1. Spondylolisthesis
Danielle and Jordon

2. 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

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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

10. Exam Findings Treatment
Physical Exam
Normal motor function
Reduced reflexes: L4, L5-S1
Positive plantar babinski
Radiology
X-ray revealed DDD with Grade 1 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)

11. 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.

12. Questions?

13. References
Das P. Spondylolisthesis Treatment. Physiotherapy-Treatment.com. Accessed on July 10, 2016 from treatment.com/spondylolisthesis-treatment.html
Driver C. Spondylolisthesis. MedicineNet. Reviewed on May 8, Accessed on July 10, 2016 from
Meade K, Flanagan P, Gomez JM. Orthotic Treatment of Degenerative Disc Disease with Degenerative Spondylolisthesis: A Case Study. JPO 2006; 18: Retrieved from American Academy of Orthotists and Prosthetists Website. Accessed July 10, 2015.
Perrin A. Lumbosacral Spondylolisthesis Clinical Presentation. Medscape. Updated Feb 1, Accessed on July 10, 2016 from
Spondylolisthesis. Disease and Conditions Cleveland Clinic. Retrieved from Updated October 9, 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: DOI: /NEJMoa