Spondylolisthesis

Developmental (seldom seen below the age of 5, but 5% of population has it by age 7) or degenerative (typically found in women over age 50 with many years of non-disabling, intermittent bouts of LBP). Increased slipping rarely occurs after the age of 20 in developmental spondylolisthesis. The defect is in the isthmus or pars interarticularis. When there is actual slippage of one vertebra on the other, it is called spondylolisthesis. When there is a defect but no actual slippage, it is called spondylolysis.

The most common clinical presentation is low back pain that can begin at any stage of the patient’s life. Many patients remain asymptomatic their entire lives. Fifty percent of patients who develop the onset of low back pain cannot associate onset to an injury or incident (although, in industry, almost all will report an associated incident). Often, the patient will first become symptomatic of low back pain following a period of relative physical inactivity. (For example, after a worker has been promoted to a desk job from a physically active position).

If there is a history of significant trauma, then a fracture of the pars interarticularis may need to be ruled out, though such a fracture is exceeding rare. A bone scan, within three months of the fracture, will be positive.

Palpable ridging (a step off) can often be appreciated at the spondylo level, and acute localized hyperlordosis is common. Range of motion is usually normal, though tight hamstrings are common. There will be pain with extension.

Can be diagnosed on routine radiograph. Patients over age 50 should be radiographed in a standing position, since the slippage may be missed in a supine position.

A recent study (Osullivan, l997) indicated that lumbar stabilization training was found to be beneficial. The study included grade 1 and 2 spondylolisthesis. At ten weeks and thirty month follow-ups, the patients had decreasing pain scores and increased function. Hamstring flexibility is also important to decrease symptoms, particularly in runners and people with sedentary jobs. Lumbar support, for flare-ups, can be helpful, as can ice and NSAIDS.

Surgical fusion may be considered for the patient with chronic pain that significantly impairs function, when the patient has failed aggressive conservative treatment. Fusion will not enable the patient to resume heavy work, is associated with extensive morbidity and a long recovery period, and therefore should not be considered unless all other options have been attempted. Non-instrumented fusion–at lower cost and with lower risks–has similar results to fusion with pedicle screws (Moeller, l999).

Heavy lifting (e.g., over 40-50 pounds) generally needs to be restricted, if the patient has recurrent or ongoing symptoms.