Spondylolisthesis


Article Author:
Steven Tenny


Article Editor:
Christopher Gillis


Editors In Chief:
Sisira Reddy
Joseph Nahas
Chokkalingam Siva


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Khalid Alsayouri
Kyle Blair
Radia Jamil
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Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/18/2019 10:57:45 PM

Introduction

Spondylolisthesis is the slippage of one vertebral body with respect to the adjacent vertebral body causing mechanical or radicular symptoms or pain. It can be due to congenital, acquired, or idiopathic causes. Spondylolisthesis is graded based on the degree of slippage of one vertebral body on the adjacent vertebral body.[1]

Etiology

Spondylolisthesis commonly classifies as one of five major etiologies: degenerative, isthmic, traumatic, dysplastic, or pathologic. Degenerative spondylolisthesis occurs from degenerative changes in the spine without any defect in the pars interarticularis. It is usually related to combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body relative to the adjacent vertebral body. Isthmic spondylolisthesis results from defects in the pars interarticularis. The cause of isthmic spondylolisthesis is undetermined, but a possible etiology includes microtrauma in adolescence related to sports such as wrestling, football, and gymnastics, where repeated lumbar extension occurs. Traumatic spondylolisthesis occurs after fractures of the pars interarticularis or the facet joint structure and is most common after trauma. Dysplastic spondylolisthesis is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment.  In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation. Pathologic spondylolisthesis can be from systemic causes such as bone or connective tissue disorders or a focal process, including infection, neoplasm, or iatrogenic origin. Additional risk factors for spondylolisthesis include a first-degree relative with spondylolisthesis, scoliosis, or occult spina bifida at the S1 level.[1]

Epidemiology

Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the cervical spine and rarely, except for trauma, in the thoracic spine. Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese. Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males. Dysplastic spondylolisthesis is more common in the pediatric population, with females more commonly affected than males. Current estimates for prevalence are 6 to 7% for isthmic spondylolisthesis by the age of 18 years, and up to 18% of adult patients undergoing MRI of the lumbar spine. Grade I spondylolisthesis accounts for 75% of all cases. Spondylolisthesis most commonly occurs at the L5-S1 level with anterior translation of the L5 vertebral body on the S1 vertebral body. The L4-5 level is the second most common location for spondylolisthesis. 

Pathophysiology

Any process that can weaken the supports keeping vertebral bodies aligned can allow spondylolisthesis to occur. As one vertebra moves relative to the adjacent vertebrae, local pain can occur from mechanical motion or radicular or myelopathic pain can occur due to compression of the exiting nerve roots or spinal cord, respectively. Pediatric patients are more likely to increase spondylolisthesis grade when going through puberty. Older patients with lower grades I or II spondylolistheses are less likely to progress to higher grades over time.

History and Physical

Patients typically have intermittent and localized low back pain for lumbar spondylolisthesis and localized neck pain for cervical spondylolisthesis. The pain is exacerbated by flexing and extending at the affected segment, as this can cause mechanic pain from motion. Pain may be exacerbated by direct palpation of the affected segment. Pain can also be radicular in nature as the exiting nerve roots become compressed due to the narrowing of nerve foramina as one vertebra slips on the adjacent vertebrae, the traversing nerve root (root to the level below) can also be impinged through associated lateral recess narrowing, disc protrusion, or central stenosis. Pain can sometimes improve in certain positions such as lying supine. This improvement is due to the instability of the spondylolisthesis that reduces with supine posture, thus relieving the pressure on the bony elements as well as opening the spinal canal or neural foramen. Other symptoms associated with lumbar spondylolisthesis include buttock pain, numbness, or weakness in the leg(s), difficulty walking, and rarely loss of bowel or bladder control.

Evaluation

Anteroposterior and lateral plain films, as well as lateral flexion-extension plain films, are the standard for the initial diagnosis of spondylolisthesis. One is looking for the abnormal alignment of one vertebral body to the next as well as possible motion with flexion and extension, which would indicate instability. In isthmic spondylolisthesis, there may be a pars defect, which is termed the "Scotty dog collar." The "Scotty dog collar" shows a hyperdensity where the collar would be on the cartoon dog, which represents the fracture of the pars interarticularis. Computed tomography (CT) of the spine provides the highest sensitivity and specificity for diagnosing spondylolisthesis. Spondylolisthesis can be better appreciated on sagittal reconstructions as compared to axial CT imaging. MRI of the spine can show associated soft tissue and disc abnormalities, but it is relatively more challenging to appreciate bony detail and a potential pars defect on MRI.[2][3]

Treatment / Management

For grade I and II spondylolisthesis, treatment typically begins with conservative therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), heat, light exercise, traction, bracing, and/or bed rest. Approximately 10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment and need surgical treatment. No definitive standards exist for surgical treatment. Surgical treatment includes a varying combination of decompression, fusion with or without instrumentation, or interbody fusion. Patients with instability are more likely to require operative intervention.  Some surgeons recommend a reduction of the spondylolisthesis if able as this not only decreases foraminal narrowing but also can improve spinopelvic sagittal alignment and decrease the risk for further degenerative spinal changes in the future. The reduction can be more difficult and riskier in higher grades and impacted spondylolisthesis.[4][5][6][7][8][2][9][10]

Pearls and Other Issues

Meyerding’s classification of spondylolisthesis is the most commonly used grading method. Its basis is on the percentage of anterior translation relative to the adjacent level. Grade I spondylolisthesis is 1 to 25% slippage, grade II is up to 50% slippage, grade III is up to 75% slippage, and grade IV is 76-100% slippage. If there is more than 100% slippage, it is known as spondyloptosis or grade V spondylolisthesis.  

Subclasses of isthmic spondylolisthesis are subtype A (stress fractures of the pars), subtype B (elongation of the pars without overt fracture), subtype C (acute fracture of the pars).

Subclasses of pathologic spondylolisthesis are subtype A (systemic causes) and subtype B (focal processes).

Enhancing Healthcare Team Outcomes

An interprofessional team consisting of a specialty-trained orthopedic nurse, physical therapist, and an orthopedic surgeon or neurosurgeon will provide the best outcome and long-term care of patients with degenerative spondylolisthesis. Chiropractors may also have involvement, as they may be the first to encounter the condition on X-rays. The treating clinician will decide on the management plan, and then have the other team members engaged - surgical cases with include the nursing staff in pre-, intra-, and post-operative care, and coordinating with PT for rehabilitation. In non-operative cases, the PT will keep the rest of the team informed of progress or lack thereof. The team should encourage weight loss as weight reduction may reduce symptoms and increase the quality of life. Interprofessional collaboration, as above, will drive patient outcomes to their best results. [Level 5]


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    Contributed by Christopher Gillis, MD and Steven Tenny, MD
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Spondylolisthesis - Questions

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Which of the following is defined as the anterior slippage of one vertebra on another?



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Which of the following is the most common cause of low back pain in a 22-year-old athlete?



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What type of traumatic spondylolisthesis is characterized by acute fracture of the pars?



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What type of traumatic spondylolisthesis is characterized by elongation of the pars?



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What type of traumatic spondylolisthesis is characterized by fatigue fracture of the pars?



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What is the most appropriate treatment for a new diagnosis of spondylolisthesis?



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A 42-year-old female presents with low intermittent back pain for 6 months which worsens as she bends to pull weeds in her garden. The pain improves when she reclines in her recliner. A plain film x-ray of the lumbar spine is reported as showing "mild grade I spondylolisthesis without significant change between flexion or extension and without other significant abnormalities." What is the probability that she will fail conservative therapy and require surgical treatment?



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What is the Meyerding classification for the pictured spondylolisthesis?

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Spondylolisthesis - References

References

Degenerative Spondylolisthesis., Koreckij TD,Fischgrund JS,, Journal of spinal disorders & techniques, 2015 Aug     [PubMed]
Randall RM,Silverstein M,Goodwin R, Review of Pediatric Spondylolysis and Spondylolisthesis. Sports medicine and arthroscopy review. 2016 Dec;     [PubMed]
Bouras T,Korovessis P, Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review. European journal of orthopaedic surgery     [PubMed]
Baker JF,Errico TJ,Kim Y,Razi A, Degenerative spondylolisthesis: contemporary review of the role of interbody fusion. European journal of orthopaedic surgery     [PubMed]
Matz PG,Meagher RJ,Lamer T,Tontz WL Jr,Annaswamy TM,Cassidy RC,Cho CH,Dougherty P,Easa JE,Enix DE,Gunnoe BA,Jallo J,Julien TD,Maserati MB,Nucci RC,O'Toole JE,Rosolowski K,Sembrano JN,Villavicencio AT,Witt JP, Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. The spine journal : official journal of the North American Spine Society. 2016 Mar;     [PubMed]
Schöller K,Alimi M,Cong GT,Christos P,Härtl R, Lumbar Spinal Stenosis Associated With Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-analysis of Secondary Fusion Rates Following Open vs Minimally Invasive Decompression. Neurosurgery. 2017 Mar 1;     [PubMed]
Kreiner DS,Baisden J,Mazanec DJ,Patel RD,Bess RS,Burton D,Chutkan NB,Cohen BA,Crawford CH 3rd,Ghiselli G,Hanna AS,Hwang SW,Kilincer C,Myers ME,Park P,Rosolowski KA,Sharma AK,Taleghani CK,Trammell TR,Vo AN,Williams KD, Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis. The spine journal : official journal of the North American Spine Society. 2016 Dec;     [PubMed]
Alqarni AM,Schneiders AG,Cook CE,Hendrick PA, Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2015 Aug;     [PubMed]
Schulte TL,Ringel F,Quante M,Eicker SO,Muche-Borowski C,Kothe R, Surgery for adult spondylolisthesis: a systematic review of the evidence. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2016 Aug;     [PubMed]
Alfieri A,Gazzeri R,Prell J,Röllinghoff M, The current management of lumbar spondylolisthesis. Journal of neurosurgical sciences. 2013 Jun;     [PubMed]

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