• Clinical science

Spondylolisthesis

Abstract

The term spondylolisthesis defines a condition in which the vertebral bodies slip forward in relation to the vertebrae beneath. Most commonly L5 slips over S1. The disease affects approx. 6–9% of the population. The condition most commonly occurs in children, adolescents, and in individuals > 50 years old. Risk factors are repetitive hyperextension of the spine (e.g., gymnastics), trauma, bone pathologies, or degenerative spine disease. Spondylolisthesis may be asymptomatic or cause lumbar pain on exertion, gait problems, radiculopathic pain, or urinary incontinence. In some patients a step-off at the lumbosacral area is palpable. Diagnosis is established through imaging. Most patients achieve good results with conservative treatment (e.g., physical therapy). Surgical treatment (e.g, vertebral fusion, decompression of the nerves) is reserved for patients with refractory cases and neurologic deficits. Overall, children and adolescents achieve better results than adults and elderly.

Epidemiology

  • Affects up to 10% of the population
  • Most common in children < 6 years, 12–17 years (congenital and spondylolytic form) and adults aged > 50 years (degenerative form)
  • Sex: > (congenital and spondylolytic form); > (degenerative form)
  • Defect most commonly occurs in the lumbar spine (L5 in 80% of cases), L4 in 15% of cases

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Risk factors:
    • Congenital malformation (dysplasia or hypoplasia) of the lumbosacral joints in L5–S1
    • Repetitive hyperextension and rotation movements at L5–S1
      • Commonly associated with gymnastics, swimming, and weight lifting
    • Spondylolysis: lytic defect in the pars interarticularis, permitting forward slippage of the superior vertebra
    • Degenerative disease: most commonly in the elderly at L4–L5
    • Trauma
    • Local or systemic pathology (e.g., tumor, Paget's disease, osteogenesis imperfecta, Tbc)

References:[1]

Clinical features

  • Asymptomatic (∼ 90% of cases)
  • Chronic lumbar pain that worsens with exertion and/or when reclining
  • Gait problems (e.g., waddling gait)
  • Possibly urinary or bowel incontinence

References:[1]

Diagnostics

  • Physical examination
  • Provocative test: The relief from pain after local injection of lidocaine at the level of the pars interarticularis may help confirm the diagnosis.
  • Radiologic examination:
    • Conventional x-ray of lumbosacral spine
      • Indication: to evaluate the vertebral structures, the degree and severity of forward slippage, the slip angle, and the presence of concomitant spine pathologies
      • Usually spondylolisthesis is an incidental finding.
      • Meyerding classification5 stages: The amount of forward translation of the cranial vertebra over the caudal vertebra is measured in percentage on a lateral radiograph.
      • Specific signs:
        • Scotty dog with a collar sign in spondylolysis: normal appearance of the lumbar spine in an oblique projection at 45° is referred to as "Scotty dog sign" → in spondylolysis, the fracture line appears as the "dog's collar"
        • Inverted Napoleon's hat sign in spondyloptosis: in the case of severe subluxation of L5 over S1
  • CT scan: used to rule out other causes of pain (e.g., tumor), in traumatic cases, and to guide surgical treatment.
  • MRI: helps visualize the compression of the nerve roots
  • SPECT (Single-photon emission computed tomography): useful in detecting stress injuries or defects, their progression and healing potential, guiding the treatment

References:[5]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

The main goals in the treatment of spondylolisthesis are to reduce pain, restore the mobility of the spine, and prevent further disease progression.

  • Conservative treatment
    • Indication: patients with low-grade spondylolisthesis (< 50% slippage of cranial vertebra over the caudal vertebra) and degenerative spondylolisthesis with no neurological deficits
    • Physical therapy emphasizing training of back and abdominal muscles
    • Activity modification: avoid sports which contribute to spondylolisthesis
    • Orthotic braces
    • Facet or epidural steroid injections to relieve radicular pain.
    • Regular follow-ups every 6 months
  • Surgical treatment
    • Indication: high-grade spondylolisthesis (> 50% slippage of cranial vertebra over the caudal vertebra), neurologic deficits, traumatic spondylolisthesis or if symptoms progress despite conservative treatment
    • Standard procedure: vertebral fusion
    • Nerve decompression in the case of radiculopathic pain or bowel/bladder dysfunction

References:[5][1]

Prognosis

  • Conservative treatment gives satisfactory results in 80% of cases.
  • The rate of success from surgical treatment is higher in children than in adults.

References:[6][7][8][9]

  • 1. Vokshoor A. Spondylolisthesis, Spondylolysis, and Spondylosis. In: Spondylolisthesis, Spondylolysis, and Spondylosis. New York, NY: WebMD. http://emedicine.medscape.com/article/1266860-overview#a11. Updated February 3, 2017. Accessed February 16, 2017.
  • 2. Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009; 34(2): pp. 199–205. doi: 10.1097/BRS.0b013e31818edcfd.
  • 3. Tebet MA . Current concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia. 2014; 49(1). doi: 10.1016/j.rbo.2013.04.011.
  • 4. Perrin AE. Lumbosacral Spondylolisthesis. In: Lumbosacral Spondylolisthesis. New York, NY: WebMD. http://emedicine.medscape.com/article/2179163-overview#a6. Updated February 1, 2016. Accessed February 28, 2017.
  • 5. Froese BB. Lumbar Spondylolysis and Spondylolisthesis. In: Lumbar Spondylolysis and Spondylolisthesis. New York, NY: WebMD. http://emedicine.medscape.com/article/310235. Updated February 18, 2016. Accessed February 16, 2017.
  • 6. Frennered AK, Danielson BI, Nachemson AL. Natural history of symptomatic isthmic low-grade spondylolisthesis in children and adolescents: a seven-year follow-up study. J Pediatr Orthop. 1991; 11(2): pp. 209–13. pmid: 2010523.
  • 7. Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. J Pediatr Orthop. 1987; 7(6): pp. 631–8. pmid: 2963019.
  • 8. Seitsalo S, Osterman K, Hyvãrinen H, Tallroth K, Schlenzka D, Poussa M. Progression of spondylolisthesis in children and adolescents. A long-term follow-up of 272 patients. Spine (Phila Pa 1976). 1991; 16(4): pp. 417–21. pmid: 2047915.
  • 9. Floman Y. Progression of lumbosacral isthmic spondylolisthesis in adults. Spine (Phila Pa 1976). 2000; 25(3): pp. 342–7. pmid: 10703107.
  • Tebet MA. Current concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Rev Bras Ortop. 2014; 49(1): pp. 3–12. doi: 10.1016/j.rboe.2014.02.003.
  • Osterman K, Schlenzka D, Poussa M, Seitsalo S, Virta L. Isthmic spondylolisthesis in symptomatic and asymptomatic subjects, epidemiology, and natural history with special reference to disk abnormality and mode of treatment. Clin Orthop Relat Res. 1993: pp. 65–70. pmid: 8242953.
last updated 04/06/2018
{{uncollapseSections(['CcYqeL', 'ycYdUL', 'AcYRUL', '-cYDUL', 'a1YQ2L', 'b1YH2L', 'X1Y92L', '11Y2fL'])}}