Spondylolisthesis

Spondylolisthesis: What is it?

Spondylolisthesis is the translation of one vertebra over another vertebra. This translation can occur in a forward direction (anterolisthesis) or a backward direction (retrolisthesis). (Tebet, 2014) For the translation of a vertebra over another to occur, there must be an interruption of normal anatomy – a fracture of the pars interarticularis – or Spondylolysis.

Symptoms of spondylolisthesis:

• Low-back pain
• Pain radiating down the leg
• Neurological symptoms (possible evolution towards cauda equine syndrome)
• Atrophy of the muscles, muscle weakness
• Tense hamstrings, hamstrings spasms
• Diminished ROM (spine)
• Disturbances in coordination and balance (Wicker, A. et al, 2008)

Diagnosis with imaging

Diagnosis is usually confirmed using x-ray. A lateral view of the lumbo-sacral region can show the anterior or posterior translation of the vertebra. The degree of translation is commonly graded using the Myerding Classification:

Grade I: <25%

Grade II: 25-50%

Grade III: 50-75%

Grade IV: 75-100%

Grade V: Spondyloptosis (Niggerman et al., 2012)

An oblique view of the lumbar spine should also be taken, to identify the location of a pars fracture; the characteristic of which is the Scottie dog collar. (Foreman, P. et al., 2013) While the presence of a Scottie dog collar does not itself mean a spondylolisthesis is going to happen, it is evidence of spondylolysis, which can lead to spondylolisthesis. Further imaging may be required (CT, MRI) if neurological symptoms are present. (Kalpakcioglua, B. et al., 2009)

Management/Treatment

Hands on manual therapy and exercise therapy are used in the treatment of spondylolisthesis. Improving back and trunk stability, as well as improving flexibility and reducing muscle tension all assist in the management or spondylolisthesis. Stretching of the hamstrings, hip flexors and lumbar paraspinal muscles is usually also prescribed. They may also assist in pain reduction. (American Academy of Orthopaedic Surgeons, 2019) (Van Tulder M. W. et al, 1997) (Ferreira, P. H. et al, 2006)

Surgery is only used in situations where patients may be experiencing chronic and disabling symptoms, and when they do not response to conservative management. (Weinstein, 2007)

Prognosis

For patients suffering from Grade I-II spondylolisthesis, improvement in symptoms is usually seen within a few weeks of commencing treatment. Research has shown that for patients in this category, there is no short- or long-term difference between manual/exercise treatment and surgery. (Ekman, 2005)

Grade III+ patients are less likely to have favourable outcomes from manual/exercise treatment and may require referral for surgical intervention if they do not respond to conservative treatment. Athletes with Grade III+ spondylolisthesis are generally referred for surgery if they have not responded to 6 months of exercise rehabilitation. (Radcliff, K. et al, 2009)