Spondylolisthesis: Difference between revisions

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'''Original Editors ''' - [[User:Margo De Mesmaeker|Margo De Mesmaeker]]
<p><b>Original Editors </b> - <a href="User:Margo De Mesmaeker">Margo De Mesmaeker</a>
 
</p><p><b>Top Contributors</b> - <span class="fck_mw_template">{{Special:Contributors/{{FULLPAGENAME}}}}</span> &nbsp;  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
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== Definition / Description  ==
<h2> Definition / Description  </h2>
 
<p>Spondylolisthesis is a deviation of the spine when a shift of the vertebra occurs compared to the one just below. It is frequently situated at the fourth and fifth lumbar vertebra<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="N.J. Rosenberg">N.J. Rosenberg. Degenerative spondylolisthesis. Predisposing factors. The journal of Bone and Joint Surgery (1975) 57:467-474. (1C)</span>. This shift is forward orientated, sometimes backwards, but this is rather uncommon. <br />A forward shift is called an anterolysthesis and a backward shift is called retrolysthesis. The degree of spondylolisthesis is generally mild, with a mean of 14%. Because of the shift it is possible that a nerve can be compressed or that the spinal canal is narrowed. <br />  
Spondylolisthesis is a deviation of the spine when a shift of the vertebra occurs compared to the one just below. It is frequently situated at the fourth and fifth lumbar vertebra<ref name="N.J. Rosenberg">N.J. Rosenberg. Degenerative spondylolisthesis. Predisposing factors. The journal of Bone and Joint Surgery (1975) 57:467-474. (1C)</ref>. This shift is forward orientated, sometimes backwards, but this is rather uncommon. <br>A forward shift is called an anterolysthesis and a backward shift is called retrolysthesis. The degree of spondylolisthesis is generally mild, with a mean of 14%. Because of the shift it is possible that a nerve can be compressed or that the spinal canal is narrowed. <br>  
</p><p>Type I = Dysplastic or congenital spondylolisthesis<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Newman et al, Classification of Spondylolisis and Spondylolisthesis,  Clinical  Orthopaedics &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Related Research, 1976</span><br />While this type is rare, symptoms will not occur in childhood but wil start in adolescence. The cause mostly is a&nbsp;congenital defect of the lumbosacrale facet joints or the processus articularis. In some cases it can be caused by pars interarticularis that is too long.<br />  
 
</p><p>Type II = Isthmic or spondylolylitic spondylolisthesis<br />This type is most common and can be divided into 3 subcategories:  
Type I = Dysplastic or congenital spondylolisthesis<ref>Newman et al, Classification of Spondylolisis and Spondylolisthesis,  Clinical  Orthopaedics &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Related Research, 1976</ref><br>While this type is rare, symptoms will not occur in childhood but wil start in adolescence. The cause mostly is a&nbsp;congenital defect of the lumbosacrale facet joints or the processus articularis. In some cases it can be caused by pars interarticularis that is too long.<br>  
</p><p><img src="/images/8/81/Cond-spon_type_II.gif" _fck_mw_filename="Cond-spon type II.gif" _fck_mw_type="frame" alt="" class="fck_mw_frame fck_mw_right" />
 
</p>
Type II = Isthmic or spondylolylitic spondylolisthesis<br>This type is most common and can be divided into 3 subcategories:  
<div><br />  
 
<p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Type II A: Stressfracture of the pars interarticularis&nbsp;<br />&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Type II B: Elongation of the pars interarticularis by &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;microtrauma<br />&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Type II C: Acute fracture of the &nbsp;pars interarticularis  
[[Image:Cond-spon type II.gif|frame]]
</p><p>&nbsp;  
<div><br>  
</p><p><br />  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Type II A: Stressfracture of the pars interarticularis&nbsp;<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Type II B: Elongation of the pars interarticularis by &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;microtrauma<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Type II C: Acute fracture of the &nbsp;pars interarticularis  
</p><p><br />  
 
</p><p>Type III = Degenerative spondylolisthesis  
&nbsp;  
</p>
 
<br>  
 
<br>  
 
Type III = Degenerative spondylolisthesis  
<div>An also common type that occurs around the age of 40 to 50. This will mostly effect females over men. The cause of this type are the effects of aging such as degenerative arthrosis of the facet joints or degeneration of the disci.</div>  
<div>An also common type that occurs around the age of 40 to 50. This will mostly effect females over men. The cause of this type are the effects of aging such as degenerative arthrosis of the facet joints or degeneration of the disci.</div>  
Type IV = Traumatic spondylolisthesis<br>This type is rather rare and involves an acute fracture of the posterior elements of the vertebra, excluding the pars interarticularis<br>  
<p>Type IV = Traumatic spondylolisthesis<br />This type is rather rare and involves an acute fracture of the posterior elements of the vertebra, excluding the pars interarticularis<br />  
 
</p><p>Type V = Pathological spondylolisthesis&nbsp;occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;  
Type V = Pathological spondylolisthesis&nbsp;occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;  
</p><p><img src="/images/e/ee/Spondylolisthesis.jpg" _fck_mw_filename="Spondylolisthesis.jpg" alt="" />
 
</p>
[[Image:Spondylolisthesis.jpg]]
</div>  
</div>  
== Clinically Relevant Anatomy<br>  ==
<h2> Clinically Relevant Anatomy<br />  </h2>
 
<p>An understanding of the shape of the lumbar vertebrae (as this condition usually occurs in this region) is needed. &nbsp;Seperation or disruption occurs at the pars interarticularis, which is along the vertebral arch, and is the most common cause of spondylolisthesis.&nbsp;<img src="/images/2/26/Lumbar_region.png" _fck_mw_filename="Lumbar region.png" _fck_mw_location="center" alt="" class="fck_mw_center" />
An understanding of the shape of the lumbar vertebrae (as this condition usually occurs in this region) is needed. &nbsp;Seperation or disruption occurs at the pars interarticularis, which is along the vertebral arch, and is the most common cause of spondylolisthesis.&nbsp;[[Image:Lumbar region.png|center]]
</p>
 
<h2> Mechanism of Injury / Pathological Process<br />  </h2>
== Mechanism of Injury / Pathological Process<br>  ==
<p>Depending on the type of spondylolisthesis, there are a variety of causes. &nbsp;Either through trauma, microtrauma, factors associated with aging or bone diseases.&nbsp;<br />  
 
</p>
Depending on the type of spondylolisthesis, there are a variety of causes. &nbsp;Either through trauma, microtrauma, factors associated with aging or bone diseases.&nbsp;<br>  
<h2> Clinical Presentation<br />  </h2>
 
<p>Symptoms that can occur with spondylolisthesis are low back pain, pain in the legs or a combination of both. Patients complain of deep, dull pain typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine. The range of motion is diminished and the hamstrings are tense. When there is a compression of a nerve, patients mostly develop numbness, pain or tingling. If the compression is very severe it may be possible that the patient develops the cauda equine syndrome.  
== Clinical Presentation<br>  ==
</p>
 
<h2> Diagnostic Procedures  </h2>
Symptoms that can occur with spondylolisthesis are low back pain, pain in the legs or a combination of both. Patients complain of deep, dull pain typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine. The range of motion is diminished and the hamstrings are tense. When there is a compression of a nerve, patients mostly develop numbness, pain or tingling. If the compression is very severe it may be possible that the patient develops the cauda equine syndrome.  
<p>Spondylolisthesis is featured by the following characteristics. It is mostly clear that the patient has complaints of pain in the lower back and leg. In the history the majority of the people have had a fall or trauma. During the inspection and physical examination of the patient there are typically no visible signs of spondylolisthesis but there may be a tightness of the hamstrings. The abdominal muscles are weakened and there can be an increase of the lumbar lordosis<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="B. Kalpakcioglu">B. Kalpakcioglu, T. Altinbilek, K. Senel. Determination of spondylolisthesis in low back pain by clinical evaluation. Jounal of Back a Musculoskeletal Rehabilitation 22 (2009) 27-32. (2B)</span>. The patient has trouble with flexion and extension of the spine because it hurts.  
 
</p><p><br />  
== Diagnostic Procedures  ==
</p><p>When the physiotherapist is not sure, an axial loaded MRI can always identify the disorder<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="P. Jayakumar">P. Jayakumar et al. Dynamic degenerative lumbar spondylolisthesis: diagnosis with axial loaded magnetic resonance imaging, Spine. (Phila Pa 1976) 2006 May 1;31 (10): E298-301. (2B)</span>.  
 
</p><p><br />  
Spondylolisthesis is featured by the following characteristics. It is mostly clear that the patient has complaints of pain in the lower back and leg. In the history the majority of the people have had a fall or trauma. During the inspection and physical examination of the patient there are typically no visible signs of spondylolisthesis but there may be a tightness of the hamstrings. The abdominal muscles are weakened and there can be an increase of the lumbar lordosis<ref name="B. Kalpakcioglu">B. Kalpakcioglu, T. Altinbilek, K. Senel. Determination of spondylolisthesis in low back pain by clinical evaluation. Jounal of Back a Musculoskeletal Rehabilitation 22 (2009) 27-32. (2B)</ref>. The patient has trouble with flexion and extension of the spine because it hurts.  
</p><p>The severity of spondylolisthesis is expressed according to the Meyerding grading system. The system categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This distance is then reported as a percentage of the total superior vertebral body length.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">H.W., Meyerding, Spondylolisthesis., Surg Gynecol Obsted. 1932</span>  
 
</p><p>According the degree of shift, there are five grades:<br />- Grade 1: &lt;25%<br />- Grade 2: 25% - 50%<br />- Grade 3: 51% - 75%<br />- Grade 4: &gt;75%  
<br>  
</p><p>(Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.)<br />  
 
</p><p><br />  
When the physiotherapist is not sure, an axial loaded MRI can always identify the disorder<ref name="P. Jayakumar">P. Jayakumar et al. Dynamic degenerative lumbar spondylolisthesis: diagnosis with axial loaded magnetic resonance imaging, Spine. (Phila Pa 1976) 2006 May 1;31 (10): E298-301. (2B)</ref>.  
</p><p><img src="/images/5/50/Lumbar_spondylolisthesis_grades.jpg" _fck_mw_filename="Lumbar spondylolisthesis grades.jpg" alt="Image:Lumbar_spondylolisthesis_grades.jpg" />
 
</p>
<br>  
<h2> Outcome Measures  </h2>
 
<p><a href="http://www.physio-pedia.com/Oswestry_Disability_Index">Oswestry Disability Index</a>
The severity of spondylolisthesis is expressed according to the Meyerding grading system. The system categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This distance is then reported as a percentage of the total superior vertebral body length.<ref>H.W., Meyerding, Spondylolisthesis., Surg Gynecol Obsted. 1932</ref>  
</p>
 
<h2> Management / Interventions<br />  </h2>
According the degree of shift, there are five grades:<br>- Grade 1: &lt;25%<br>- Grade 2: 25% - 50%<br>- Grade 3: 51% - 75%<br>- Grade 4: &gt;75%  
<p><u>General<br /></u>• Initially resting and avoiding movements like lifting, bending and sports.<br />• Anti-inflammatory medicine to improve the infection and diminish the pain<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="M.W van Tulder">M.W van Tulder et al. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group. Spine 2000 25:2501–2513. (1A)</span> .<br />• A corticosteroid injection can be used if patients have pain in the leg or numbness<br />• Sometimes a hyperextension brace can be used. This is useful because during the hyperextension of the lumbar spine the verterbrae get closer together.<br />• When the condition is very severe a surgical intervention may be necessary to attach the vertebras together.<br />• A surgical intervention has better results than a nonsurgical care in case of neurological symptoms<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="J.N. Weinstein">J.N. Weinstein et al. Surgical versus non-surgical treatment for lumbar degenerative spondylolisthesis. N. Engl. J. Med 2007 May 31;356 (22): 2557-2270. (1B)</span>.  
 
</p><p><br />  
(Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.)<br>  
</p><p><u>Physical therapy<br /></u>The initial therapy for spondylolisthesis is a conservative treatment done by the physiotherapist. Physical therapy is used to improve the range of motion of the lumbar spine and the hamstrings. Also improving the strength of the abdominal muscles is a very important part of the therapy, so that the spine can be stabilized.  
 
</p><p>The physiotherapist needs to give the patient information about the posture, lifting techniques and the use of heat to diminish the symptoms.<br />A brace can be used to reduce the pain, but it does not reduce the shift of the vertebra<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="L. Kalichman">L. Kalichman et al. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J (2008) 17;327 – 335. (2B)</span>. So it is a good aid during the painful periods but it is not to be used when the patients complaints are reduced. <br />  
<br>  
</p><p>Strengthening the deep abdominal muscles is a very important part of the physical therapy. Isometric and isotonic exercises for the main muscle groups of the trunk provide a stabilization of the spine and a reduction of the pain<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="M. Sinaki">M. Sinaki et al. Lumbar spondylolisthesis: retrospective comparison and three year follow-up of two conservative treatment programs. Arch Phys Med Rehabil 1989 70:594-598. (1B)</span>. Also the hamstrings need to be stretched, so that their mobility can be improved. <br />An excellent exercise is stationary bicycling because it promotes the spine flexion. Impact sports like running should not be done because it provokes wear. Other sports that can be practiced are walking and swimming. They have no value in improving the shift, but these sports are good alternatives for cardiovascular exercises<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="L. Kalichman" />. <br />  
 
</p>
[[Image:Lumbar spondylolisthesis grades.jpg|Image:Lumbar_spondylolisthesis_grades.jpg]]
<h2> Differential Diagnosis<br />  </h2>
 
<p>Differential Diagnosis&nbsp;<br />  
== Outcome Measures  ==
</p>
 
<h2> Key Evidence  </h2>
[http://www.physio-pedia.com/Oswestry_Disability_Index Oswestry Disability Index]
<p>add text here relating to key evidence with regards to any of the above headings<br />  
 
</p>
== Management / Interventions<br>  ==
<h2> Resources <br />  </h2>
 
<p><a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00588">Information from the AAOS</a>
<u>General<br></u>• Initially resting and avoiding movements like lifting, bending and sports.<br>• Anti-inflammatory medicine to improve the infection and diminish the pain<ref name="M.W van Tulder">M.W van Tulder et al. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group. Spine 2000 25:2501–2513. (1A)</ref> .<br>• A corticosteroid injection can be used if patients have pain in the leg or numbness<br>• Sometimes a hyperextension brace can be used. This is useful because during the hyperextension of the lumbar spine the verterbrae get closer together.<br>• When the condition is very severe a surgical intervention may be necessary to attach the vertebras together.<br>• A surgical intervention has better results than a nonsurgical care in case of neurological symptoms<ref name="J.N. Weinstein">J.N. Weinstein et al. Surgical versus non-surgical treatment for lumbar degenerative spondylolisthesis. N. Engl. J. Med 2007 May 31;356 (22): 2557-2270. (1B)</ref>.  
</p>
 
<h2> Case Studies  </h2>
<br>  
<p>add links to case studies here (case studies should be added on new pages using the <a href="Template:Case Study">case study template</a>)<br />  
 
</p>
<u>Physical therapy<br></u>The initial therapy for spondylolisthesis is a conservative treatment done by the physiotherapist. Physical therapy is used to improve the range of motion of the lumbar spine and the hamstrings. Also improving the strength of the abdominal muscles is a very important part of the therapy, so that the spine can be stabilized.  
<h2> References  </h2>
 
<p>References will automatically be added here, see <a href="Adding References">adding references tutorial</a>.  
The physiotherapist needs to give the patient information about the posture, lifting techniques and the use of heat to diminish the symptoms.<br>A brace can be used to reduce the pain, but it does not reduce the shift of the vertebra<ref name="L. Kalichman">L. Kalichman et al. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J (2008) 17;327 – 335. (2B)</ref>. So it is a good aid during the painful periods but it is not to be used when the patients complaints are reduced. <br>  
</p><p><span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" />
 
</p><a _fcknotitle="true" href="Category:Vrije_Universiteit_Brussel_Project">Vrije_Universiteit_Brussel_Project</a> <a href="Category:Musculoskeletal/Orthopaedics">Orthopaedics</a> <a _fcknotitle="true" href="Category:Lumbar">Lumbar</a>
Strengthening the deep abdominal muscles is a very important part of the physical therapy. Isometric and isotonic exercises for the main muscle groups of the trunk provide a stabilization of the spine and a reduction of the pain<ref name="M. Sinaki">M. Sinaki et al. Lumbar spondylolisthesis: retrospective comparison and three year follow-up of two conservative treatment programs. Arch Phys Med Rehabil 1989 70:594-598. (1B)</ref>. Also the hamstrings need to be stretched, so that their mobility can be improved. <br>An excellent exercise is stationary bicycling because it promotes the spine flexion. Impact sports like running should not be done because it provokes wear. Other sports that can be practiced are walking and swimming. They have no value in improving the shift, but these sports are good alternatives for cardiovascular exercises<ref name="L. Kalichman" />. <br>  
 
== Differential Diagnosis<br>  ==
 
Differential Diagnosis&nbsp;<br>  
 
== Key Evidence  ==
 
add text here relating to key evidence with regards to any of the above headings<br>  
 
== Resources <br>  ==
 
[http://orthoinfo.aaos.org/topic.cfm?topic=A00588 Information from the AAOS]
 
== Case Studies  ==
 
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
 
== References  ==
 
References will automatically be added here, see [[Adding References|adding references tutorial]].  
 
<references />  
 
[[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Lumbar]]

Revision as of 17:41, 19 December 2014

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors

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 source]

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Clinically Relevant Anatomy[edit source]

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Epidemiology /Etiology[edit source]

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Characteristics/Clinical Presentation[edit source]

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Differential Diagnosis[edit source]

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Diagnostic Procedures[edit source]

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Outcome Measures[edit source]

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Examination[edit source]

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Medical Management
[edit source]

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Physical Therapy Management
[edit source]

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Key Research[edit source]

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources
[edit source]

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Clinical Bottom Line[edit source]

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References[edit source]

see adding references tutorial.

Original Editors - <a href="User:Margo De Mesmaeker">Margo De Mesmaeker</a>

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

Spondylolisthesis is a deviation of the spine when a shift of the vertebra occurs compared to the one just below. It is frequently situated at the fourth and fifth lumbar vertebraN.J. Rosenberg. Degenerative spondylolisthesis. Predisposing factors. The journal of Bone and Joint Surgery (1975) 57:467-474. (1C). This shift is forward orientated, sometimes backwards, but this is rather uncommon.
A forward shift is called an anterolysthesis and a backward shift is called retrolysthesis. The degree of spondylolisthesis is generally mild, with a mean of 14%. Because of the shift it is possible that a nerve can be compressed or that the spinal canal is narrowed.

Type I = Dysplastic or congenital spondylolisthesisNewman et al, Classification of Spondylolisis and Spondylolisthesis, Clinical Orthopaedics &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Related Research, 1976
While this type is rare, symptoms will not occur in childhood but wil start in adolescence. The cause mostly is a congenital defect of the lumbosacrale facet joints or the processus articularis. In some cases it can be caused by pars interarticularis that is too long.

Type II = Isthmic or spondylolylitic spondylolisthesis
This type is most common and can be divided into 3 subcategories:

<img src="/images/8/81/Cond-spon_type_II.gif" _fck_mw_filename="Cond-spon type II.gif" _fck_mw_type="frame" alt="" class="fck_mw_frame fck_mw_right" />


          Type II A: Stressfracture of the pars interarticularis 
          Type II B: Elongation of the pars interarticularis by                                                microtrauma
          Type II C: Acute fracture of the  pars interarticularis

 



Type III = Degenerative spondylolisthesis

An also common type that occurs around the age of 40 to 50. This will mostly effect females over men. The cause of this type are the effects of aging such as degenerative arthrosis of the facet joints or degeneration of the disci.

Type IV = Traumatic spondylolisthesis
This type is rather rare and involves an acute fracture of the posterior elements of the vertebra, excluding the pars interarticularis

Type V = Pathological spondylolisthesis occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases.                                                                                                                                                                                                                             

<img src="/images/e/ee/Spondylolisthesis.jpg" _fck_mw_filename="Spondylolisthesis.jpg" alt="" />

Clinically Relevant Anatomy

An understanding of the shape of the lumbar vertebrae (as this condition usually occurs in this region) is needed.  Seperation or disruption occurs at the pars interarticularis, which is along the vertebral arch, and is the most common cause of spondylolisthesis. <img src="/images/2/26/Lumbar_region.png" _fck_mw_filename="Lumbar region.png" _fck_mw_location="center" alt="" class="fck_mw_center" />

Mechanism of Injury / Pathological Process

Depending on the type of spondylolisthesis, there are a variety of causes.  Either through trauma, microtrauma, factors associated with aging or bone diseases. 

Clinical Presentation

Symptoms that can occur with spondylolisthesis are low back pain, pain in the legs or a combination of both. Patients complain of deep, dull pain typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine. The range of motion is diminished and the hamstrings are tense. When there is a compression of a nerve, patients mostly develop numbness, pain or tingling. If the compression is very severe it may be possible that the patient develops the cauda equine syndrome.

Diagnostic Procedures

Spondylolisthesis is featured by the following characteristics. It is mostly clear that the patient has complaints of pain in the lower back and leg. In the history the majority of the people have had a fall or trauma. During the inspection and physical examination of the patient there are typically no visible signs of spondylolisthesis but there may be a tightness of the hamstrings. The abdominal muscles are weakened and there can be an increase of the lumbar lordosisB. Kalpakcioglu, T. Altinbilek, K. Senel. Determination of spondylolisthesis in low back pain by clinical evaluation. Jounal of Back a Musculoskeletal Rehabilitation 22 (2009) 27-32. (2B). The patient has trouble with flexion and extension of the spine because it hurts.


When the physiotherapist is not sure, an axial loaded MRI can always identify the disorderP. Jayakumar et al. Dynamic degenerative lumbar spondylolisthesis: diagnosis with axial loaded magnetic resonance imaging, Spine. (Phila Pa 1976) 2006 May 1;31 (10): E298-301. (2B).


The severity of spondylolisthesis is expressed according to the Meyerding grading system. The system categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This distance is then reported as a percentage of the total superior vertebral body length.H.W., Meyerding, Spondylolisthesis., Surg Gynecol Obsted. 1932

According the degree of shift, there are five grades:
- Grade 1: <25%
- Grade 2: 25% - 50%
- Grade 3: 51% - 75%
- Grade 4: >75%

(Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.)


<img src="/images/5/50/Lumbar_spondylolisthesis_grades.jpg" _fck_mw_filename="Lumbar spondylolisthesis grades.jpg" alt="Image:Lumbar_spondylolisthesis_grades.jpg" />

Outcome Measures

<a href="http://www.physio-pedia.com/Oswestry_Disability_Index">Oswestry Disability Index</a>

Management / Interventions

General
• Initially resting and avoiding movements like lifting, bending and sports.
• Anti-inflammatory medicine to improve the infection and diminish the painM.W van Tulder et al. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group. Spine 2000 25:2501–2513. (1A) .
• A corticosteroid injection can be used if patients have pain in the leg or numbness
• Sometimes a hyperextension brace can be used. This is useful because during the hyperextension of the lumbar spine the verterbrae get closer together.
• When the condition is very severe a surgical intervention may be necessary to attach the vertebras together.
• A surgical intervention has better results than a nonsurgical care in case of neurological symptomsJ.N. Weinstein et al. Surgical versus non-surgical treatment for lumbar degenerative spondylolisthesis. N. Engl. J. Med 2007 May 31;356 (22): 2557-2270. (1B).


Physical therapy
The initial therapy for spondylolisthesis is a conservative treatment done by the physiotherapist. Physical therapy is used to improve the range of motion of the lumbar spine and the hamstrings. Also improving the strength of the abdominal muscles is a very important part of the therapy, so that the spine can be stabilized.

The physiotherapist needs to give the patient information about the posture, lifting techniques and the use of heat to diminish the symptoms.
A brace can be used to reduce the pain, but it does not reduce the shift of the vertebraL. Kalichman et al. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J (2008) 17;327 – 335. (2B). So it is a good aid during the painful periods but it is not to be used when the patients complaints are reduced.

Strengthening the deep abdominal muscles is a very important part of the physical therapy. Isometric and isotonic exercises for the main muscle groups of the trunk provide a stabilization of the spine and a reduction of the painM. Sinaki et al. Lumbar spondylolisthesis: retrospective comparison and three year follow-up of two conservative treatment programs. Arch Phys Med Rehabil 1989 70:594-598. (1B). Also the hamstrings need to be stretched, so that their mobility can be improved.
An excellent exercise is stationary bicycling because it promotes the spine flexion. Impact sports like running should not be done because it provokes wear. Other sports that can be practiced are walking and swimming. They have no value in improving the shift, but these sports are good alternatives for cardiovascular exercises.

Differential Diagnosis

Differential Diagnosis 

Key Evidence

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