about spondylesthisis

1. SPONDYLOLISTHESIS
DR. V Venkata RamaKrishnaiah
Mpt Ortho,MSc phycology

2. DEFINATION
 The term spondylolisthesis is derived from the
Greek words spondylo = vertebra, and olisthesis
= translation.
 Spondylolisthesis is defined as a translation of
one vertebra over the adjacent caudal
vertebra.
 This can be a translation in the anterior
(anterolisthesis) or posterior direction
(retrolysthesis) or, in more serious cases,
anterior-caudal direction.

3. CLASSIFICATIONS
 According to Wiltse-Newman ,It is classified
in six types on the basis of aetiology. These
are :
 Dysplastic (congenital),
 Isthmic,
 Degenerative,
 Traumatic,
 Pathologic and
 Iatrogenic spondylolisthesis.

4. TYPE 1 : CONGENITAL SPONDYLOLISTHESIS
(DYSPLASTIC )
 An elongation of the pars interarticularis can be
seen in congenital spondylolisthesis, in which the
pars lesion is due to a congenital anomaly of the
L5-S1 facet articulation.
 Secondary to congenital abnormalities of
lumbosacral articulation including mal-oriented or
hypoplastic facets, sacral deficiency, poorly
developed pars
 As the slip progresses, the pars elongates in
response to the deformity. Therefore, with an
elongated pars, it is important to evaluate the
lumbosacral facets to properly classify the lesion.
 The symptoms usually develop during the
adolescent growth period.

5. TYPE 2: ISTHMIC SPONDYLOLISTHESIS
 Isthmic spondylolisthesis, or spondylolisthesis
due to a lesion of the pars interarticularis, is a
common source of pain and disability in both
pediatric and adult population.
 The basic lesion in isthmic spondylolisthesis is
in the pars interarticularis and mainly appears at
the lumbosacral level (L5-S1).
 It is characterized by high lordosis angles and
lordotic wedging of the affected vertebra (L5)
and very high L4-5 intervertebral disc wedging.

6.  Isthmic spondylosithesis is typically
considered as a pediatric condition.
 Spondylolisthesis is mostly often caused by
spondyloslysis.
 Spondylolysis is considerd a stressfracture
caused by an eccesive amount of mechanical
stress that affects the isthmus.
 This part of the vertebrae forms the
connection between the corpus and the facet
joints, at the back of the vertebrae. Therefore,
a load for the facet joints result in a stressor
for the isthmus.
 The stress on the pars interarticularis is the
highest with extension and rotation.
 Anterior pelvic tilt, abdominal muscle
weakness and hamstring thightness magnify
these biomechanical forces.

7. Wiltse et al. divided this category into three
subtypes:
 The lytic lesion of the pars (Type II-A) is the
most common cause of spondylolisthesis and is
termed spondylolysis. This defect is present in
6% of the population by young adulthood.
 The elongation of the pars interarticularis
(Type II-B) is thought to be due to repetitive
microfractures with subsequent healing in an
elongated position. Elongation of the pars can
also be seen in congenital spondylolisthesis.
 An acute fracture of the pars (Type II-C), the
third subtype, resulting from a single traumatic
episode. Wiltse et al. suggested that this type of
isthmic spondylolisthesis could also be classified
as traumatic spondyloslisthesis.

8. TYPE 3 : DEGENERATIVE SPONDYLOLISTHESIS
 Degenerative spondylolisthesis is most common
in adults.In this type the L4–L5 vertebral space
is affected 6 to 9 times more commonly than
other spinal levels.
 It is characterized by a significant constriction of
the cauda equina, combined with a diminished
cross-sectional area of the vertebral canal,
thickening and buckling of the ligamentum
flavum and hypertrophy of adjacent facet joints
 It is also a common condition in the elderly (>50
years).

9.  The main causes are:
• Disc degeneration;
• Facet joint arthrosis;
• Malfunction of the ligamentous stabilizing
component;
• Ineffectual muscular stabilization.
 Degenerative spondylolisthesis is believed to
result from chronic intersegmental instability.
 Degenerative changes to both the facet joints
and
the intervertebral disk cause the slip.
 Sagittal orientation of the facet joints and
facet
tropism also have been related to the
development
of degenerative spondylolisthesis.

10. Type 4: Traumatic spondylolisthesis
Traumatic spondylolisthesis is caused by a fracture
in a region other than the pars. This fracture leads
to slippage of the vertebrae.
Type 5: pathological spondylolisthesis
Pathological spondylolisthesis is due to generalized
or localized musculoskeletal processes affecting the
posterior elements and causing instability.
Diffuse or local disease compromises the usual
structure integrity that prevents slippage.
Type 6: iatrogenic spondylolisthesis
Iatrogenic spondylolisthesis results from excessive
removal of the posterior elements after laminectomy.

11.  According to Marchetti-Bartolozzi
Classification:
 Developmental – including Wiltse 1 and 2
 Acquired – by
o traumatic ,
o postsurgical,
o pathological,
o degenerative

12. MYERDING CLASSIFICATION
 Grade1- <25%
 Grade 2- 25 – 50%
 Grade 3- 50-75%
 Grade 4- 75-100%
 Grade 5- spondyloptosis

13. SYMPTOMS AND FINDINGS
 Low-back Pain and leg pain
 Trophic changes
 Atrophy of the muscles, muscle weakness
 Tense hamstrings, hamstrings spasms
 Disturbance in patterns
 Diminished ROM (spine)
 Disturbances in coördination and balance
 Neurological symptoms (possible evolution towards
cauda equine syndrome)
 Dull pain, typically situated in the lumbosacral region
after exercise, especially with an extension of the lumbar
spine.

14.  Patients usually report that their symptoms vary as a
function of mechanical loads (such as in going from
supine to erect position) and pain frequently worsens
over the course of the day .
 Radiation into the posterolateral thighs is also
common and is independent of neurologic signs and
symptoms.
 The pain could be diffuse in the lower extremities,
involving the L5 and/or L4 roots unilaterally or
bilaterally, but generally bilaterally .
 Symptoms decrease with sitting or standing with
lumbar flexion and with lying.
 As symptoms worsen patients are more and more
limited in their activities and walking distance. This
relationship is known as neurogenic intermittend
claudication .

15. DIFFERENTIAL DIAGNOSIS
 Spondylolysis
 Metastatic disease
 Low back pain
 Osteoarthritis
 Neuroforaminal stenosis
 Spinal Stenosis

16. DIAGNOSIS
 Radiographic examination provides the best
diagnostic information when
spondylolisthesis (or spondylosis) is
suspected.
 Standard lumbar anteroposterior and lateral
views are needed, but for a better look at the
problem oblique views are essential to
visualize the pars interarticularis directly.
These views may demonstrate a pars
interarticularis abnormality,

17. X-ray
Overall X-ray of the spine and lumbosacral X-ray are seen as
the golden standard for diagnosis.There are multiple views
used with the most common one being the anteroposterior,
lateral and oblique views. Multiple characteristics can be
seen, such as the degree of the slip or the slip angle. The
most prominent sign remains the defect of the pars
interarticularis, or more commonly named the broken collar or
neck of the “Scottie Dog”.
CT and MRI
Advanced imaging techniques like MRI and CT have to be
used when neurological symptoms are present, and when
surgical intervention is indicated.
CT and MRI, which give an accurate localization and a better
illustration of the lesion , are taken when one of the following
signs are present:
• Significant and progressing neurologic claudication
• Radiculopathies and the clinical suspicion that another
condition may be causative
• Bladder or bowel complaints
• Metastatic disease

18. MEDICAL MANAGEMENT
 General:
 Initially resting and avoiding movements like
lifting, bending and sports.
 Analgesics and NSAIDs reduce musculoskeletal
pain and have an anti-inflammatory effect on
nerve root and joint irritation.
 Epidural steroid injections can be used to relieve
low back pain, lower extremity pain related to
radiculopathy and neurogenic claudication.
 A brace may be useful to decrease segmental
spinal instability and pain.

19. SURGERY
 Patients with chronic and disabling symptoms,
who fail to respond to conservative management
may be referred for surgery.
 When the condition of spinal instability is very
severe, a surgical intervention may be necessary
to attach the vertebras together.
 It can help the patient to reduce pain, improve
spinal function and increase the quality of life.
 The goal of surgery is to stabilize the segment with
listhesis, decompress the neural elements,
reconstruction of the disc space height and
restoration of normal sagittal alignment.
 When evaluating a patient, many factors, such as
age, degree of slip and risk of slip progression,
must be considered.

20.  There are several different options for
surgical treatment; one of them is fusion (e.g.
posterolateral fusion).
 Other treatment options include
decompression (Gill laminectomy),
supplemental instrumentation and
supplemental anterior column support.

21. PHYSICAL THERAPY MANAGEMENT
 Spondylolisthesis should be treated first with conservative therapy,
which includes physical therapy, rest, medication and braces.
 Exercise therapy:
 exercise therapy, which consists of strengthening exercises of the
deep abdominal musculature.
 In addition, isometric and isotonic exercises may be beneficial for
strengthening of the main muscle groups of the trunk, which
stabilize the spine. These techniques may also play a role in pain
reduction.
 In order to improve the patient’s mobility, physical therapy includes
stretching exercises of the hamstrings, hip flexors and lumbar
paraspinal muscles.
 Furthermore endurance training is effective for chronic low back
pain.
 There is evidence that suggests that specific stabilization
exercises and core stability exercises can be useful in reducing
pain and disability in chronic low back pain in patient
with spondylolisthesis.

22.  There is evidence that suggests that specific
stabilization exercises and core stability
exercises can be useful in reducing pain and
disability in chronic low back pain in patient
with spondylolisthesis.

23.  Lumbosacral braces or corset
 Posture and lifting techniques
 Massage therapy
 Kinesiotaping
 Maitland mobilisation
 Muscle energy techniques etc...