a recommendation for or against the use of palpation in the physical exam diagnosis of adult patients with isthmic spondylolisthesis. Grade of Recommendation: I (Insufficient Evidence) <br>2. Approximately half of adult patients with symptomatic isthmic spondylolisthesis will have a positive straight leg test on examination.  Grade of Recommendation: B (Suggested) <br>The most appropriate diagnostic tests for adult isthmic spondylolisthesis:<br>There is a relative paucity of high-quality studies on imaging in adult patients with isthmic spondylolisthesis. <br>• It is the opinion of the work group that in adult patients with history and physical examination findings consistent with isthmic spondylolisthesis, standing plain radiographs, with or without oblique views or dynamic radiographs, be considered as the most appropriate, non-invasive test to confirm the presence of isthmic spondylolisthesis. <br>• In the absence of a reliable diagnosis on plain radiographs, computed tomography scan is considered the most reliable diagnostic test to diagnose a defect of the pars interarticularis. <br>• In adult patients with radiculopathy, magnetic resonance imaging should be considered. <br>
 
* [[Straight Leg Raise Test]]-Straight raising of the leg with patient lying on the back causes pain and triggers the entire trunk.
* The clinical signs on examination include: a) flattened lumbar lordosis with palpable step of the spinous process (SP). The prominent SP may be tender in case of traumatic spondylolisthesis due to pars fracture. In isthmic L5/S1 spondylolisthesis the palpable SP is the L5, whereas in dysplastic L5/S1 spondylolisthesis the palpable is the S1; b) limitation of lumbar range of motion in flexion/extension; c) pain with single-limb standing lumbar extension. This manoeuvre is usually painful on the affected side; d) popliteal angles measuring more than 45 indicating hamstring tightness, which is present in 80% of symptomatic patients; e) positive straight leg raise test.<ref name=":5" />
 
=== Radiological Examination ===
[[File:Spondylolisthesis MRI.jpg|right|frameless]][[X-Rays|X Ray]]<nowiki/>s - Anteroposterior and lateral plain films, as well as lateral flexion-extension plain films, are the standard for the initial diagnosis of spondylolisthesis. One is looking for the abnormal alignment of one vertebral body to the next as well as possible motion with flexion and extension, which would indicate instability. In isthmic spondylolisthesis, there may be a pars defect, which is termed the "Scotty dog collar." The "Scotty dog collar" shows a hyperdensity where the collar would be on the cartoon dog, which represents the fracture of the pars interarticularis


Work Group Consensus Statement<br>1. MRI is suggested to identify neuroforaminal stenosis in adult patients with isthmic spondylolisthesis<ref name=":6" /><ref>Lonstein, J.E., Spondylolisthesis in children Cause, natural history, and management. Spine, 1999, 24, (24), 2640–2648. (Level of evidence: 2A)
* The slip angle (SA) was the first to describe the kyphotic relationship of L5 to S1.Together with the percentage of slippage, SA is used to assess segmental instability and progression of spondylolisthesis during conservative or surgical management.
</ref><ref name=":9">Sonne-Holm, S. et al, Lumbar spondylolysis: a life long dynamic condition? A cross sectional survey of 4,151 adults. European Spine Journal, 2007, 16, 821-828. (Level of evidence: 2B)
* Lumbo-sacral angle (LSA) relies on landmarks least affected by the spondylolisthesis pathophysiology. It is used to classify spondylolisthesis into: a) non-progressive, with a ‘horizontal’ sacrum producing an LSA of 100 or more, which seldom needs surgery and b) progressive, with a ‘vertical’ sacrum producing an LSA less than 100, which is usually symptomatic requiring surgical treatment. Furthermore, if the LSA fails to improve to 100 or more on preoperative hyperextension and traction films an anterior prior to the posterolateral fusion would be recommended.Even though other angles have been used to assess lumbosacral kyphosis the LSA shows the strongest correlation with the slippage grade.  
</ref> . Grade of Recommendation: B (Suggested)<br>2. There is insufficient evidence to make a recommendation for or against the use of magnetic resonance imaging to differentiate isthmic versus degenerative spondylolisthesis in adult patients<ref name=":9" /> . Grade of Recommendation: I (Insufficient Evidence)<br>3. There is insufficient evidence to make a recommendation for or against the use of discography to evaluate adult patients with isthmic spondylolisthesis<ref>Amato, M. et al, Spondylolysis of the lumbar spine: demonstration of defects and laminal fragmentation. Radiology, 1984, 153, 627-629. (Level of evidence: 2B)
* Pelvic incidence (PI) is defined as the angle between a perpendicular line to the mid-point of the sacral plate and a line from the mid-point of the sacral plate to the axis of the femoral heads.  
</ref> . Grade of Recommendation: I (Insufficient Evidence)<br>4. Computed tomography may be considered as an option to diagnose isthmic spondylolisthesis in adult patients<ref name=":8" /> . Grade of Recommendation: C (May Be Considered; Option)<br>5. There is insufficient evidence to make a recommendation for or against the use of single-photon emission computed tomography (SPECT) in evaluating isthmic spondylolisthesis in adult patients<ref>Belfi, L.M. et al, Computed tomography evaluation of spondylolysis and spondylolisthesis in asymptomatic patients. Spine (Phila Pa 1976), 2006, 31, E907-10. (Level of evidence: 2B)
* Sacral slope (SS) is the angle of the S1 endplate to the horizontal level.
</ref>. Grade of Recommendation: I (Insufficient Evidence)
* Pelvic tilt (PT) is the angle of the line crossing the midpoint of the S1 endplate and the vertical axis of the femoral heads. The PI is the sum of PT and SS (PI ¼ SS þ PI).PI may increase slightly during childhood but remains a constant anatomical parameter following skeletal maturity. In contrast, PT and SS are spatial orientation parameters and may vary for a given pelvis depending on the version or sagittal orientation of the sacrum/pelvis. A high PT indicates a retroverted pelvis, whereas a low PT tends to be associated with an anteverted pelvis. PI corresponds to the size of lumbar lordosis (LL) with deviation of 10 between the two measurements. Increased PI predisposes to the development of isthmic or the progression of dysplastic spondylolisthesis.<ref name=":5" />  


• '''X-ray'''<br>Overall X-ray of the spine and lumbosacral X-ray are seen as the golden standard for diagnosis.<ref name="Metzger" /> There are multiple views used with the most common one being the anteroposterior, lateral and oblique views.<ref>Tsirikos AI et al, Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010 Jun;92(6):751-9. doi: 10.1302/0301-620X.92B6.23014 (Level of evidence 1A)</ref> Multiple characteristics can be seen, such as the degree of the slip or the slip angle. The most prominent sign remains the defect of the pars interarticularis, or more commonly named the broken collar or neck of the “Scottie Dog”. <ref name="Foreman" /><br>• '''CT and MRI'''<br>Advanced imaging techniques like MRI and CT have to be used when neurological symptoms are present, and when surgical intervention is indicated.<ref>Kalpakcioglua B. et al; Determination of spondylolisthesis in low back pain by clinical evaluation; Journal of Back and Musculoskeletal Rehabilitation 22 (2009) 27–32 ( level of evidence 2B)</ref>  CT and MRI, which give an accurate localization and a better illustration of the lesion<ref name="Fisk" /> , are taken when one of the following signs are present<ref name=":8" />:<br>• Significant and progressing neurologic claudication <br>• Radiculopathies and the clinical suspicion that another condition may be causative <br>• Bladder or bowel complaints <br>• Metastatic disease<ref name="Metzger" />


CT and MRI give the best visualization of bone morphology and are therefore, most often used to check the alignment of the facet joints and their degenerative changes. <ref>Tsirikos AI et al, Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010 Jun;92(6):751-9. doi: 10.1302/0301-620X.92B6.23014 (Level of evidence 1A)</ref> Images resulting from CT and MRI are the most sensitive and specific when a pars fracture is present.<ref name="Foreman" />  Myelography can be used together with CT, but nowadays MRI is used instead. <ref name=":8" />
Computed tomography ([[CT Scans|CT]]) of the spine -  provides the highest sensitivity and specificity for diagnosing spondylolisthesis. Spondylolisthesis can be better appreciated on sagittal reconstructions as compared to axial CT imaging. 


<br> [[Image:Diagnostic.png]]<br><br><br><br>
[[MRI Scans|MRI]] of the spine can show associated soft tissue and disc abnormalities, but it is relatively more challenging to appreciate bony detail and a potential pars defect on MRI.<ref name=":1" />


== Outcome Measures ==
== Outcome Measures ==
* Disability: <font color="#0066cc">Oswestry Disability Index, the SF-36 Physical Functioning scale, the Quebec Back Pain Disability Scale</font><ref>Davidson, M. & Keating, J.L., A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther. 2002 Jan;82(1):8-24 (Level of evidence 2B)
* Disability: <font color="#0066cc">Oswestry Disability Index, the SF-36 Physical Functioning scale, the Quebec Back Pain Disability Scale</font><ref>Davidson M, Keating JL. [https://academic.oup.com/ptj/article-abstract/82/1/8/2836935 A comparison of five low back disability questionnaires: reliability and responsiveness.] Physical therapy. 2002 Jan 1;82(1):8-24.
</ref>  
</ref>
* Dysfunctional thoughts: <font color="#0066cc">Short Form of the Medical Outcomes Study (SF-36)</font><ref name=":14">Monticone M. et al., Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial. Eur Spine J. (2014) Jan 23(1):87-95. (LE 1B)
* Dysfunctional thoughts: <font color="#0066cc">Short Form of the Medical Outcomes Study (SF-36)</font><ref name=":14">Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Bruno MB. [https://link.springer.com/article/10.1007/s00586-013-2889-z Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial.] European spine journal. 2014 Jan;23(1):87-95.  
</ref>
</ref>
* Pain: <font color="#0066cc">Pain Numerical Rating Scale, [[Visual Analogue Scale|VAS]].</font>  
* Pain: <font color="#0066cc">Pain Numerical Rating Scale, [[Visual Analogue Scale|VAS]].</font>  
Line 142: Line 113:
* Kinesiophobia and Catastrophising: <font color="#0066cc">Tampa Scale for Kinesiophobia, Pain Catastrophising Scale</font><ref name=":14" />
* Kinesiophobia and Catastrophising: <font color="#0066cc">Tampa Scale for Kinesiophobia, Pain Catastrophising Scale</font><ref name=":14" />


== Examination ==
== Medical Management ==
* History: Specific questions referring to pain, location, severity, duration, quality- tingling, burning sensations, exacerbating factors, alleviating factors, leisure activities , occupational risks and pain changes throughout day- difference morning compared to evening/night?
For grade I and II spondylolisthesis, treatment typically begins with conservative therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), heat, light exercise, traction, bracing, and/or bed rest.  
* General<ref name=":2" /><br>
 
== Medical Management  ==
 
'''Conservative''' <ref name="Kalichman" />&nbsp;<ref name="Weinstein">James N. Weinstein, Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis,New England Journal of Medicine. May 2007; 356:2257-2270. (Level of evidence 2B)</ref>


*Initially resting and avoiding movements like lifting, bending, and sports.  
=== Conservative &nbsp; ===
*Initially resting and avoiding movements like lifting, bending, and sports.<ref name="Kalichman" />
*Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-inflammatory effect&nbsp;on nerve root and joint irritation.  
*Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-inflammatory effect&nbsp;on nerve root and joint irritation.  
*Epidural steroid injections can be used to relieve low back pain, lower extremity pain related to radiculopathy and neurogenic claudication.
*Epidural steroid injections can be used to relieve low back pain, lower extremity pain related to radiculopathy and neurogenic claudication.<ref name="Weinstein">Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa FP, Albert TJ. [https://www.nejm.org/doi/full/10.1056/NEJMoa070302 Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis.] New England Journal of Medicine. 2007 May 31;356(22):2257-70.</ref>
*A brace may be useful to decrease segmental spinal instability and pain. <ref name="Funao" />
*A brace may be useful to decrease segmental spinal instability and pain. <ref name="Funao">Funao H, Tsuji T, Hosogane N, Watanabe K, Ishii K, Nakamura M, Chiba K, Toyama Y, Matsumoto M. [https://link.springer.com/article/10.1007/s00586-012-2374-0 Comparative study of spinopelvic sagittal alignment between patients with and without degenerative spondylolisthesis.] European Spine Journal. 2012 Nov;21(11):2181-7.</ref>
 
*Physiotherapy focuses on relieving extension stresses from the lumbosacral junction (hamstring and hip flexor stretching), as well as working on core strengthening (deep abdominal muscles and lumbar multifidus strengthening).
<br>'''Surgical'''
 
Patients with chronic and disabling symptoms, who fail to respond to conservative management may be referred for surgery.<ref name=":14" /> Severe spinal instability may also require spinal fusion. The goal of surgery is to stabilize the segment with spondylolisthesis, decompress the neural elements, reconstruction of the disc space height and restoration of normal sagittal alignment.<ref name=":0" /><ref name=":15">Chang Hyun Oh et al., Slip Reduction Rate between Minimal Invasive and Conventional Unilateral Transforaminal Interbody Fusion in Patients with Low-Grade Isthmic Spondylolisthesis, Korean J Spine, 2013 (Level of evidence 2C)
</ref>It can also help to reduce pain, improve spinal function and increase the quality of life The grade of spondylolisthesis can be reduced to some extent, but a complete reduction is rarely achieved.<ref name=":15" /> Surgical complications such as neurological complications, vascular injury, instrument failure, and infections may occur.<ref name=":12" />
 
'''Indications for Surgery'''<ref name=":8" /><ref>Sairyo K., Decompression Surgery For Lumbar Spondylolysis Without Fusion: A Review Article, The Internet Journal of Spine Surgery, 2005. (Level of evidence 1A)
</ref>  


*Neurologic signs- neurogenic claudication / radiculopathy 
=== Surgical ===
*Myelopathy
Approximately 10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment and need surgical treatment.
*High-grade slip (&gt;50%)
* No definitive standards exist for surgical treatment.
*Type 1 and 2 slips with evidence of instability, progression of spondylolisthesis
* Surgical treatment includes a varying combination of decompression, fusion with or without instrumentation, or interbody fusion.
*Type 3  spondylolisthesis with gross instability and incapacitating pain
* Patients with instability are more likely to require operative intervention. 
*Bladder or bowel symptoms (especially in type 3)
* Some surgeons recommend a reduction of the spondylolisthesis if able as this not only decreases foraminal narrowing but also can improve spinopelvic sagittal alignment and decrease the risk for further degenerative spinal changes in the future. The reduction can be more difficult and riskier in higher grades and impacted spondylolisthesis<ref name=":1" /><nowiki/><u></u><sub></sub><sup></sup>
*Traumatic spondylolisthesis  
* The Scott technique utilizing cerclage wire fixation has been successful with satisfactory results varying between 80%–100%. The butterfly plate technique, Pedicle screw hook fixation, Pedicle screw rod fixation in combination with a screw hook, , pedicle screw cable system, and an intralaminar link construct are some of the other surgical <nowiki/><u></u><sub></sub><sup></sup>techniques.
*Iatrogenic spondylolisthesis
*Postural deformity and gait abnormality
 
'''Contra-indications to Surgery'''<ref name=":0" />
 
*Poor medical health
*High operative risk (higher risk than potential benefits)
*High risk of hemorrhage: Anticoagulation with warfarin, or antiplatelet therapy
*Smoking
 
<br>There are several different options for surgical treatment; one of them is fusion (e.g. posterolateral fusion). The aim of fusion is to reduce pain by reducing the motion of the segment. Other treatment options include decompression (Gill laminectomy), supplemental instrumentation and supplemental anterior column support. Controversies exist about the effectiveness of these treatment options that can be used separately or in any combination.<ref name=":12" /><ref name=":8" />. <u></u><sub></sub><sup></sup>The same principles are maintained with children: conservative treatment is recommended and proven to be effective. Instrumented posterolateral fusion is indicated in patients with persistent symptoms and for iatrogenic cases.<ref name=":11" />
== Physical Therapy Management  ==
== Physical Therapy Management  ==


A systematic review including 10 articles from which 5 were RCT, concluded that no consensus could be reached on the role of nonoperative care vs. surgery due to the heterogeneity of the different studies reported. Spondylolisthesis should be treated first with conservative therapy, which includes physical therapy, rest, medication and braces.<ref>Serena S. Hu et al., Spondylolisthesis and Spondylolysis, J Bone Joint Surg Am, 2008 Mar 01;90(3):656-671 (Level of evidence 3A)
Spondylolisthesis should be treated first with conservative therapy, which includes physical therapy, rest, medication and braces.<ref>Hu SS, Tribus CB, Diab M, Ghanayem AJ. [https://journals.lww.com/jbjsjournal/fulltext/2008/03000/spondylolisthesis_and_spondylolysis.25.aspx Spondylolisthesis and spondylolysis.] JBJS. 2008 Mar 1;90(3):656-71.
</ref><ref>Kalpakcioglua B. et al; Determination of spondylolisthesis in low back pain by clinical evaluation; Journal of Back and Musculoskeletal Rehabilitation 22 (2009) 27–32 ( level of evidence 2B)
</ref><ref>Kalpakcioglu B, Altınbilek T, Senel K. [https://content.iospress.com/articles/journal-of-back-and-musculoskeletal-rehabilitation/bmr00212 Determination of spondylolisthesis in low back pain by clinical evaluation.] Journal of Back and Musculoskeletal Rehabilitation. 2009 Jan 1;22(1):27-32.
</ref>
</ref>


<br>
The Rehabilitation exercise program should be designed to improve muscle balance rather than muscle strength alone. <ref name=":17">Nava-Bringas TI, Ramírez-Mora I, Coronado-Zarco R, Macías-Hernández SI, Cruz-Medina E, Arellano-Hernández A, Hernández-López M, León-Hernández SR. [https://content.iospress.com/articles/journal-of-back-and-musculoskeletal-rehabilitation/bmr00457 Association of strength, muscle balance, and atrophy with pain and function in patients with degenerative spondylolisthesis.] Journal of back and musculoskeletal rehabilitation. 2014 Jan 1;27(3):371-6.
*&nbsp;Exercise therapy
</ref>


There is strong evidence for exercise therapy, which consists of strengthening exercises of the deep abdominal musculature.. In addition, isometric and isotonic exercises may be beneficial for strengthening of the main muscle groups of the trunk, which stabilize the spine. These techniques may also play a role in pain reduction.. In order to improve the patient’s mobility, physical therapy includes stretching exercises of the hamstrings, hip flexors and lumbar paraspinal muscles<ref>Jerrad MD. Et al., Bony Healing in a Patient with Bilateral L5 Spondylolysis. Current Sports Medicine Reports, (2005) 35-37. (Level of evidence 5)
Good exercise choices include:
</ref><ref name=":16">Van Tulder M.W. et al, Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions, Spine, 1997; 22(18): 2128-2156 f(Level of evidence 1A) </ref><ref name=":13" />  
* Isometric and isotonic exercises beneficial for strengthening of the main muscles of the trunk, which stabilize the spine. These techniques may also play a role in pain reduction<ref name=":3">Zimmerman J, Simons SM. [https://link.springer.com/content/pdf/10.1007/s11932-005-0028-2.pdf Bony healing in a patient with bilateral L5 spondylolysis.] Current sports medicine reports. 2005 Jan 1;4(1):35-7.  
 
</ref><ref name=":16">Van Tulder MW, Koes BW, Bouter LM. [https://journals.lww.com/spinejournal/fulltext/1997/09150/conservative_treatment_of_acute_and_chronic.12.aspx Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions]. Spine. 1997 Sep 15;22(18):2128-56.</ref><ref name=":13">Sinaki M, Lutness MP, Ilstrup DM, Chu CP, Gramse RR. [https://www.archives-pmr.org/article/0003-9993(89)90085-3/abstract Lumbar spondylolisthesis: retrospective comparison and three-year follow-up of two conservative treatment programs.] Archives of physical medicine and rehabilitation. 1989 Aug 1;70(8):594-8.
Furthermore, endurance training is effective for chronic low back pain.<ref name=":16" /><ref>Margaret L. McNeely et al.; A systematic review of physiotherapy for spondylolysis and spondylolisthesis; Manual Therapy (2003) 8(2), 80–91. ( level of evidence 1B)
</ref>.
</ref>The objective of stretching and strengthening is to decrease the extension forces on the lumbar spine, due to agonist muscle tightness, antagonist weakness, or both, which may result in decreased lumbar lordosis.<ref name=":16" /> Rehabilitation programs should be designed to improve muscle balance rather than muscle strength alone. <ref name=":17">Nava-Bringasa T.I. et al; Association of strength, muscle balance, and atrophy with pain and function in patients with degenerative spondylolisthesis; Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 371–376 (level of evidence 2B)
* [[Core Stability|Core stability exercises]], useful in reducing pain and disability in chronic low back pain in patient with spondylolisthesis.<ref>Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K. [https://www.sciencedirect.com/science/article/pii/S0004951406700435 Specific stabilisation exercise for spinal and pelvic pain: a systematic review.] Australian Journal of Physiotherapy. 2006 Jan 1;52(2):79-88.
</ref>  
</ref><ref name=":17" />
* Movements in closed-chain-kinetics, antilordotic movement patterns of the spine, elastic band exercises in the lying position
* [[Gait|Gait training]]
* Stretching and strengthening exercises, objective of stretching and strengthening is to decrease the extension forces on the lumbar spine, due to agonist muscle tightness, antagonist weakness, or both, which may result in decreased lumbar lordosis.<ref name=":16" /> In order to improve the patient’s mobility stretching exercises of the hamstrings, hip flexors and lumbar paraspinal muscles are important.<ref name=":3" /><ref name=":16" /><ref name=":13" />
* Balance training including - Sensomotoric training on unstable devices, walking in all variations, coordinative skills<br>[[Hydrotherapy]]
* Endurance training of muscles, effective for chronic low back pain.<ref name=":16" /><ref>McNeely ML, Torrance G, Magee DJ. [https://www.sciencedirect.com/science/article/pii/S1356689X02000668 A systematic review of physiotherapy for spondylolysis and spondylolisthesis.] Manual therapy. 2003 May 1;8(2):80-91.
</ref>
* Cardiovascular exercise -  Athletes with spondylolysis and first-degree spondylolisthesis can take part in all sports activities. However, attention should be given to those kinds of sport where recurring trauma resulting from repeated flexion, hyperextension and twisting is usually undertaken (e.g. gymnastics, aerobics, swimming in the dolphin technique). Athletes with a grade 2, 3 or 4 can also participate in all the sport activities but have to do this with a special and individually adapted directive.Low aerobic impact sports are highly recommended. Sports that certainly can be practiced are walking, swimming and cross-training. Although these activities will not improve the shift, these sports are a good alternative for cardiovascular exercises. Impact sports like running should not be done in order to avoid wear. The adolescent athlete or manual laborer should avoid hyperextension and/or contact sports.
* [[Williams Flexion Exercise|Williams flexion exercises]] are a set of exercises that decrease lumbar extension and focuses on lumbar flexion. These include
*# Pelvic Tilts
*# Partial sit-ups
*# Knee-to-chest
*# Hamstring stretch
*# Standing lunges
*# Seated trunk flexion
*# Full squat
<br>[[Image:Exercise strengthening deep abdominal muscles.png]]


There is evidence that suggests that specific stabilization exercises and core stability exercises can be useful in reducing pain and disability in chronic low back pain in patient with spondylolisthesis.<ref>Paulo H Ferreira et al.; Specific stabilisation exercise for spinal and pelvic pain: A systematic review; Australian Journal of Physiotherapy 2006 Vol. 52 ( level of evidence 1A)
Figure 3: Strengthening of the deep abdominal muscles.<br>Alternating legs, with leg extension while exhaling,&nbsp;maintaining contraction of transverse abdominis, paravertebral and pelvic floor muscles <ref name="Garcia">Garcia AN, Costa LD, da Silva TM, Gondo FL, Cyrillo FN, Costa RA, Costa LO. [https://academic.oup.com/ptj/article-abstract/93/6/729/2735330 Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial.] Physical therapy. 2013 Jun 1;93(6):729-47.</ref>&nbsp;<br>  
</ref><ref name=":17" /> 
 
**Movements in closed-chain-kinetics
**Renewing of the motion-pattern
**Antilordotic movement patterns of the spine
**Elastic band exercises in the lying position
**Gait training
**Brace-gymnastics
**Stretching exercises
**Sensomotoric training on unstable devices
**Functional electric stimulation
**Walking in all variations
**Underwater therapy
**Balance training
**Coordinative skills<br><br>
 
<br>
 
[[Image:Exercise strengthening deep abdominal muscles.png]]
 
Figure 3: Strengthening of the deep abdominal muscles.<br>Alternating legs, with leg extension while exhaling,&nbsp;maintaining contraction of transverse abdominis, paravertebral and pelvic floor muscles <ref name="Garcia">Garcia A.N. et al., Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain : a randomized controlled trial, Phys Ther, 2013; 93(6):729-47. (Level of evidence 1B)</ref>&nbsp;<br>  


<br>[[Image:Exercise horizontal slide support.png]]<br>  
<br>[[Image:Exercise horizontal slide support.png]]<br>  


Figure 4: Horizontal side support exercise for core stability <ref name="Childs">Childs J.D. et al, Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers: a cluster randomized trial, Phys Ther, 2010; 90 (10): 1404-12. (Level of evidence 1B)</ref>&nbsp;.<br>  
Figure 4: Horizontal side support exercise for core stability <ref name="Childs">Childs JD, Teyhen DS, Casey PR, McCoy-Singh KA, Feldtmann AW, Wright AC, Dugan JL, Wu SS, George SZ. [https://academic.oup.com/ptj/article-abstract/90/10/1404/2737706 Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers: a cluster randomized trial.] Physical therapy. 2010 Oct 1;90(10):1404-12.</ref>&nbsp;.<br>  


[[Image:Exercise stretching erector spine.png]]  
[[Image:Exercise stretching erector spine.png]]  
Line 228: Line 172:
<br>  
<br>  


Figure 5: Stretching of the erector spine muscles. <ref name="Garcia" />  
Figure 5: Stretching of the erector spine muscles. <ref name="Garcia" />


*Lumbosacral braces or corset
=== Treatment Options Other Than Exercise Include ===


In healthy subjects, it has been found that the lumbosacral brace can improve the sitting position of the patient. The fact that there was wear of the brace, indicates that the brace has an important function in the sitting position.<ref>Mathias M. et al, In healthy subjects, the sitting position can be used to validate the postural effects induced by wearing a lumbar lordosis brace. , Ann Phys Rehabil Med. 2010 Oct (level of evidence 2B)</ref> According to Prateepavanich et al., a lumbosacral corset can be used to improve walking distance and to reduce pain in daily activities<ref>Prateepavanich P. et al., The effectiveness of lumbosacral corset in symptomatic degenerative lumbar spinal stenosis, J Med Assoc Thai., 2001; 84(4):572-6. (Level of evidence 2B)</ref>, but it does not reduce the shift of the vertebra. It is a good aid during the painful periods but should be discontinued when the patients' complaints are reduced.  
==== Lumbosacral Braces or Corset ====
*&nbsp;Posture and lifting techniques
In healthy subjects, it has been found that the lumbosacral brace can improve the sitting position of the patient. The fact that there was wear of the brace, indicates that the brace has an important function in the sitting position.<ref>Mathias M, Rougier PR. [https://www.sciencedirect.com/science/article/pii/S1877065710001909 In healthy subjects, the sitting position can be used to validate the postural effects induced by wearing a lumbar lordosis brace]. Annals of physical and rehabilitation medicine. 2010 Oct 1;53(8):511-9.</ref> According to Prateepavanich et al., a lumbosacral corset can be used to improve walking distance and to reduce pain in daily activities<ref>ANICH PP, SANTISATISAKUL P. [http://www.jmatonline.com/files/journals/1/articles/4451/public/4451-21913-1-PB.pdf The Effectiveness of Lumbosacral Corset in Sympto-matic Degenerative Lumbar Spinal Stenosis.] J Med Assoc Thai. 2001;84:572-6.</ref>, but it does not reduce the shift of the vertebra. It is a good aid during the painful periods but should be discontinued when the patients' complaints are reduced. It aids in decreasing neurogenic claudication while walking.<ref>Bydon M, Alvi MA, Goyal A. [https://books.google.com/books?hl=en&lr=&id=wlmXDwAAQBAJ&oi=fnd&pg=PA299&dq=Bydon+M,+Alvi+MA,+Goyal+A.+Degenerative+lumbar+spondylolisthesis.+definition,+natural+history,+conservative+management,+and+surgical+treatment.+2019+Jul+5%3B30:299-304.&ots=eKOQ802tvw&sig=ZJrxXQDrH2t2fRnkioBcrHPTTVA Degenerative lumbar spondylolisthesis. definition, natural history, conservative management, and surgical treatment.] 2019 Jul 5;30:299-304.
</ref>


Special attention has to be given to posture and proper lifting techniques<ref name=":10" /> wherein the physiotherapist has an important educational role. Lifting techniques is effective for chronic low back pain.<ref>Margaret L. McNeely et al.; A systematic review of physiotherapy for spondylolysis and spondylolisthesis; Manual Therapy (2003) 8(2), 80–91. ( level of evidence 1B)
==== Education - Posture and Lifting Techniques ====
</ref><ref name=":16" />  
Special attention has to be given to posture and proper lifting techniques<ref name=":10">Agabegi SS, Fischgrund JS. [https://www.sciencedirect.com/science/article/pii/S1529943010001282 Contemporary management of isthmic spondylolisthesis: pediatric and adult.] The Spine Journal. 2010 Jun 1;10(6):530-43.
*&nbsp;Management of catastrophising and kinesiophobia
</ref> wherein the physiotherapist has an important educational role. Lifting techniques is effective for chronic low back pain.<ref>McNeely ML, Torrance G, Magee DJ. [https://www.sciencedirect.com/science/article/pii/S1356689X02000668 A systematic review of physiotherapy for spondylolysis and spondylolisthesis]. Manual therapy. 2003 May 1;8(2):80-91.
</ref><ref name=":16" />


Physical therapy treatment in combination with management of catastrophising and kinesiophobia gave good results. The disability, pain, dysfunctional thoughts were significant reduced.<ref>Monticone M. et al, Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial , Eur Spine J. 2014 Jan (level of evidence 1B)
==== Management of Catastrophising and Kinesiophobia ====
</ref>  
Physical therapy treatment in combination with management of catastrophising and kinesiophobia gave good results. The disability, pain, dysfunctional thoughts were significant reduced.<ref>Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Bruno MB. [https://link.springer.com/article/10.1007/s00586-013-2889-z Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis.] A randomised controlled trial. European spine journal. 2014 Jan;23(1):87-95.
</ref>


*&nbsp;Alternative cardiovascular exercise
'''Massage therapy'''


Athletes with spondylolysis and first-degree spondylolisthesis can take part in all sports activities. However, attention should be given to those kinds of sport where recurring trauma resulting from repeated flexion, hyperextension and twisting is usually undertaken (e.g. gymnastics, aerobics, swimming in the dolphin technique). Athletes with a grade 2, 3 or 4 can also participate in all the sport activities but have to do this with a special and individually adapted directive.<ref>Antony Wicker et al; Spondylolysis and spondylolisthesis in sports; International SportMed Journal, Vol. 9 No.2, 2008 pp.74-7 (level of evidence 2B)
A case report showed that the onset of low back pain was delayed during walking/standing.  During a prescribed course of [[Massage|massage therapy]]:<ref name=":0">Halpin S. [https://www.sciencedirect.com/science/article/pii/S1360859211000684 Case report: The effects of massage therapy on lumbar spondylolisthesis]. Journal of bodywork and movement therapies. 2012 Jan 1;16(1):115-23.
</ref> <u></u><sub></sub><sup></sup>Low aerobic impact sports are highly recommended.<ref name=":10" /> Sports that certainly can be practiced are walking, swimming and cross-training. Although these activities will not improve the shift, these sports are a good alternative for cardiovascular exercises.<ref name=":8" /> Impact sports like running should not be done in order to avoid wear. The adolescent athlete or manual laborer should avoid hyperextension and/or contact sports.<ref name=":10" /> 
* Massage therapy
A case report showed that the onset of low back pain was delayed during walking/standing over the course of treatment, hyperlordosis decreased, and hypertonicity of iliopsoas and quadratus lumborum muscles decreased. Bilateral net reduction of illial rotation was achieved, but with irregular changes. These results were inconclusive but bring into question the role of hip flexor and spinal extensor muscles in normalizing postural misalignment associated with spondylolisthesis.<ref>Halpin, Shannon. "Case report: The effects of massage therapy on lumbar spondylolisthesis." Journal of bodywork and movement therapies 16.1 (2012): 115-123. (level of evidence: 4)
</ref>
</ref>
* Pulsed radiofrequency (PRF)
* Hyperlordosis decreased
Results of a cohort study demonstrated that the application of PRF might be more effective than steroid and bupivacaine injection in decreasing back pain due to degenerative facet pain and improvement in function of patients with degenerative spondylolisthesis.<ref>Hashemi, Masoud, et al. "Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis." European Spine Journal 23.9 (2014): 1927-1932. (level of evidence 2B)
* Hypertonicity of iliopsoas and quadratus lumborum muscles decreased
</ref><br><br>
* Bilateral net reduction of ilial rotation was achieved, but with irregular changes.
 
These results were inconclusive but bring into question the role of hip flexor and spinal extensor muscles in normalizing postural misalignment associated with spondylolisthesis<ref name=":0" />.
== Key Research  ==


• Steven, S.A. et al, (20mc10). Contemporary management of isthmic spondylolisthesis: pediatric and adult. The Spine Journal, 2010, 530-543. (Level of evidence: 1A)<br>• Van Tulder M.W. et al, Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions, Spine, 1997; 22(18): 2128-2156 f(Level of evidence 1A)<br>• Paulo H Ferreira et al.; Specific stabilisation exercise for spinal and pelvic pain: A systematic review; Australian Journal of Physiotherapy 2006 Vol. 52 ( level of evidence 1A)<br>
== Key Research ==
== Clinical bottom line  ==
* Agabegi SS, Fischgrund JS. [https://www.sciencedirect.com/science/article/pii/S1529943010001282 Contemporary management of isthmic spondylolisthesis: pediatric and adult.] The Spine Journal. 2010 Jun 1;10(6):530-43.
* Van Tulder MW, Koes BW, Bouter LM. [https://journals.lww.com/spinejournal/fulltext/1997/09150/conservative_treatment_of_acute_and_chronic.12.aspx Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions.] Spine. 1997 Sep 15;22(18):2128-56.
* Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K. [https://www.sciencedirect.com/science/article/pii/S0004951406700435 Specific stabilisation exercise for spinal and pelvic pain: a systematic review.] Australian Journal of Physiotherapy. 2006 Jan 1;52(2):79-88.


Spondylolisthesis is defined as a translation of one vertebra over the adjacent caudal vertebra. This can be a translation in the anterior (anterolisthesis) or posterior direction (retrolysthesis) or, in more serious cases, anterior-caudal direction. It is classified on the basis of etiology into the following six types by Wiltse: Dysplastic (congenital), isthmic, degenerative, traumatic, pathologic and iatrogenic spondylolisthesis.<br>Radiographic examination provides the best diagnostic information when spondylolisthesis (or spondylosis) is suspected. Spondylolisthesis should be treated first with conservative therapy and when this fails, surgery is referred. When the condition of spinal instability is very severe, a surgical intervention may be necessary to fuse the vertebras together. This can be a fusion or Gill laminectomy. <br>  
== Clinical Bottom Line  ==
* An inter-professional team consisting of a speciality-trained orthopedic nurse, physical therapist, and an orthopedic surgeon or neurosurgeon will provide the best outcome and long-term care of patients with degenerative spondylolisthesis.
* Treating clinician will decide on the management plan, and then have the other team members engaged - surgical cases with include the nursing staff in pre-, intra-, and post-operative care, and coordinating with PT for rehabilitation.  
* In non-operative cases (majority), the PT keeps the rest of the team informed of progress (or lack of).  
* The team should encourage weight loss as weight reduction may reduce symptoms and increase the quality of life.
* Inter-professional collaboration, as above, will drive patient outcomes to their best results.<ref name=":1" />


== References  ==
== References  ==
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] [[Category:Cerebral_Palsy]] [[Category:Primary Contact]]
[[Category:Vrije_Universiteit_Brussel_Project]]  
[[Category:Cerebral_Palsy]]  
[[Category:Primary Contact]]
<references />
[[Category:Conditions]]
[[Category:Lumbar Spine]]
[[Category:Lumbar Spine - Conditions]]

Latest revision as of 17:14, 29 February 2024

Original Editor - Margo De Mesmaeker

Top Contributors - Maëlle Cormond, Simisola Ajeyalemi, Evi Peeters, Margo De Mesmaeker, Kim Jackson, Admin, Chrysolite Jyothi Kommu, Kenneth de Becker, Shaimaa Eldib, Lucinda hampton, Rachael Lowe, Mike Myracle, Evan Thomas, Carlos De Coster, Johnathan Fahrner, Aminat Abolade, Mariam Hashem, Shreya Pavaskar, Camille Linussio, Claire Knott, Rucha Gadgil, Laura Ritchie, Jess Bell, Kirenga Bamurange Liliane and Scott Buxton

Definition/Description[edit | edit source]

Spondylolisthesis grading.jpg

Spondylolisthesis is the slippage of one vertebral body with respect to the adjacent vertebral body causing mechanical or radicular symptoms or pain. It can be due to congenital, acquired, or idiopathic causes. Spondylolisthesis is graded based on the degree of slippage (Meyerding Classification) of one vertebral body on the adjacent vertebral body.[1]

Clinical Anatomy[edit | edit source]

Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the cervical spine and rarely, except for trauma, in the thoracic spine.[1]

Spondylolisthesis, regardless of the type, is mostly common preceded by spondylolysis. This pathology involves

  • A fractured pars interarticularis of the lumbar vertebrae, also called the isthmus.
  • This affects the supporting structural integrity of the vertebrae, which could lead to slippage of the corpus of the vertebrae, called spondylolysthesis.
  • In turn, leads to one of the most obvious manifestations of lumbar instability.
  • Slippage can occur in 2 directions- most commonly in anterior translation, called anterolisthesis, or a backward translation, called retrolisthesis.[2]

A study of Dai L.Y. analysed the correlation between disc degeneration and the age, duration and severity of clinical symptoms and grade of vertebral slip. The disc degeneration on sub segmental level was significantly related to age and duration of clinical symptoms, although it was not related to the severity of clinical symptoms or the grade of vertebral slip[3].

Epidemiology[edit | edit source]

  • Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese.
  • Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males.
  • Dysplastic spondylolisthesis is more common in the pediatric population, with females more commonly affected than males. Current estimates for prevalence are 6 to 7% for isthmic spondylolisthesis by the age of 18 years, and up to 18% of adult patients undergoing MRI of the lumbar spine. 
  • Grade I spondylolisthesis accounts for 75% of all cases.
  • Spondylolisthesis most commonly occurs at the L5-S1 level with anterior translation of the L5 vertebral body on the S1 vertebral body.
  • The L4-5 level is the second most common location for spondylolisthesis.[1] 

Etiology[edit | edit source]

  • Repetitive stress to the pars interarticularis
  • Decreased strength of the neural arch at a young age predisposes children and adolescents to a higher risk of fracture.
  • Traumatic accidental injuries
  • Microtrauma in sports
  • Pathological causes - Neoplasm, connective tissue disease, etc.
  • Iatrogenic - After laminectomy
  • Adolescents and children also have more elastic intervertebral disks which cause increased stress to be placed on the pars interarticularis

Classification[edit | edit source]

There are different classification systems regarding the etiology, terminology, subtypes of spondylolysis and spondylolisthesis, and treatment.
A. Wiltse Classification [4] is one of the most commonly used classification systems to convey the etiology of spondylolisthesis (see table below). It has five major etiologies: degenerative, isthmic, traumatic, dysplastic, or pathologic.

Scottie dog .png[5]
  1. Dysplastic spondylolisthesis (Type 1) is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment.  In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation.
  2. Isthmic spondylolisthesis results from defects in the pars interarticularis. The cause of isthmic spondylolisthesis is undetermined, but a possible etiology includes microtrauma in adolescence related to sports such as wrestling, football, and gymnastics, where repeated lumbar extension occurs. Type II is isthmic and is separated into Type IIA and Type IIB. Type IIA is caused by a stress fracture of the pars interarticularis (spondylolysis) that results in anterior slippage of the vertebrae. Type II B is caused by repetitive fractures and subsequent healing which results in lengthening of the pars interarticularis leading to anterior slippage of the vertebrae.[4]
  3. Degenerative spondylolisthesis (Type 3) occurs from degenerative changes in the spine without any defect in the pars interarticularis. It is usually related to combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body relative to the adjacent vertebral body. Arthritis of facet joint which in turn causes weakness of ligamentum flavum leads to anterior slippage of vertebra.
  4. Traumatic spondylolisthesis (Type 4)occurs after fractures of the pars interarticularis or the facet joint structure and is most common after trauma.
  5. Pathologic spondylolisthesis (Type 5) can be from systemic causes such as bone or connective tissue disorders or a focal process, including infection, neoplasm.
  6. Iatrogenic spondylolisthesis (Type 6) is a potential sequela of spinal surgery. Frequently, these patients will have undergone prior laminectomy

Additional risk factors for spondylolisthesis include a first-degree relative with spondylolisthesis, scoliosis, or Spina Bifida at the S1 level[1]

Wlitse.jpg


The Myerding classification defines the amount of vertebral slippage on X-ray in reference to the caudal vertebrae.4 There are five grades of spondylolisthesis in the Myerding classification. Grade I is less than 25 percent slippage, grade II is 26–50% slippage, grade III is 51–75% slippage, grade IV is 76–100% slippage, and grade V is over 100% slippage and is referred to as spondyloptosis[4].

Clinical Presentation[edit | edit source]

Symptoms and findings in spondylolisthesis [6]

  • Patients typically have low back pain which mimics radiculopathy for lumbar spondylolisthesis and localized/radiating neck pain for cervical spondylolisthesis.
  • Pain is exacerbated by extending at the affected segment, as this can cause mechanic pain from motion, leading to diminished ROM (spine). Pain decreases as the patient assumes flexed posture which reduces stress on the nerve being impinged.
  • Pain may be exacerbated by direct palpation of the affected segment.
  • Pain can also be radicular in nature as the exiting nerve roots become compressed due to the narrowing of nerve foramina as one vertebra slips on the adjacent vertebrae, the traversing nerve root (root to the level below) can also be impinged through associated lateral recess narrowing, disc protrusion, or central canal stenosis.
  • Pain can sometimes improve in certain positions such as lying supine. This improvement is due to the instability of the spondylolisthesis that reduces with supine posture, thus relieving the pressure on the bony elements as well as opening the spinal canal or neural foramen.
  • Spondylolisthesis can also present as an acute or acute-onchronic episode with the patient having severe exacerbation of pre-existing back pain, neurological deficits, hamstrings spasm and a crouched gait.[7]The patient develops a crouched gait (Phalen-Dickson sign) due to the vertical position of the sacrum, lumbosacral kyphosis, compensatory lordosis of the proximal spine and flexion of the knees and hips, which may be present regardless of the degree of slippage.
  • Atrophy of the muscles, muscle weakness
  • Tense hamstrings, hamstrings spasms
  • Disturbances in coordination and balance, difficulty walking
  • Rarely loss of bowel or bladder control.[1]

Spondylolisthesis can occur with other disorders and seems to have a link with some of them

Differential Diagnosis[edit | edit source]

  1. Spondylolysis [14]  [15] 
  2. Metastatic disease [16] 
  3. Low back pain [17]
  4. Osteoarthritis [17] 
  5. Neuroforaminal stenosis [17] 
  6. Spinal Stenosis [17]

Diagnostic Procedures[edit | edit source]

Physical Examination[edit | edit source]

Step off sign
  • Step off Sign-A noticeable Step off sign is palpated at the Lumbo sacral area due to slippage of the vertebrae.
  • Straight Leg Raise Test-Straight raising of the leg with patient lying on the back causes pain and triggers the entire trunk.
  • The clinical signs on examination include: a) flattened lumbar lordosis with palpable step of the spinous process (SP). The prominent SP may be tender in case of traumatic spondylolisthesis due to pars fracture. In isthmic L5/S1 spondylolisthesis the palpable SP is the L5, whereas in dysplastic L5/S1 spondylolisthesis the palpable is the S1; b) limitation of lumbar range of motion in flexion/extension; c) pain with single-limb standing lumbar extension. This manoeuvre is usually painful on the affected side; d) popliteal angles measuring more than 45 indicating hamstring tightness, which is present in 80% of symptomatic patients; e) positive straight leg raise test.[7]

Radiological Examination[edit | edit source]

Spondylolisthesis MRI.jpg

X Rays - Anteroposterior and lateral plain films, as well as lateral flexion-extension plain films, are the standard for the initial diagnosis of spondylolisthesis. One is looking for the abnormal alignment of one vertebral body to the next as well as possible motion with flexion and extension, which would indicate instability. In isthmic spondylolisthesis, there may be a pars defect, which is termed the "Scotty dog collar." The "Scotty dog collar" shows a hyperdensity where the collar would be on the cartoon dog, which represents the fracture of the pars interarticularis

  • The slip angle (SA) was the first to describe the kyphotic relationship of L5 to S1.Together with the percentage of slippage, SA is used to assess segmental instability and progression of spondylolisthesis during conservative or surgical management.
  • Lumbo-sacral angle (LSA) relies on landmarks least affected by the spondylolisthesis pathophysiology. It is used to classify spondylolisthesis into: a) non-progressive, with a ‘horizontal’ sacrum producing an LSA of 100 or more, which seldom needs surgery and b) progressive, with a ‘vertical’ sacrum producing an LSA less than 100, which is usually symptomatic requiring surgical treatment. Furthermore, if the LSA fails to improve to 100 or more on preoperative hyperextension and traction films an anterior prior to the posterolateral fusion would be recommended.Even though other angles have been used to assess lumbosacral kyphosis the LSA shows the strongest correlation with the slippage grade.
  • Pelvic incidence (PI) is defined as the angle between a perpendicular line to the mid-point of the sacral plate and a line from the mid-point of the sacral plate to the axis of the femoral heads.
  • Sacral slope (SS) is the angle of the S1 endplate to the horizontal level.
  • Pelvic tilt (PT) is the angle of the line crossing the midpoint of the S1 endplate and the vertical axis of the femoral heads. The PI is the sum of PT and SS (PI ¼ SS þ PI).PI may increase slightly during childhood but remains a constant anatomical parameter following skeletal maturity. In contrast, PT and SS are spatial orientation parameters and may vary for a given pelvis depending on the version or sagittal orientation of the sacrum/pelvis. A high PT indicates a retroverted pelvis, whereas a low PT tends to be associated with an anteverted pelvis. PI corresponds to the size of lumbar lordosis (LL) with deviation of 10 between the two measurements. Increased PI predisposes to the development of isthmic or the progression of dysplastic spondylolisthesis.[7]


Computed tomography (CT) of the spine - provides the highest sensitivity and specificity for diagnosing spondylolisthesis. Spondylolisthesis can be better appreciated on sagittal reconstructions as compared to axial CT imaging. 

MRI of the spine can show associated soft tissue and disc abnormalities, but it is relatively more challenging to appreciate bony detail and a potential pars defect on MRI.[1]

Outcome Measures[edit | edit source]

  • Disability: Oswestry Disability Index, the SF-36 Physical Functioning scale, the Quebec Back Pain Disability Scale[18]
  • Dysfunctional thoughts: Short Form of the Medical Outcomes Study (SF-36)[19]
  • Pain: Pain Numerical Rating Scale, VAS.
  • Quality of life: Short-Form Health Survey [19]
  • Kinesiophobia and Catastrophising: Tampa Scale for Kinesiophobia, Pain Catastrophising Scale[19]

Medical Management[edit | edit source]

For grade I and II spondylolisthesis, treatment typically begins with conservative therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), heat, light exercise, traction, bracing, and/or bed rest.

Conservative  [edit | edit source]

  • Initially resting and avoiding movements like lifting, bending, and sports.[16]
  • Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-inflammatory effect on nerve root and joint irritation.
  • Epidural steroid injections can be used to relieve low back pain, lower extremity pain related to radiculopathy and neurogenic claudication.[20]
  • A brace may be useful to decrease segmental spinal instability and pain. [21]
  • Physiotherapy focuses on relieving extension stresses from the lumbosacral junction (hamstring and hip flexor stretching), as well as working on core strengthening (deep abdominal muscles and lumbar multifidus strengthening).

Surgical[edit | edit source]

Approximately 10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment and need surgical treatment.

  • No definitive standards exist for surgical treatment.
  • Surgical treatment includes a varying combination of decompression, fusion with or without instrumentation, or interbody fusion.
  • Patients with instability are more likely to require operative intervention. 
  • Some surgeons recommend a reduction of the spondylolisthesis if able as this not only decreases foraminal narrowing but also can improve spinopelvic sagittal alignment and decrease the risk for further degenerative spinal changes in the future. The reduction can be more difficult and riskier in higher grades and impacted spondylolisthesis[1]
  • The Scott technique utilizing cerclage wire fixation has been successful with satisfactory results varying between 80%–100%. The butterfly plate technique, Pedicle screw hook fixation, Pedicle screw rod fixation in combination with a screw hook, , pedicle screw cable system, and an intralaminar link construct are some of the other surgical techniques.

Physical Therapy Management[edit | edit source]

Spondylolisthesis should be treated first with conservative therapy, which includes physical therapy, rest, medication and braces.[22][23]

The Rehabilitation exercise program should be designed to improve muscle balance rather than muscle strength alone. [24]

Good exercise choices include:

  • Isometric and isotonic exercises beneficial for strengthening of the main muscles of the trunk, which stabilize the spine. These techniques may also play a role in pain reduction[25][26][27].
  • Core stability exercises, useful in reducing pain and disability in chronic low back pain in patient with spondylolisthesis.[28][24]
  • Movements in closed-chain-kinetics, antilordotic movement patterns of the spine, elastic band exercises in the lying position
  • Gait training
  • Stretching and strengthening exercises, objective of stretching and strengthening is to decrease the extension forces on the lumbar spine, due to agonist muscle tightness, antagonist weakness, or both, which may result in decreased lumbar lordosis.[26] In order to improve the patient’s mobility stretching exercises of the hamstrings, hip flexors and lumbar paraspinal muscles are important.[25][26][27]
  • Balance training including - Sensomotoric training on unstable devices, walking in all variations, coordinative skills
    Hydrotherapy
  • Endurance training of muscles, effective for chronic low back pain.[26][29]
  • Cardiovascular exercise - Athletes with spondylolysis and first-degree spondylolisthesis can take part in all sports activities. However, attention should be given to those kinds of sport where recurring trauma resulting from repeated flexion, hyperextension and twisting is usually undertaken (e.g. gymnastics, aerobics, swimming in the dolphin technique). Athletes with a grade 2, 3 or 4 can also participate in all the sport activities but have to do this with a special and individually adapted directive.Low aerobic impact sports are highly recommended. Sports that certainly can be practiced are walking, swimming and cross-training. Although these activities will not improve the shift, these sports are a good alternative for cardiovascular exercises. Impact sports like running should not be done in order to avoid wear. The adolescent athlete or manual laborer should avoid hyperextension and/or contact sports.
  • Williams flexion exercises are a set of exercises that decrease lumbar extension and focuses on lumbar flexion. These include
    1. Pelvic Tilts
    2. Partial sit-ups
    3. Knee-to-chest
    4. Hamstring stretch
    5. Standing lunges
    6. Seated trunk flexion
    7. Full squat


Exercise strengthening deep abdominal muscles.png

Figure 3: Strengthening of the deep abdominal muscles.
Alternating legs, with leg extension while exhaling, maintaining contraction of transverse abdominis, paravertebral and pelvic floor muscles [30] 


Exercise horizontal slide support.png

Figure 4: Horizontal side support exercise for core stability [31] .

Exercise stretching erector spine.png


Figure 5: Stretching of the erector spine muscles. [30]

Treatment Options Other Than Exercise Include[edit | edit source]

Lumbosacral Braces or Corset[edit | edit source]

In healthy subjects, it has been found that the lumbosacral brace can improve the sitting position of the patient. The fact that there was wear of the brace, indicates that the brace has an important function in the sitting position.[32] According to Prateepavanich et al., a lumbosacral corset can be used to improve walking distance and to reduce pain in daily activities[33], but it does not reduce the shift of the vertebra. It is a good aid during the painful periods but should be discontinued when the patients' complaints are reduced. It aids in decreasing neurogenic claudication while walking.[34]

Education - Posture and Lifting Techniques[edit | edit source]

Special attention has to be given to posture and proper lifting techniques[35] wherein the physiotherapist has an important educational role. Lifting techniques is effective for chronic low back pain.[36][26]

Management of Catastrophising and Kinesiophobia[edit | edit source]

Physical therapy treatment in combination with management of catastrophising and kinesiophobia gave good results. The disability, pain, dysfunctional thoughts were significant reduced.[37]

Massage therapy

A case report showed that the onset of low back pain was delayed during walking/standing. During a prescribed course of massage therapy:[38]

  • Hyperlordosis decreased
  • Hypertonicity of iliopsoas and quadratus lumborum muscles decreased
  • Bilateral net reduction of ilial rotation was achieved, but with irregular changes.

These results were inconclusive but bring into question the role of hip flexor and spinal extensor muscles in normalizing postural misalignment associated with spondylolisthesis[38].

Key Research[edit | edit source]

Clinical Bottom Line[edit | edit source]

  • An inter-professional team consisting of a speciality-trained orthopedic nurse, physical therapist, and an orthopedic surgeon or neurosurgeon will provide the best outcome and long-term care of patients with degenerative spondylolisthesis.
  • Treating clinician will decide on the management plan, and then have the other team members engaged - surgical cases with include the nursing staff in pre-, intra-, and post-operative care, and coordinating with PT for rehabilitation.
  • In non-operative cases (majority), the PT keeps the rest of the team informed of progress (or lack of).
  • The team should encourage weight loss as weight reduction may reduce symptoms and increase the quality of life.
  • Inter-professional collaboration, as above, will drive patient outcomes to their best results.[1]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Tenny S, Gillis CC. Spondylolisthesis. InStatPearls [Internet] 2019 Mar 27. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK430767/ (last accessed 26.1.2020)
  2. ↑ Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K. Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis. Clinical Spine Surgery. 2002 Apr 1;15(2):93-9.
  3. ↑ Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K. Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis. Clinical Spine Surgery. 2002 Apr 1;15(2):93-9.
  4. ↑ 4.0 4.1 4.2 Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. Spondylolysis and spondylolisthesis: a review of the literature. Journal of orthopaedics. 2018 Jun 1;15(2):404-7.
  5. ↑ Foreman P. et al, L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus, Childs Nerv Syst. 2013;29(2):209-16 (Level of evidence 1B)
  6. ↑ Wicker A. Spondylolysis and spondylolisthesis in sports: FIMS Position Statement. International SportMed Journal. 2008 Jan 1;9(2):74-8.
  7. ↑ 7.0 7.1 7.2 Mataliotakis GI, Tsirikos AI. Spondylolysis and spondylolisthesis in children and adolescents: current concepts and treatment. Orthopaedics and Trauma. 2017 Dec 1;31(6):395-401.
  8. ↑ Mays S. Spondylolysis, spondylolisthesis, and lumbo‐sacral morphology in a medieval English skeletal population. American Journal of Physical Anthropology: The Official Publication of the American Association of Physical Anthropologists. 2006 Nov;131(3):352-62.
  9. ↑ Sairyo K, Goel VK, Vadapalli S, Vishnubhotla SL, Biyani A, Ebraheim N, Terai T, Sakai T. Biomechanical comparison of lumbar spine with or without spina bifida occulta. A finite element analysis. Spinal Cord. 2006 Jul;44(7):440-4.
  10. ↑ Burkus JK. Unilateral spondylolysis associated with spina bifida occulta and nerve root compression. Spine. 1990 Jun 1;15(6):555-9.
  11. ↑ Sakai T, Yamada H, Nakamura T, Nanamori K, Kawasaki Y, Hanaoka N, Nakamura E, Uchida K, Goel VK, Vishnubhotla L, Sairyo K. Lumbar spinal disorders in patients with athetoid cerebral palsy: a clinical and biomechanical study. Spine. 2006 Feb 1;31(3):E66-70.
  12. ↑ Sakai T, Sairyo K, Suzue N, Kosaka H, Yasui N. Incidence and etiology of lumbar spondylolysis: review of the literature. Journal of orthopaedic science. 2010 May 1;15(3):281-8.
  13. ↑ Andersen T, Christensen FB, Langdahl BL, Ernst C, Fruensgaard S, Østergaard J, Andersen JL, Rasmussen S, Niedermann B, Høy K, Helmig P. Degenerative spondylolisthesis is associated with low spinal bone density: a comparative study between spinal stenosis and degenerative spondylolisthesis. BioMed research international. 2013 Jan 1;2013.
  14. ↑ Tsirikos AI, Garrido EG. Spondylolysis and spondylolisthesis in children and adolescents. The Journal of bone and joint surgery. British volume. 2010 Jun;92(6):751-9.
  15. ↑ Thein-Nissenbaum J, Boissonnault WG. Differential diagnosis of spondylolysis in a patient with chronic low back pain. Journal of Orthopaedic & Sports Physical Therapy. 2005 May;35(5):319-26.
  16. ↑ 16.0 16.1 Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine. 2009 Jan 15;34(2):199.
  17. ↑ 17.0 17.1 17.2 17.3 Metzger R, Chaney S. Spondylolysis and spondylolisthesis: What the primary care provider should know. Journal of the American Association of Nurse Practitioners. 2014 Jan;26(1):5-12.
  18. ↑ Davidson M, Keating JL. A comparison of five low back disability questionnaires: reliability and responsiveness. Physical therapy. 2002 Jan 1;82(1):8-24.
  19. ↑ 19.0 19.1 19.2 Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Bruno MB. Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial. European spine journal. 2014 Jan;23(1):87-95.
  20. ↑ Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa FP, Albert TJ. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. New England Journal of Medicine. 2007 May 31;356(22):2257-70.
  21. ↑ Funao H, Tsuji T, Hosogane N, Watanabe K, Ishii K, Nakamura M, Chiba K, Toyama Y, Matsumoto M. Comparative study of spinopelvic sagittal alignment between patients with and without degenerative spondylolisthesis. European Spine Journal. 2012 Nov;21(11):2181-7.
  22. ↑ Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. JBJS. 2008 Mar 1;90(3):656-71.
  23. ↑ Kalpakcioglu B, Altınbilek T, Senel K. Determination of spondylolisthesis in low back pain by clinical evaluation. Journal of Back and Musculoskeletal Rehabilitation. 2009 Jan 1;22(1):27-32.
  24. ↑ 24.0 24.1 Nava-Bringas TI, Ramírez-Mora I, Coronado-Zarco R, Macías-Hernández SI, Cruz-Medina E, Arellano-Hernández A, Hernández-López M, León-Hernández SR. Association of strength, muscle balance, and atrophy with pain and function in patients with degenerative spondylolisthesis. Journal of back and musculoskeletal rehabilitation. 2014 Jan 1;27(3):371-6.
  25. ↑ 25.0 25.1 Zimmerman J, Simons SM. Bony healing in a patient with bilateral L5 spondylolysis. Current sports medicine reports. 2005 Jan 1;4(1):35-7.
  26. ↑ 26.0 26.1 26.2 26.3 26.4 Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997 Sep 15;22(18):2128-56.
  27. ↑ 27.0 27.1 Sinaki M, Lutness MP, Ilstrup DM, Chu CP, Gramse RR. Lumbar spondylolisthesis: retrospective comparison and three-year follow-up of two conservative treatment programs. Archives of physical medicine and rehabilitation. 1989 Aug 1;70(8):594-8.
  28. ↑ Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Australian Journal of Physiotherapy. 2006 Jan 1;52(2):79-88.
  29. ↑ McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual therapy. 2003 May 1;8(2):80-91.
  30. ↑ 30.0 30.1 Garcia AN, Costa LD, da Silva TM, Gondo FL, Cyrillo FN, Costa RA, Costa LO. Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical therapy. 2013 Jun 1;93(6):729-47.
  31. ↑ Childs JD, Teyhen DS, Casey PR, McCoy-Singh KA, Feldtmann AW, Wright AC, Dugan JL, Wu SS, George SZ. Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers: a cluster randomized trial. Physical therapy. 2010 Oct 1;90(10):1404-12.
  32. ↑ Mathias M, Rougier PR. In healthy subjects, the sitting position can be used to validate the postural effects induced by wearing a lumbar lordosis brace. Annals of physical and rehabilitation medicine. 2010 Oct 1;53(8):511-9.
  33. ↑ ANICH PP, SANTISATISAKUL P. The Effectiveness of Lumbosacral Corset in Sympto-matic Degenerative Lumbar Spinal Stenosis. J Med Assoc Thai. 2001;84:572-6.
  34. ↑ Bydon M, Alvi MA, Goyal A. Degenerative lumbar spondylolisthesis. definition, natural history, conservative management, and surgical treatment. 2019 Jul 5;30:299-304.
  35. ↑ Agabegi SS, Fischgrund JS. Contemporary management of isthmic spondylolisthesis: pediatric and adult. The Spine Journal. 2010 Jun 1;10(6):530-43.
  36. ↑ McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual therapy. 2003 May 1;8(2):80-91.
  37. ↑ Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Bruno MB. Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial. European spine journal. 2014 Jan;23(1):87-95.
  38. ↑ 38.0 38.1 Halpin S. Case report: The effects of massage therapy on lumbar spondylolisthesis. Journal of bodywork and movement therapies. 2012 Jan 1;16(1):115-23.
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