What are Spondylolysis and Spondylolisthesis?

Spondylolysis is a primary stress fracture of the pars interarticularis of the vertebral arch.  In the image to the right, this region is seen as the middle arrow of the facet joint region. The fifth and fourth lumbar vertebra are most often involved.  The defect itself can occur on one or both sides of the vertebra. When it occurs on both sides, the angle of the sacral base can promote a forward slippage of the vertebra, resulting in a spondylolisthesis. In an average population, the incidence of spondylolisthesis can be as high as 11.5% (Kalichman 2009).  Among an athletic adolescent population with low back pain, the incidence of spondylolysis was found to be as high as 47% (Micheli 1994).

Subtypes of Spondylolisthesis

Spodylolisthesis can be further classified according to it’s type.  5 subtypes are often described.

Type I: Dysplastic Spondylolisthesis

Dysplastic spondylolisthesis is a congenital lesion of the sacral base or the L5.  These abnormal congenital changes don’t provide resistance to forward shearing of the vertebra.

Type II: Isthmic Spondylolisthesis

Isthmic spondylolisthesis develops due to a defect in the pars interarticularis. This subtype is typically caused by a fatigue fracture of the pars interarticularis and are usually seen between the ages of 5 and 50.

Type III: Degenerative Spondylolisthesis

The degenerative type of spondylolisthesis occurs in response to long standing intersegmental instability. Due to their degenerative nature, this type is rarely seen under the age of 50.

Type IV: Traumatic Spondylolisthesis

Traumatic type spondylolisthesis occurs due to an acute fracture of a structure other than the pars interarticularis.  This type of spondylolisthesis is almost always due to a severe trauma.

Type V: Pathological Spondylolisthesis

In the case of pathological spondylolisthesis, integrity of the verterbra has been compromised due to a local or generalized bone disease.

Classification of Spondylolisthesis

Spondylolisthesis is commonly classified according to the Meyerding scale.  This scale describes the percentage migration of the upper vertebra on the lower vertebra.

• Grade 1: Translation less than 25%
• Grade 2: Translation between 26% – 50%
• Grade 3: Translation between 51% – 75%
• Grade 4: Translation between 76% – 100%

Do you have Spondylolisthesis?

Most patients with spondylolisthesis will complain of low back pain, much like other sources of back pain that were discussed in a previous blog post.  Nerve symptoms may also be present, which your physiotherapist should check for during the initial consultation.  Your symptoms will often worsen throughout the day and with severe stenosis there may be reports of changes in bowel and bladder function.  Leg symptoms may be present and will typically reduce with rest or flexed spinal postures.  These nerve symptoms may affect one or both sides.

Moeller et al showed that the incidence of symptoms in a spondylolisthesis population were:

• Low back pain with sciatica 62%
• Low back pain only 31%
• Sciatica only 7%
• 68% lumbosacral tenderness
• Reduced lateral bending 46%
• Hamstring tightness 22%

What is the Treatment for Spondylolisthesis?

Conservative management for spondylolysis and spondylolisthesis is the primary treatment strategy before surgical options are considered.  One qualitative meta-analysis of children and young adults with non surgical management of spondylosis and spondylolisthesis suggested 83.9% of patients treated non-operatively showed a successful clinical outcome after at least 1 year (Klein 2009). Physiotherapy interventions have been shown to be moderately effective in the treatment of low-grade spondylolisthesis (McNeely 2003). Specific treatment protocols have included:

• The use of spinal flexion exercises being more beneficial on pain reduction as compared with extension exercises (Sinaki 1989)
• Abdominal strengthening exercises in the absence of neurological or autonomic involvement (McNeely 2003)
• Specific segmental training of the transversus abdominus and co-activation of transversus abdominus with segmental lumbar multifidus with progression to limb loading strategies and functional positions (O’Sullivan 1997)
• General strengthening, stretching and motor control exercises (Hardwick 2012)

What Should I do?

The first step in conservative management should be to get an appropriate assessment by a physiotherapist with the training and experience to assess your symptoms.  This includes a thorough and detailed history of your symptoms, measures to determine nerve involvement and assessment of muscle strength to develop an appropriate treatment plan for you.  Treatment may include manual therapy techniques to improve movement of neighbouring stiff regions, core exercises to improve and reduce your symptoms and education on management strategies.

References:

Hardwick D, Tierney D, Fein C, Reinmann S, Donaldson M. Outcomes of strengthening approaches in the treatment of low-grade spondylolisthesis.  Physical Therapy Reviews 2012; 17(5): 284-91

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 34(2):199–205

Klein G, Mehlman CT, McCarty M. Nonoperative Treatment of Spondylolysis and Grade I Spondylolisthesis in Children and Young Adults A Meta-analysis of Observational Studies. Journal of Pediatric Orthopedics. 2009; 29(2):146-56

McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis.  Manual Therapy 2003; 8(2): 80-91

Micheli L, Wood R. Back pain in young athletes: significant differences from adults in causes and pattern.  Archives of Pediatric Adolescent Medicine 1995; 149(1): 15-18

Moller H, Sundin A, Hedlund R. Symptoms, Signs and Functional Disability in Adult Spondylolisthesis.  Spine 2000; 25(6): 683-9

O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilization exercises in the treatment of chronic low back pain with radiological diagnosis of spondylolysis or spondylolisthesis. Spine, 1997; 22(24): 2959-67

Sinaki M, Lutness MP, Duane D, M. Ilstrup M, 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; 70: 594-98