Spondylolysis and Spondylolisthesis

By admin On Nov 7, 2023

Ovid: 5-Minute Sports Medicine Consult, The

David A. Scott

Kyle J. Cassas

Basics

Description

From Greek, spondylo vertebra + lysis loosening, listhesis slippage
Spondylolysis:
- Involves a defect in the pars interarticularis of the vertebral complex
- Usually an acquired stress fracture or stress reaction of the lower lumbar spine
- Most common cause of significant back pain in athletes
- Most commonly involves L5 (85–95% of cases) and L4 (5–15% of cases)
Spondylolisthesis:
- Results from anterior displacement of a vertebral body on the subjacent vertebra
- Most common segment involved is the L5–S1 level, followed by L4–5. Most cases (80%) are bilateral.
- Defect may be secondary to fracture, arthrosis, or systemic disease.

Epidemiology

Incidence up to 11% in athletic populations; 2–5% in the general population.
Highest incidence in sports emphasizing extension activities (eg, gymnastics, ballet, volleyball, weightlifting, football, and wrestling)
Peak age of symptomatic onset is 10–15 yrs, although spondylolysis usually originates between ages 5 and 10 yrs.
By the end of childhood, incidence is estimated to be 6% overall (1).
In the general adult and elderly population, the incidence is roughly 11.5% as measured by CT (2).

Risk Factors

Possible genetic component
Eskimo population
Male: Female, ratio 2:1
Association with high-risk sports involving repetitive hyperextension forces and rotational movement on the spine (ie, diving, weightlifters, wrestlers, football lineman, gymnastics, and track high jump)
Anatomic variations: Spina bifida occulta, transitional vertebrae, and elongated pars intra-articularis
Female athlete triad

Etiology

Physical shear forces may account for the etiology of spondylolysis.
Shear forces on the normal lumbar lordosis are increased in extension and accentuated by combined extension and lateral side-bending.
Genetic factors may play a role:
- High incidence (25–69%) demonstrated in studies on twins and 1st-degree relatives
Spondylolysis may be either an overuse injury to the affected vertebral level or a traumatic fracture.
Vertebral translation can be a source of pain, radiculopathy (spinal nerve injury), or spinal cord injury.
Degenerative spondylolisthesis is associated with arthritic changes and is seen in adults and elderly patients.
Isthmic spondylolisthesis is a result of fracture, and is the most common form in athletes.

Diagnosis

Classification of spondylolisthesis:
- Isthmic (spondylolytic):
  - Listhesis caused by breakdown of the pars interarticularis
  - Most common cause of listhesis, representing up to 50% in some series
- Dysplastic (congenital):
  - Failure of development of the superior facets
  - Represents 20% of all cases of listhesis
  - Major slippage can occur.
- Degenerative:
  - Degeneration of the superior facets or disc material
  - Major cause of spinal stenosis
- Traumatic:
  - Disruption of the posterior elements of the neural arch other than pars (pedicles or lamina)
- Pathologic:
  - Due to osteoporosis, rheumatoid arthritis, tumor, or infection
Grading of spondylolisthesis:
- Grading system proposed by Meyerding in 1932:
  - Grade I: L5 vertebral body has slipped forward on the sacrum a distance of up to 25% of its length (or the length of the subadjacent vertebrae).
  - Grade II: L5 vertebral body has slipped forward a distance of 25–50% of its length.
  - Grade III: L5 vertebral body has slipped a distance of 50–75% of its length.
  - Grade IV: L5 vertebral body has slipped a distance of >75% of its length.
- Some add grade V to include L5 vertebral body that has slipped off the sacrum; also termed spondyloptosis.
- In addition to grading slips as described above, when monitoring a slip, specific percentages of listhesis relative to the subadjacent vertebrae should be documented to track changes.

History

Insidious onset of low back pain is the most common complaint of symptomatic patients.
May note increase in symptoms with an increase in intensity or volume of training
Pain may radiate into the buttocks or thigh, but patients rarely experience radicular signs or symptoms.
Pain is usually worse with activity, especially extension/lateral side-bending, and alleviated with rest.
May progress to having pain that becomes more constant and associated with daily activities
Should not usually report numbness, paresthesias, weakness, bowel or bladder changes, gait disturbance, or constitutional symptoms (fever, weight loss, night pain, or rashes)

Physical Exam

Symptomatic patient may be tender to palpation of the paraspinal musculature or affected spinal level.
Patient often exhibits hamstring tightness, hyperlordosis.
May exhibit limited range of motion and pain with extension.
Some suggest performing the “stork” test or single leg lumbar hyperextension test:
- Pain when a patient stands on one leg and hyperextends the back may indicate active spondylolysis.
- This maneuver creates combined extension/lateral side-bending, which may produce pain.
If significant listhesis is present (grade III or more, see below), may appreciate a step-off when palpating the spinous processes.
Gait abnormality
Neurological findings are rare.

Diagnostic Tests & Interpretation

Imaging

The following are different imaging modalities. Although plain films are valuable, and should be the starting point for an evaluation, subsequent tests should be chosen on a case-by-case basis. Influential factors may include duration of pain, index of suspicion for soft tissue lesions, patient age, and radiation exposure:

Plain films:
- May include erect anteroposterior (AP), lateral, and oblique views
- Evaluate for number of lumbar vertebrae, scoliosis, spina bifida occulta, transitional vertebrae, etc.
- May be normal in the acute or subacute stage
- Oblique films may allow visualization of the “scotty dog.” When visualizing this image, attention should be paid to the dog's neck. A radiolucent line through the neck may represent a defect through the pars interarticularis. AP and lateral images may be useful as well, showing sclerosis and listhesis in some cases, respectively.
- Standing lateral x-ray can help with grading of listhesis.
- Weight-bearing x-rays may worsen the apparent slip by up to 25%.
- On standing AP view, when a large slip has occurred (grade IV/V), an “inverted Napoleon's hat sign” can be seen, representing the radiographic appearance of spondyloptosis. Clinically, this puts the cauda equina at risk for compromise.
Triple-phase bone scan:
- Often necessary to evaluate the acuity of the injury
- Defect may be present on x-ray and not be the cause of symptoms.
- X-ray may be negative, while the bone scan demonstrates the defect.
- Bone scan can be positive as soon as 48–72 hr after injury.
- Test less helpful in older patients, especially those with significant osteoarthritis of the L-spine due to high-false positive rate.
- Not recommended in asymptomatic patients or in patients with symptoms >1 yr
Single-photon emission computed tomographic (SPECT) scan:
- Improves resolution of bone scans, especially with SPECT fusion scan
- May be more helpful in demonstrating stress reactions at the pars
- Advantage: May also help delineate the acute “hot” lesion with potential to heal, vs more chronic “cold” lesion that may not heal or progress to a fibrous union.
- Disadvantage: May not be widely available, and much greater radiation exposure

P.551

CT scan:
- Useful after SPECT to help stage and determine treatment stratification
- Reverse Gantry thin-cut CT at the level seen on bone scan or SPECT activity
- Delineates bony pars defect or neural compression
- May detect osseus fragments near the pars defect
- Advantage: Visualization of bony anatomy, assessment of healing at later interval (6 mos)
- Disadvantage: Radiation exposure (50 × plain films)
MRI:
- Advantages: Lack of radiation, ability to detect other pathology (diskitis, disc pathology, tumor).
- Sagittal short T1 inversion recovery sequences may reveal early stress reaction or pars defect.
- May see false positives in younger patients secondary to normal bone marrow edema
- Some would consider MRI first line vs SPECT scan.

Differential Diagnosis

Infection
Tumor
Herniated nucleus pulposus
Mechanical low back pain
Spinal stenosis

Treatment

Goal is to return the athlete to pain-free participation in sports along with the prevention of further slippage and spondylolisthesis. Low-grade slips can often be treated conservatively; higher-grade listhesis or listhesis in the context of neurological findings should be referred for surgical opinion.
Relative rest to allow healing has been shown to be effective in young soccer players (3):
- A period of at least 3 mos is generally recommended for acute lesions (4).
- Depending upon acuity of lesion, rest may or may not allow healing, but should help symptoms (4).
- For lesions with chronic features on CT, healing is unlikely and rest should continue until full resolution of symptoms (4).
- Some advocate use of braces, such as the thoracolumbar sacral orthosis.
- When to use these braces remains controversial
- Most suggest using the brace if initial attempts at relative rest, NSAIDs, and ice do not significantly improve pain.
- >83% of patients treated conservatively for spondylolysis and Grade 1 spondylolisthesis had clinical improvement at 1 yr (1)
- Reported duration of bracing is variable, ranging from 6 wks to 6 mos. If bracing is used, it should continue until patient is asymptomatic with all activities (3).
- Patients with positive x-ray and negative bone scan demonstrate a chronic injury that usually does not need to be braced.
- For advanced cases creating substantial pain or neural compromise, surgical intervention may be indicated, and may include vertebral body fusion. This procedure carries a risk of “adjacent segment” disease, or arthritic change above or below the surgical level. Laminectomy and segmental fixation may also be performed.
Spondylolisthesis:
- Higher-grade listhesis, specifically beyond 50%, and any neurological findings should be evaluated by a surgeon (3).
- For cases of higher-grade listhesis, and specifically those with canal stenosis, surgical intervention has been shown to provide more lasting relief of pain (5).
- Standard surgical intervention in the presence of canal compromise is decompressive laminectomy with fusion (5)

Additional Treatment

Additional Therapies

Initial treatment will include modalities followed by strengthening activity.
Typical rehabilitation includes hamstring stretching and core strengthening (low back, hip, and abdominal musculature).
Water therapy, including water running, is very helpful when available.
Aerobic conditioning with progression to sport-specific drills.

Surgery/Other Procedures

Indications include:
- Slip progression
- Persistent pain or gait abnormality despite treatment
- Neurologic deficit
- High amount of slip in the skeletally immature patient (Grade III/IV or high slip angle >55 degrees)
Surgical procedure:
- Most suggest in situ fusion (ie, fusion of one level of vertebral body to another).
- Postoperative casting/bracing is not generally indicated.
- Return to noncontact sports permissible

In-Patient Considerations

Initial Stabilization

PRICES: Protection (and Pain medications), Rest Ice, Compression, Elevation, Support (and strengthening/stretching exercises)
Anti-inflammatory drugs:
- Will help decrease symptoms
- If one class of NSAIDs does not work, try a different class.
- Allow adequate trial of NSAIDs (up to 7 days).

Ongoing Care

Follow-Up Recommendations

Monitor symptoms, gait abnormalities, and radiographic progression.
In the skeletally immature, monitoring is more important, as changes are common during growth (4).
Some recommend plain x-ray every 6–12 mos in skeletally immature (4).
Most patients with spondylolysis eventually will have mild-to-no symptoms.
X-rays: Data on the timing and frequency of follow-up x-rays are not clear. After skeletal maturity, progression is less likely.
Risk factors to consider when assessing for slip progression of listhesis:
- Clinical factors: Age (10–15 yrs), gender (female), recurrent symptoms, and postural deformity (gait disturbances)
- Radiographic factors: Type of slip (dysplastic spondylolisthesis), degree of slip (Grades III/IV), and increasing angle of slip

References

1. Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop. 2009;29:146–156.

2. Kalichman L, Kim DH, Li L, et al. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine. 2009;34:199–205.

3. Purcell L, Micheli L. Low back pain in young athletes. SportsHealth: A Multidisciplinary Approach. 2009;1:212–222.

4. Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil. 2007;88:537–540.

5. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009;91:1295–1304.

Additional Reading

Comstock CP, Carragee EJ. Spondylolisthesis in the young athlete. Phys Sport Med. 1994;22:39–46.

Frymoyer JW. Degenerative spondylolisthesis: diagnosis and treatment. J Am Acad Orthop Surg. 1994;2:9–15.

Hensinger RN. Current concepts review: spondylolysis and spondylolisthesis. J Bone Joint Surg. 1989;71A:1098–1107.

Hilibrand AS, Urquhart AG, Graziano GP, et al. Acute spondylolytic spondylolisthesis: risk of progression and neurological complications. J Bone Joint Surg. 1995;77A:190–196.

Ikata T, Miyake R, Katoh S, et al. Pathogenesis of sports-related spondylolisthesis in adolescents. Radiographic and magnetic resonance imaging study. Am J Sports Med. 1996;24:94–98.

Jimenez CE. Advantages of diagnostic nuclear medicine. Phys Sports Med. 1999;27.

Johnson RJ. Low-back pain in sports: managing spondylolysis. Phys Sports Med. 1993;21:53–68.

Muschik M, Hähnel H, Robinson PN, et al. Competitive sports and the progression of spondylolisthesis. J Pediatr Orthop. 1996;16:364–369.

Pizzutillo PD, Hummer CD. Nonoperative treatment for painful adolescent spondylolysis or spondylo-listhesis. J Pediatr Orthop. 1989;9:538–540.

Radcliff KE, Kalantar SB, Reitman CA. Surgical management of spondylolysis and spondylolisthesis in athletes: indications and return to play. Curr Sports Med Rep. 2009;8:35–40.

Renshaw TS. Managing spondylolysis: when to immobilize. Phys Sports Med. 1995;23:75–80.

Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med. 1993;12:517–528.

Codes

ICD9

738.4 Acquired spondylolisthesis
756.11 Congenital spondylolysis, lumbosacral region
756.12 Spondylolisthesis, congenital