1. Dr. Dibyendunarayan Bid MPT, PGDSPT Senior LecturerThe Sarvajanik College of Physiotherapy, Surat.

2. Kilian, Robert, and Lambl firstdescribed spondylolysis accompaniedby spondylolisthesis in the literature inthe mid 1800s. 3. Radiograph of the lumbosacral junctionshowing a grade 1 spondylolyticspondylolisthesis at L5-S1. 4. Spondylolisthesis,spondylolysis, andspondylosis.Isthmicspondylolisthesis(type IIa) with grade2 slippage of L5over S1 andspondylolysis (lyticpars defect) isdepictedposteriorly. 5. Pathophysiology Spondylolysis is a defect in the parsinterarticularis that may or may not beaccompanied by forward translation ofone vertebra relative to another(spondylolisthesis). 6. Wiltse, Macnab, and Newman developeda classification to help outline causes ofvertebral translation in an anteriordirection. Their categories include the following: Type I: Congenital spondylolisthesis Type II: Isthmic spondylolisthesis Type III: Degenerative spondylolisthesis Type IV: Traumatic spondylolisthesis Type V: Pathologic spondylolisthesis 7. Type I: Congenital spondylolisthesis ischaracterized by presence ofdysplastic sacral facet joints allowingforward translation of one vertebrarelative to another. Orientation offacets in an axial or sagittal plane mayallow for forwardtranslation, producing undue stress onthe pars, resulting in a fracture. 8. Type II: Isthmic spondylolisthesis iscaused by the development of a stressfracture of the pars interarticularis. 9. Type III: Degenerativespondylolisthesis is commonly causedby intersegmental instability producedby facet arthropathy. This variationusually occurs in the adult populationand, in most cases, does not progressbeyond a grade I spondylolisthesis. 10. Type IV: Traumatic spondylolisthesiscan, in rare instances, result fromacute stresses (trauma) to the facet orpars. Type V: Any bone disorder maydestabilize the facet mechanismproducing pathologicspondylolisthesis. Iatrogenic spondylolisthesis, lastly, mayoccur if an overzealous surgeon performstoo great of a facetectomy. 11. The most commonly used grading system forspondylolisthesis is the one proposed by Meyerding in1947. The degree of slippage is measured as the percentageof distance the anteriorly translated vertebral body hasmoved forward relative to the superior end plate of thevertebra below. Classifications use the following grading system: Grade 1: 1- 25% slippage Grade 2: 26-50% slippage Grade 3: 51-75% slippage Grade 4: 76-100% slippage Grade 5: Greater than 100% slippage 12. Frequency Wiltse and Beutler each reported an incidence of 6-7% foristhmic spondylolysis. Up to 5% of children aged 5-7 years have been found tohave spondylolysis, many of whom are asymptomatic. Theincidence increases up to the 7% by age 18. Athletic activities requiring repetitive hyperextension androtation or repetitive combined flexion-extension predisposesomeathletestodevelopingpars defects.Gymnasts, linemen in college football, weight lifters, javelinthrowers, pole-vaulters, and judoists are most commonlyaffected. Approximately 82% of cases of isthmic spondylolisthesisoccur at L5-S1. Another 11.3% occur at L4-L5. Congenital defects, includingspina bifida occulta, have been linked to occurrence ofisthmic spondylolisthesis. Scoliosis has been found to occuralong with spondylolysis as well. 13. Roughly 50% of all cases ofspondylolysis are not associated withspondylolisthesis. Degenerative spondylolisthesis occursmore frequently with increasing age. The L4-L5 interspace is affected 6-10more times than any other level. Sacralization of L5 is frequently seenwith L4-5 degenerative spondylolisthesis. 14. Mortality/Morbidity Increased mortality is not associated withspondylolisthesis. While some patients may havepersistent low back pain, significant disability israre unless the patient has severe neurologiccompromise that has not been addressed. The most common morbidity is persistent lowback pain or nerve impingement. Because diskdegeneration is accelerated at the sight of levelof the spondylolysis, diskogenic pain may occur. Degenerative spondylolisthesis producescharacteristic arthritic symptoms that mayworsen with age. 15. Sex Beutler et al noted a 2:1 male-to-female ratioof occurrence in asymptomatic patients withspondylolysis. Females with isthmic spondylolytic lesionsappear to be more prone to progressivedisplacement and may need surgical interventionmore often than males. Congenital spondylolisthesis (dysplastic type)occurs with a 2:1 female-to-male ratio withsymptoms beginning around the adolescentgrowth spurt. These comprise about 14-21% ofall cases of spondylolisthesis. Degenerative spondylolisthesis occurs morecommonly in females with a 5:1 female-to-maleratio. The incidence increases after age 40 years. 16. Age Acute isthmic spondylolysis often occurs during thefirst and second decades of life. Most cases occurbefore the patient reaches age 15 years. In rare cases, acute spondylolysis may be seen inearly adulthood. Younger patients are at higher riskthan older patients for developing progressivespondylolisthesis. The risk for progression in adults is rare when thelesion is at L5. In contrast, lesions at L4-5 mayprogress into adulthood because of increasedsagittal rotation, shear translation, and axialrotation at this segment. 17. Congenital/dysplasticspondylolisthesis has beendocumented in children as young as3.5 months. Morecommonly, congenitalspondylolistheses go undiagnoseduntil later in life after an individual hasbeen ambulating for quite some time. Degenerative spondylolisthesis occursmost commonly after age 40 years. 18. History Isthmic spondylolisthesis Symptoms often occur around the time ofan adolescent growth spurt. Some report acute onset of focal low backpain during activity, while others havemore insidious onset. Radiating pain may extend to the buttocksor thigh. Pain may be more significant and havemechanical characteristics with highergrades of spondylolisthesis. 19. In most cases, patients do not complain of symptomssuggesting neurologic deficit with lower grades ofspondylolisthesis. Radicular pain becomes morecommon with larger slips. Complaints of radiating pain below the level of theknee associated with numbness and tingling in adermatomal distribution would suggest the presence aradiculopathy resulting from either the foraminalstenosis that occurs with spondylolisthesis or aconcomitant herniated disk. Nerve root impingement from the fibrocartilaginous barthat forms at the sight of the lysis may occur. Highdegrees of spondylolisthesis may present withneurogenic claudication or symptoms suggestingcauda equina impingement. 20. The patients pain usually is provoked byactivity, particularly back extensionactivities. Patients with acute spondylolysis tend todemonstrate poor tolerance of activitiesrequiring excessive spineloading, including running and jumping.Sitting usually is better tolerated. A large percentage of patients withspondylolysis are asymptomatic.Progression of a spondylolisthesis alsomay occur without symptoms. 21. Degenerative spondylolisthesis The pain begins insidiously and may beachy in character. Pain is located in thelow back and posterior thighs. Neurogenic claudication may be presentas well, with lower extremity symptomsbeing made worse with activity and betterwith rest. Symptoms are often chronic andprogressive, although patients mayexperience periods of remission. 22. Dysplastic spondylolisthesis: Symptomspresent much like isthmicspondylolisthesis, but neurologic compromiseis more likely. Traumatic spondylolisthesis Patients present with acute pain associated withtrauma. If a slip is severe enough, cauda equinacompression may occur and present with classicsymptoms including bowel and bladderdysfunction, radicular symptoms, or neurogenicclaudication. Pathologic spondylolisthesis: Symptoms maybe insidious in onset and associated withradicular pain/claudication. 23. Physical Findings Isthmic spondylolisthesis Hamstring tightness is observed almostuniversally, even in low-gradespondylolisthesis. Lumbar spasm may be present. A palpable step-off is noted with slips equalto or greater than grade 2. With higher degrees of spondylolisthesis, anincreased lumbosacral kyphosis is seen(50% or greater) along with a compensatorythoracolumbar lordosis. Truncal shorteningmay be present. With severe slips, the ribcage may rest on the iliac crest. 24. Dermatomal weakness may be present ifa radiculopathy or an element of stenosisis present. A waddling gait may be noted secondaryto hamstring tightness producing ashortened stride length. If spondylolisthesis is not present,spondylolysis presents with paraspinalspasm, pain provocation with lumbarspine extension, and tight hamstrings. 25. Degenerative spondylolisthesis These patients present with lessprominent physical findings. Pain often isprovoked with lumbar spine extension. If lumbar stenosis is present, then reflexesmay be diminished. Radicular findingsalso may be present. 26. Congenital/dysplastic spondylolisthesis:Physical findings are similar to those described above for isthmic spondylolisthesis. Traumatic and pathologicspondylolisthesis These patients also present with similar findings. A good neurologic evaluation is important. 27. Causes A genetic predisposition to isthmicspondylolisthesis is believed to be linked withpatients having a thin pars or subtlehypoplastic facet joints. Family members havea reported incidence of 28-69%. Activities requiring lumbar extension stressincrease the risk. Patients with spina bifidaocculta are known to have a higheroccurrence. 28. Degenerative spondylolisthesis is caused byfacet degeneration accompanied by diskdegeneration most commonly at the level ofL4-L5. Some studies identify sagittallyoriented facets as more prone to arthriticchange. Congenital spondylolisthesis is due todysplastic sacral or lower lumbar segments.Dysplastic facets or abnormal orientation ofthe facet joints are the cause forspondylolisthesis. 29. Traumatic spondylolisthesis is rare. In theory,severe hyperextension stress placed on thepars could produce fracture and instability.One should keep in mind that hyperflexion-distraction forces can cause facet dislocationand spondylolisthesis. Pathologic spondylolisthesis can occur as aresult of any bone lesion that might weakenthe posterior elements. Generalized skeletaldiseases including osteomalacia, syphiliticdisease, and Von Recklinghausen diseaseare some reported causes. Bony destructivelesions, including tumor or infection, are otherpotential causes. 30. Laboratory Studies Laboratory studies do not help indiagnosing spondylolyticspondylolisthesis. Workup isradiographic in nature. 31. Imaging Studies Radiography Initial workup includes anteroposterior, lateral(done while standing), and spot view radiographsof the lumbar spine and lumbosacral junction. Oblique views may provide additional informationbut are not obligatory. Flexion/extension views increase the sensitivityof radiographic studies and give the cliniciansome idea of the degree of instability that may bepresent. Percentage of slip and slip angle (calculated bymeasuring the angle formed by a line drawn fromsuperior endplate inferiorly and the inferiorendplate at the segment of involvement) areclinically valuable. 32. Radiographic studies allowvisualization and grading ofspondylolisthesis but may not alwaysreveal the presence of an isolatedspondylolysis (withoutspondylolisthesis). The Scottie dog whose neck isbroken can be seen on the obliquefilms when there is a classicspondylolysis. 33. Scottie Dog 34. Lumbar obliqueradiograph showingthe "Scottie Dog." Apars defect is seenat L5. 35. Diagram in theobliqueprojection showsthe componentsof the vertebraethat result in theappearance of aScottie dog witha collar. 36. Bone scan Bone scan with single-photon emissioncomputed tomography (SPECT) imaging ishelpful and often helps to directmanagement. If the bone scan is positive, then the lesion ismetabolically active. The physician mayconsider bracing, since healing is still inprogress. A cold scan in the context of documentedspondylolysis indicates that healing is 37. Bone scan withsingle-photonemissioncomputedtomography(SPECT)imagingshowing acutespondylolysis 38. Computed tomography (CT) scan[13] CT scan performed with 1 mmsections, including coronal and sagittalreconstructions, allows for better visualizationof the spondylolytic defect. CT scan not only documents the presenceand severity of spondylolysis, but it can helprule out more serious causes for a positivebone scan. Myelogram/CT studies are helpful indelineating the severity of central stenosis.Nerve root cut-off often is observed in the 39. Magnetic resonance imaging (MRI) MRI may visualize edema in the marrowaround the sight of an acute spondylolyticdefect. MRI also is helpful in identifying thepresence of nerve root compression as aresult of foraminal or central canalstenosis. 40. Other Tests Electromyography may provide 1more modality for identifying aconcomitant radiculopathy orpolyradiculopathy (ie, stenosis), whichmay be present as a result ofspondylolisthesis. 41. Rehabilitation Program 42. Physical Therapy Most patients with low-grade isthmicspondylolisthesis and degenerativespondylolisthesis can be treatedconservatively. If an isthmic lesion is acute, the patientshould be restricted from provocativeactivities or sports until they areasymptomatic. Physical therapy is an integral part of thepatients rehabilitation process. The mostaccepted protocol includes activity andexercise that reduces extension stress. 43. The goals of exercise are to improve abdominalstrength and increase flexibility. Since tight hamstrings are almost always part ofthe clinical picture, appropriate hamstringstretching is important. Instruction in pelvic tilt exercises may helpreduce any postural component causingincreased lumbar lordosis. Myofascial release may play a role as well inreducing pain from the surrounding soft tissues. 44. If conservative treatment is indicatedfor congenital spondylolisthesis, theabove principles apply. Adequate work up must be completedfor pathologic causes ofspondylolisthesis prior to treating withconservative means. Traumatic spondylolisthesis mostoften requires surgical stabilization. 45. Surgical Intervention Surgical treatment is indicated when any typeof spondylolisthesis is accompanied by aneurologic deficit. Persistent disabling back pain afterconservative management may beconsidered an indication. High-grade slips (greater than 50%) morecommonly require surgical intervention. Traumatic spondylolisthesis is rare but almostalways requires surgical stabilization. 46. Surgery Surgery is used when the slip is severe andwhen symptoms are not relieved with nonsurgicaltreatments. Symptoms that cause an abnormal walkingpattern, changes in bowel or bladder function, orsteady worsening in nerve function requiresurgery. Deterioration of symptoms is common in patientswith a history of significant neurologic symptomswho dont have surgery to correct the problem. If a reasonable trial of conservative care (threemonths or more) does not improve things and/orif quality of life is significantly reduced, thensurgery may be the next best solution. 47. The main types of surgery forspondylolisthesis include:laminectomy (decompression)posterior fusion with or without instrumentationposterior lumbar interbody fusion 48. Laminectomy When the vertebra slips forward, the nearbynerves that exit the spine can become pinched orirritated. In addition, the size of the spinal canal in theproblem area shrinks, placing pressure on thenerves inside the canal. To fix this, the lamina ofthe bony ring is removed to ease pressure on thenerves. The procedure to remove the lamina and releasepressure on the nerves is called laminectomy. Decompression alone is usually not advised.Studies show much better results when theoperation is combined with a fusion of theinvolved vertebrae. 49. Laminectomy 50. Posterior Fusion withInstrumentation A spinal fusion is normally doneimmediately after laminectomy forspondylolisthesis. The fusion procedure is designed to fusethe two vertebrae into one bone and stopthe slippage from worsening. The fusion is used to lock the vertebraein place and stop movement between thevertebrae, easing mechanical pain. When combined with laminectomysurgery (mentioned earlier), fusion helpsrelieve nerve compression. 51. In this procedure, the surgeon lays small grafts of boneover the back of the problem vertebrae. Sometimesfusion is done just with bone graft material. This is afusion without fixation (non-instrumentation). Instrumentation is the use of metal plates or screws tostabilize the segment during healing. Most surgeonscombine fusion with instrumentation to prevent the twovertebrae from moving. This protects the graft so it canheal better and faster. Outcomes are improved when decompression iscombined with fusion (compared with decompressionalone). Fusion and functional improvement are evenbetter when spinal instrumentation is used. There are fewer long-term problems with pain andpseudoarthrosis. 52. Posterior Lumbar InterbodyFusion When fusion surgery is needed for mild spondylolisthesis (upto 50 percent slippage), posterior lumbar interbody fusionmay be considered. In this procedure, the problem vertebraeare fused from the anterior (front) and posterior (back). Combining fusion of both portions of the spine increases thefusion surface area and improves the fusion rate. Thesurgeon works from the back of the spine and removes thedisc between the problem vertebrae. Bone graft material isinserted from the back of the spine into the space betweenthe two vertebrae where the disc was removed (the interbodyspace). The graft may be held in place with a special fusion cage thatspreads and holds the vertebrae apart. Surgeons usuallyapply some form of instrumentation (described above) on theback of the vertebrae. In some cases, additional strips of bone graft are placedalong the back surfaces of the vertebrae to be fused. Thisincreases the mechanical strength of the spine. 53. Fusion with Biologics New materials for fusion are being developed and tested.For example, bone morphogenetic proteins (BMP) mixedwith bone graft in a putty is under investigation. Thissubstance may help reduce the need for instrumentationwith fusion. BMP helps promote faster and more bone growth in theunstable spinal segment. Studies of safety andeffectiveness of this material have been very favorable sofar. Without the need to harvest bone graft and placeinstrumentation, surgical time is much less with BMP putty.And the fusion rate is much higher with BMP alonecompared with fusion alone or fusion with fixation. 54. Motion-SparingTechnologies The Food and Drug Administration (FDA) is reviewingthe use of devices inserted without invasive surgery tolimit vertebral motion. For example, a special titaniumimplant has been designed to fit between the spinousprocesses of the vertebrae in lower back. These motion-sparing devices are currently used withpatients who have spinal stenosis (narrowing of thespinal canal or foramen). With spondylolisthesis, the goal is to reduce the load onthe disc and facets while increasing the space insidethe spinal canal and foramen, thus relieving symptoms.The vertebral segment is stabilized enough to preventfurther progression of the spondylolisthesis. 55. SPONDYLOLYSTHESIS 56. Other Treatment Bracing for acute isthmic spondylolysis/spondylolisthesis iscontroversial, but it has been shown in some studies to reducesymptoms and to facilitate healing. Most sources discuss use of a thoracolumbosacral spinalorthosis or modified Boston Brace for low-grade slips or forisolated spondylolytic lesions (without spondylolisthesis). Some sources advocate more extensive bracing with inclusionof most of the thorax (to the nipple line) and the thighs.Recommend use of the device for 3-6 months. Steroid injections for pars pain have been advocated by somephysicians. Epidural steroid injections may help radicular pain orneurogenic claudication. 57. Treatment for degenerativespondylolisthesis may includebracing, facet or epidural steroidinjections, along with the abovementioned physical therapy approach. 58. Medication The goal of medication in care ofspondylolysis or spondylolisthesis ofany type is to mitigate pain. NSAIDs are used most commonlywhile narcotic analgesics are used forbreakthrough pain. 59. Further Outpatient Care Because risk of progression exists inyounger patients with isthmic or congenitalspondylolisthesis, obtain serial radiographson a semiannual basis to rule out thepossibility of progression if symptoms arepersistent. 60. Inpatient & OutpatientMedications Anti-inflammatories and other analgesicsare the only medications used in the care ofpatients with spondylolysis orspondylolisthesis. 61. Deterrence Prevention of isthmic spondylolisthesismay be difficult in athletes who mustperform repetitive activities requiringhyperextension.The best prevention is to avoidrepetitive hyperextension if at allpossible, since this activity appears toplace athletes at the greatest risk. 62. Complications The most common complication ofspondylolisthesis of any type is nerve rootimpingement/radiculopathy at the level ofspondylolisthesis. Spinal stenosis and cauda equina syndromemay occur when a significant slip hasoccurred. Disk degeneration occurs at the level of thespondylolisthesis faster than at other levels ofthe spine, increasing the risk of diskogeniclow back pain. 63. Nonsurgical Rehabilitation Back pain associated with spondylolisthesis will graduallyimprove in up to one-third of all patients. Slippage of onevertebra over the other does not increase in this group.Worsening of symptoms is not expected in patients whodont have neurologic symptoms at the time of diagnosis. Nonsurgical treatment for spondylolisthesis commonlyinvolves physical therapy a few times each week for four tosix weeks. In some cases, patients may need a fewadditional weeks of care. The first goal of treatment is to control symptoms. Physiotherapist works with patient to find positions andmovements that ease pain. Treatments ofheat, cold, ultrasound, and electrical stimulation may beused to calm pain and muscle spasm. Patients are shown how to stretch tight muscles, especiallythe hamstring muscles. 64. As patients recover, they gradually advance in a seriesof strengthening exercises for the abdominal and lowback muscles. Working these core muscles helpspatients move easier and lessens the chances of futurepain and problems. A primary purpose of therapy is to help you learn how totake care of symptoms and prevent future problems. Patient is given a home program of exercises tocontinue improving flexibility, posture, endurance, andlow back and abdominal strength. The therapist will alsodescribe strategies that can be used if symptoms flareup. 65. Rehabilitation After Surgery Rehabilitation after surgery is more complex. Patientswho have surgery for spondylolisthesis usually stay inthe hospital for a few days afterward. Some surgeons require patients to wear a rigid brace orcast for up to four months after fusion surgery forspondylolisthesis. Patients whove had fusion surgeryfor a severe slip may also be required to stay off theirfeet for four months. After lumbar fusion surgery forspondylolisthesis, patients must normally wait fourmonths before beginning a rehabilitation program. Thisdelay is needed to give the fusion a chance to starthealing. Patients typically need to attend therapysessions for six to eight weeks and should expect fullrecovery to take at least 12 months. 66. Ideally, patients are able to return to theirprevious activities. However, some patientsmay need to modify or discontinue certainactivities to avoid future problems. The therapist will continue to be a resourcefor patient. But patient will be in charge ofdoing exercises as part of an ongoing homeprogram. 67. Prognosis In general, patients with grade 1 or grade 2 isthmic slips doquite well with conservative management. Patients mayreturn to play once they are asymptomatic. A flexion-based home exercise protocol is vital. Overall long-term outcome is quite favorable, specifically with lowergrades of listhesis not accompanied by neurologicimpairment. Higher grades of isthmic spondylolisthesis have a variableprognosis with regard to persistent low back pain. Surgical intervention does provide nice improvement inclaudication or radicular symptoms. Diskogenic pain may produce more persistent lower lumbardiscomfort. 68. Patients with degenerative spondylolisthesis seemto have persistent waxing and waning painoriginating from the facet joints. Surgical decompression for neurologic compromisehas a high rate of success in relieving lowerextremity symptoms. 69. Patient Education Athletes involved in higher risk sports should beeducated about the risk of developing aspondylolysis. Instruction regarding an appropriate home exerciseprogram, including a flexion-based spine exerciseprotocol and hamstring stretching, should be a partof treatment. 70. Thanks foryour attention