Introduction

Among several causes of low back pain, spondylosis, a fracture that may or may not heal, is among the commonest causes. About 10% of the population has this problem. Spondylolisthesis is a shift in one vertebra on top of the other. The condition usually involves top vertebra slipping in front of the other.
Spondylolisthesis is classified into stages, from 1 to 4. Stage 1 can be managed conservatively while stage 4 requires surgery. This condition is associated with instability, a sign of weakness in the core. It may also be associated with a vetebral fracture.

Research has shown that patients with hamstring contractures have a high degree of spondylolisthesis than those without.

Types of Spondylolisthesis

There are different types of spondylolisthesis as described by Wiltse. The two most common forms are isthmic spondylolisthesis and degenerative spondylolisthesis.

  • Isthmic spondylolisthesis
  • Isthmic Spondylolisthesis
    Figure 1: Isthmic Spondylolisthesis
    This is a defect of the pars interarticularis. This defect in the pars interaticulais is called spondylolytic defect. Isthmic spondylosis usually occurs at L5-S1 spinal segment and the defect is generally present by age 5. It is uncommon to bring symptoms in teenagers but occassionally or due to injuries, symptoms may present though require surgery rarely. Typically, isthmic spondylolisthesis results in leg radicular pain in the L5 dermatome segment. This is because L5-S1 isthmic spondylolisthesis involves L5 prs interarticularis. This may lead to compession of L5 nerve root. Different form of kinds of isthmic spondylolisthesis include lytic, elongated and acute fracture of the pars, not same as traumatic.
    In the adolescents, this form of spondylolisthesis may primarily present as low back pain while in adults it may also present with leg pain. If a spondylolisthesis increases, it may lead to increased instability and more anterior slippage. Increase in the spondylolisthesis leads to increase in central spinal canal. The increased instability may lead to disc herniation at the level of the spondylolisthesis. Nerve root irritation may result due to instability of the motion segment and pseudoarthrosis material that may cause a mass effect that may encroach on the nerve root within the subarticular recess. Spondylolisthesis
    Fig 2: Isthmic spondylolisthesis due to a defect as shown by the arrows
    Treatment of this form of spondylolisthesis involves activity modification, physiotherapy and oral anti-inflammatory medication. If this fails, a surgical procedure, called Gill Procedure may be considered. This is laminectomy and decompression of the nnerves followed by posterolateral fusion.
    The same treatment approach can be used while dealing with lumbar spine disk herniation.
  • Degenerative spondylolisthesis
  • Degenerative Spondylolisthesis
    Fig 3: Degeneative Spondylolisthesis
    During the degeneration process, there is hypermobility between superior and inferior vertebral segments. Intevertebral space is reduced and facet joints become hypermobile. Narowing of the spinal canal leads to neurological deficits. Facet joint hypermobility may also result in osteophyte (bone spur) formation and enlargement of the superior articular process of that motion segment, narrowing the subarticular recess and leading to lateral recess stenosis encroaching on the nerve root. When both sides of the sinal nerve root have been affected, bilateral leg pain in 50% of patients who concurrently have a stenosis is inevitable.
  • Dysplastic (congenital) spondylolisthesis
  • This is common in abnormalities of the upper sacrum or the arch or L5
  • Post-traumatic spondylolisthesis
  • This is caused by fractures in the areas of the bony hook, not the pars
  • Pathologic spondylolisthesis
  • This results from generalized or localized disease

    Signs and Symptoms

    low-grade-spondylolisthesis Descriptively, the patient may report pain that:
    • Increases with standing
    • Increases with walking
    • Decreases with sitting
    • On an X-ray, there is a characteristic scotty dog appearance
      Movement wise, the following may be present:
    • Decreased and painful extension
    • Passive testing (posterior/anterior) easily results in pain
    • A "step" while palpating the area
    • Passive Physiological Movemet Test (PP-MT test) is positive for instability

    Mechanisms of Nerve Root Compression in Spondylolisthesis

    The following are some of the nerve root compression mechanisms in isthmic spondylolisthesis according to Macnab:

    • Disc herniation of L4-L5
    • The free fragment of the L5 posterior neural arch rotating anteriorly and pivoting on the sacrum, with compression of the L5 root between the distal pars remnant and the sacrum
    • Occasional kinking of the L5 root around the L5 pedicle in spondylolysis
    • Encroachment by a degenerative, bulging anulus fibrosus at L5-S 1
    • Neuroforaminal stenosis
    • Extraforaminal entrapment between the L5 corpotransverse ligament and the sacral ala

    Physiotherapy Treatment of Spondylolisthesis

    Physiotherapy for lumbar spndylolisthesis primarily involves exercises that strengthen the core to avoid progression. Exercises ae also done to manage pain. The following are some of the exercises that can help you get a relief:
    • Posterior Pelvic Tilt
    • Patient lying on their back, bend both knees and then push downward with their pelvis. The easiest way to understand this is by putting your hand under their belt and tell them to squeeze it. Do 10 to 15 repetions. Make 50 repetios your target within one to two months.
    • Posterio pelvic tilt with abdominal crunches. Do 10 to 15 repetitions but the goal should be 50 repetitions
    • Posterior pelvic tilt with knee lift
    • Posterior Pelvic tilt with knees to chest
    • Gentle abdominal crunches with a twist and bending the hip on the side you ae twisting your body to.Keep the pelvis posterioly tilted

    A common treatment protocol by the chiropractics is performing a sponylolisthesis distraction adjustment, also known as The Cox Technique. In this procedure, a patient lies prone with a roll under the spondylolisthesis segment. The doctor, contacts the spinous process above the spondylolisthesis i.e. if spondylolisthesis is at L5, the doctor will contact L4 spinous process.

    Precautions and Contraindications

    When someone has a spondylolisthesis, the following are contraindicated:

    • Spinal Manipulation: Maitland's posteroanterior glides
    • Overhead activities involving trunk extension
    • Stepping on the back, a common traditional Malawian way of dealing with back pain

    References:

    1. Donatelli, R & Wooden, M (2001). Orthopedic Physical Therapy. 3rd Edition. Churchill Livingstone. Philadelphia, Pennsylvania, Uinted States of America.
    2. Haldeman, Scott; Kirkaldy-Willis, William; Bernard, Thomas Jr (2002).The Encyclopedia of Visual Medicine Series: An Atlas of Back Pain. The Parthenon Publishing Group. New York, United States of America.
    3. Cox, James (1991). Low Back Pain: Mechanism, Diagnosis and Treatment . 6th Edition.Williams & Wilkins. Maryland, United States of America


Cardiopulmonary Physiotherapy
Chimwemwe Masina, PT

Author: Chimwemwe Masina

Chimwemwe Masina is currently working as a Resident Physiotherapist at DDT College of Medicine in Gaborone, Botswana. Before joining DDT College of Medicine, he worked in the Ministry of Health at Kamuzu Central Hospital in Malawi, MagWaz Physiotherapy and Wellness Services in Lilongwe, Malawi. as well as Volunteering at Physiopedia.
His interest is in Neuromusculoskeletal Physiotherapy and currently he is an assisting lecturer in Manual Therapy and Lumbar Spine Management.

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