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)
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)
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)
American Academy of Orthopaedic Surgeons. (2019, April 9). Spondylolysis and Spondylolisthesis. Retrieved from OrthoInfo: https://orthoinfo.aaos.org/en/diseases–conditions/spondylolysis-and-spondylolisthesis/
Ekman, P. M. (2005). The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. The Spine Journal, 36-44.
Ferreira, P. H. et al. (2006). Specific stabilisation exercise for spinal and pelvic pain: A systematic review. Australian Journal of Physiotherapy, 79-88.
Foreman, P. et al. (2013). L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus. Childs Nervous System, 209-16.
Kalpakcioglua, B. et al. (2009). Determination of spondylolisthesis in low back pain by clinical evaluation. Journal of Back and Musculoskeletal Rehabilitation, 27–32.
Niggerman et al. (2012). Spondylolysis and isthmic spondylolisthesis: impact of vertebral hypoplasia on the use of the Meyerding Classification. The British Journal of Radiology, 368-362.
Radcliff, K. et al. (2009). Surgical Management of Spondylolysis and Spondylolisthesis in Athletes. Current Sports Medicine Reports, 35-40.
Tebet, M. (2014). Currents concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia, 3-12.
Van Tulder M. W. et al. (1997). Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine, 2128-2156.
Weinstein, J. N. (2007). Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. New England Journal of Medicine, 2257-2270.
Wicker, A. et al. (2008). Spondylolysis and spondylolisthesis in sports. International SportMed Journal, 74-7.