Comprehensive Overview of Spondylolisthesis: Types, Diagnosis, and Clinical Features

Comprehensive Overview of Spondylolisthesis: Types, Diagnosis, and Clinical Features

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  Spondylolisthe sis Dr. Satyen Bhattacharyya
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  Spondylolisthesis • Spondylolisthesis denotesthe slippage of one vertebra relative to the one below. • Anterolisthesis (More common) • Retrolisthesis
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  Spondylolisthesis Two vertical linesare drawn along the posterior cortex superior and inferior vertebra. (Meyerding classification)
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  Instability in spondylolisthesis- Direct sign •Functional flexion/extension radiographs are considered the gold standard for diagnosing the presence of instability in the setting of spondylolisthesis
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  Instability in spondylolisthesis- Indirectsigns
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  Radiograph of the lumbosacraljunction showing a grade 1 spondylolytic spondylolisthesis at L5-S1.
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  Spondylolisthesis, spondylolysis, and spondylosis. Isthmic spondylolisthesis(type IIa) with grade 2 slippage of L5 over S1 and spondylolysis (lytic pars defect) is depicted posteriorly.
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  Pathophysiolo gy • Spondylolysis isa defect in the pars interarticularis that may or may not be accompanied by forward translation of one vertebra relative to another (spondylolisthesis).
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  Types • Wiltse, Macnab,and Newman developed a classification to help outline causes of vertebral translation in an anterior direction. • Their categories include the following: • Type I: Congenital spondylolisthesis • Type II: Isthmic spondylolisthesis • Type III: Degenerative spondylolisthesis • Type IV: Traumatic spondylolisthesis • Type V: Pathologic spondylolisthesis
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  Type I: Congenital spondylolisthe sis • Thisis characterized by presence of dysplastic sacral facet joints allowing forward translation of one vertebra relative to another. Orientation of facets in an axial or sagittal plane may allow for forward translation, producing undue stress on the pars, resulting in a fracture.
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  Type II: Isthmic spondylolisthesi s •This is caused by the development of a stress fracture of the pars interarticularis.
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  Type III: Degenerative spondylolisthesi s • Thisis commonly caused by intersegmental instability produced by facet arthropathy. This variation usually occurs in the adult population and, in most cases, does not progress beyond a grade I spondylolisthesis.
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  Type IV: Traumatic spondylolisthe sis • Thiscan, in rare instances, result from acute stresses (trauma) to the facet or pars.
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  Type V: Pathologic spondylolisthe sis • Anybone disorder may destabilize the facet mechanism producing pathologic spondylolisthesis. • Iatrogenic spondylolisthesis, lastly, may occur if an overzealous surgeon performs too great of a facetectomy.
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  • The mostcommonly used grading system for spondylolisthesis is the one proposed by Meyerding in 1947. • The degree of slippage is measured as the percentage of distance the anteriorly translated vertebral body has moved forward relative to the superior end plate of the vertebra below. • Classifications use the following grading system: • Grade 1: 1- 25% slippage • Grade 2: 26-50% slippage • Grade 3: 51-75% slippage • Grade 4: 76-100% slippage • Grade 5: Greater than 100% slippage
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  Frequency • Wiltse andBeutler each reported an incidence of 6-7% for isthmic spondylolysis. • Up to 5% of children aged 5-7 years have been found to have spondylolysis, many of whom are asymptomatic. The incidence increases up to the 7% by age 18. • Athletic activities requiring repetitive hyperextension and rotation or repetitive combined flexion-extension predispose some athletes to developing pars defects. Gymnasts, linemen in college football, weight lifters, javelin throwers, pole-vaulters, and judoists are most commonly affected. • Approximately 82% of cases of isthmic spondylolisthesis occur at L5-S1. • Another 11.3% occur at L4-L5. Congenital defects, including spina bifida occulta, have been linked to occurrence of isthmic spondylolisthesis. Scoliosis has been found to occur along with spondylolysis as well.
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  • Roughly 50%of all cases of spondylolysis are not associated with spondylolisthesis. • Degenerative spondylolisthesis occurs more frequently with increasing age. • The L4-L5 interspace is affected 6-10 more times than any other level. • Sacralization of L5 is frequently seen with L4-5 degenerative spondylolisthesis.
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  Mortality/ Morbidity • Increased mortalityis not associated with spondylolisthesis. While some patients may have persistent low back pain, significant disability is rare unless the patient has severe neurologic compromise that has not been addressed. • The most common morbidity is persistent low back pain or nerve impingement. Because disk degeneration is accelerated at the sight of level of the spondylolysis, diskogenic pain may occur. • Degenerative spondylolisthesis produces characteristic arthritic symptoms that may worsen with age.
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  Sex • Beutler etal noted a 2:1 male-to-female ratio of occurrence in asymptomatic patients with spondylolysis. • Females with isthmic spondylolytic lesions appear to be more prone to progressive displacement and may need surgical intervention more often than males. • Congenital spondylolisthesis (dysplastic type) occurs with a 2:1 female-to-male ratio with symptoms beginning around the adolescent growth spurt. These comprise about 14-21% of all cases of spondylolisthesis. • Degenerative spondylolisthesis occurs more commonly in females with a 5:1 female-to-male ratio. The incidence increases after age 40 years.
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  Age • Acute isthmicspondylolysis often occurs during the first and second decades of life. Most cases occur before the patient reaches age 15 years. • In rare cases, acute spondylolysis may be seen in early adulthood. Younger patients are at higher risk than older patients for developing progressive spondylolisthesis. • The risk for progression in adults is rare when the lesion is at L5. In contrast, lesions at L4-5 may progress into adulthood because of increased sagittal rotation, shear translation, and axial rotation at this segment.
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  • Congenital/dysplastic spondylolisthesis hasbeen documented in children as young as 3.5 months. More commonly, congenital spondylolistheses go undiagnosed until later in life after an individual has been ambulating for quite some time. • Degenerative spondylolisthesis occurs most commonly after age 40 years.
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  History • Isthmic spondylolisthesis •Symptoms often occur around the time of an adolescent growth spurt. • Some report acute onset of focal low back pain during activity, while others have more insidious onset. • Radiating pain may extend to the buttocks or thigh. • Pain may be more significant and have mechanical characteristics with higher grades of spondylolisthesis.
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  • In mostcases, patients do not complain of symptoms suggesting neurologic deficit with lower grades of spondylolisthesis. Radicular pain becomes more common with larger slips. • Complaints of radiating pain below the level of the knee associated with numbness and tingling in a dermatomal distribution would suggest the presence a radiculopathy resulting from either the foraminal stenosis that occurs with spondylolisthesis or a concomitant herniated disk. • Nerve root impingement from the fibrocartilaginous bar that forms at the sight of the lysis may occur. High degrees of spondylolisthesis may present with neurogenic claudication or symptoms suggesting cauda equina impingement.
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  • The patient'spain usually is provoked by activity, particularly back extension activities. • Patients with acute spondylolysis tend to demonstrate poor tolerance of activities requiring excessive spine loading, including running and jumping. Sitting usually is better tolerated. • A large percentage of patients with spondylolysis are asymptomatic. Progression of a spondylolisthesis also may occur without symptoms.
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  • Degenerative spondylolisthesis •The pain begins insidiously and may be achy in character. Pain is located in the low back and posterior thighs. • Neurogenic claudication may be present as well, with lower extremity symptoms being made worse with activity and better with rest. • Symptoms are often chronic and progressive, although patients may experience periods of remission.
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  • Dysplastic spondylolisthesis:Symptoms present much like isthmic spondylolisthesis, but neurologic compromise is more likely. • Traumatic spondylolisthesis • Patients present with acute pain associated with trauma. • If a slip is severe enough, cauda equina compression may occur and present with classic symptoms including bowel and bladder dysfunction, radicular symptoms, or neurogenic claudication. • Pathologic spondylolisthesis: Symptoms may be insidious in onset and associated with radicular pain/claudication.
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  Physical Findings • Isthmicspondylolisthesis • Hamstring tightness is observed almost universally, even in low-grade spondylolisthesis. • Lumbar spasm may be present. • A palpable step-off is noted with slips equal to or greater than grade 2. • With higher degrees of spondylolisthesis, an increased lumbosacral kyphosis is seen (50% or greater) along with a compensatory thoracolumbar lordosis. Truncal shortening may be present. With severe slips, the rib cage may rest on the iliac crest.
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  • Dermatomal weaknessmay be present if a radiculopathy or an element of stenosis is present. • A waddling gait may be noted secondary to hamstring tightness producing a shortened stride length. • If spondylolisthesis is not present, spondylolysis presents with paraspinal spasm, pain provocation with lumbar spine extension, and tight hamstrings.
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  • Degenerative spondylolisthesis •These patients present with less prominent physical findings. Pain often is provoked with lumbar spine extension. • If lumbar stenosis is present, then reflexes may be diminished. Radicular findings also may be present.
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  • Congenital/dysplastic spondylolisthesis: Physicalfindings are similar to those described above for isthmic spondylolisthesis. • Traumatic and pathologic spondylolisthesis • These patients also present with similar findings. • A good neurologic evaluation is important.
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  Causes • A geneticpredisposition to isthmic spondylolisthesis is believed to be linked with patients having a thin pars or subtle hypoplastic facet joints. Family members have a reported incidence of 28-69%. • Activities requiring lumbar extension stress increase the risk. Patients with spina bifida occulta are known to have a higher occurrence.
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  • Degenerative spondylolisthesisis caused by facet degeneration accompanied by disk degeneration most commonly at the level of L4-L5. Some studies identify sagittally oriented facets as more prone to arthritic change. • Congenital spondylolisthesis is due to dysplastic sacral or lower lumbar segments. Dysplastic facets or abnormal orientation of the facet joints are the cause for spondylolisthesis.
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  • Traumatic spondylolisthesisis rare. In theory, severe hyperextension stress placed on the pars could produce fracture and instability. One should keep in mind that hyperflexion-distraction forces can cause facet dislocation and spondylolisthesis. • Pathologic spondylolisthesis can occur as a result of any bone lesion that might weaken the posterior elements. Generalized skeletal diseases including osteomalacia, syphilitic disease, and Von Recklinghausen disease are some reported causes. Bony destructive lesions, including tumor or infection, are other potential causes.
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  Laboratory Studies • Laboratory studiesdo not help in diagnosing spondylolytic spondylolisthesis. Workup is radiographic in nature.
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  Imaging Studies • Radiography •Initial workup includes anteroposterior, lateral (done while standing), and spot view radiographs of the lumbar spine and lumbosacral junction. • Oblique views may provide additional information but are not obligatory. • Flexion/extension views increase the sensitivity of radiographic studies and give the clinician some idea of the degree of instability that may be present. • Percentage of slip and slip angle (calculated by measuring the angle formed by a line drawn from superior endplate inferiorly and the inferior endplate at the segment of involvement) are clinically valuable.
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  Scottie Dog
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  Normal spine in oblique view- ( ScottyDog sign)
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  Normal spine in oblique view- ( ScottyDog sign)
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  • Radiographic studiesallow visualization and grading of spondylolisthesis but may not always reveal the presence of an isolated spondylolysis (without spondylolisthesis). • The 'Scottie dog' whose neck is broken can be seen on the oblique films when there is a classic spondylolysis.
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  Lumbar oblique radiograph showing the "ScottieDog." A pars defect is seen at L5.
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  Diagram in the obliqueprojection shows the components of the vertebrae that result in the appearance of a Scottie dog with a collar.
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  • Bone scan •Bone scan with single-photon emission computed tomography (SPECT) imaging is helpful and often helps to direct management. • If the bone scan is positive, then the lesion is metabolically active. The physician may consider bracing, since healing is still in progress. • A cold scan in the context of documented spondylolysis indicates that healing is complete; therefore, bracing is of limited utility.
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  Bone scan with single-photon emission computed tomography (SPECT)imaging showing acute spondylolysis
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  • Computed tomography(CT) scan[13] • CT scan performed with 1 mm sections, including coronal and sagittal reconstructions, allows for better visualization of the spondylolytic defect. • CT scan not only documents the presence and severity of spondylolysis, but it can help rule out more serious causes for a positive bone scan. • Myelogram/CT studies are helpful in delineating the severity of central stenosis. Nerve root cut-off often is observed in the presence of radiculopathy.
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  • Magnetic resonanceimaging (MRI) • MRI may visualize edema in the marrow around the sight of an acute spondylolytic defect. • MRI also is helpful in identifying the presence of nerve root compression as a result of foraminal or central canal stenosis.
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  Other Tests • Electromyographymay provide 1 more modality for identifying a concomitant radiculopathy or polyradiculopathy (ie, stenosis), which may be present as a result of spondylolisthesis.
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  Rehabilitatio n Program
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  Physical Therapy Most patients withlow-grade isthmic spondylolisthesis and degenerative spondylolisthesis can be treated conservatively. If an isthmic lesion is acute, the patient should be restricted from provocative activities or sports until they are asymptomatic. Physical therapy is an integral part of the patient's rehabilitation process. The most accepted protocol includes activity and exercise that reduces extension stress.
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  Visceral Approach
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  Duodenal Approach
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  Cecum Approach
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  The goals ofexercise are to improve abdominal strength and increase flexibility. Since tight hamstrings are almost always part of the clinical picture, appropriate hamstring stretching is important. Instruction in pelvic tilt exercises may help reduce any postural component causing increased lumbar lordosis. Myofascial release may play a role as well in reducing pain from the surrounding soft tissues.
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  If conservative treatmentis indicated for congenital spondylolisthesis, the above principles apply. Adequate work up must be completed for pathologic causes of spondylolisthesis prior to treating with conservative means. Traumatic spondylolisthesis most often requires surgical stabilization.
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  Surgical Interventio n Surgical treatment isindicated when any type of spondylolisthesis is accompanied by a neurologic deficit. Persistent disabling back pain after conservative management may be considered an indication. High-grade slips (greater than 50%) more commonly require surgical intervention. Traumatic spondylolisthesis is rare but almost always requires surgical stabilization.
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  Surgery • Surgery isused when the slip is severe and when symptoms are not relieved with nonsurgical treatments. • Symptoms that cause an abnormal walking pattern, changes in bowel or bladder function, or steady worsening in nerve function require surgery. • Deterioration of symptoms is common in patients with a history of significant neurologic symptoms who don't have surgery to correct the problem. • If a reasonable trial of conservative care (three months or more) does not improve things and/or if quality of life is significantly reduced, then surgery may be the next best solution.
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  The main types ofsurgery for spondylolisthes is include: laminectomy (decompression) posterior fusion with or without instrumentation posterior lumbar interbody fusion
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  Laminecto my When the vertebraslips forward, the nearby nerves that exit the spine can become pinched or irritated. In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal. To fix this, the lamina of the bony ring is removed to ease pressure on the nerves. The procedure to remove the lamina and release pressure on the nerves is called laminectomy. Decompression alone is usually not advised. Studies show much better results when the operation is combined with a fusion of the involved vertebrae.
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  Laminectom y
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  Posterior Fusion with Instrumentati on A spinalfusion is normally done immediately after laminectomy for spondylolisthesis. The fusion procedure is designed to fuse the two vertebrae into one bone and stop the slippage from worsening. The fusion is used to lock the vertebrae in place and stop movement between the vertebrae, easing mechanical pain. When combined with laminectomy surgery (mentioned earlier), fusion helps relieve nerve compression.
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  • In thisprocedure, the surgeon lays small grafts of bone over the back of the problem vertebrae. Sometimes fusion is done just with bone graft material. This is a fusion without fixation (non-instrumentation). • Instrumentation is the use of metal plates or screws to stabilize the segment during healing. Most surgeons combine fusion with instrumentation to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster. • Outcomes are improved when decompression is combined with fusion (compared with decompression alone). Fusion and functional improvement are even better when spinal instrumentation is used. • There are fewer long-term problems with pain and pseudoarthrosis.
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  Posterior Lumbar Interbody Fusion When fusion surgeryis needed for mild spondylolisthesis (up to 50 percent slippage), posterior lumbar interbody fusion may be considered. In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back). Combining fusion of both portions of the spine increases the fusion surface area and improves the fusion rate. The surgeon works from the back of the spine and removes the disc between the problem vertebrae. Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage that spreads and holds the vertebrae apart. Surgeons usually apply some form of instrumentation (described above) on the back of the vertebrae. In some cases, additional strips of bone graft are placed along the back surfaces of the vertebrae to be fused. This increases the mechanical strength of the spine.
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  Fusion with Biologics New materials forfusion are being developed and tested. For example, bone morphogenetic proteins (BMP) mixed with bone graft in a putty is under investigation. This substance may help reduce the need for instrumentation with fusion. BMP helps promote faster and more bone growth in the unstable spinal segment. Studies of safety and effectiveness of this material have been very favorable so far. Without the need to harvest bone graft and place instrumentation, surgical time is much less with BMP putty. And the fusion rate is much higher with BMP alone compared with fusion alone or fusion with fixation.
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  Motion- Sparing Technologi es The Food andDrug Administration (FDA) is reviewing the use of devices inserted without invasive surgery to limit vertebral motion. For example, a special titanium implant has been designed to fit between the spinous processes of the vertebrae in lower back. These motion-sparing devices are currently used with patients who have spinal stenosis (narrowing of the spinal canal or foramen). With spondylolisthesis, the goal is to reduce the load on the disc and facets while increasing the space inside the spinal canal and foramen, thus relieving symptoms. The vertebral segment is stabilized enough to prevent further progression of the spondylolisthesis.
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  SPONDYLOLYSTHESIS
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  Other Treatment Bracing for acuteisthmic spondylolysis/spondylolisthesis is controversial, but it has been shown in some studies to reduce symptoms and to facilitate healing. Most sources discuss use of a thoracolumbosacral spinal orthosis or modified Boston Brace for low-grade slips or for isolated spondylolytic lesions (without spondylolisthesis). Some sources advocate more extensive bracing with inclusion of most of the thorax (to the nipple line) and the thighs. Recommend use of the device for 3-6 months. Steroid injections for pars pain have been advocated by some physicians. Epidural steroid injections may help radicular pain or neurogenic claudication.
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  • Treatment fordegenerative spondylolisthesis may include bracing, facet or epidural steroid injections, along with the above mentioned physical therapy approach.
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  Medication • The goalof medication in care of spondylolysis or spondylolisthesis of any type is to mitigate pain. • NSAIDs are used most commonly while narcotic analgesics are used for breakthrough pain.
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  Further Outpatien t Care • Becauserisk of progression exists in younger patients with isthmic or congenital spondylolisthesis, obtain serial radiographs on a semiannual basis to rule out the possibility of progression if symptoms are persistent.
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  Inpatient & Outpatient Medications •Anti-inflammatories and other analgesics are the only medications used in the care of patients with spondylolysis or spondylolisthesis.
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  Deterrenc e • Prevention ofisthmic spondylolisthesis may be difficult in athletes who must perform repetitive activities requiring hyperextension. • The best prevention is to avoid repetitive hyperextension if at all possible, since this activity appears to place athletes at the greatest risk.
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  Complicatio ns The most commoncomplication of spondylolisthesis of any type is nerve root impingement/radiculopathy at the level of spondylolisthesis. Spinal stenosis and cauda equina syndrome may occur when a significant slip has occurred. Disk degeneration occurs at the level of the spondylolisthesis faster than at other levels of the spine, increasing the risk of diskogenic low back pain.
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  Nonsurgical Rehabilitati on 1 Back pain associated with spondylolisthesi swill gradually improve in up to one-third of all patients. Slippage of one vertebra over the other does not increase in this group. Worsening of symptoms is not expected in patients who don't have neurologic symptoms at the time of diagnosis. 2 Nonsurgical treatment for spondylolisthesi s commonly involves physical therapy a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care. 3 The first goal of treatment is to control symptoms. 4 Physiotherapist works with patient to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm. 5 Patients are shown how to stretch tight muscles, especially the hamstring muscles.
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  • As patientsrecover, they gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move easier and lessens the chances of future pain and problems. • A primary purpose of therapy is to help you learn how to take care of symptoms and prevent future problems. • Patient is given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also describe strategies that can be used if symptoms flare up.
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  Rehabilitati on After Surgery Rehabilitation aftersurgery is more complex. Patients who have surgery for spondylolisthesis usually stay in the hospital for a few days afterward. Some surgeons require patients to wear a rigid brace or cast for up to four months after fusion surgery for spondylolisthesis. Patients who've had fusion surgery for a severe slip may also be required to stay off their feet for four months. After lumbar fusion surgery for spondylolisthesis, patients must normally wait four months before beginning a rehabilitation program. This delay is needed to give the fusion a chance to start healing. Patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take at least 12 months.
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  • Ideally, patientsare able to return to their previous activities. However, some patients may need to modify or discontinue certain activities to avoid future problems. • The therapist will continue to be a resource for patient. But patient will be in charge of doing exercises as part of an ongoing home program.
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  Prognosis • In general,patients with grade 1 or grade 2 isthmic slips do quite well with conservative management. Patients may return to play once they are asymptomatic. • A flexion-based home exercise protocol is vital. Overall long-term outcome is quite favorable, specifically with lower grades of listhesis not accompanied by neurologic impairment. • Higher grades of isthmic spondylolisthesis have a variable prognosis with regard to persistent low back pain. • Surgical intervention does provide nice improvement in claudication or radicular symptoms. • Diskogenic pain may produce more persistent lower lumbar discomfort.
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  • Patients withdegenerative spondylolisthesis seem to have persistent waxing and waning pain originating from the facet joints. • Surgical decompression for neurologic compromise has a high rate of success in relieving lower extremity symptoms.
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  Patient Education • Athletesinvolved in higher risk sports should be educated about the risk of developing a spondylolysis. • Instruction regarding an appropriate home exercise program, including a flexion- based spine exercise protocol and hamstring stretching, should be a part of treatment.
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