Spondylolysis and Spondylolisthesis

Normal Anatomy

• Pars interarticularis– Part of vertebra between

inferior and superior articular process of the facet joint

Pathophysiology

• Spondylolysis– A fracture in the pars

articularis– Usually a fatigue fracture

• Spondylolisthesis– A displacement of one

vertebrae over another– Usually L5 anteriorly– Although can be any level

and any direction– Usually occurs due to

spondylolysis

Classification

Spondylolisthesis: Classification

• Grade 1: 0-25% vertebral slippage• Grade 2: 25-50% vertebral slippage• Grade 3: 50-75% vertebral slippage• Grade 4: 75-100% vertebral slippage• Grade 5: Complete slippage of the vertebral

disc.

Mechanism of Injury• Insidious

– Isthmic• Repeated microtrauma usually into

extension– Wrestling– Weightlifting– Gymnastics– Dancing– Carrying a heavy back pack– Athletics

– Degenerative• Intervertebral disc degenerates

changing joint orientation• Period of instability• Can cause excessive motion of the

segment• Causing tipping or compression of

vertebrae

• Insidious– Pathological

• Weakening of posterior elements e.g metastasis

– Dysplastic• Congenital genetics –

common in spina bifida occulta

• Traumatic– Hyperflexion with

compression and rotation– Hyperextension

Associated Pathologies

• Spondylolisthesis• Spondylolysis• Degenerative Disc Disease• Stenosis• Spina Bifida Occulta

Pathophysiology

• Continued excessive mechanical stress (or trauma/pathology/congenital) on the posterior elements of the vertebra

• Causes fracture in weakest part of vertebra (pars) (Spondylolysis)

• Shear forces throughout the vertebral column can result in displacement (Spondylolisthesis)

Subjective

• Most commonly aged 10 – 15, Female > Male• History of mechanical stress into extension– Gymnastics, dancing, athletics, weightlifting, diving

• Localised paraspinal pain• Pain with prolonged standing and hyperextension• Pain on compression• +/- Radiculopathy if neural compression• Leg symptoms may switch sides if central neural

compression

Objective

• Hyperlordotic• Pain extremes ROM• Extension and Rotation• Hypermobile and

Vertebral Hinging• Step Deformity • Tight hamstrings (80%)

Special Tests

• One Legged hyperextension manoeuvre

Further Investigation

• Standing lateral oblique X ray (Scotty Dog with Collar)

• CT and MRI to rule out other pathologies

Further Investigation

• Standing lateral oblique X ray (Scotty Dog with Collar)

• CT and MRI to rule out other pathologies

General Management

• Activity modification avoiding positions of extension

• Manual Therapy for pain relief ONLY• Treat instability• Refer if neurological symptoms present

without prior investigations or worsening of neurological symptoms with previous investigations

Conservative - Management

• Pain Relief– Massage, NSAID’s, Ice, Activity Modification

• Restore Normal Mobility– Hamstrings, Hip Extension, upper lumber and thoracic extension

• Restore Normal Motor Control– Anterior Core (Anti Extension)

• Dead Bug• Over Head Pallof Press• etc

– Glutes, Anti Rotational Core• Restore Dynamic Stability• Return to Sport Specific

Plan B - Management

• Epidural steroid injection if radiculopathy is present

• Surgical after 6 months of conservative treatment– Decompressive lumbar laminectomy in posterior

fusion