spondylolisthesis ax

NUR IZZATTY BINTI SUHAIMI

57179211269

PUAN AZLINDAHANI BINTI OTHMAN

SPONDYLOLISTHESIS

SEMESTER 6

DEFINITION

SPONDYLO : SPINE

LISTHESIS : SLIP FORWARD

Spondylolisthesis occurs when one vertebra slips forward onto the vertebrae below it. This

produces both a gradual deformity of the lower spine and also a narrowing of the vertebral

canal. It is often associated with pain. This is most common level that a spondylolisthesis occurs

is at L5/S1.

ANATOMY OF SPINE

Vertebrae

Vertebrae are the 33 individual bones that interlock with each other to form the spinal column.

The vertebrae are numbered and divided into regions: cervical, thoracic, lumbar, sacrum, and

coccyx (Fig. 2). Only the top 24 bones are moveable; the vertebrae of the sacrum and coccyx

are fused. The vertebrae in each region have unique features that help them perform their main

functions.

Cervical (neck) - the main function of the cervical spine is to support the weight of the head

(about 10 pounds). The seven cervical vertebrae are numbered C1 to C7. The neck has the

greatest range of motion because of two specialized vertebrae that connect to the skull. The first

vertebra (C1) is the ring-shaped atlas that connects directly to the skull. This joint allows for the

nodding or “yes” motion of the head. The second vertebra (C2) is the peg-shaped axis, which

has a projection called the odontoid, that the atlas pivots around. This joint allows for the side-

to-side or “no” motion of the head.

Thoracic (mid back) - the main function of the thoracic spine is to hold the rib cage and protect

the heart and lungs. The twelve thoracic vertebrae are numbered T1 to T12. The range of

motion in the thoracic spine is limited.

Lumbar (low back) - the main function of the lumbar spine is to bear the weight of the body.

The five lumbar vertebrae are numbered L1 to L5. These vertebrae are much larger in size to

absorb the stress of lifting and carrying heavy objects.

Sacrum - the main function of the sacrum is to connect the spine to the hip bones (iliac). There

are five sacral vertebrae, which are fused together. Together with the iliac bones, they form a

ring called the pelvic girdle.

Coccyx region - the four fused bones of the coccyx or tailbone provide attachment for

ligaments and muscles of the pelvic floor.

PATHOPHYSIOLOGY

Pathophysiology base on type of spondylisthesis:

TYPE:

1. Congenital spondylolisthesis - Congenital means "present at birth." Congenital

spondylolisthesis is the result of abnormal bone formation.

2. Isthmic spondylolisthesis - This type occurs as the result of spondylolysis, a condition

that leads to small stress fractures (breaks) in the vertebrae.

3. Degenerative spondylolisthesis - This is the most common form of the disorder. With

aging, the discs , the cushions between the vertebral bones (lose water, becoming less

spongy and less able to resist movement by the vertebrae.)

4. Traumatic spondylolisthesis - in which an injury leads to a spinal fracture or slippage

5. Pathological spondylolisthesis - which results when the spine is weakened by disease

such as osteoporosis an infection, or tumor.

Spondylolisthesis is graded according to the amount that one vertebral body has slipped

forward on another:

Grade I – Less than 25 percent slip

Grade II – Between 25 and 50 percent slip

Grade III – Between 50 and 75 percent slip

Grade IV – More than 75 percent slip

Grade V – This means that the upper vertebral body has slid all the way forward off the front of

the lower vertebral body. This is a special situation that is called a spondyloptosis and is very

rare.

CAUSES OF SPONDYLOLISTHESIS

In children, spondylolisthesis is usually due to a birth defect in that area of the spine, or the

result of a sudden injury.

In adults, it is most commonly caused by age-related wear of the spine or a degenerative

disease such as arthritis.

Other possible causes in adults are:

1. a bone disease

2. a fracture as a result of a sudden injury

3. a stress (hairline) fracture as a result of sustained pressure on the spine - commonly

seen in gymnasts and weight lifters.

SYMPTOMS OF SPONDYLOLISTHESIS

Spondylolisthesis may not cause any symptoms for years or after the slippage has occurred. If

you do have symptoms, they may include:

1. low back pain

2. buttock pain

3. numbness, tingling, pain, muscle tightness or weakness in the leg (sciatica)

4. increased sway back

These symptoms are usually aggravated by standing, walking, running or sports that involve

hyperextension. eg gymnastics, cricket and other activities, while rest will provide temporary

relief.

CLINICAL FEATURES

Pain with back motion,particularly extension – cause radiation

Increased lumbar lordosis

Tight hamstring & hip muscles

Impaired sensation,strength and muscle reflexes with root injury.

DOCTOR’S MANAGEMENT

1. Medical History and Physical Examination

After knowing the symptoms and medical history, doctor will examine back. Looking at the back

and pushing on different areas to see if it hurts.Doctor may have to bend forward, backward,

and side-to-side to look for limitations or pain.

2. Imaging Tests

X-rays

Magnetic resonance imaging (MRI).

Computed tomography (CT). These scans are more detailed than X-rays and can create

cross-section images of your spine.

Nonsurgical Treatment

1) Physical therapy and exercise.

Specific exercises can strengthen and stretch your lower back and abdominal muscles.

2) Medication.

Pain medications, such as acetaminophen or NSAID’s (e.g. ibuprofen, COX-2 inhibitors)

or oral steroids to reduce inflammation in the area.

3) Steroid injections.

Cortisone is a powerful anti-inflammatory. Cortisone injections around the nerves can

decrease swelling.

Surgical treatment

Laminectomy. Removing the pressure involves opening up the spinal canal.

Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the

painful vertebrae.

PHYSIOTHERAPY’S MANAGEMENT

Modalities : ultrasound, electric stimulation, hot packs, cold packs, and manual

"hands on" therapy to reduce pain and muscle spasms.

Stretching exercise: to improve posture and help to reduce back pain or leg

symptoms.

Strengthening exercise: strengthening the muscles that support spine and will

help to keep back and upper body stable. Keeping these muscles strong can

relieve back pain and prevent further injury.

Developing your back and stomach muscles will help stabilize your spine and

support your body.

Stretching exercise Strengthening exercise

Knee to chest Bird dog exercise

Using gymball Bridging exercise

Pelvic tilt Abdominal bracing

- Abdominal crunch

- Dead bug exercise

A)PATIENT PARTICULAR.

NAME: Mdm. M

AGE: 67 years old

SEX: Female

D.O. REFEREL: 13 April 2014

D.O. ASSESMENT: 13 April 2014

DR. Δ: L4, L5 Spondylolisthesis

DR. MX: Conservative management:

1)Medication

2)Refer To Physio

INVESTIGATION: X-ray done on 12 april 2014

:-result : L4, L5 spondylolisthesis.

B)SUBJECTIVE ASSESMENT.

C/O: Pain at Rt. Lower back until Rt. Lower leg and numbness at Rt. big toe.

PAIN ASSESMENT

PAIN SCALE

0/10 : Rest

2/10 : During Assessment

5/10 : Aggravating

PAIN AREA : Rt. Lower back, Rt. Lower leg and Rt. Big toe.

NATURE OF PAIN: Aching pain at Rt. Lower back

AGGRAVATING: 5/10 : No specific movement.

EASE: Oilment.

24 HOURS SYMPTOMS: a.m :

p.m : on-off

night:

IRRITABILITY: Medium

PRESENT HX

Current pain at Rt lower back when went to vacation to Bandung on 21/3/2014 till

24/3/2014. After back from vacation, she went to clinic near by her son house at KL.

Doctor give medication management.

PAST HX: H/o fall from stairs about ten years ago. Her buttock crashing on the

ground. She never go to get treatment .

PAST MEDICAL HX: NIL

SURGICAL HX: NIL

MEDICATION HX: Pain killer and oilment.

FAMILY HX: NIL

SOCIAL HX

OCCUPATION: Ex-staffnurse

NATURE OF JOB: Office hour 9 a.m to 5 p.m

ALLERGIC BACKGROUND: NIL

MARITAL STATUS: Married and have 3 children.

HOME ENVIRONMENT: Double storey. (not disturb pain)

HOBBY: Gardening.

ALCOHOLIC/SMOKING: NIL.

PRE-MORBID POST-MORBID

Do all activity with no pain and doesn’t

disturb activity.

Disturb while praying

C)OBJECTIVE ASSESMENT

GENERAL OBSERVATION: A women with moderate body size came to department

independently without using assistant device accompany with her daughter. Pt look

healthy.

GAIT : Normal

POSTURE OBSERVATION.

Anteriorly

-Ear level symmetry

-Sh. level is symmetry for both side

-Elbow crest symmetry

Laterally

-No kyphotic posture noted

-No lordotic noted

Posteriorly

-Ear level symmetry

-Shoulder level symmetry

-Scapula level symmetry

-Pelvic level symmetry

LOCAL OBSERVATION: 1) ⁰Redness at Rt. Lower back and Rt lower limb.

2) ⁰Swelling at Rt. Lower back and Rt lower limb.

3)⁰Scar at Rt. Lower back and Rt lower limb.

4)⁰Bony deformity form at Rt. Lower back and Rt lower limb.

5)⁰Muscle wasting at Rt. Lower back and Rt lower limb.

PALPATION: 1) Tenderness over lumbar region.

2)⁰Warmness over lumbar region.

3)Muscle spasm at Rt lower back.

ROM (TRUNK)

MOVEMENT STARTING

POSITION (CM)

ACTIVE (CM) PASSIVE (CM)

FLEXION 66 8 with ERP 5 with ERP

EXTENSION 66 52 with ERP 54 with ERP

RT. SIDE FLEXION 66 40 with ERP 33 with ERP

LT. SIDE FLEXION 66 43 with ERP 37 with ERP

RT. SIDE ROTATION 56 42 with ERP 40 with ERP

LT. SIDE ROTATION 56 41 with ERP 39 with ERP

INTERPRETATION: Limited ROM of extension of trunk due to pain.

MUSCLE POWER (TRUNK)

MOVEMENT MUSCLE POWER

FLEXION 5/5 within range

EXTENSION 5/5 within range

RT. SIDE FLEXION 5/5 within range

LT. SIDE FLEXION 5/5 within range

RT. SIDE ROTATION 5/5 within range

LT. SIDE ROTATION 5/5 within range

INTERPRETATION: Muscle power of trunk is 5/5. Normal.

Passive Accessory Intervertebral Movement (PAIVM)

Central

L1

L2 Mobile with no pain

L3

L4

L5 Hypomobile with localized pain grade 2

S1

SPECIAL TEST

1) Straight leg raise – positive with tight hamstring over Rt. side of leg

2) Slump test – positive with hamstring tightness over Rt. Side of leg

INTERPRETATION: Positive SLR and Slump test d/t hamstring tightness over the

left leg at 70 degree.

NEUROLOGICAL TEST

Hot and cold – intact

PHYSIOTHERAPY IMPRESSION

1) Pain over Rt. Lower back till Rt. Lower limb d/t pathological changes.

2) Decrease Range Of Motion of extension of trunk d/t pain.

3) Muscle spasm at Rt. Lower back d/t over used.

SHORT TERM GOAL

1) To reduce pain at Rt. Lower back till Rt. Lower limb 1/12

2) To increase range of motion of extension of trunk 1/12

3) To reduce muscle spasm at Rt. lower back 1/12

LONG TERM GOAL

1) To optimize functional activity.

2) To prevent any recurrent condition.

PLAN OF TREATMENT

1) Pain management

Hot pack

IFT

Ultrasound

2) Therapeutic exercise

3) Home exercise program

INTERVENTION

1) Pain management

Hotpack

-Patient’s position : pr. Lying

-Hot pack is applied over lower back and Rt. calf

-Duration : 20 mins

IFT

-Patient’s position : pr.lying

-Modulated IFT is applied lower back and Rt. calf

-Duration : 15 mins

Ultrasound

-Patient’s position: pr.lying

-u/s is applied at lower back and Rt. Calf

-Intensity: 1mhz, 0.8wcm3, 5 minutes each.


Straight leg raise exs.

-Patient’s position: sup.ly

-Patient was asked to do exs by lift up Rt. Leg straight but not over than Lt.

leg.

-Repetition: 10 reps , 3 sets

Piriformis stretch


-Patient’ was asked to bend one leg and another leg cross over the bend leg.

Active pull the bend leg toward chest.

-Repetition : 10 reps, hold 10 sec, 3 sets

Trunk Flexion Stretch (sustained flexion)

-Patient’s position: kneeling

-Tuck in chin and arch back. Slowly sit back on heels, dropping shoulders

towards floor.

-Repetition: 10 reps, hold 10 sec, 3 sets.

Cat and Camel Exercise

-Patient’s position: kneel on hands and knees.

-Ask pt to do arch back , letting head drop slightly. Keep abdomen and

buttock muscles tightened.

-Holds 10 sec, 10 reps

-Let back sag towards floor while keeping arms straight and weight evenly

distributed between legs and arms.

-Hold for 10 sec, 10 reps.

HOME EXERCISE PROGRAMME

Advice to apply hot pack on back at home for 15min when needed to reduce

pain.

Advice to avoid lifting heavy weights + proper lifting technique demonstrated.

Advice and teach patient on how to wake up from bed and lying down on bed.

Ask pt to continue exercises at home as been taught for 3x/day.

Pamphlet of back care is given.

EVALUATION

-Pt cooperates well when the treatment given.

-Pt complaint that her pain reduce from 2/10 to 0/10.

REASSESSMENT

-Reassess pain scale of patient next visit

-Reassess range of motion of trunk next visit

FOLLOW UP (24/4/2014)

S-

-c/o reduce pain at Rt. Lower back.

-Pain at Rt lower leg.

-Numbness at Rt big toe.

-Pain scale: 4/10

O-

- GENERAL OBSERVATION: A women with moderate body size came to

department independently without using assistant device accompany with her

daughter. Pt look healthy.

GAIT : Normal

POSTURE OBSERVATION.

Anteriorly

-Ear level symmetry

-Sh. level is symmetry for both side

-Elbow crest symmetry

Laterally

-No kyphotic posture noted

-No lordotic noted

Posteriorly

-Ear level symmetry

-Shoulder level symmetry

-Scapula level symmetry

-Pelvic level symmetry

LOCAL OBSERVATION:

1) ⁰Redness at Rt. Lower back pain and Rt lower limb.

2) ⁰Swelling at Rt. Lower back pain and Rt lower limb.

3)⁰Scar at Rt. Lower back pain and Rt lower limb.

4)⁰Bony deformity form at Rt. Lower back pain and Rt lower limb.

5)⁰Muscle wasting at Rt. Lower back pain and Rt lower limb.

PALPATION:

1) Tenderness over lumbar region.

2)⁰Warmness over lumbar region.

3)Muscle spasm at Rt lower back.

ROM (TRUNK)

MOVEMENT STARTING

POSITION (CM)

ACTIVE

(CM)

PASSIVE

(CM)

FLEXION 66 5 with ERP 0

EXTENSION 66 45 with ERP 42 with ERP

RT. SIDE

FLEXON

66 38 with ERP 33 with ERP

LT. SIDE FLEXON 66 40 with ERP 35 with ERP

RT. SIDE

ROTATION


LT. SIDE

ROTATION


INTERPRETATION: Limited ROM of extension due to pain.

MUSCLE POWER (TRUNK)

MOVEMENT MUSCLE POWER

FLEXION 5/5 within ERP

EXTENSION 5/5 within ERP

RT. SIDE FLEXON 5/5 within ERP

LT. SIDE FLEXION 5/5 within ERP

RT. SIDE ROTATION 5/5 within ERP

LT. SIDE ROTATION 5/5 within ERP

INTERPRETATION: Muscle power of trunk is 5/5. Normal.

A-

1)Pain over Rt. Lower back till Rt. Lower limb d/t pathological changes.

2)Decrease Range Of Motion of extension of trunk d/t pain.

3)Muscle spasm at Rt. Lower back d/t over used.

P-

1) Pain management

•Hot pack

•IFT

•Ultrasound


3) Home exercise program

I-

1)Pain management

•Hotpack

-Patient’s position : pr. Lying

-Hot pack is applied over lower back and Rt. calf

-Duration : 20 mins

•IFT

-Patient’s position : pr.lying

-Modulated IFT is applied lower back and Rt. calf

-Duration : 15 mins

•Ultrasound

-Patient’s position: pr.lying

-u/s is applied at Rt. Calf

-Intensity: 1mhz, 0.8wcm3, 5 minutes .

2)Therapeutic exercise

•Straight leg raise exs.


-Patient was asked to do exs by lift up Rt. Leg straight but not over than Lt.

leg.

-Repetition: 10 reps, hold 10 sec, 3 sets

•Piriformis stretch


-Patient’s was asked to bend one leg and another leg cross over the bend

leg. Active pull the bend leg toward chest.

-Repetition : 10 reps, hold 10 sec, 3 sets.

Bridging

-Patient’s position: cr. Ly.

-Bridging 10 reps, hold 10 sec.

Mckenzie

-Patient’s position : pr. Lying.

-Patient’s was asked to do exs by using lower arm.

-Repeat for 10 reps, in 3 sets.

Trunk Flexion Stretch (sustained flexion)

-Patient’s position: kneeling

-Tuck in chin and arch back. Slowly sit back on heels, dropping

shoulders towards floor.

-Repetition: 10 reps, hold 10 sec, 3 sets.

Cat and Camel Exercise

-Patient’s position: kneel on hands and knees.

-Ask pt to do arch back , letting head drop slightly. Keep abdomen and

buttock muscles tightened.

-Holds 10 sec, 10 reps

-Let back sag towards floor while keeping arms straight and weight

evenly distributed between legs and arms.

-Hold for 10 sec, 10 reps.

HOME EXERCISE PROGRAMME

Advice to apply hot pack on back at home for 15min when needed to

reduce pain.

Advice to avoid lifting heavy weights + proper lifting technique

demonstrated

Advice and teach patient on how to wake up from bed and lying down

on bed.

Ask pt to continue exercises at home as been taught for 3x/day

Pamphlet of back care is given.

EVALUATION

Pt cooperates well when the treatment given

Pt claim that her pain decrease to 0/10

REFERRENCES

1) Raj, P.P. et al (2008). Intervertebral Disc : Anatomy, Physiology, Pathophysiology

and Treatment, World Institute of Pain, Vol. 8, Issue 1, 18-44.

2) Hertling, D., & Kessler, R. M. (2006). Management of Common Muskuloskeletal

Disoders: Physical Therapy Principles & Methods.Philadelphia: Lippincott Williams &

Wilkins.

3) Kraemer, J. (2008). Intervertebral Disk Disease: Causes, Diagnosis, Treatment &

Prophylaxis. 3rd ed. Philadelphia. Pg 195-200

4) Jeong H, You J, Sohn H, Park S. (2013) Radiologic evaluation of degeneration in

isthmic and degenerative spondylolisthesis. Asian Spine J.;7(1):25-33.

5) Kovacs FM, Royuela A, Jensen T, Estremera A, Amengual G, Muriel A, et al. (2009)

Agreement in the interpretation of magnetic resonance images of the lumbar spine.

Acta Radiol.;50(5):497-506.

CONCLUSION

Spondylolisthesis may sound like a common case, but the impact may be severe to some

people. It may affect patient daily activities or some serious cases, prohibit the patient from

moving.