SPONDYLOLISTHESIS

Outcomes  Be familiar with the definition of Spondylolisthesis.  Be familiar with the pathology of a typical Spondylolisthesis.  Be familiar with the types of Spondylolisthesis.  Be familiar with the clinical presentation of a typical patient with Spondylolisthesis.  Be familiar with the most widely used physiotherapy treatment protocols for a patient with typical Spondylolisthesis.  Be able to give appropriate advice to a patient with typical Spondylolisthesis.

Definition  Anterior displacement (antero-listhesis) of a vertebral body upon the bottom vertebral body  Usually occurs between L4-L5 and between L5-S1  Generally occurs in families  Posterior displacement: retro- listhesis

Spondylolisthesis

Pathology  In the standing position there is a constant downward and forward force on the lower lumbar vertebrae  Body mass and normal movement may give rise to spondylolisthesis  The anatomical structure of the lumbo- sacral area of the vertebral column is affected

Pathology  The degree of antero displacement is explained in Grades I to IV  These grades each comprise a quarter of the surface of the bottom vertebrae  Grade I and II is treated conservatively  Grade III and IV should undergo a fusion

Five types  Congenital spondylolisthesis (L5/S1) – more common in girls and sometimes associated with spina bifida.  Spondylolytic spondylolisthesis (L5) – due to bilateral spondylolisthesis  Traumatc spondylolisthesis – due to a fracture of the pars interarticulari e.g. Parachute jumping

Five types  Degenerative spondylolisthesis (L4) – uncommon before the age of 50  Pathological spondylolisthesis – after local or general bone diseases e.g. tumour or infections

X-rays

Signs and symptoms  Back or leg pain  Back feels weak  Sometimes lumbar scoliosis and increased kyphosis  Step is felt in the back  Unilateral and sometimes bilateral nerve root compression with pain in the legs  Segmental instability  Stiff back extensors, hamstring and m psoas – attempt to stabilise the pelvis

Signs and symptoms  Extension is the most common restricted range  Pain increases during standing especially in high heeled shoes, walking down hill, prone and other extension activities  Experiencing difficulty to come out of flexion, must press on thighs with hands  Extension is painful and restricted  SLR is restricted  Pain relief while sitting, supine and crook-lying (stable positions)

Treatment  Asymptomatic: No treatment  Symptomatic: Severe cases – bed rest static traction localised heat analgesics Stable cases – relief of symptoms stabilisation improvement of posture advise

Relief of symptoms  Maitland mobilisations (no strong techniques as a result of the instability)  Rotation up to Grade IV-  Longitudinal in flexion  Palpation techniques no further than Grade II (be extremely careful)  Static traction (27,5 kg – 35 kg)

Relief of symptoms  Trigger points  Neural mobilisations  Stretch of back extensors and m psoas  Strengthening of abdominal stabilisers, m gluteus and m quadriceps  Re-education of correct posture

Advise  Sitting is better than standing  Avoid running, jumping, horseback riding and other jerky movements  Swimming and cycling are good exercises  Avoid contact sport

Advise  Avoid becoming overweight  Wear a corset with painful activities  Housewife must use trolley during shopping  Retain abdominal stabilisation at all times  Comfortable position is usually with pillow underneath the legs