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| '''Original Editors ''' - <a href="User:Margo De Mesmaeker">Margo De Mesmaeker</a>
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| '''Top Contributors''' - <img class="FCK__MWTemplate" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" _fckfakelement="true" _fckrealelement="9" _fck_mw_template="true">
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| == Definition / Description ==
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| 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>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>
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| 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;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 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>
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| Type II = Isthmic or spondylolylitic spondylolisthesis<br>This type is most common and can be divided into 3 subcategories:
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| <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" />
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| <div><br>
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| Type II A: Stressfracture of the pars interarticularis <br> Type II B: Elongation of the pars interarticularis by microtrauma<br> Type II C: Acute fracture of the pars interarticularis
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| Type III = Degenerative spondylolisthesis
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| <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>
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| 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>
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| 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.
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| <img src="/images/e/ee/Spondylolisthesis.jpg" _fck_mw_filename="Spondylolisthesis.jpg" alt="" />
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| </div>
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| == Clinically Relevant Anatomy<br> ==
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| 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" />
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| == Mechanism of Injury / Pathological Process<br> ==
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| Depending on the type of spondylolisthesis, there are a variety of causes. Either through trauma, microtrauma, factors associated with aging or bone diseases. <br>
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| == Clinical Presentation<br> ==
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| 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.
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| == Diagnostic Procedures ==
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| 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>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.
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| <br>
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| When the physiotherapist is not sure, an axial loaded MRI can always identify the disorder<ref>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>.
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| 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>
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| According the degree of shift, there are five grades:<br>- Grade 1: <25%<br>- Grade 2: 25% - 50%<br>- Grade 3: 51% - 75%<br>- Grade 4: >75%
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| (Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.)<br>
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| <br>
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| <img src="/images/5/50/Lumbar_spondylolisthesis_grades.jpg" _fck_mw_filename="Lumbar spondylolisthesis grades.jpg" alt="Image:Lumbar_spondylolisthesis_grades.jpg" />
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| == Outcome Measures ==
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| <a href="http://www.physio-pedia.com/Oswestry_Disability_Index">Oswestry Disability Index</a>
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| == Management / Interventions<br> ==
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| <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>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>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>.
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| <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.
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| 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>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>
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| 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>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="L. Kalichman" />. <br>
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| == Differential Diagnosis<br> ==
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| Differential Diagnosis <br>
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| == Key Evidence ==
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| add text here relating to key evidence with regards to any of the above headings<br>
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| == Resources <br> ==
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| <a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00588">Information from the AAOS</a>
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| == Case Studies ==
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| 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>
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| == References ==
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| References will automatically be added here, see <a href="Adding References">adding references tutorial</a>.
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| <span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" />
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| <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>
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