SPONDYLOLISTHESIS

DEFINITION: Spondylolisthesis refers to the forward slippage of one vertebral body with respect to the one beneath it. It was first coined by Killian in 1854, utilizing the Latin roots spondy which means spine and olisthesis which means a slippage of. This condition is most common at the lower lumbar and lumbosacral levels. SYNONYMS AND RELATED KEYWORDS: anterolisthesis, retrolisthesis, spondylolytic spondylolisthesis, degenerative spondylolisthesis, congenital spondylolisthesis, traumatic spondylolisthesis, pathologic spondylolisthesis PREDISPOSING FACTORS:

Congenital (present at birth)

A joint damaged by an accident or other trauma

A joint damaged by an infection or arthritis or other bone diseases

Physical stresses to the spine PATHOPHYSIOLOGY: Spondylolisthesis is the forward slippage of one vertebra on another. It can be asymptomatic and approximately 5-6% of males and 2-3% of females have a spondylolisthesis with males more likely to develop symptoms from the disorder primarily due to their engaging in more physical activities. Wiltse et al developed a classification to help outline causes of vertebral translation in an anterior direction which divides spondylolisthesis into five groups depending on the etiology of the slip:

Type I: The dysplastic (congenital) type represents a defect in the upper sacrum or arch of L5. A high rate of associated spina bifida occulta and a high rate of nerve root involvement exist.

Type II: The isthmic (early in life) type results from a defect in pars interarticularis, which permits forward slippage of the superior vertebra, usually L5

Type III: The degenerative (late in life) type is an acquired condition resulting from chronic disc degeneration and facet incompetence, leading to long-standing segmental instability and gradual slippage, usually at L4-5. Spondylosis is a general term reserved for acquired age-related degenerative changes on the spine (ie, discopathy or facet arthropathy) that can lead to this type of spondylolisthesis.

Type IV: The traumatic (any age) type results from fracture of any part of the neural arch or pars that leads to listhesis. Type V: The pathologic type results from generalized bone disease, such as Paget disease or osteogenesis imperfecta.

The most commonly used grading system for spondylolisthesis is the one proposed by Meyerding in 1947. The degree of slippage is measured as the percentage of distance the anteriorly translated vertebral body has moved forward relative to the superior end plate of the Vertebra below. Classifications use the following grading system:

Normal

1-25% slippage

26-50% slippage

51-75% slippage

76-100% slippage

Greater than 100% slippage (spondyloptosis)

SIGNS AND SYMPTOMS: marked lordosis lower back pain localized tenderness over the spine just above the pelvis pain in the thighs pain in the buttocks tight hamstrings stiffness in the back

DIAGNOSTIC TESTS: X-RAYS of the lumbo-sacral (A.P., lateral and oblique views) x-rays will show if any of the vertebrae in your back have fractures or cracks and have slipped out of place. CAT Scan can show a crack or defect in the bone more clearly. MRI - to clearly show the soft tissue structures of the spine (including the nerves and discs between the vertebrae) and their relationship to the cracked vertebra and any slippage. It also will show whether any of the nearby discs have suffered any wear or tear because of spondylolisthesis.

MANAGEMENT: Approximately 5% of the population has a spondylolisthesis, most of whom will never need any treatment as their spondylolisthesis is stable, and non-progressive. MEDICAL Corset or Brace is useful to provide additional support to the spine. This support may derease muscle spasm and pain. Physical Therapy (Exercise Program) to develop back and stomach muscles to help stabilize spine and support body.

Bed Rest follow doctors directions on how long to stay in bed. Activity restriction Physician may prescribe medications to reduce inflammation, muscle spasms and pain. SURGICAL: Spinal Fusion used when instability of spine is significant and cannot be treated with brace and stabilization exercises, then stabilization of the spine with a fusion may be essential to reduce pain and disability.

Lumbar Decompression used to remove pressure on spinal nerve as it may be compressed by the forward slip so surgery may be needed to reopen a tunnel or space, for the nerve. NURSING: Administer pain medications as prescribed by the Physician. Instruct patients with spondylolisthesis to avoid activities that might cause more stress to lumbar spine such as heavy lifting and sports activities like gymnastics, football, competitive swimming and diving. Educate and train patients with spondylolisthesis in performing activites of daily living without placing added stress on lower back. Provide comfort with proper fit of corset or brace and assess skin integrity under and around the brace frequently. PHARMACOLOGIC: Analgesics (non-prescription medications) - to control pain (aspirin, ibuprofen, naproxen sodium, acetaminophen) Nonsteroidal Anti-inflammatory Drugs (NSAIDs) to reduce swelling and inflammation that may occur.(ex: aspirin, ibuprofen, acetaminophen) Narcotic Analgesic used in severe persistent pain that is not relieved by other analgesic and NSAIDS. (ex. Codeine) Corticosteroid Medication for more severe back pain because of their very powerful anti inflammatory effect. (ex. Prednisone)