7. Spondylolysis/listhesis Flashcards
Stress fracture of the pars interarticularis
Spondylolysis
When one vertebra slips forward over an adjacent vertebra
Spondylolisthesis
What is the difference between isthmic and degenerative spondylolisthesis?
Isthmic is a stress fracture (spondylolysis) with slippage, while degenerative is just slippage
In what percentage of symptomatic spondylolysis cases is the stress fracture bilateral?
80%
What is the most common pars that will fracture?
L5 (85-95%)
What is the second most common pars that will fracture?
L4 (5-15%)
What is the usual cause of spondylolysis?
Repetitive overuse
What is the prevalence of spondylolysis in the general population?
6-13%
How often is spondylolysis/listhesis symptomatic?
Most (90%) are asymptomatic. It does not seem to be a major cause of LBP in general population
How often is spondylolysis the cause of LBP in young athletes? In adult athletes?
47% of LBP in young athletes
5% of LBP in adult athletes
Spondylolysis is more common in which gender?
Male/female is 2:1 in adults but is 4x more likely in young girls
At the time of detection, spondylolysis is
associated with anterior translation of the
vertebrae (spondylolisthesis) about _____ % of the time
25
slippage is usually minor with only about
_____% of adolescents and _____% of adults
progressing to more than 10mm of slippage.
11:5
What percentage of spondylolysis cases in athletes are under 20 years old?
75%
Is the onset of pain associated with spondylolysis sudden or gradual?
50% are sudden and 50% are gradual over time and related only to certain activities.
Describe the pain associated with spondylolysis?
- Ranges from mild to moderate
- lancinating when acute and dull/achy when chronic
- worse with hyperextension
- focal tenderness when acute
- aggravated by deep percussion
What is the most commonly reported history and physical finding in athletes with spondylolysis?
Pain associated with hyperextension although AROM is normal
What muscles will common spasm with spondylolysis?
Hamstring
Psoas
WHat is a classic but controversial physical exam test for spondylolysis?
Stork test - stand on one leg and extend spine
Would there be neurological signs with spondylolysis?
Very uncommonly, because this type of fracture does not form new periosteal bone with fibrous union of fracture, therefore it is less likely that there will be enough proliferation around the fracture to cause NR impingement
What imaging is indicated for spondylolysis?
- Radiographs (AP and lateral) although they can be inconclusive in early cases
- follow up with AP axial lumbosacral spot and/or oblique if AP/laterals was inconclusive
- if all radiographs are equivocal but there is still high suspicion, can order MRI, CT or SPECT
What are the pros and cons of using CT to diagnose spondylolysis?
Pro: specific and can also reveal other spinal pathologies not seen on radiograph or SPECT
Con: high radiation and cannot distinguish between active or inactive lesions
What are the pros and cons of using MRI to diagnose spondylolysis?
Pro: can detect early edematous stress without fracture line that CT and radiographs miss. No radiation
Cons: expensive and therefore reserved for cases with neurological presentations
What are the pros and cons of using SPECT to diagnose spondylolysis?
Cons: substantial false positives and negatives, high radiation, can’t detect chronic, non-union fractures and can’t distinguish between neoplasm, infection, facet arthritis and fracture
Pros: gold standard for detecting active/occult spondylolysis because it identifies areas of increased physiological activity (inflammation of early fracture)
What are the primary objectives for management of spondylolysis?
- avoid sport!!!
- control pain
- prevent slippage
- promote healing
What is the prognosis for spondylolysis with conservative care?
95% had good to excellent outcomes
How long do most patient’s need to abstain from sport with spondylolysis?
5.4-5.5 months
What are the treatment interventions for acute spondylolysis/listhesis?
- stop sport
- ice
- stretch hip flexors (psoas) and hamstring
- rigid bracing
What is a typical rigid brace RX?
- worn for 20-23 hours a day for approximately 3-6 months.
- weaned off it as symptoms resolve
- start with 30 minutes of brace free time 3x/dy for the first day; each day for (2 weeks) add 30 more minutes without brace
What are the 5 classifications of spondylolisthesis?
- congenital (dysplastic)
- isthmic (stress)
- degenerative (arthritis)
- post trauma (rare)
- pathological (Paget’s)
Most common spondylolisthesis is ____ in young patients and ____ in older patients.
isthmic
degenerative
Spondylolisthesis is an unlikely cause of back pain in adults (especially after age 40) with no history of symptoms before age ____ years; usually, another diagnosis must be identified
30
Under what 4 conditions is spondylolisthesis more likely to be a pain generator?
- when associated with a healed but active spondylolysis
- when spondylolisthesis is unstable
- when spondylolisthesis is degenerative and also associated with canal stenosis
- when it is associated with radiculopathy or CES
What postural findings are common with spondylolisthesis?
- phalen Dickson- hip and knee flexion
- functional scoliosis
What are common palpatory findings with spondylolisthesis?
- tenderness to deep palpation of SP above the slip (L4 usually because L5 is slipped)
- paraspinal muscle spasm and tenderness
- step off defect (+LR 4.6) with possible hypermobility in P->A
What muscles are most commonly in spasm with spondylolisthesis?
Hamstrings and psoas
What is a positive passive leg extension test and what does it indicate?
- Positive if it cause pain or feeling of heaviness in the low back that disappears when legs are lowered.
- this suggests unstable spondylolisthesis (+LR 8.8)
What combination of clues are suggested as key evidence for spondylolisthesis?
- step defect by inspection or palpation
- segmental hypermobility
What causes degenerative sponsylolisthesis?
Posterior elements (pars, etc) degenerates and the disc thins. This causes slippage that may be unstable
What is the total amount of sagittal translation on flexion and extension that would indicate an unstable spondylolisthesis?
More than 4mm of translation on radiographic stress views
Who typically gets degenerative spondylolisthesis?
Over 60
Women 5-6x more common
Men are more unstable
Anterior translation of L4 over L5 is most common
Degenerative spondylolisthesis is associated with general symptoms of ______
Osteoarthritis
Ex: stiffness and aching that is worse in AM, crepitus,
What activities are often palliative with degenerative spondylolisthesis?
- movement/light walking (not uphill)
- hot shower
- Lying supine with hips/knees bent
What range of motion do patients with degenerative spondylolisthesis have?
Usually WNL however full extension is painful and prolonged forward flexion may be uncomfortable
What are some possible signs of instability from the history and physical exam in a patient with degenerative spondylolisthesis?
- to bend over, patient bends hips and knees (phalen dicksen style) to avoid L/S movement
- to bend back upright, patient first extends L/S and then hip joints in a ratcheting movement
What kind of leg pain is associated with spondylolisthesis?
- if present, is more likely deep referred
- radicular leg pain is uncommon and only occurs with larger slips (12%)
- inferior nerve root (L5) can possibly become impinged by slippage or scar tissue of healing spondylolisthesis
How are spondylolisthesis graded?
Measuring amount of slippage on lateral radiograph.
- 0-25% = grade 1
- 25-50% = grade 2
- 50-75% = grade 3
- 75-99% = grade 4
- 100% = complete
What is another term for a complete/100% spondylolisthesis?
Spondyloptosis
Low grade isthmic spondylolisthesis corresponds to ____% or less listhesis?
50
What are the key management options for conservative care of spondylolisthesis?
- rest/limit offending activities
- rigid bracing
- hamstring stretches
- spinal manipulation/flexion-distraction
- lumbar stabilization and flexion exercises
What cautions should be taking with manual therapy of spodylolisthesis?
- treat based on all findings not just imaging
- joint dysfunction and myofascial paint generators should be assessed
- CMT may offer pain relief but be cautious of P-A thrust over spondylolisthesis
- postitioning patient in flexion for manipulation is generally favored (side posture, prone with flexion bias)
Describe how flexion distraction would be performed for spondylolisthesis
- small roll placed under slipped segment
- SP of vertebra above SP is lifted cephalad as table is flexed
- three 20 second distractions
- repeat 5-6 times
Describe an exercise program for spondylolisthesis
- Begin after rest period/pain of ADLs has subsided
- begin with rigid brace until symptoms decrease
- flexion exercises (knee to chest)
- core stabilization (McGills big 3)
- hamstring stretches
- general aerobic
With spondylolisthesis and spondylolysis, when should athletes return to sport?
- Not until pain free and follow up xrays show no further progression (generally 3 months or more)
- high level athlete can return once symptoms become tolerable
What is the prognosis for spondylolisthesis and spondylolysis?
Generally good Lower grade (0-1) listhesis have better prognosis (80-90%) vs higher (2+) grade (66%)
When is surgery indicated with spondylolisthesis/lysis?
- Absolute indication: When there is serious or progressive neurological deficits secondary to instability causing dynamic stenosis with high grade slippage
- relative indication: persistent radiculopathy and/or LBP for 6 months despite conservative treatment, loss of quality of life
What advice should be given to patients being referred for surgical consultation?
Get a second opinion because there is a large discordance between first and second opinion regarding need for spinal surgery in this case
What is the average return to sport following surgery for spondylolisthesis/lysis?
6-12 months
What are the possible surgical options for spondylolisthesis/lysis?
Decompression and/or fusion
