spondylolisthesis and plif.pdf

7/28/2019 Spondylolisthesis and PLIF.pdf

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Spondylolysis and Spondylolisthesis

What are spondylolysis and spondylolisthesis?

Your lower back is called your lumbar spine. It is made up of five bones called

lumbar vertebrae. The vertebrae have two major parts, a solid part called the

body and a bony ring through which the lower part of the spinal cord and

nerves travel. Between the bodies of the vertebrae is shock absorbing

material called disks. Part of the ring of each vertebra touches the vertebra

above it and the vertebra below it.

Spondylolysis is a condition where there is a break in one or both sides of the

ring of a vertebra. Spondylolisthesis is a condition in which a break in the ring

allows the body of the vertebra to slip forward. Spondylolysis and

spondylolisthesis most commonly occur at the fourth or fifth lumbar vertebrae.

These conditions are also called stress fractures.

How does it occur?

Spondylolysis and spondylolisthesis result from repetitive extension of the

back (bending backward). This weakens the rings of the lumbar vertebrae,

eventually leading to a break (fracture) in a ring. Less commonly, theseconditions may result from an injury to the back. Some people may be born

with weak vertebral rings.

Gymnasts, dancers, and football players are most commonly diagnosed with

these conditions.
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Inside Me..What are the symptoms?

You may have low back pain or spasms, or you may have no symptoms at all.

You may have pain all the time or only from time to time. Spondylolysis or

spondylolisthesis usually do not damage the nerves.

How is it diagnosed?

Your healthcare provider will examine your back and look for tenderness

along your vertebrae or spasm in the muscles next to your vertebrae. You will

have an X-ray to check for a break in the ring of a vertebra or slippage of a

vertebra. You may have a bone scan, CT scan, or an MRI.

How is it treated?

If the break is new and your provider thinks that the bones can heal without

surgery, you may need to wear a brace for 1 to 3 months. Severe cases of

spondylolisthesis may require surgery.

To treat this condition:

Put an ice pack, gel pack, or package of frozen vegetables, wrapped ina cloth on the area every 3 to 4 hours, for up to 20 minutes at a time.

Take an anti-inflammatory medicine such as ibuprofen, or othermedicine as directed by your provider. Nonsteroidal anti-inflammatorymedicines (NSAIDs) may cause stomach bleeding and other problems.

These risks increase with age. Read the label and take as directed.Unless recommended by your healthcare provider, do not take for morethan 10 days.

When can I return to my normal activities?

Everyone recovers from an injury at a different rate. Return to your activities

depends on how soon your back recovers, not by how many days or weeks it

has been since you started having symptoms. In general, the longer you have

symptoms before you start treatment, the longer it will take to get better. Thegoal is to return to your normal activities as soon as is safely possible. If you

return too soon you may worsen your injury.

It is important that you fully recover from your back pain before you return to

any strenuous activity. You must be able to have the same range of motion

that you had before your injury. You must be able


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Inside Me..to walk and twist without pain.

How can I prevent these conditions?

You can best prevent these conditions by having strong back and abdominal

muscles and by not being overweight. To help prevent these injuries, do backexercises and avoid activities that force the back to extend, such as tackling in

football.

Spondylolisthesis

Medical Codes

ICD-9-CM:738.4, 756.12

Definition

Reed Group

Spondylolisthesis describes a condition of a forward slippage of one vertebra over another, which may or

may not be associated with demonstrable instability. The vertebrae of the spine are stacked one on top of

the other and held in place by ligaments, muscles, joints, and discs. The healthy spine is flexible and

moves in many planes, including flexion, extension, and rotation.

There are five types of spondylolisthesis (congenital/dysplastic, isthmic, degenerative, traumatic, and

pathological). Congenital or dysplastic spondylolisthesis is a defect in the posterior part of L5 or S1, and


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Inside Me..the abnormal orientation of the bones permits forward slippage of one vertebra on another. It is a rare

condition and is frequently associated with neurologic involvement. The severity of subluxation is graded

as follows: Grade I is 0% to 25%, Grade II is 26% to 50%, Grade III is 51% to 75%, and Grade IV is more

than 75% of vertebral slippage as evidenced onx-ray(Devereaux).

The most common type of spondylolisthesis is isthmic or spondylolytic spondylolisthesis.Spondylolysis,

which is generally a stress fracture in the posterior part of the vertebra, called the pars interarticularis, is

present in this type of spondylolisthesis. Spondylolysis is the most common cause of spondylolisthesis.

Isthmic spondylolisthesis most commonly occurs in the lumbar region, at the level between the fifth

lumbar vertebra and the first sacral vertebra (L5-S1 level).

Degenerative spondylolisthesis is an acquired condition related to chronic degenerative disc disease and

the associated changes that may lead to segmental instability The pars interarticularis is not affected in

degenerative spondylolisthesis. The degeneration of intervertebral discs (degenerative disc disease)

results in narrowing of the disc space, which allows the supporting structures to become lax and can lead

to segmental instability, most common at L4-L5. The facet joints are also affected: the result is persistent

slippage (subluxation) of the facet joints with decreased resistance to forward slippage of one vertebra on

another. The slippage is limited by the structures at the back of the spine that are still intact. Degenerativespondylolisthesis is more common in women and occurs most often at L4-5.

Spondylolisthesis can also be caused by atraumaticfracture (traumatic spondylolisthesis) of the posterior

elements of the vertebra, by destruction of the posterior aspect of the spine throughtumor,infection, or

osteoporosis (pathological spondylolisthesis), and by spinal surgery (postsurgical spondylolisthesis).

Risk: Individuals at risk for spondylolisthesis include those who have spondylolysis and those with an

abnormal forwardcurvature of the lumbar spine(lordosis). The risk is increased in individuals who engage

in contact sports (football, volleyball, or soccer), certain kinds of gymnastics, or weight lifting. Individuals

with radiographic osteoarthritis and postmenopausal women with osteoporosis are also at greater risk of

developing spondylolisthesis.

Spondylolytic (isthmic) spondylolisthesis is most common in white males (Froese). Women are more likely

to progress to a higher degree of slippage than men (Froese).

Incidence and Prevalence:

Degenerative spondylolisthesis is three times more common in blacks than whites and usually occurs

after the age of 40 (Irani). It is more common in females than males by 5 to 1 (Froese).

Congenital spondylolisthesis is twice as common in females as in males, and symptom onset is usually

during adolescence (Irani).

In the US, the incidence of isthmic spondylolysis is 6% to 7%, with 11.3% of
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cases occurring at the L4-L5 level, and 82% occurring at the L5-S1 level (Froese).

The prevalence of degenerative spondylolisthesis is 5.8% in men and 9.1% in women (Vokshoor).

The prevalence of spondylolisthesis in osteoporotic women is 28.4%, with 12% occurring at the L3-L4

level, 73% occurring at the L4-L5 level, and 28% occurring at the L5-S1 level (Nizard).

The incidence of postoperative spondylolisthesis is 11% to 14% at the vertebral level above thefused

segments

Source:

(Nizard).

Medical Disability Advisor

Diagnosis

History: Low back pain is the most common presenting symptom. Individuals with spondylolisthesis may

also present with lordosis, localized tenderness over the spine just above the pelvis, pain in the thighs or

buttocks, tightness in the hamstrings, and back stiffness. Isthmic spondylolisthesis may be an incidental

finding on imaging studies that becomes apparent during the evaluation of low back pain in adults, and

must be evaluated in the context of degenerative disc disease or other causes of low back pain.

Individuals with severe grades of slippage may not be able to walk normally, and stumble or drag their

feet instead. Neurologic signs often correlate with the degree of slippage. In describing pain, individuals

may report that it is aggravated when they rise out of a sitting position, walk up stairs or inclines, get in

and out of cars, and lean backward (extension). The pain is relieved at rest when lying flat with the knees

bent, or leaning forward (flexion).

Degenerative spondylolisthesis is generally seen in older patients, who may present with low back pain,

symptoms of neurogenic claudication (heaviness in the legs with walking that is alleviated by sitting),

radiculopathy, or a combination of those symptoms.
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Physical exam:

Tests:

A complete examination of the lumbar spine, including musculoskeletal and neurological

components, is performed to rule out any other underlying pathology and to determine the extent of nerve

involvement. Findings of the exam may reveal decreased sensation and tendon reflexes and weakness of

lower leg muscles. Examination of the spine by manual touching and massaging of the areas of concern

(palpation) may reveal a step-off in higher-grade slippage. Findings are also likely to reveal a limited

range of motion of the spine; increased pain when leaning backward; relief of pain when leaning forward;

clumsy, swayed walking (waddling gait); and tight hamstrings.

Spondylolisthesis is usually identified by plain x-rays (radiographs). Additional studies such

asMRIandCTscans will routinely be performed to evaluate for nerve involvement, degenerative disc

disease, disk herniation, spondylosis, and spinal stenosis. The amount and percentage of slippage should

be measured on a standing lateral x-ray. A change in the percentage of slippage when the individual

bends forward or leans backward is an indication of dynamic instability. This means that the amount of

vertebral slippage changes with spinal motion.

In cases of spondylolysis, the diagnosis may not be evident in plain x-rays. Oblique plain films may be

helpful. Both CT and MRI can define damage to the pars interarticularis (pars defect) and nerve root

impingement, although CT may be better for the purposes of identifying the bony defect, and MRI may

reveal more detail about neurologic involvement. MRI also helps define the status of the disc at the

impaired level and the level adjacent to the slip.

If the spondylolysis is believed to be recent, a bone scan may be useful to confirm or exclude an acute

fracture.Electromyography(EMG) andnerve conduction studies

Source:

check nerve function.


Treatment

Conservative treatment for spondylolisthesis includes rest (not excessive), activity modification (to

minimize offending activity),physical therapy(to strengthen trunk muscles, especially the abdominals,

and to stretch the hamstrings), and analgesics. Corsets or braces are also prescribed when necessary to

minimize motion across the area of the slippage and to decrease pain.
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Surgical intervention is considered when conservative therapy fails, pain becomes disabling, or a

progressive neurological deficit occurs. Age is not a contraindication to surgery. Many elderly individuals

seem to benefit a great deal from surgical intervention. The primary surgical procedure for treating

spondylolisthesis isspinal fusion, in which 2 or more vertebrae are united by bone graft (with or without

instrumentation) that heals to prevent further slippage of the vertebrae. Internal fixation devices, usually

pedicle screws with or without an underbody fusion cage, may be used to enhance stability and thus the

chances of successful fusion. Posterior lumbar interbody fusion (PLIF) enjoys a high success rate for

Grades I and II spondylolisthesis, with nearly 100% of individuals experiencing a solid fusion (Brislin;

Vokshoor). More severe grades of slippage may require both anterior and posterior fusion. If there is

neurologic deficit, a decompression may be performed in addition to the fusion. In decompression for

spondylolisthesis, the surgeon removes bone and ligamentous tissue compressing the lumbar nerve

roots.

Source:Medical Disability Advisor

Prognosis

In young patients with spondylolisthesis, surgical fusion with or without decompression may be curative,

and no further intervention may be required. Individuals who have sustained an acutefracturewith

minimal slippage may completely recover if the fracture heals. Individuals with progressive degenerative

changes may continue to have intermittent symptoms. Surgery (fusion, decompression) can be curative,

but some individuals may experience only partial or intermittent relief.

The risk of degenerative spondylolisthesis increases with age, and progression of vertebral slippage

occurs in 30% of individuals (Nizard). If vertebral slippage progresses, the neural foramen may narrow,

causingnerve compressionorsciatica

Source:

that may require surgical decompression. Surgical outcomes are

improved when fusion is performed in addition to decompression (Sengupta).


Rehabilitation

Rehabilitationfor spondylolisthesis varies depending on the severity of the disease and the symptoms. If

the spinal cord is compromised, seeSpinal Cord Injury. If surgery is considered, the literature suggests

that a 6-week period of rehabilitation treatment should be undertaken prior to surgical intervention.

Rehabilitation includes modalities such as heat and cold to control pain (Braddom). Once pain is

controlled, general stretching and strengthening exercises of the trunk are indicated and progressed as

tolerated. Therapists teach a home exercise program to complement the supervised rehabilitation.

Individuals should be advised to continue these exercises on a regular basis, including after discharge

from therapy, regardless of symptoms (Matsunaga). Instruction in proper posture and body mechanics for

all activities of daily living should be reviewed.
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If surgery is indicated for severe and progressive spondylolisthesis, a postoperative protocol must be

followed (Moller). This will include ambulation and transfer training, possibly with an orthosis to stabilize

the trunk. Following surgery, some individuals may benefit fromoccupational therapy

FREQUENCY OF REHABILITATION VISITS

to assess the need

for devices to promote independence in daily activities. After several weeks, general low back stretching,

strengthening and stabilization exercises can be initiated and progressed as indicated by the treating

physician.

Whether managed operatively or nonoperatively, an ergonomic assessment may be beneficial prior to

return to work.

Nonsurgical

Specialist Spondylolisthesis

Physical Therapist Up to 15 visits within 6 weeks

Surgical

Specialist Spondylolisthesis

Physical Therapist Up to 6 visits within 6 weeks

Note on Surgical Guidelines: Rehab usually begins after tissue healing, about 6 to 8 weeks after surgery.

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It

provides a framework based on the duration of tissue healing time and standard clinical practice.


Complications

Progression of the slippage with increased pressure ortractionon the spinal nerve roots may complicate

treatment.

For individuals requiring surgery to stabilize the spondylolisthesis, complications includenerve root

injury(less than 1%), cerebrospinal fluid leak (2% to 10%), fusion failure (5% to 25%), and infection and

hemorrhage from surgery (1% to 5%). Among individuals who smoke, thenonunionrate of lumbar fusion

is up to 50% (Vokshoor).
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Return to Work (Restrictions / Accommodations)

Work restrictions may include the elimination of overhead work that involves hyperextension of the back.

The individual may also be restricted in performing unassisted heavy lifting, repetitive bending, or pushing

heavy objects. Some individuals may not be able to perform activities that require twisting at the waist.

Use of a rigid corset (orthotic) may be needed to limit motion of the spine. Safety issues should be

evaluated, as well as drug-testing policies, since individuals may need to take pain medication.

Individuals with severe pain and hamstring spasm, individuals with Grade III or IV vertebral slippage, and

individuals who have had spinal fusion are generally restricted to sedentary, light, or moderate work.


Spondylolisthesis Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a condition of

thespinewhereby one of thevertebraslips forward or backward compared

to the next vertebra. Forward slippage of one vertebra on another is

referred to as anterolisthesis, while backward slippage is referred to as

retrolisthesis. Spondylolisthesis can lead to a deformity of the spine as well

as a narrowing of the spinal canal (centralspinal stenosis)

orcompression

What causes spondylolisthesis?

of the exiting nerve roots (foraminal stenosis).

There are five major types of lumbar spondylolisthesis.

1. Dysplastic spondylolisthesis: Dysplastic spondylolisthesis iscaused by a defect in the formation of part of the vertebra called the

facet that allows it to slip forward. This is a condition that a patient is

born with (congenital).
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2. Isthmic spondylolisthesis: In Isthmic spondylolisthesis, there is a

defect in a portion of the vertebra called the pars interarticularis. If

there is a defect without a slip, the patient has spondylolysis. Isthmic

spondylolisthesis can be caused by repetitivetraumaand is more

common in athletes exposed to hyperextension motions including

gymnasts, and football linemen.

3. Degenerative spondylolisthesis: Degenerative spondylolisthesis

occurs due to arthritic changes in the joints of thevertebraedue

tocartilagedegeneration. Degenerative spondylolisthesis is more

common in older patients.

4. Traumatic spondylol isthesis: Traumatic spondylolisthesis is due to

direct trauma orinjuryto the vertebrae. This can be caused by

afractureof the pedicle,laminaor facet joints that allows the front

portion of the vertebra to slip forward with respect to the back portion

of the vertebra.

5. Pathologic spondylolis thesis: Pathologic spondylolisthesis is

caused by a defect in the bone caused by abnormal bone, such asfrom atumor.

What are the risk factors for spondylolisthesis?

Risk factors for spondylolisthesis include afamily historyof back problems.

Other risk factors include a history of repetitive trauma or hyperextension of

the lower back or lumbar spine. Athletes such as gymnasts, weight lifters,

and football linemen who have large forces applied to the spine during

extension are at greater risk for developing isthmic spondylolisthesis.
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What are the symptoms of spondylolisthesis?Comment on

The most common symptom of spondylolisthesis islower back pain. This is

often worse afterexerciseespecially with extension of the lumbar spine.

Other symptoms include tightness of the hamstrings and decreasedrange

of motionof the lower back. Some patients can develop pain, numbness,

tingling orweaknessin the legs due tonerve compression. Severe

compression of the nerves can cause loss of control of bowel or bladder

function, orcauda equina syndrome.

How is spondylolisthesis diagnosed?

In most cases it is not possible to see visible signs of spondylolisthesis by

examining a patient. Patients typically have complaints of pain in the back

with intermittent pain to the legs. Spondylolisthesis can often cause muscle

spasms, or tightness in the hamstrings.

Spondylolisthesis is easily identified using plain radiographs. A lateral X-ray

(from the side) will show if one of the vertebra has slipped forward

compared to the adjacent vertebrae. Spondylolisthesis is graded according

the percentage of slip of the vertebra compared to the neighboring

vertebra.

1. Grade I is a slip of up to 25%,

2. grade II is between 26%-50%,

3. grade III is between 51%-75%,
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4. grade IV is between 76% and 100%, and

5. Grade V, or spondyloptosis occurs when the vertebra has completely

fallen off the next vertebra.

If the patient has complaints of pain, numbness, tingling or weakness in the

legs, additional studies may be ordered. These symptoms could be caused

by stenosis or narrowing of the space for the nerve roots to the legs. ACT

scanorMRIscan can help identify compression of the nerves associated

with spondylolisthesis. Occasionally, aPET scancan help determine if the

bone at the site of the defect is active. This can play a role in treatmentoptions for spondylolisthesis as described below.

What is the treatment for spondylolisthesis

The initial treatment for spondylolisthesis is conservative and based on the

symptoms.

A short period of rest or avoiding activities such as lifting and bendingand athletics may help reduce symptoms.

Physical therapycan help to increase range of motion of the lumbar

spine and hamstrings as well as strengthen the coreabdominal

muscles.

Anti-inflammatory medications can help reduce pain by decreasingtheinflammationof the muscles and nerves.

Patients with pain, numbness and tingling in the legs may benefit

from anepidural steroid (cortisone) injection.
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Patients with isthmic spondylolisthesis may benefit from a

hyperextension brace. This extends the lumbar spine bringing the two

portions of the bone at the defect closer together and may allow for

healing to occur.

For patients whose symptoms fail to improve with conservative treatment

surgery may be an option. The type of surgery is based on the type of

spondylolisthesis. Patients with isthmic spondylolisthesis may benefit from

a repair of the defective portion of the vertebra, or a pars repair. If an MRI

scan or PET scan shows that the bone is active at the site of the defect it is

more likely to heal with a pars repair. This involves removing any scar

tissue from the defect and placing some bone graft in the area followed by

placement of screws across the defect.

If there are symptoms in the legs the surgery may include a decompression

to create more room for the exiting nerve roots. This is often combined with

a fusion that may be performed either with or without screws to hold thebone together. In some cases the vertebrae are moved back to the normal

position prior to performing the fusion, and in others the vertebrae are

fused where they are after the slip. There is some increased risk of injury to

the nerve with moving the vertebra back to the normal position.

Can spondylolisthesis be prevented?

Spondylolisthesis cannot be completely prevented. Certain activities such

as gymnastics, weight-lifting and football are known to increase the stress

on the vertebrae and increase the risk of developing spondylolisthesis.


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What are the complications of spondylolisthesis?

Complications of spondylolisthesis includechronic painin the lower back or

legs, as well as numbness, tingling or weakness in the legs. Severe

compression of the nerve can cause problems with bowel or bladder

control, but this is very uncommon.

What is the outlook for spondylolisthesis?

The outlook for patients with spondylolisthesis is good. In most cases

patients respond well to a conservative treatment plan. For those with

continued severe symptoms, surgery can help alleviate the leg symptoms

by creating more space for the nerve roots. The back pain can be helpedthrough alumbar fusion.

Spondylolisthesis At A Glance

Spondylolisthesis is a forward or backward slippage of one vertebra

on an adjacent vertebra.

Causes of spondylolisthesis include trauma, degenerative, tumor, and

birth defects.

Symptoms of spondylolisthesis include lower back or leg pain,

hamstring tightness, and numbness and tingling in the legs.

Most people with spondylolisthesis can be treated conservatively,

without the need for surgery.

Patients who fail to improve with conservative treatment may be a

candidate for surgery.
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Inside Me.. I was diagnosed in 1991 with Spondylolithesis at L5 S1. I was 16. At

that time, I tried the medications, physical therapy and back brace. After

2 years of pain and trying to be a normal teenage girl I made the

decision to have thespinal fusionsurgery in May 1993. For me, it wasone of the best decisions I ever could have made! I had the old style

surgery with the battlescarsto prove it. It was a week in the hospital, 12

weeks on bed rest, 18 months for the bone in my hip to grow back and

to this day my hip tells me when it is going to rain, but I would not trade

that! I have not had handicap parking since 1994. I do not take pain

medication. I do have regular massages which is all I need to keep the

remaining discomfort at bay. As my doctor put it, the surgery is not a

cure but a treatment option. He is retired now or I would be

recommending him to all of you. He gave me my life back. Don't give up

until you find the right treatment option for you.

I was diagnosed at age 12 due tolower back pain. Mine is the

congenital type. I finally knew it was time to do something at age 45

when I had horrific pain down my legs alternating with numbness. A

simple x-ray revealed that I no longer had a disk between L5 and S1.

After an anterior-posterior decompression and fusion, I live withchronicpain, but have a stable back. I am able toexerciseregularly and move

better than I have in years. Even though I take medication for pain

everyday, I am very happy with my result.

I am 49 and was diagnosed with spondylolethisis, anterior grade 4,

along with spinal stenosis, andbone spurs. I'm deteriorating; it has

causedscoliosisand I have now been diagnosed with neuropathy in my

left leg. I was hit by a car at age 4, which broke my pelvis in two places

and my left femur. I was in traction, a body cast, and had to learn to

walk all over again. My left leg is inches longer then my right. I was

never to run again and walked with a limp, yet ended up being a very

strong top athlete. I've had three kids, whom I played with and trained in

sports. I just stopped playing softball five
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Inside Me..years ago. I also biked, hiked, adventured raced, and did so many

outdoor things. But eight months ago, all this came to an abrupt end. I

fell down some stairs, which really did some damage. When my X-rays

were read, the doctors discovered my condition. September 13th, 2012,began a very fast deterioration. The hip cramps at night keep me from

sleeping, the pain in my left hip travels around to my quad to my knee,

down my shin, to the top of my foot, where it sometimes leaves me in

tears. It's so unbearable. I can hardly walk anymore; I'm losing motor

control. It's taking a toll on my speech, my focus, and my attitude.

Stretching does not help, nor does icing or adjustments. Only a high

dose of pain meds help, but they make me violently ill and depressed,

and Isleepfor two days sometimes. I'm told I will more than likely be

paralyzed by 60, and I'm 49. My nerve damage is getting so severe that

I may not make it another 4-5 years. I have three grandbabies, and I

can't even hold them, let alone play with them. I've read about the

surgeries and I am getting to the point of desiring it. At one time, I was

against surgery and tried to keep people away from it with the very

positive and effective body work I've done. I want my life back so bad

and I'm feeling resentful and suffering majordepression. I readsomeone else's post about how other people in their life diminish the

pain they suffer. Well, you are not the only one. It frustrates me that

anyone can call what we suffer minimal, undermine us, or call us

hypochondriacs. I'd love to see any one of them spend time in our

bodies for just a day, or maybe from the time we have to get out of bed

each day up to trying to get into the shower. And then they get upset

with us for how cranky we are. I'm glad that I could vent how I'm feeling.

Some days I cry out of frustration. From being an athlete to nothing.

Losing 30 pounds, suffering atrophy, and muscle loss everywhere. I've

lost my butt muscles and none of my clothes fit. I've even been accused

of being on meth! I want my life back.
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Inside Me.. I am 47 and was diagnosed withSpondylolisthesisand Spinal Stenosis

10 years ago. Although the doctors tell me that it is mild

spondylolisthesis, only grade one, I am mostly in some sort of pain

daily. My biggest problem is the dreadedSciatica, I have to be socareful and avoid at all costs lifting, pulling or pushing anything around, I

am a farmer so a lot of heavy work is involved daily, but I have someone

to help out with the heavy work. When the doctor uses the word mild I

feel like slapping him across the face and asking him how mild does that

feel. Pain is pain and living with it daily can be depressing, but I refuse

to let it control me, which it used to do. I do not take any medication

such as anti inflammatory, this are pure poison to anyone's stomach. I

would rather suffer back pain than to partake in any type of anti

inflammatory drug.

SOURCE: http://www.medicinenet.com/spondylolisthesis/

Lumbar Spondylolisthesis

A Patient's Guide to Lumbar SpondylolisthesisIntroduction

Normally, the bones of the spine (the vertebrae) stand neatlystacked on top of one another. Ligaments and joints support the

spine. Spondylolisthesis alters the alignment of the spine. In thiscondition, one of the spine bones slips forward over the onebelow it. As the bone slips forward, the nearby tissues and nervesmay become irritated and painful.

This guide will help you understand
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Inside Me.. how the problem develops

how doctors diagnose the condition

what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae.Vertebrae are stacked on top of one another to create the spinalcolumn. The spinal column gives the body its form. It is the body'smain upright support. The section of the spine in the lower back iscalled thelumbar spine.

The lumbar spine is made of the lower five vertebrae. Doctorsoften refer to these vertebrae as L1 to L5. These five vertebraeline up to give the low back a slight inward curve. The lowestvertebra of the lumbar spine, L5, connects to the top ofthe sacrum

Each vertebra is formed by a round block of bone, called

a

, a triangular bone at the base of the spine that fitsbetween the two pelvic bones.

vertebral body. A circle of bone attaches to the backof the vertebral body. When the vertebrae are stacked on top of

each other, these bony rings create a
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Inside Me..hollow tube. This tube, called the spinal canal, surrounds thespinal cord as it passes through the spine. J ust as the skullprotects the brain, the bones of the spinal column protect thespinal cord.

The spinal cord only extends to L2. Below this level, the spinalcanal encloses a bundle of nerves that goes to the lower limbsand pelvic organs. The Latin term for this bundle of nerves

is cauda equina, meaning horse's tail.

Two sets of bones form the spinal canal's bony ring. Two pediclebones attach to the back of each vertebral body. Two lamina

bones complete the ring. The place where the lamina and pediclebones meet is called the pars interarticularis, or pars for short.There are two such meeting points on the back of each vertebra,one on the left and one on the right. The pars is thought to be theweakest part of the bony ring.

Intervertebral discs separate the vertebral bodies. The discsnormally work like shock absorbers. They protect the spineagainst the daily pull of gravity. They also protect the spine during

strenuous activities that put strong force on the spine, such asjumping, running, and lifting.
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The lumbar spine is supported by ligaments and muscles.The ligaments, which connect bones together, are arranged inlayers and run in multiple directions. Thick ligaments connect thebones of the lumbar spine to thesacrum (the bone below L5) andpelvis.

Between the vertebrae of each spinal segment are two facetjoints. The facet joints are located on the back of the spinalcolumn. There are two facet joints between each pair ofvertebrae, one on each side of the spine. Afacet jointis made ofsmall, bony knobs that line up along the back of the spine. Wherethese knobs meet, they form a joint that connects the two

vertebrae. The alignment of the facet joints of the lumbar spineallows freedom of movement as you bend forward and back.

Theanatomy of the lumbar spineis often discussed in terms

ofspinal segments

Causes

. Each spinal segment includes two vertebraeseparated by an intervertebral disc, the nerves that leave thespinal cord at that level, and the facet joints that link each level ofthe spinal column.
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Inside Me..Why do I have this problem?

Spondylolisthesis may very rarely be congenital, which means it ispresent at birth. It can also occur in childhood as a result of injury.

In older adults, degeneration of the disc and facet (spinal) jointscan lead to spondylolisthesis.

Spondylolisthesis from degeneration usually affects people over50 years old. This condition occurs in African Americans moreoften than in whites. Women are affected more often than men.

The effect of the female hormone estrogen on ligaments andjoints is to cause laxity or looseness. The higher levels ofestrogen in women may account for the greater incidence of

spondylolisthesis. Degenerative spondylolisthesis mainly involvesslippage of L4 over L5.

In younger patients (under 20 years old), spondylolisthesis usuallyinvolves slippage of the fifth lumbar vertebra over the top of thesacrum. There are several reasons for this. First, the connectionof L5 and the sacrum forms an angle that is tilted slightly forward,mainly because the top of the sacrum slopes forward. Second,the slight inward curve of the lumbar spine creates an additional

forward tilt where L5 meets the sacrum. Finally, gravity attemptsto pull L5 in a forward direction.

Facet joints are small joints that connect the back of the spinetogether. Normally, the facet joints connecting L5 to the sacrumcreate a solid buttress to prevent L5 from slipping over the top ofthe sacrum. However, when problems exist in the disc, facet

joints, or bony ring of L5, the buttress becomes ineffective. As aresult, the L5 vertebra can slip forward over the top of the sacrum.
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Inside Me..A condition called spondylolysis can lead to the slippage thathappens with spondylolisthesis. Spondylolysis is a defect in thebony ring of the spinal column. It affects the pars interarticularis,mentioned earlier. This defect is most commonly thought to be a

stress fracture that happens from repeated strains on the bonyring. Participants in gymnastics and football commonly sufferthese strains. Spondylolysis can lead to the spine slippage whena fracture occurs on both sides of the bony ring. This slippage iscalled spondylolisthesis. The slippage is graded from I through IV,one being mild, IV often causing neurological symptoms. Theback section of the bony ring separates from the main vertebralbody, so the injured vertebra is no longer connected by bone to

the one below it. In this situation, the facet joints can't providetheir normal support.

A traumatic fracture in the bony ring can lead to slippage whenthe fracture goes completely through both sides of the bony ring.

The facet joints are no longer able to provide a buttress, allowingthe vertebra with the crack in it to slip forward. This is similar towhat happens when spondylolysis (mentioned earlier) occurs onboth sides of the bony ring, but in this case it happens all at once.

Degenerative changes in the spine (those from wear and tear)can also lead to spondylolisthesis. The spine ages and wearsover time, much like hair turns gray. These changes affect the

structures that normally support healthy spine alignment.Degeneration in the disc and facet joints of a spinal segmentcauses the vertebrae to move more than they should. Thesegment becomes loose, and the added movement takes anadditional toll on the structures of the spine. The disc weakens,

pressing the facet joints together.
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Inside Me..Eventually, the support from the facet joints becomes ineffective,and the top vertebra slides forward.

Symptoms

What does the condition feel like?

An ache in the low back and buttock areas is the most commoncomplaint in patients with spondylolisthesis. Pain is usually worsewhen standing, walking, or bending backward and may be easedby resting or bending the spine forward. Leaning on a counter top,piece of furniture, or shopping cart are common waysto alleviate

Spasm is also common in the low back muscles. The

(reduce) the symptoms.

hamstringmuscleson the back of the thighs may become tight.

The pain can be from mechanical causes. Mechanical pain iscaused by wear and tear on the parts of the spine. When thevertebra slips forward, it puts a painful strain on the disc and facet

joints.

Slippage can also cause nerve compression. Nerve compressionis a result of pressure on a nerve. As the spine slips forward, thenerves may be squeezed where they exit the spine. This conditionalso reduces space in the spinal canal where the vertebra hasslipped. This can put extra pressure on the nerve tissues inside

the canal. Nerve compression can cause symptoms where thenerve travels and may include numbness, tingling, slowedreflexes, and muscle weakness in the legs.
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Inside Me..Nerve pressure on the cauda equina (mentioned earlier), thebundle of nerve roots within the lumbar spinal canal, can affectthe nerves that go to the bladder and rectum. When this happens,bowel and/or bladder function can be affected. The pressure may

causelow back pain, pain running down the back of both legs,and numbness or tingling between the legs in the area you wouldcontact if you were seated on a saddle.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam.Your doctor will ask questions about your symptoms and howyour problem is affecting your daily activities. Your doctor will alsowant to know what positions or activities make your symptomsworse or better.

Next the doctor examines you by checking your posture and theamount of movement in your low back. Your doctor checks to seewhich back movements cause pain or other symptoms. Your skinsensation, muscle strength, and reflexes are also tested.

Doctors will usually order X-rays of the low back. The X-rays aretaken with your spine in various positions. They can be used tosee which vertebra is slipping and how far it has slipped.

If more information is needed, your doctor may order computedtomography (a CT scan). This is a detailed X-ray that lets thedoctor see slices of the body's tissue. If you have nerve problems,the doctor may combine the CT scan withmyelography. To dothis, a special dye is injected into the space around the spinal

canal, the subarachnoid space. During the
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Inside Me..CT scan, the dye highlights the spinal nerves. The dye canimprove the accuracy of a standard CT scan for diagnosing thehealth of the nerves.

Your doctor may also order a magnetic resonance imaging

Treatment

(MRI)scan. The MRI machine uses magnetic waves rather than X-raysto show the soft tissues of the body. It can help in the diagnosis ofspondylolisthesis. It can also provide information about the healthof nerves and other soft tissues.

What treatment options are available?

Nonsurgical TreatmentStudies have not been done yet to determine the best treatmentfor this condition. Conservative care is preferred, especially whenthe vertebra hasn't slipped very far. Most patients with symptomsfrom degenerative spondylolisthesis do not need surgery andrespond well to nonoperative care. Medications may beprescribed to help ease pain and muscle spasm. In some cases,the patient's condition is simply monitored to see if symptoms

improve.

Your doctor may ask that you rest your back by limiting youractivities. This is to help decrease inflammation and calm musclespasm. You may need to take time away from sports or otherstrenuous activities to give your back a chance to heal.

If your doctor diagnoses an acute pars fracture that has thepotential to heal, it may be recommended that you wear a rigid

back brace for two to three months. This
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Inside Me..usually occurs in children and teenagers who begin having back

pain and see their doctor early on. X-rays may show afresh fracture of the pars area of the vertebra on one, or both,sides. A CT scan or bone scan may be recommended todetermine if the fracture is likely to heal. If so, a brace isrecommended. X-rays or a CT scan may be ordered in six to eightweeks to see if the fracture is healing. IF not, the brace will bediscontinued.

Some patients who continue to have symptoms are givenanepidural steroid injection(ESI). Steroids are powerful anti-inflammatories, meaning they reduce pain and swelling. In anESI, medication is injected into the space around the lumbar

nerve roots. This area is called the epidural space. Some doctorsinject only a steroid. Most doctors, however, combine a steroidwith a long-lasting numbing medication. Generally, an ESI isgiven only when other treatments aren't working. But ESIs are notalways successful in relieving pain. If they do work, they may onlyprovide temporary relief.

Patients often work with a physical therapist. After evaluating yourcondition, your therapist can assign positions and exercises to

ease your symptoms. Your therapist can design an exerciseprogram to improve flexibility in your low back and hamstrings andto strengthen your back and abdominal muscles.
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Inside Me..The use of a stationary bike can promote aerobic conditioning andputs you in the optimal position to open the spaces where thenerve roots exit. This type if exercise program can aid in reducingthe painful symptoms.

Surgery

Surgery is used when the slip is severe and when symptoms arenot relieved with nonsurgical treatments. Symptoms that cause anabnormal 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 ofsignificant 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 your quality of life is significantlyreduced, then surgery may be the next best solution. The maintypes of surgery for spondylolisthesis include

laminectomy(decompression)

posterior fusionwith or without instrumentation

posterior lumbar interbody fusion

Laminectomy

When the vertebra slips forward, the nearby nerves that exit the

spine can become pinched or irritated. In addition, the size of thespinal canal in the problem area shrinks, placing pressure on thenerves inside the canal. To fix this, the lamina of the bony ring isremoved to ease pressure on the nerves. The procedure to

remove the lamina and release pressure on thenerves is called laminectomy.
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Inside Me..Decompression alone is usually not advised. Studies show muchbetter results when the operation is combined with a fusion of theinvolved vertebrae (see below).

Posterior Fusionwith Instrumentation

A spinal fusion

In this procedure, the surgeon lays small grafts of bone over the

back of the problem vertebrae.

is normally done immediately after laminectomyfor spondylolisthesis. The fusion procedure is designed to fusethe two vertebrae into one bone and stop the slippage fromworsening. The fusion is used to lock the vertebrae in place andstop movement between the vertebrae, easing mechanical pain.When combined with laminectomy surgery (mentioned earlier),fusion helps relieve nerve compression.

Sometimes fusion isdone just with bone graft material. This is a fusion without fixation(non-instrumentation).Instrumentation

Outcomes are improved when decompression is combined withfusion (compared with decompression alone). Fusion andfunctional improvement are even better when spinalinstrumentation is used. There are fewer long-term problems with

is the use of metal plates orscrews to stabilize the segment during healing. Most surgeonscombine fusion with instrumentation to prevent the two vertebraefrom moving. This protects the graft so it can heal better andfaster.
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SOURCE:

(formation of movement or false jointswithin the fusion).

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Spondylolisthesis

Spondylolisthesis is the displacement of one vertebra on top of another. This

displacement can occur when there is significant acute damage to the area,

from a contact sports injury say, or as a result of more chronic issues such

as cervicaldegenerative disc disease, osteoarthritis, and other cervical spinal

issues. Unchecked, degenerative spondylolisthesis can lead tocervical spinal

stenosis(Kalichman, 2008).

Physicians usually classify spondylolisthesis according to its cause, with the

most common being degenerative spondylolisthesis. This is caused by

chronic degenerative changes in the ligaments, facet joints, bones, and

cartilage that hold the spinal/vertebral column in position. This degeneration

can lead to spondylolisthesis as the vertebral column loses its ability to stay

together and the vertebrae slip out of position. Isthmic spondylolisthesis is

the result of spondylolysis; a defect in the pars interarticularis (part of the

vertebrae) most commonly caused by repetitive microtrauma in childhood

through activities such as gymnastics, diving, soccer, football, and wrestling

(Standaert, 2000).
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Traumatic spondylolisthesis is due to direct trauma inflicted upon the

vertebrae causing a fracture of the pedicle, lamina, or facet joints and

allowing the front of the vertebrae to move forward.Cervical

spondylolysis

Understanding the cause means that the correct treatment can be applied,

such as adequate rest from the microtrauma-inducing sport, analgesics,

anti-inflammatories, physical therapy, or surgery in cases where significant

damage has occurred and conservative treatment has proved ineffective.

Spondylolysis normally does not require surgical intervention, unless it

progresses into spondylolisthesis. The use of a brace may be helpful in

reducing neck pain in the meantime. Identifying the exacerbating activity is

key to preventing future occurrences of the condition, meaning that correct

posture, and core muscle strengthening, along with neck strengthening

exercises are key to a positive outcome. In the case of lumbar or

can lead to spondylolisthesis by altering the normal structure

of the vertebral column and causing vertebral displacement. Congenital

abnormalities of the facet joints can lead to spondylolisthesis, as the

vertebrae are allowed to slip out of place. The condition is referred to as

dysplastic spondylolisthesis. A further classification is pathological

spondylolisthesis, where a defect of the bone, or a tumour causes the slip to

occur.

cervical

spine surgery, typically a spinal fusion is the procedure used to correct

spondylolisthesis.

Causes of Spondylolisthesis
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There are five major types ofspondylolisthesis, all with different causes. The

most common is degeneration of the components of the vertebral column

and spine - degenerative spondylolisthesis. These structures, when

healthy, maintain the spines correct position, allowing for strength and

flexibility of movement. As these components degrade, through chronic wear

and tear they lose their ability to stay supple and strong, making shifts in

the spinal structure more likely, including the slippage of the vertebrae as

occurs in spondylolisthesis. Cartilage calcification and degeneration,

ligaments stretching and tearing,bone spursor osteophyte growth, and

changes in the shock absorbing and cushioning qualities of the intervertebral

discs means that the vertebra can slide forward (or backward in the case of

retrolisthesis), and cause deformity of the spine, with associated pain,

paraesthesia,pinched nerves, numbness, muscle weakening, and impaired

mobility.

Degeneration with age is not, however, the only cause of spondylolisthesis.

Congenital abnormalities such as misshapen bones in the spinal column, or

problems with the pelvic incidence (tilt), can also
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cause excess pressure on the spinal column leading to slippage of the

vertebrae and spondylolisthesis (Labelle, 2004). This is known as dysplastic

spondylolisthesis.

Isthmic spondylolisthesis is a further classification, used to describe the

condition that results fromspondylolysis. This is a condition where repetitive

microtrauma causes defects in the pars interarticularis, a specific part of the

vertebrae, which may develop into spondylolisthesis if the vertebrae slip

forward due to this defect. Spondylolysis is commonly caused in adolescents

and children by activities such as gymnastics, football, wrestling, and diving.

With appropriate rest and possible use of a brace it should correct itself

without developing into spondylolisthesis.

Specific injury or damage to the vertebrae through complications of

surgery,epidural injections, assault, or accidents, such aswhiplash, can

cause traumatic spondylolisthesis. These types of injury can result in

fractures of the lamina, facet joints, or pedicle, and allow the vertebrae to

slide forward. The final class is pathologic spondylolisthesis

Symptoms of Spondylolisthesis

. This is

where the vertebrae slip forward due to an abnormal growth such as a

tumour or bone growth. The specific pathology of the spondylolisthesis

requires careful diagnosis in order to apply appropriate treatment.

In some cases the patient may be asymptomatic and only discover

thespondylolisthesisby chance when having an x-ray conducted for an

unrelated reason. Many cases involving children cause no, or few,

symptoms. Other patients suffer extreme
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symptoms, involving persistent,severe neck pain, back and spine, with

radiating pain down the legs and arms. Pain may be worsened when

hyperextending (arching) the back, making some activities such as yoga or

pilates potentially unsuitable for those with spondylolisthesis. In general,

however, these activities would be excellent for maintaining back and neck

health.

Some patients may experience neurological symptoms, such as intermittent

claudication or vesicorectal disorder; in most cases these patients will

requirespine surgeryto correct the slippage and compression on spinal

structures.Pinched nervesin the cervical spine may lead to weakness and

numbness in the arms and shoulders, along with paraesthesia.Pain in

neckand head can occur, depending on the location of the slippage and

which nerves are being impinged upon. Symptoms of spondylolisthesis may

share commonalities with symptoms of bulging or herniated discs, spinal

stenosis, andcervical arthritis, as well as the issues found with severe

osteophyte growth in the spine. If the patient experiences numbness in the

genital area, or loses bladder or bowel control then they should seek medical

help immediately as they may be signs of cauda equina syndrome which is

considered a medical emergency.
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As there are numerous blood vessels in the cervical area, including the

arteries and veins leading up to the head, it is possible that spondylolisthesis

can cause compression of these blood vessels. This may occur upon

movement, with patients experiencing light-headedness upon rotation or

flexion of the neck and head. If this occurs it is essential to seek medical

assistance immediately as it may lead to blackouts, falls, and accidents as

circulation to the brain is impaired.

Physical signs of theslippage of the vertebraecan, in extreme cases, include

deformity of the back and neck, withstiffness of the neck, pain on rotation,

flexion, and extension, and an abnormal tilt to the posture. Those with

spondylolisthesis of the lumbar area may experience tightness in their

hamstrings, sciatic nerve pain, and numbness in the legs and buttocks; the

latter is a sign of cauda equina syndrome and
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should be thoroughly investigated.

Diagnosis of Spondylolisthesis

In general it will not be possible for a physician to observe outward signs

ofspondylolisthesisupon examining a patient. Taking a history of

symptoms, and a detailed record of trauma and activities such as contact

sports, the physician will recommend further tests and scans as they see fit.

They may also ask patients to conduct some simple stretches, rotation

orflexion of the neck, and to apply resistance during gentle pressure on

their hands, shoulders, and head from the physician. The production, or

relief, of pain from these physical tests can be enlightening as to the

aetiology of theirspine condition, and also make it easier for the physician to

estimate the specific area which is damaged so as to scan that area.

Commonsymptoms of spondylolisthesis, such as tight hamstrings, muscle

spasms, and pain, may overlap with other conditions, such as muscle

strain,disc herniation,spinal stenosis, and diabetic neuropathy, making it

extremely important to obtain the correct diagnosis prior to commencing

treatment.
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Grades of Spondylolisthesis

X-rays taken from the side (lateral) can identify slippage of vertebra relative

to the adjacent vertebrae. The degree of slippage can be calculated and is

graded as follows: Grade 1 is a slip of up to 25%, grade 2 is a slip of 26%-

50%, grade 3 is a slip of 51%-75%, and grade 4 76%-100%. Grade 5 is

known as spondyloptosis and is where the vertebra has slipped off the next

vertebra completely.

MRI or CT scans can be helpful in identifying any stenosis of the spine that

may be causing neck, back, andshoulder pain, andradiating painto the

extremities. Paraesthesia, numbness, and weakness indicate nerve

problems, possibly with a pinched nerve such as can occur in disc herniation.

If aspinal fusionsurgical procedure is being considered then a PET scan can

ascertain whether the defective bone site has active bone growth occurring.

This will affect the likely healing of the patients spine post-surgery, making
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decisions about the effectiveness of certain treatments simpler.

Treatment of Spondylolisthesis

Conservative Treatment

Conservative treatment is the usual therapeutic course for patients with

spondylolisthesis. In small children, where the slip is normally quite minor,

the usual therapeutic plan is simple observation and restriction of boisterous

activities. More significant slips pose a threat of progressive complication

and justify the use of more invasive treatment methods. NSAIDs and

analgesics are likely to be used, alongside physical therapy, and the

condition will be monitored closely. If treatment is unsuccessful after six

months or so, or if an acute exacerbation occurs, then surgery may be

required.

If intermittent claudication and other neurological symptoms are present

then the need for surgical intervention is more likely. Favored treatment

plans for minor cases involve the use of analgesics and NSAIDs, or

alternative supplements for those concerned with the potential side-effects

of pharmaceutical medications. Epidural steroid injections and selective

nerve root blocks may be used to provide relief from the condition and break

the cycle of inflammation often found in spondylolisthesis. If the patient has

adequate rest and refrains from any exacerbating activities, it is possible

that the combination of anti-inflammatories, physical therapy and flexion

strengthening exercises can alleviate, or even correct, the problem.

Exercises to strengthen the core abdominal muscles are also likely to benefit

a patient with spondylolisthesis as these may


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help correct underlying postural issues and alleviate some pressure on the

spine. The use of a hyperextension brace may also assist those with isthmic

spondylolisthesis as it can help to extend the lumbar spine and promote

healing.

Surgical Treatment

Surgery varies depending on the type of spondylolisthesis. Isthmic

spondylolisthesis patients are likely to have repair work done on the portion

of the vertebrae that is defective, most notably the pars interarticularis.

Healthy post-surgical healing is likely to occur if an MRI or PET scan reveals

active bone at the defective site. In this procedure the scar tissue will be

removed and a bone graft put in place with screws to hold it across the

defect, thus encouraging the re-knitting of the bone. Those patients with

neurological symptoms will likely undergo a decompression procedure to

make the foramina through which the nerves exit the spine more spacious.

Decompression surgery is often conducted alongside fusion to reposition the

vertebrae correctly and hold them in place with plates. In some cases the

vertebrae are fused in the position they have moved to, to prevent further

slippage. This is done in cases where moving the vertebrae back has an

increased risk of further nerve damage.

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Spondylolisthesis -DegnerativeSpondylolisthesis occurs when one vertebra slips forward over thevertebra below. Degenerative spondylolisthesis often affects thelumbar (low back) spine, often at L4-L5 (4th and 5th lumbar vertebrallevels). Degenerative changes in vertebral structure may cause jointsbetween vertebrae to slip forward creating a spondylolisthesis.Sometimes spinal stenosis develops with spondylolisthesis.Degenerative spondylolisthesis is more common in older femalepatients over age 60.

SymptomsSome people with spondylolisthesis are symptom-free.Spondylolisthesis may be discovered when the patient has a lumbar x-ray for back pain or another problem. Symptoms may include:

Low back pain Sciatica

Muscle spasms Leg weakness Tight hamstring muscles Irregular gait or a limp

An accurate diagnosis of spondylolisthesis can be made by aphysician with expertise in spinal disorders. This may include thefollowing steps.

Medical history

The doctor asks you about your symptoms, severity, treatments tried,and the results.

Physical examinationThe physician examines you for movement limitations, balance

problems, and pain. He tests your reflexes,


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