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Spondylolisthesis Physiotherapy Singapore

Spondylolisthesis refers to the movement/translation of one of your spine joints (known as vertebra) over the caudal vertebra; and this movement can be:

  • forward (known as anterior/anterolisthesis) or
  • backwards (known as posterior/retrolisthesis) or
  • in more serious cases: anterior-caudal direction

Spondylolisthesis is classified into 5 different causes:

  • Dysplastic (congenital)
  • isthmic
  • degenerative
  • traumatic
  • pathologic spondylolisthesis

Clinically Relevant Anatomy

The main structures involved is the fractured pars interarticularis of the lumbar vertebrae, and on top of that, other structures can also be damaged: the ligamentous structures, including the iliolumbar ligament, between L5 and the sacrum, are stronger than those between L4 and L5, by which the vertebral slip commonly develops in L4.

Isthmic or spondylolytic spondylolisthesis (type II) seems to happen at the lower back (lumbo-sacral) level. (L5-S1), which is is characterized by high lordosis angles and lordotic wedging of the affected vertebra (L5) and very high L4-5 intervertebral disc wedging.

Degenerative spondylolisthesis (type III) seems to happen mainly at the L4-5 level and is characterized by 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.

Epidemiology / Etiology

Occurrences and incidences of spondylolisthesis varies considerably depending on ethnicity, sex, and sports activity. Several epidemiological studies have revealed that the incidence of symptomatic listhesis in Caucasian populations varies from 4 to 6%, but rises as high as 26% in secluded Eskimo populations and varies from 19 to 69% among first-degree relatives of the affected patients.

Type I: Congenital spondylolisthesis. Symptoms usually develop during the adolescent growth period.

Type II: Isthmic spondylolisthesis. It is typically considered as a pediatric condition. Saraste (1987) demonstrated that the onset of symptoms tends to occur after childhood, with a mean age at presentation of 20 years.

Type III: Degenerative spondylolisthesis. In this type the L4–L5 vertebral space is affected 6 to 9 times more commonly than other spinal levels. It is also a common condition in the elderly (>50 years). The main causes are:

  • Disc degeneration;
  • Facet joint arthrosis;
  • Malfunction of the ligamentous stabilizing component;
  • Ineffectual muscular stabilization.

Potential risk factors are:

  • Increasing age;
  • Female sex;
  • Pregnancies;
  • African-American ethnicity;
  • Generalized joint laxity
  • Anatomical predisposition (sagitally oriented facet joints, hyperlordosis, high pelvic incidence)

Characteristics / Clinical Presentation

  • Low back pain;
  • Pain the legs;
  • Dull pain, typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine;
  • Diminished mobility/range of movement in the spine;
  • Tense hamstrings;
  • Neurological symptoms (possible evolution towards cauda equine syndrome)

Patients usually report that their symptoms vary in function of mechanical loads (such as in going from supine to erect position) and pain frequently worsens over the course of the day (figure 3). 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.

In addition to these findings, each type of spondylolythesis has its own characteristics

Spondylolisthesis can occur together with other disorders and seems to have a link with some of them:

  • Spina bifida occulata -Several studies support a positive association between spina bifida occulta and spondylolysthesis. This high association may not be due to mechanical factors but to genetich factors
  • Cerebral palsy - A number of studies proved the association between cerebral palsy and spondylolysthesis, certainly in athetoid cerebral palsy (60%)
  • Scheuermann’s disease - Ogilvie and Sherman reported a 50% incidence of spondylolysthesis in 18 patients with Scheuermann’s disease. Greene et al. found spondylolysthesis (grade I or II) at L5-S1 in 32% of patients with Scheuermann’s disease

  • Scoliosis -Fisk et al. reported that the incidence in 539 patients with ideopatic scoliosis was 6.2%, which corresponded to that found in the general population. But the relation between scoliosis and spondylolysthesis has not been clarified.

Differential Diagnosis

Diagnostic Procedures / Examination

History Taking

Specific questions should be asked referring to:

  • Pain - Location, Severity, Duration, Quality (for example: tingling, burning,.. sensations), Exacerbating factors, Alleviating factors
  • Leisure activities
  • Occupational risks
  • Pain changes throughout day: difference morning compared to evening/night?

Imaging

Most commonly used clinical imaging is X-ray, CT and MRI

X-rayOverall 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 - 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

And used for one of the following reasons:

  • Evaluating an atypical presentation including pre-lysis
  • Determining the condition of the intervertebral disc
  • Evaluating vertebral slipping and possible neural element compression 

CT and MRI give the best visualization of bone morphology and are therefore, most often used to check the alignment of the facet joints and their degenerative changes. Images resulting from CT and MRI are the most sensitive and specific when a pars fracture is present

Myelography can be used together with CT, but nowadays MRI is used instead. 

Physical examination

The following signs are observable during the physical examination:

  • A significant lumbosacral kyphosis
  • A hyperlordotic posture
  • Lumbosacral tenderness 
  • A palpable “step-off deformity” 
  • Pain on lumbar hyperextention (common) 
  • Dull back pain exacerbated by rotation and hyperextension 
  • Hamstrings contracture (common) and/or spasms
  • Gait disturbance: Crouching, Short stride length, Incomplete swing phase
  • Potential distal neurological symptoms
  • Scoliosis may be associated
Outcome Measures- Oswestry Disability Index 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.

Surgery

When the condition is very severe, a surgical intervention may be necessary to attach the vertebras together. 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. The grade of listhesis can be reduced to some extent, but complete reduction is rarely achieved. There is a wide variety of complications, such as neurological complications, vascular injury, instrument failure, and infections.

There are several different options for surgical treatment; one of them is fusion (e.g. posterolateral fusion). The aim of fusion is to reduce pain by reducing the motion of the segment. Other treatment options include decompression (Gill laminectomy), supplemental instrumentation and supplemental anterior column support. Controversies exist about the effectiveness of these treatment options that can be used separately or in any combination.

A surgical intervention has better results than nonoperative treatment in case of neurological symptoms and for treating pain and functional limitation. 

When evaluating a patient, many factors, such as age, degree of slip and risk of slip progression, must be considered. Also a thorough evaluation of social and physiological factors should be undertaken. Therefor each patient's treatment program should be individualized to achieve optimal outcome.

  • Neurologic signs / neurogenic claudication / radiculopathy (unresponsive to conservative measures)
  • Myelopathy
  • High-grade slip (>50%)
  • Type 1 (congenital) and 2 (isthmic) slips with evidence of instability, progression of listhesis, or lack of response to conservative measures
  • Type 3 (degenerative) listhesis with gross instability and incapacitating pain
  • Bladder or bowel symptoms (especially in type 3)
  • Traumatic spondylolisthesis
  • Iatrogenic spondylolisthesis
  • Postural deformity and gait abnormality

Contra-indications

  • Poor medical health
  • High operative risk (higher risk than potential benefits)
  • High risk of hemorrhage: Anticoagulation with warfarin, or antiplatelet therapy
  • Smoking

Physical Therapy / Physiotherapy Management

If there are no indications for surgery (as described above in medical management) physical therapy is always recommended to start with.

Optionally in combination with medication or bracing.

Nonoperative treatment should be the initial course of action in most cases of degenerative spondylolisthesis and symptomatic isthmic spondylolisthesis, with or without neurologic symptoms. Children or young adults with a high-grade dysplastic or isthmic spondylolisthesis or adults with any type of spondylolisthesis, who does not respond to nonoperative care, should consider surgery. 

In all the other cases, spondylolisthesis should be treated first with conservative therapy, which include physical therapy, rest, medication and braces. 

Traumatic spondylolisthesis can be treated successfully using conservative methods, but most authors suggested it would result in posttraumatic translational instability or chronic low back pain. 

There is strong evidence that exercise therapy, which consists of strengthening exercises, isometric and isotonic exercises, stretching exercises, lifting techniques and endurance training, is effective for chronic low back pain (level 1) 

Physical therapy treatment may include strengthening 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 of the hamstrings, hip flexors and lumbar paraspinal muscles.

The objective of stretching and strengthening is to decrease the extension forces on the lumbar spine, due to agonist muscle tightness, antagonist weakness, or both, which may result in decreased lumbar lordosis.

Special attention has to be given to posture and proper lifting techniques, wherein the physiotherapist has an important educational role.

An excellent exercise is stationary bicycling, because it promotes spine flexion.

Sports that can be practiced are walking, swimming and cross-training. Although these activities will not improve the shift, these sports are a good alternative for cardiovascular exercises. Impact sports like running should not be done in order to avoid wear. The adolescent athlete or manual laborer should avoid hyperextension and/or contact sports.

Exercises should be done on a daily basis and physiotherapy to be done regularly.

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