Spondylolisthesis Danielle and Jordon

What is it? A condition of the spine whereby one of the vertebra slips forward or backward compared to the next vertebra. Spondylolisthesis can lead to: Deformity of the spine A narrowing of the spinal canal (central spinal stenosis) Compression of the exiting nerve roots (foraminal stenosis). Last stage of progression of the spondylo-’s Spondylosis -> spondylolysis -> spondylolisthesis Most commonly occurs in the lumbar spine but can also occur in the thoracic and cervical spine Spondylosis = degeneration of the spinal column/disc Spondylolysis = stress fracture of the pars articularis (scotty dog fracture) -> if bilateral then can lead to spondylolisthesis More commonly seen in women then men

Types Most Common Less Common Degenerative: breakdown of IVD Isthmic: results from spondylolysis, aka “scottie dog fracture” Congenital: abnormal bone formation Less Common Traumatic: severe hyperextension Pathological: weakened by disease Post-surgical: defect becomes worse after spinal surgery Degenerative: IVD loses water decreasing its ability to resist excessive movement in the spine---leads to instability Isthmic: small stress fractures of par interarticularis what can weaken vertebrae; continued stresses lead to complete fx and vertebral slippage. Congenital: the facets are malformed from birth or have a shape that makes them vulnerable to misalignment Traumatic: MVAs but mostly sport activities such as gymnastics, wt. Lifting and football Pathological: osteoporosis, infection, or tumor Post-surgical: occurs or becomes worse after spinal surgery (surgery on structurally compromised bone) Most common occurs at L4-5, then L3-4, followed by L5-S1

Grades Grades 1 & 2 typically respond well to conservative treatment Grades 3 & 4 might require surgery depending on neurological compromise Includes: spinal fusion and/or laminectomy Surgical approach for degenerative spondylolisthesis along with spinal stenosis has long term benefits. (NEJM, 2007) Grade of slippage is important factor in deciding course of treatment Biggest contributor to management is controlling amount of pain pt. Is in followed by creating stability of the compromised segment RTC from NEJM: surgical decompressive laminectomy compared to no intervention at all with follow up at 6w, 3m, 6m, 1yr, and 2 yrs. Surgical intervention was shown to have greater improvement on QOL (use of Oswestry disability index, VAS, and medical outcome tools). *Note patients had grade 3 spondi along with stenosis of the spinal canal. Cleveland Clinic (2009)

Clinical Manifestations Patients are usually asymptomatic However, those that are symptomatic most commonly report PAIN as their main issue Exacerbated by twisting and extension movements If slippage is severe enough, Can develop N/T or weakness of the legs due to nerve compression Can lose control of bowel and bladder function due to cauda equina syndrome Other signs: Tightness in hamstrings Decreased ROM W/ advanced stages of pregnancy, reported symptoms become more severe Pain -> due to neural involvement from nerve root compression or due to the actual area of the slippage placing stress on structures around the slippage Pain is worse with activities that involve extension of the spine

Physical Examination Findings Tenderness to deep palpation of the spinous process above the slip With high-grade slips, a palpable step-off may be felt over the spinous process at the level above the slipped vertebrae Paraspinal muscle spasms Abnormal gait pattern that is “waddle -like” due to hamstring tightness Weakness in Anterior Tibialis (L4) is common Neural Signs

Treatment Approaches Generally, Those that are grades 1 and 2 will have the most benefit from conservative approaches Unless, neural signs are present during these grades, then it is recommended to receive surgery Those that are grades 3 and 4 surgery is recommended to correct it Conservative Approaches Physical Therapy Bracing Rest and avoiding activities that involve lifting and bending NSAID’s, ice, and heat Epidural cortisone injection Bracing to reduce lordotic curve NSAID’s, ice and heat to reduce inflammation and pain Cortisone injection into disc space to reduce pain from neural compression

Physical Therapy Approach to Treatment Therapeutic Exercise Strengthen abdominal muscles Exercises that promote flexion Posterior tilt exercises Hamstring stretching Stabilization exercises Therapeutic Exercise + Bracing Best results in reduction of pain when used in combination Patient education to maintain healthy weight and well-balanced diet as well as to avoid activities/sports that involve hyper-extension of the back Ther Ex to help correct the deformity of the spine Work on posterior tilt to reduce exaggerated lumbar lordosis Pt education about weight because more abdominal fat will aid in exaggerating lordotic curve Brace must be worn continuously, helps keep proper alignment of the spine and reduce lordotic curve

Orthotic Treatment of DDD with Degenerative Spondylolisthesis: A Case Study Meade K, Flanagan P, Gomez JM JOP 2006 The Patient 66 y.o. Female, mother of 7, full-time retail worker with bilateral TKA Back pain since 1999, worsening with achy, burning sensation from right buttock down to her foot VAS: 8/10 Unable to walk more than 50 yards without having to sit to relieve pain Restless sleep pattern due to cramping and numbness in bilateral LEs Ambulates with considerable bend forward posture Takes 6 NSAID tablets daily to control pain Attempted PT but was restricted by pain levels No significant event brought on her back pain

Exam Findings Treatment Physical Exam Normal motor function Reduced reflexes: 2 @ L4, 0 @ L5-S1 Positive plantar babinski Radiology X-ray revealed DDD with Grade 1 Spondi @ L5-S1 and advanced DDD at L4-L5 MRI confirmed spinal stenosis at L4- L5 Treatment Custom anterior opening LSO along with PT Casted with pt in supine with knees bent to reduce sacral angle Regular visits during first 4 months to check fit along with x-rays while wearing orthotic to track progress After 4 months, follow up was made every 4 months via phone calls until end of 18 months. * Pt. opted for conservative treatment even though surgery was recommended due to her neurological symptoms. Normal LE strength and motor function Diminished reflexes along with positive babinski indicates UMN involvement; suspected neural compromise from DDD and secondary to the spondi Treatment: careful watch over the patient’s sacral angle (degree of slippage b/w L5-S1), qualitative measurements taken on the phone (pain and activity levels plus amount of time spending in the brace and how often doing HEP)

Results Reported immediate relief in pain and ability to sleep through the night (wearing orthotic at night) At 4 months Able to remain standing for 30 minutes and normal duties at work At 6 months VAS 2/10 and complete discontinuation of NSAIDS At 18 months X-ray confirmed reduction in sacral angulation (equates to a 42% reduction in shear forces) Pt reduced orthotic wear to 4-6 hours a day, during most active time of day with continuation of prescribed exercises. Pt. preferred treatment Immediate relief of pain believed to be from reduction of sacral angle, decreasing compression/neural compromise. Wore brace throughout the night for first 4 months of treatment At last evaluation. Measurements between L5-S1 concluded normalization of angle---reduction of spondi and significant amount of reduction to the shear forces on her IVDs. Reduced time having to wear orthotic, continued to sleep through night and return to normal ADLs. Limitation of the case study: did not specify exactly what home exercises pt was given and lack of detailed follow up between 4 months to 18 months. Relevance: in practical use of custom orthotic to control pain but not an article for the benefits of physical therapy alone.

Questions?

References Das P. Spondylolisthesis Treatment. Physiotherapy-Treatment.com. Accessed on July 10, 2016 from http://www.physiotherapy- treatment.com/spondylolisthesis-treatment.html Driver C. Spondylolisthesis. MedicineNet. Reviewed on May 8, 2015. Accessed on July 10, 2016 from http://www.medicinenet.com/spondylolisthesis/article.htm. Meade K, Flanagan P, Gomez JM. Orthotic Treatment of Degenerative Disc Disease with Degenerative Spondylolisthesis: A Case Study. JPO 2006; 18: 8-14. Retrieved from American Academy of Orthotists and Prosthetists Website. http://www.oandp.org/olc/course_jpo.asp?frmCourseId=87E71C33-9615-4CDD-BE40-0CD809D9F0B7. Accessed July 10, 2015. Perrin A. Lumbosacral Spondylolisthesis Clinical Presentation. Medscape. Updated Feb 1, 2016. Accessed on July 10, 2016 from http://emedicine.medscape.com/article/2179163-clinical#b3 Spondylolisthesis. Disease and Conditions Cleveland Clinic. Retrieved from http://my.clevelandclinic.org/health/diseases_conditions/hic_your_back_and_neck/hic_Spondylolisthesis. Updated October 9, 2009. Accessed July 5, 2016. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. N Engl J Med 2007; 356: 2257-2270. DOI: 10.1056/NEJMoa070302.