Upload
sal-lie
View
223
Download
3
Embed Size (px)
Citation preview
7/28/2019 Spondylolisthesis and PLIF.pdf
1/107
Inside Me..
Spondylolysis and Spondylolisthesis
What are spondylolysis and spondylolisthesis?
Your lower back is called your lumbar spine. It is made up of five bones called
lumbar vertebrae. The vertebrae have two major parts, a solid part called the
body and a bony ring through which the lower part of the spinal cord and
nerves travel. Between the bodies of the vertebrae is shock absorbing
material called disks. Part of the ring of each vertebra touches the vertebra
above it and the vertebra below it.
Spondylolysis is a condition where there is a break in one or both sides of the
ring of a vertebra. Spondylolisthesis is a condition in which a break in the ring
allows the body of the vertebra to slip forward. Spondylolysis and
spondylolisthesis most commonly occur at the fourth or fifth lumbar vertebrae.
These conditions are also called stress fractures.
How does it occur?
Spondylolysis and spondylolisthesis result from repetitive extension of the
back (bending backward). This weakens the rings of the lumbar vertebrae,
eventually leading to a break (fracture) in a ring. Less commonly, theseconditions may result from an injury to the back. Some people may be born
with weak vertebral rings.
Gymnasts, dancers, and football players are most commonly diagnosed with
these conditions.
http://media.summitmedicalgroup.com/media/db/relayhealth-images/spondyl_2.jpg7/28/2019 Spondylolisthesis and PLIF.pdf
2/107
Inside Me..What are the symptoms?
You may have low back pain or spasms, or you may have no symptoms at all.
You may have pain all the time or only from time to time. Spondylolysis or
spondylolisthesis usually do not damage the nerves.
How is it diagnosed?
Your healthcare provider will examine your back and look for tenderness
along your vertebrae or spasm in the muscles next to your vertebrae. You will
have an X-ray to check for a break in the ring of a vertebra or slippage of a
vertebra. You may have a bone scan, CT scan, or an MRI.
How is it treated?
If the break is new and your provider thinks that the bones can heal without
surgery, you may need to wear a brace for 1 to 3 months. Severe cases of
spondylolisthesis may require surgery.
To treat this condition:
Put an ice pack, gel pack, or package of frozen vegetables, wrapped ina cloth on the area every 3 to 4 hours, for up to 20 minutes at a time.
Take an anti-inflammatory medicine such as ibuprofen, or othermedicine as directed by your provider. Nonsteroidal anti-inflammatorymedicines (NSAIDs) may cause stomach bleeding and other problems.
These risks increase with age. Read the label and take as directed.Unless recommended by your healthcare provider, do not take for morethan 10 days.
When can I return to my normal activities?
Everyone recovers from an injury at a different rate. Return to your activities
depends on how soon your back recovers, not by how many days or weeks it
has been since you started having symptoms. In general, the longer you have
symptoms before you start treatment, the longer it will take to get better. Thegoal is to return to your normal activities as soon as is safely possible. If you
return too soon you may worsen your injury.
It is important that you fully recover from your back pain before you return to
any strenuous activity. You must be able to have the same range of motion
that you had before your injury. You must be able
7/28/2019 Spondylolisthesis and PLIF.pdf
3/107
Inside Me..to walk and twist without pain.
How can I prevent these conditions?
You can best prevent these conditions by having strong back and abdominal
muscles and by not being overweight. To help prevent these injuries, do backexercises and avoid activities that force the back to extend, such as tackling in
football.
Spondylolisthesis
Medical Codes
ICD-9-CM:738.4, 756.12
Definition
Reed Group
Spondylolisthesis describes a condition of a forward slippage of one vertebra over another, which may or
may not be associated with demonstrable instability. The vertebrae of the spine are stacked one on top of
the other and held in place by ligaments, muscles, joints, and discs. The healthy spine is flexible and
moves in many planes, including flexion, extension, and rotation.
There are five types of spondylolisthesis (congenital/dysplastic, isthmic, degenerative, traumatic, and
pathological). Congenital or dysplastic spondylolisthesis is a defect in the posterior part of L5 or S1, and
7/28/2019 Spondylolisthesis and PLIF.pdf
4/107
Inside Me..the abnormal orientation of the bones permits forward slippage of one vertebra on another. It is a rare
condition and is frequently associated with neurologic involvement. The severity of subluxation is graded
as follows: Grade I is 0% to 25%, Grade II is 26% to 50%, Grade III is 51% to 75%, and Grade IV is more
than 75% of vertebral slippage as evidenced onx-ray(Devereaux).
The most common type of spondylolisthesis is isthmic or spondylolytic spondylolisthesis.Spondylolysis,
which is generally a stress fracture in the posterior part of the vertebra, called the pars interarticularis, is
present in this type of spondylolisthesis. Spondylolysis is the most common cause of spondylolisthesis.
Isthmic spondylolisthesis most commonly occurs in the lumbar region, at the level between the fifth
lumbar vertebra and the first sacral vertebra (L5-S1 level).
Degenerative spondylolisthesis is an acquired condition related to chronic degenerative disc disease and
the associated changes that may lead to segmental instability The pars interarticularis is not affected in
degenerative spondylolisthesis. The degeneration of intervertebral discs (degenerative disc disease)
results in narrowing of the disc space, which allows the supporting structures to become lax and can lead
to segmental instability, most common at L4-L5. The facet joints are also affected: the result is persistent
slippage (subluxation) of the facet joints with decreased resistance to forward slippage of one vertebra on
another. The slippage is limited by the structures at the back of the spine that are still intact. Degenerativespondylolisthesis is more common in women and occurs most often at L4-5.
Spondylolisthesis can also be caused by atraumaticfracture (traumatic spondylolisthesis) of the posterior
elements of the vertebra, by destruction of the posterior aspect of the spine throughtumor,infection, or
osteoporosis (pathological spondylolisthesis), and by spinal surgery (postsurgical spondylolisthesis).
Risk: Individuals at risk for spondylolisthesis include those who have spondylolysis and those with an
abnormal forwardcurvature of the lumbar spine(lordosis). The risk is increased in individuals who engage
in contact sports (football, volleyball, or soccer), certain kinds of gymnastics, or weight lifting. Individuals
with radiographic osteoarthritis and postmenopausal women with osteoporosis are also at greater risk of
developing spondylolisthesis.
Spondylolytic (isthmic) spondylolisthesis is most common in white males (Froese). Women are more likely
to progress to a higher degree of slippage than men (Froese).
Incidence and Prevalence:
Degenerative spondylolisthesis is three times more common in blacks than whites and usually occurs
after the age of 40 (Irani). It is more common in females than males by 5 to 1 (Froese).
Congenital spondylolisthesis is twice as common in females as in males, and symptom onset is usually
during adolescence (Irani).
In the US, the incidence of isthmic spondylolysis is 6% to 7%, with 11.3% of
http://www.mdguidelines.com/x-rayhttp://www.mdguidelines.com/x-rayhttp://www.mdguidelines.com/x-rayhttp://www.mdguidelines.com/spondylolysis-lumbar-regionhttp://www.mdguidelines.com/spondylolysis-lumbar-regionhttp://www.mdguidelines.com/spondylolysis-lumbar-regionhttp://www.mdguidelines.com/traumahttp://www.mdguidelines.com/traumahttp://www.mdguidelines.com/traumahttp://www.mdguidelines.com/bone-tumors-benign-and-malignanthttp://www.mdguidelines.com/bone-tumors-benign-and-malignanthttp://www.mdguidelines.com/bone-tumors-benign-and-malignanthttp://www.mdguidelines.com/infectionhttp://www.mdguidelines.com/infectionhttp://www.mdguidelines.com/infectionhttp://www.mdguidelines.com/curvature-of-the-spine-acquiredhttp://www.mdguidelines.com/curvature-of-the-spine-acquiredhttp://www.mdguidelines.com/curvature-of-the-spine-acquiredhttp://www.mdguidelines.com/curvature-of-the-spine-acquiredhttp://www.mdguidelines.com/infectionhttp://www.mdguidelines.com/bone-tumors-benign-and-malignanthttp://www.mdguidelines.com/traumahttp://www.mdguidelines.com/spondylolysis-lumbar-regionhttp://www.mdguidelines.com/x-ray7/28/2019 Spondylolisthesis and PLIF.pdf
5/107
Inside Me..
cases occurring at the L4-L5 level, and 82% occurring at the L5-S1 level (Froese).
The prevalence of degenerative spondylolisthesis is 5.8% in men and 9.1% in women (Vokshoor).
The prevalence of spondylolisthesis in osteoporotic women is 28.4%, with 12% occurring at the L3-L4
level, 73% occurring at the L4-L5 level, and 28% occurring at the L5-S1 level (Nizard).
The incidence of postoperative spondylolisthesis is 11% to 14% at the vertebral level above thefused
segments
Source:
(Nizard).
Medical Disability Advisor
Diagnosis
History: Low back pain is the most common presenting symptom. Individuals with spondylolisthesis may
also present with lordosis, localized tenderness over the spine just above the pelvis, pain in the thighs or
buttocks, tightness in the hamstrings, and back stiffness. Isthmic spondylolisthesis may be an incidental
finding on imaging studies that becomes apparent during the evaluation of low back pain in adults, and
must be evaluated in the context of degenerative disc disease or other causes of low back pain.
Individuals with severe grades of slippage may not be able to walk normally, and stumble or drag their
feet instead. Neurologic signs often correlate with the degree of slippage. In describing pain, individuals
may report that it is aggravated when they rise out of a sitting position, walk up stairs or inclines, get in
and out of cars, and lean backward (extension). The pain is relieved at rest when lying flat with the knees
bent, or leaning forward (flexion).
Degenerative spondylolisthesis is generally seen in older patients, who may present with low back pain,
symptoms of neurogenic claudication (heaviness in the legs with walking that is alleviated by sitting),
radiculopathy, or a combination of those symptoms.
http://www.mdguidelines.com/arthrodesishttp://www.mdguidelines.com/arthrodesishttp://www.mdguidelines.com/arthrodesishttp://www.mdguidelines.com/arthrodesishttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/arthrodesishttp://www.mdguidelines.com/arthrodesis7/28/2019 Spondylolisthesis and PLIF.pdf
6/107
Inside Me..
Physical exam:
Tests:
A complete examination of the lumbar spine, including musculoskeletal and neurological
components, is performed to rule out any other underlying pathology and to determine the extent of nerve
involvement. Findings of the exam may reveal decreased sensation and tendon reflexes and weakness of
lower leg muscles. Examination of the spine by manual touching and massaging of the areas of concern
(palpation) may reveal a step-off in higher-grade slippage. Findings are also likely to reveal a limited
range of motion of the spine; increased pain when leaning backward; relief of pain when leaning forward;
clumsy, swayed walking (waddling gait); and tight hamstrings.
Spondylolisthesis is usually identified by plain x-rays (radiographs). Additional studies such
asMRIandCTscans will routinely be performed to evaluate for nerve involvement, degenerative disc
disease, disk herniation, spondylosis, and spinal stenosis. The amount and percentage of slippage should
be measured on a standing lateral x-ray. A change in the percentage of slippage when the individual
bends forward or leans backward is an indication of dynamic instability. This means that the amount of
vertebral slippage changes with spinal motion.
In cases of spondylolysis, the diagnosis may not be evident in plain x-rays. Oblique plain films may be
helpful. Both CT and MRI can define damage to the pars interarticularis (pars defect) and nerve root
impingement, although CT may be better for the purposes of identifying the bony defect, and MRI may
reveal more detail about neurologic involvement. MRI also helps define the status of the disc at the
impaired level and the level adjacent to the slip.
If the spondylolysis is believed to be recent, a bone scan may be useful to confirm or exclude an acute
fracture.Electromyography(EMG) andnerve conduction studies
Source:
check nerve function.
Medical Disability Advisor
Treatment
Conservative treatment for spondylolisthesis includes rest (not excessive), activity modification (to
minimize offending activity),physical therapy(to strengthen trunk muscles, especially the abdominals,
and to stretch the hamstrings), and analgesics. Corsets or braces are also prescribed when necessary to
minimize motion across the area of the slippage and to decrease pain.
http://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/magnetic-resonance-imaginghttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/electromyographyhttp://www.mdguidelines.com/electromyographyhttp://www.mdguidelines.com/electromyographyhttp://www.mdguidelines.com/nerve-conduction-studieshttp://www.mdguidelines.com/nerve-conduction-studieshttp://www.mdguidelines.com/nerve-conduction-studieshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/physical-therapyhttp://www.mdguidelines.com/physical-therapyhttp://www.mdguidelines.com/physical-therapyhttp://www.mdguidelines.com/physical-therapyhttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/nerve-conduction-studieshttp://www.mdguidelines.com/electromyographyhttp://www.mdguidelines.com/computerized-tomographyhttp://www.mdguidelines.com/magnetic-resonance-imaging7/28/2019 Spondylolisthesis and PLIF.pdf
7/107
Inside Me..
Surgical intervention is considered when conservative therapy fails, pain becomes disabling, or a
progressive neurological deficit occurs. Age is not a contraindication to surgery. Many elderly individuals
seem to benefit a great deal from surgical intervention. The primary surgical procedure for treating
spondylolisthesis isspinal fusion, in which 2 or more vertebrae are united by bone graft (with or without
instrumentation) that heals to prevent further slippage of the vertebrae. Internal fixation devices, usually
pedicle screws with or without an underbody fusion cage, may be used to enhance stability and thus the
chances of successful fusion. Posterior lumbar interbody fusion (PLIF) enjoys a high success rate for
Grades I and II spondylolisthesis, with nearly 100% of individuals experiencing a solid fusion (Brislin;
Vokshoor). More severe grades of slippage may require both anterior and posterior fusion. If there is
neurologic deficit, a decompression may be performed in addition to the fusion. In decompression for
spondylolisthesis, the surgeon removes bone and ligamentous tissue compressing the lumbar nerve
roots.
Source:Medical Disability Advisor
Prognosis
In young patients with spondylolisthesis, surgical fusion with or without decompression may be curative,
and no further intervention may be required. Individuals who have sustained an acutefracturewith
minimal slippage may completely recover if the fracture heals. Individuals with progressive degenerative
changes may continue to have intermittent symptoms. Surgery (fusion, decompression) can be curative,
but some individuals may experience only partial or intermittent relief.
The risk of degenerative spondylolisthesis increases with age, and progression of vertebral slippage
occurs in 30% of individuals (Nizard). If vertebral slippage progresses, the neural foramen may narrow,
causingnerve compressionorsciatica
Source:
that may require surgical decompression. Surgical outcomes are
improved when fusion is performed in addition to decompression (Sengupta).
Medical Disability Advisor
Rehabilitation
Rehabilitationfor spondylolisthesis varies depending on the severity of the disease and the symptoms. If
the spinal cord is compromised, seeSpinal Cord Injury. If surgery is considered, the literature suggests
that a 6-week period of rehabilitation treatment should be undertaken prior to surgical intervention.
Rehabilitation includes modalities such as heat and cold to control pain (Braddom). Once pain is
controlled, general stretching and strengthening exercises of the trunk are indicated and progressed as
tolerated. Therapists teach a home exercise program to complement the supervised rehabilitation.
Individuals should be advised to continue these exercises on a regular basis, including after discharge
from therapy, regardless of symptoms (Matsunaga). Instruction in proper posture and body mechanics for
all activities of daily living should be reviewed.
http://www.mdguidelines.com/spinal-fusionhttp://www.mdguidelines.com/spinal-fusionhttp://www.mdguidelines.com/spinal-fusionhttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/fracturehttp://www.mdguidelines.com/fracturehttp://www.mdguidelines.com/fracturehttp://www.mdguidelines.com/neuralgia-neuritis-and-radiculitishttp://www.mdguidelines.com/neuralgia-neuritis-and-radiculitishttp://www.mdguidelines.com/neuralgia-neuritis-and-radiculitishttp://www.mdguidelines.com/sciaticahttp://www.mdguidelines.com/sciaticahttp://www.mdguidelines.com/sciaticahttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/rehabilitation-therapyhttp://www.mdguidelines.com/rehabilitation-therapyhttp://www.mdguidelines.com/spinal-cord-injuryhttp://www.mdguidelines.com/spinal-cord-injuryhttp://www.mdguidelines.com/spinal-cord-injuryhttp://www.mdguidelines.com/spinal-cord-injuryhttp://www.mdguidelines.com/rehabilitation-therapyhttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/sciaticahttp://www.mdguidelines.com/neuralgia-neuritis-and-radiculitishttp://www.mdguidelines.com/fracturehttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/spinal-fusion7/28/2019 Spondylolisthesis and PLIF.pdf
8/107
Inside Me..If pain is severe seeLow Back Painfor additional guidelines.
If surgery is indicated for severe and progressive spondylolisthesis, a postoperative protocol must be
followed (Moller). This will include ambulation and transfer training, possibly with an orthosis to stabilize
the trunk. Following surgery, some individuals may benefit fromoccupational therapy
FREQUENCY OF REHABILITATION VISITS
to assess the need
for devices to promote independence in daily activities. After several weeks, general low back stretching,
strengthening and stabilization exercises can be initiated and progressed as indicated by the treating
physician.
Whether managed operatively or nonoperatively, an ergonomic assessment may be beneficial prior to
return to work.
Nonsurgical
Specialist Spondylolisthesis
Physical Therapist Up to 15 visits within 6 weeks
Surgical
Specialist Spondylolisthesis
Physical Therapist Up to 6 visits within 6 weeks
Note on Surgical Guidelines: Rehab usually begins after tissue healing, about 6 to 8 weeks after surgery.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It
provides a framework based on the duration of tissue healing time and standard clinical practice.
Source:Medical Disability Advisor
Complications
Progression of the slippage with increased pressure ortractionon the spinal nerve roots may complicate
treatment.
For individuals requiring surgery to stabilize the spondylolisthesis, complications includenerve root
injury(less than 1%), cerebrospinal fluid leak (2% to 10%), fusion failure (5% to 25%), and infection and
hemorrhage from surgery (1% to 5%). Among individuals who smoke, thenonunionrate of lumbar fusion
is up to 50% (Vokshoor).
http://www.mdguidelines.com/low-back-painhttp://www.mdguidelines.com/low-back-painhttp://www.mdguidelines.com/low-back-painhttp://www.mdguidelines.com/occupational-therapyhttp://www.mdguidelines.com/occupational-therapyhttp://www.mdguidelines.com/occupational-therapyhttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/tractionhttp://www.mdguidelines.com/tractionhttp://www.mdguidelines.com/tractionhttp://www.mdguidelines.com/nerve-injuryhttp://www.mdguidelines.com/nerve-injuryhttp://www.mdguidelines.com/nerve-injuryhttp://www.mdguidelines.com/nerve-injuryhttp://www.mdguidelines.com/malunion-and-nonunion-of-fracturehttp://www.mdguidelines.com/malunion-and-nonunion-of-fracturehttp://www.mdguidelines.com/malunion-and-nonunion-of-fracturehttp://www.mdguidelines.com/malunion-and-nonunion-of-fracturehttp://www.mdguidelines.com/nerve-injuryhttp://www.mdguidelines.com/nerve-injuryhttp://www.mdguidelines.com/tractionhttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/occupational-therapyhttp://www.mdguidelines.com/low-back-pain7/28/2019 Spondylolisthesis and PLIF.pdf
9/107
Inside Me..Source:Medical Disability Advisor
Return to Work (Restrictions / Accommodations)
Work restrictions may include the elimination of overhead work that involves hyperextension of the back.
The individual may also be restricted in performing unassisted heavy lifting, repetitive bending, or pushing
heavy objects. Some individuals may not be able to perform activities that require twisting at the waist.
Use of a rigid corset (orthotic) may be needed to limit motion of the spine. Safety issues should be
evaluated, as well as drug-testing policies, since individuals may need to take pain medication.
Individuals with severe pain and hamstring spasm, individuals with Grade III or IV vertebral slippage, and
individuals who have had spinal fusion are generally restricted to sedentary, light, or moderate work.
Source:Medical Disability Advisor
Spondylolisthesis Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a condition of
thespinewhereby one of thevertebraslips forward or backward compared
to the next vertebra. Forward slippage of one vertebra on another is
referred to as anterolisthesis, while backward slippage is referred to as
retrolisthesis. Spondylolisthesis can lead to a deformity of the spine as well
as a narrowing of the spinal canal (centralspinal stenosis)
orcompression
What causes spondylolisthesis?
of the exiting nerve roots (foraminal stenosis).
There are five major types of lumbar spondylolisthesis.
1. Dysplastic spondylolisthesis: Dysplastic spondylolisthesis iscaused by a defect in the formation of part of the vertebra called the
facet that allows it to slip forward. This is a condition that a patient is
born with (congenital).
http://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topicshttp://www.medicinenet.com/script/main/art.asp?articlekey=5529http://www.medicinenet.com/script/main/art.asp?articlekey=5529http://www.medicinenet.com/script/main/art.asp?articlekey=5986http://www.medicinenet.com/script/main/art.asp?articlekey=5986http://www.medicinenet.com/script/main/art.asp?articlekey=5986http://www.medicinenet.com/script/main/art.asp?articlekey=84876http://www.medicinenet.com/script/main/art.asp?articlekey=84876http://www.medicinenet.com/script/main/art.asp?articlekey=84876http://www.medicinenet.com/script/main/art.asp?articlekey=39885http://www.medicinenet.com/script/main/art.asp?articlekey=39885http://www.medicinenet.com/script/main/art.asp?articlekey=39885http://www.medicinenet.com/script/main/art.asp?articlekey=15599http://www.medicinenet.com/script/main/art.asp?articlekey=15599http://www.medicinenet.com/script/main/art.asp?articlekey=15599http://www.medicinenet.com/script/main/art.asp?articlekey=15599http://www.medicinenet.com/script/main/art.asp?articlekey=39885http://www.medicinenet.com/script/main/art.asp?articlekey=84876http://www.medicinenet.com/script/main/art.asp?articlekey=5986http://www.medicinenet.com/script/main/art.asp?articlekey=5529http://www.mdguidelines.com/medical-topicshttp://www.mdguidelines.com/medical-topics7/28/2019 Spondylolisthesis and PLIF.pdf
10/107
Inside Me..
2. Isthmic spondylolisthesis: In Isthmic spondylolisthesis, there is a
defect in a portion of the vertebra called the pars interarticularis. If
there is a defect without a slip, the patient has spondylolysis. Isthmic
spondylolisthesis can be caused by repetitivetraumaand is more
common in athletes exposed to hyperextension motions including
gymnasts, and football linemen.
3. Degenerative spondylolisthesis: Degenerative spondylolisthesis
occurs due to arthritic changes in the joints of thevertebraedue
tocartilagedegeneration. Degenerative spondylolisthesis is more
common in older patients.
4. Traumatic spondylol isthesis: Traumatic spondylolisthesis is due to
direct trauma orinjuryto the vertebrae. This can be caused by
afractureof the pedicle,laminaor facet joints that allows the front
portion of the vertebra to slip forward with respect to the back portion
of the vertebra.
5. Pathologic spondylolis thesis: Pathologic spondylolisthesis is
caused by a defect in the bone caused by abnormal bone, such asfrom atumor.
What are the risk factors for spondylolisthesis?
Risk factors for spondylolisthesis include afamily historyof back problems.
Other risk factors include a history of repetitive trauma or hyperextension of
the lower back or lumbar spine. Athletes such as gymnasts, weight lifters,
and football linemen who have large forces applied to the spine during
extension are at greater risk for developing isthmic spondylolisthesis.
http://www.medicinenet.com/script/main/art.asp?articlekey=8171http://www.medicinenet.com/script/main/art.asp?articlekey=8171http://www.medicinenet.com/script/main/art.asp?articlekey=8171http://www.medicinenet.com/script/main/art.asp?articlekey=25924http://www.medicinenet.com/script/main/art.asp?articlekey=25924http://www.medicinenet.com/script/main/art.asp?articlekey=25924http://www.medicinenet.com/script/main/art.asp?articlekey=2644http://www.medicinenet.com/script/main/art.asp?articlekey=2644http://www.medicinenet.com/script/main/art.asp?articlekey=25495http://www.medicinenet.com/script/main/art.asp?articlekey=25495http://www.medicinenet.com/script/main/art.asp?articlekey=25495http://www.medicinenet.com/script/main/art.asp?articlekey=2035http://www.medicinenet.com/script/main/art.asp?articlekey=2035http://www.medicinenet.com/script/main/art.asp?articlekey=6208http://www.medicinenet.com/script/main/art.asp?articlekey=6208http://www.medicinenet.com/script/main/art.asp?articlekey=6208http://www.medicinenet.com/script/main/art.asp?articlekey=5863http://www.medicinenet.com/script/main/art.asp?articlekey=5863http://www.medicinenet.com/script/main/art.asp?articlekey=18321http://www.medicinenet.com/script/main/art.asp?articlekey=18321http://www.medicinenet.com/script/main/art.asp?articlekey=18321http://www.medicinenet.com/script/main/art.asp?articlekey=5863http://www.medicinenet.com/script/main/art.asp?articlekey=6208http://www.medicinenet.com/script/main/art.asp?articlekey=2035http://www.medicinenet.com/script/main/art.asp?articlekey=25495http://www.medicinenet.com/script/main/art.asp?articlekey=2644http://www.medicinenet.com/script/main/art.asp?articlekey=25924http://www.medicinenet.com/script/main/art.asp?articlekey=81717/28/2019 Spondylolisthesis and PLIF.pdf
11/107
Inside Me..
What are the symptoms of spondylolisthesis?Comment on
The most common symptom of spondylolisthesis islower back pain. This is
often worse afterexerciseespecially with extension of the lumbar spine.
Other symptoms include tightness of the hamstrings and decreasedrange
of motionof the lower back. Some patients can develop pain, numbness,
tingling orweaknessin the legs due tonerve compression. Severe
compression of the nerves can cause loss of control of bowel or bladder
function, orcauda equina syndrome.
How is spondylolisthesis diagnosed?
In most cases it is not possible to see visible signs of spondylolisthesis by
examining a patient. Patients typically have complaints of pain in the back
with intermittent pain to the legs. Spondylolisthesis can often cause muscle
spasms, or tightness in the hamstrings.
Spondylolisthesis is easily identified using plain radiographs. A lateral X-ray
(from the side) will show if one of the vertebra has slipped forward
compared to the adjacent vertebrae. Spondylolisthesis is graded according
the percentage of slip of the vertebra compared to the neighboring
vertebra.
1. Grade I is a slip of up to 25%,
2. grade II is between 26%-50%,
3. grade III is between 51%-75%,
http://www.medicinenet.com/script/main/art.asp?articlekey=289http://www.medicinenet.com/script/main/art.asp?articlekey=289http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=5208http://www.medicinenet.com/script/main/art.asp?articlekey=5208http://www.medicinenet.com/script/main/art.asp?articlekey=5208http://www.medicinenet.com/script/main/art.asp?articlekey=64119http://www.medicinenet.com/script/main/art.asp?articlekey=64119http://www.medicinenet.com/script/main/art.asp?articlekey=64119http://www.medicinenet.com/script/main/art.asp?articlekey=11745http://www.medicinenet.com/script/main/art.asp?articlekey=11745http://www.medicinenet.com/script/main/art.asp?articlekey=11745http://www.medicinenet.com/script/main/art.asp?articlekey=109762http://www.medicinenet.com/script/main/art.asp?articlekey=109762http://www.medicinenet.com/script/main/art.asp?articlekey=109762http://www.medicinenet.com/script/main/art.asp?articlekey=109762http://www.medicinenet.com/script/main/art.asp?articlekey=11745http://www.medicinenet.com/script/main/art.asp?articlekey=64119http://www.medicinenet.com/script/main/art.asp?articlekey=5208http://www.medicinenet.com/script/main/art.asp?articlekey=5208http://www.medicinenet.com/script/main/art.asp?articlekey=5208http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=2897/28/2019 Spondylolisthesis and PLIF.pdf
12/107
Inside Me..
4. grade IV is between 76% and 100%, and
5. Grade V, or spondyloptosis occurs when the vertebra has completely
fallen off the next vertebra.
If the patient has complaints of pain, numbness, tingling or weakness in the
legs, additional studies may be ordered. These symptoms could be caused
by stenosis or narrowing of the space for the nerve roots to the legs. ACT
scanorMRIscan can help identify compression of the nerves associated
with spondylolisthesis. Occasionally, aPET scancan help determine if the
bone at the site of the defect is active. This can play a role in treatmentoptions for spondylolisthesis as described below.
What is the treatment for spondylolisthesis
The initial treatment for spondylolisthesis is conservative and based on the
symptoms.
A short period of rest or avoiding activities such as lifting and bendingand athletics may help reduce symptoms.
Physical therapycan help to increase range of motion of the lumbar
spine and hamstrings as well as strengthen the coreabdominal
muscles.
Anti-inflammatory medications can help reduce pain by decreasingtheinflammationof the muscles and nerves.
Patients with pain, numbness and tingling in the legs may benefit
from anepidural steroid (cortisone) injection.
http://www.medicinenet.com/script/main/art.asp?articlekey=315http://www.medicinenet.com/script/main/art.asp?articlekey=315http://www.medicinenet.com/script/main/art.asp?articlekey=315http://www.medicinenet.com/script/main/art.asp?articlekey=315http://www.medicinenet.com/script/main/art.asp?articlekey=421http://www.medicinenet.com/script/main/art.asp?articlekey=421http://www.medicinenet.com/script/main/art.asp?articlekey=421http://www.medicinenet.com/script/main/art.asp?articlekey=11696http://www.medicinenet.com/script/main/art.asp?articlekey=11696http://www.medicinenet.com/script/main/art.asp?articlekey=11696http://www.medicinenet.com/script/main/art.asp?articlekey=11885http://www.medicinenet.com/script/main/art.asp?articlekey=11885http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=3979http://www.medicinenet.com/script/main/art.asp?articlekey=3979http://www.medicinenet.com/script/main/art.asp?articlekey=78805http://www.medicinenet.com/script/main/art.asp?articlekey=78805http://www.medicinenet.com/script/main/art.asp?articlekey=78805http://www.medicinenet.com/script/main/art.asp?articlekey=3979http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=2084http://www.medicinenet.com/script/main/art.asp?articlekey=11885http://www.medicinenet.com/script/main/art.asp?articlekey=11696http://www.medicinenet.com/script/main/art.asp?articlekey=421http://www.medicinenet.com/script/main/art.asp?articlekey=315http://www.medicinenet.com/script/main/art.asp?articlekey=315http://www.medicinenet.com/script/main/art.asp?articlekey=3157/28/2019 Spondylolisthesis and PLIF.pdf
13/107
Inside Me..
Patients with isthmic spondylolisthesis may benefit from a
hyperextension brace. This extends the lumbar spine bringing the two
portions of the bone at the defect closer together and may allow for
healing to occur.
For patients whose symptoms fail to improve with conservative treatment
surgery may be an option. The type of surgery is based on the type of
spondylolisthesis. Patients with isthmic spondylolisthesis may benefit from
a repair of the defective portion of the vertebra, or a pars repair. If an MRI
scan or PET scan shows that the bone is active at the site of the defect it is
more likely to heal with a pars repair. This involves removing any scar
tissue from the defect and placing some bone graft in the area followed by
placement of screws across the defect.
If there are symptoms in the legs the surgery may include a decompression
to create more room for the exiting nerve roots. This is often combined with
a fusion that may be performed either with or without screws to hold thebone together. In some cases the vertebrae are moved back to the normal
position prior to performing the fusion, and in others the vertebrae are
fused where they are after the slip. There is some increased risk of injury to
the nerve with moving the vertebra back to the normal position.
Can spondylolisthesis be prevented?
Spondylolisthesis cannot be completely prevented. Certain activities such
as gymnastics, weight-lifting and football are known to increase the stress
on the vertebrae and increase the risk of developing spondylolisthesis.
7/28/2019 Spondylolisthesis and PLIF.pdf
14/107
Inside Me..
What are the complications of spondylolisthesis?
Complications of spondylolisthesis includechronic painin the lower back or
legs, as well as numbness, tingling or weakness in the legs. Severe
compression of the nerve can cause problems with bowel or bladder
control, but this is very uncommon.
What is the outlook for spondylolisthesis?
The outlook for patients with spondylolisthesis is good. In most cases
patients respond well to a conservative treatment plan. For those with
continued severe symptoms, surgery can help alleviate the leg symptoms
by creating more space for the nerve roots. The back pain can be helpedthrough alumbar fusion.
Spondylolisthesis At A Glance
Spondylolisthesis is a forward or backward slippage of one vertebra
on an adjacent vertebra.
Causes of spondylolisthesis include trauma, degenerative, tumor, and
birth defects.
Symptoms of spondylolisthesis include lower back or leg pain,
hamstring tightness, and numbness and tingling in the legs.
Most people with spondylolisthesis can be treated conservatively,
without the need for surgery.
Patients who fail to improve with conservative treatment may be a
candidate for surgery.
http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=205027/28/2019 Spondylolisthesis and PLIF.pdf
15/107
Inside Me.. I was diagnosed in 1991 with Spondylolithesis at L5 S1. I was 16. At
that time, I tried the medications, physical therapy and back brace. After
2 years of pain and trying to be a normal teenage girl I made the
decision to have thespinal fusionsurgery in May 1993. For me, it wasone of the best decisions I ever could have made! I had the old style
surgery with the battlescarsto prove it. It was a week in the hospital, 12
weeks on bed rest, 18 months for the bone in my hip to grow back and
to this day my hip tells me when it is going to rain, but I would not trade
that! I have not had handicap parking since 1994. I do not take pain
medication. I do have regular massages which is all I need to keep the
remaining discomfort at bay. As my doctor put it, the surgery is not a
cure but a treatment option. He is retired now or I would be
recommending him to all of you. He gave me my life back. Don't give up
until you find the right treatment option for you.
I was diagnosed at age 12 due tolower back pain. Mine is the
congenital type. I finally knew it was time to do something at age 45
when I had horrific pain down my legs alternating with numbness. A
simple x-ray revealed that I no longer had a disk between L5 and S1.
After an anterior-posterior decompression and fusion, I live withchronicpain, but have a stable back. I am able toexerciseregularly and move
better than I have in years. Even though I take medication for pain
everyday, I am very happy with my result.
I am 49 and was diagnosed with spondylolethisis, anterior grade 4,
along with spinal stenosis, andbone spurs. I'm deteriorating; it has
causedscoliosisand I have now been diagnosed with neuropathy in my
left leg. I was hit by a car at age 4, which broke my pelvis in two places
and my left femur. I was in traction, a body cast, and had to learn to
walk all over again. My left leg is inches longer then my right. I was
never to run again and walked with a limp, yet ended up being a very
strong top athlete. I've had three kids, whom I played with and trained in
sports. I just stopped playing softball five
http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=87924http://www.medicinenet.com/script/main/art.asp?articlekey=43240http://www.medicinenet.com/script/main/art.asp?articlekey=43240http://www.medicinenet.com/script/main/art.asp?articlekey=43240http://www.medicinenet.com/script/main/art.asp?articlekey=289http://www.medicinenet.com/script/main/art.asp?articlekey=289http://www.medicinenet.com/script/main/art.asp?articlekey=289http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=98517http://www.medicinenet.com/script/main/art.asp?articlekey=98517http://www.medicinenet.com/script/main/art.asp?articlekey=98517http://www.medicinenet.com/script/main/art.asp?articlekey=10365http://www.medicinenet.com/script/main/art.asp?articlekey=10365http://www.medicinenet.com/script/main/art.asp?articlekey=10365http://www.medicinenet.com/script/main/art.asp?articlekey=10365http://www.medicinenet.com/script/main/art.asp?articlekey=98517http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=20502http://www.medicinenet.com/script/main/art.asp?articlekey=289http://www.medicinenet.com/script/main/art.asp?articlekey=43240http://www.medicinenet.com/script/main/art.asp?articlekey=879247/28/2019 Spondylolisthesis and PLIF.pdf
16/107
Inside Me..years ago. I also biked, hiked, adventured raced, and did so many
outdoor things. But eight months ago, all this came to an abrupt end. I
fell down some stairs, which really did some damage. When my X-rays
were read, the doctors discovered my condition. September 13th, 2012,began a very fast deterioration. The hip cramps at night keep me from
sleeping, the pain in my left hip travels around to my quad to my knee,
down my shin, to the top of my foot, where it sometimes leaves me in
tears. It's so unbearable. I can hardly walk anymore; I'm losing motor
control. It's taking a toll on my speech, my focus, and my attitude.
Stretching does not help, nor does icing or adjustments. Only a high
dose of pain meds help, but they make me violently ill and depressed,
and Isleepfor two days sometimes. I'm told I will more than likely be
paralyzed by 60, and I'm 49. My nerve damage is getting so severe that
I may not make it another 4-5 years. I have three grandbabies, and I
can't even hold them, let alone play with them. I've read about the
surgeries and I am getting to the point of desiring it. At one time, I was
against surgery and tried to keep people away from it with the very
positive and effective body work I've done. I want my life back so bad
and I'm feeling resentful and suffering majordepression. I readsomeone else's post about how other people in their life diminish the
pain they suffer. Well, you are not the only one. It frustrates me that
anyone can call what we suffer minimal, undermine us, or call us
hypochondriacs. I'd love to see any one of them spend time in our
bodies for just a day, or maybe from the time we have to get out of bed
each day up to trying to get into the shower. And then they get upset
with us for how cranky we are. I'm glad that I could vent how I'm feeling.
Some days I cry out of frustration. From being an athlete to nothing.
Losing 30 pounds, suffering atrophy, and muscle loss everywhere. I've
lost my butt muscles and none of my clothes fit. I've even been accused
of being on meth! I want my life back.
http://www.medicinenet.com/script/main/art.asp?articlekey=6177http://www.medicinenet.com/script/main/art.asp?articlekey=6177http://www.medicinenet.com/script/main/art.asp?articlekey=6177http://www.medicinenet.com/script/main/art.asp?articlekey=342http://www.medicinenet.com/script/main/art.asp?articlekey=342http://www.medicinenet.com/script/main/art.asp?articlekey=342http://www.medicinenet.com/script/main/art.asp?articlekey=342http://www.medicinenet.com/script/main/art.asp?articlekey=61777/28/2019 Spondylolisthesis and PLIF.pdf
17/107
Inside Me.. I am 47 and was diagnosed withSpondylolisthesisand Spinal Stenosis
10 years ago. Although the doctors tell me that it is mild
spondylolisthesis, only grade one, I am mostly in some sort of pain
daily. My biggest problem is the dreadedSciatica, I have to be socareful and avoid at all costs lifting, pulling or pushing anything around, I
am a farmer so a lot of heavy work is involved daily, but I have someone
to help out with the heavy work. When the doctor uses the word mild I
feel like slapping him across the face and asking him how mild does that
feel. Pain is pain and living with it daily can be depressing, but I refuse
to let it control me, which it used to do. I do not take any medication
such as anti inflammatory, this are pure poison to anyone's stomach. I
would rather suffer back pain than to partake in any type of anti
inflammatory drug.
SOURCE: http://www.medicinenet.com/spondylolisthesis/
Lumbar Spondylolisthesis
A Patient's Guide to Lumbar SpondylolisthesisIntroduction
Normally, the bones of the spine (the vertebrae) stand neatlystacked on top of one another. Ligaments and joints support the
spine. Spondylolisthesis alters the alignment of the spine. In thiscondition, one of the spine bones slips forward over the onebelow it. As the bone slips forward, the nearby tissues and nervesmay become irritated and painful.
This guide will help you understand
http://www.medicinenet.com/script/main/art.asp?articlekey=101597http://www.medicinenet.com/script/main/art.asp?articlekey=101597http://www.medicinenet.com/script/main/art.asp?articlekey=101597http://www.medicinenet.com/script/main/art.asp?articlekey=2026http://www.medicinenet.com/script/main/art.asp?articlekey=2026http://www.medicinenet.com/script/main/art.asp?articlekey=2026http://www.medicinenet.com/spondylolisthesis/http://www.medicinenet.com/spondylolisthesis/http://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_intro01.jpghttp://www.medicinenet.com/spondylolisthesis/http://www.medicinenet.com/script/main/art.asp?articlekey=2026http://www.medicinenet.com/script/main/art.asp?articlekey=1015977/28/2019 Spondylolisthesis and PLIF.pdf
18/107
Inside Me.. how the problem develops
how doctors diagnose the condition
what treatment options are available
Anatomy
What parts of the spine are involved?
The human spine is made up of 24 spinal bones, called vertebrae.Vertebrae are stacked on top of one another to create the spinalcolumn. The spinal column gives the body its form. It is the body'smain upright support. The section of the spine in the lower back iscalled thelumbar spine.
The lumbar spine is made of the lower five vertebrae. Doctorsoften refer to these vertebrae as L1 to L5. These five vertebraeline up to give the low back a slight inward curve. The lowestvertebra of the lumbar spine, L5, connects to the top ofthe sacrum
Each vertebra is formed by a round block of bone, called
a
, a triangular bone at the base of the spine that fitsbetween the two pelvic bones.
vertebral body. A circle of bone attaches to the backof the vertebral body. When the vertebrae are stacked on top of
each other, these bony rings create a
http://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy04.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy03.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy01a_bklt.jpghttp://www.eorthopod.com/content/lumbar-spine-anatomy7/28/2019 Spondylolisthesis and PLIF.pdf
19/107
Inside Me..hollow tube. This tube, called the spinal canal, surrounds thespinal cord as it passes through the spine. J ust as the skullprotects the brain, the bones of the spinal column protect thespinal cord.
The spinal cord only extends to L2. Below this level, the spinalcanal encloses a bundle of nerves that goes to the lower limbsand pelvic organs. The Latin term for this bundle of nerves
is cauda equina, meaning horse's tail.
Two sets of bones form the spinal canal's bony ring. Two pediclebones attach to the back of each vertebral body. Two lamina
bones complete the ring. The place where the lamina and pediclebones meet is called the pars interarticularis, or pars for short.There are two such meeting points on the back of each vertebra,one on the left and one on the right. The pars is thought to be theweakest part of the bony ring.
Intervertebral discs separate the vertebral bodies. The discsnormally work like shock absorbers. They protect the spineagainst the daily pull of gravity. They also protect the spine during
strenuous activities that put strong force on the spine, such asjumping, running, and lifting.
http://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy06.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy05.jpg7/28/2019 Spondylolisthesis and PLIF.pdf
20/107
Inside Me..
The lumbar spine is supported by ligaments and muscles.The ligaments, which connect bones together, are arranged inlayers and run in multiple directions. Thick ligaments connect thebones of the lumbar spine to thesacrum (the bone below L5) andpelvis.
Between the vertebrae of each spinal segment are two facetjoints. The facet joints are located on the back of the spinalcolumn. There are two facet joints between each pair ofvertebrae, one on each side of the spine. Afacet jointis made ofsmall, bony knobs that line up along the back of the spine. Wherethese knobs meet, they form a joint that connects the two
vertebrae. The alignment of the facet joints of the lumbar spineallows freedom of movement as you bend forward and back.
Theanatomy of the lumbar spineis often discussed in terms
ofspinal segments
Causes
. Each spinal segment includes two vertebraeseparated by an intervertebral disc, the nerves that leave thespinal cord at that level, and the facet joints that link each level ofthe spinal column.
http://www.eorthopod.com/content/facet-joint-injectionshttp://www.eorthopod.com/content/facet-joint-injectionshttp://www.eorthopod.com/content/facet-joint-injectionshttp://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy09.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy08.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_anatomy07.jpghttp://www.eorthopod.com/content/lumbar-spine-anatomyhttp://www.eorthopod.com/content/facet-joint-injections7/28/2019 Spondylolisthesis and PLIF.pdf
21/107
Inside Me..Why do I have this problem?
Spondylolisthesis may very rarely be congenital, which means it ispresent at birth. It can also occur in childhood as a result of injury.
In older adults, degeneration of the disc and facet (spinal) jointscan lead to spondylolisthesis.
Spondylolisthesis from degeneration usually affects people over50 years old. This condition occurs in African Americans moreoften than in whites. Women are affected more often than men.
The effect of the female hormone estrogen on ligaments andjoints is to cause laxity or looseness. The higher levels ofestrogen in women may account for the greater incidence of
spondylolisthesis. Degenerative spondylolisthesis mainly involvesslippage of L4 over L5.
In younger patients (under 20 years old), spondylolisthesis usuallyinvolves slippage of the fifth lumbar vertebra over the top of thesacrum. There are several reasons for this. First, the connectionof L5 and the sacrum forms an angle that is tilted slightly forward,mainly because the top of the sacrum slopes forward. Second,the slight inward curve of the lumbar spine creates an additional
forward tilt where L5 meets the sacrum. Finally, gravity attemptsto pull L5 in a forward direction.
Facet joints are small joints that connect the back of the spinetogether. Normally, the facet joints connecting L5 to the sacrumcreate a solid buttress to prevent L5 from slipping over the top ofthe sacrum. However, when problems exist in the disc, facet
joints, or bony ring of L5, the buttress becomes ineffective. As aresult, the L5 vertebra can slip forward over the top of the sacrum.
http://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_grades.jpg7/28/2019 Spondylolisthesis and PLIF.pdf
22/107
Inside Me..A condition called spondylolysis can lead to the slippage thathappens with spondylolisthesis. Spondylolysis is a defect in thebony ring of the spinal column. It affects the pars interarticularis,mentioned earlier. This defect is most commonly thought to be a
stress fracture that happens from repeated strains on the bonyring. Participants in gymnastics and football commonly sufferthese strains. Spondylolysis can lead to the spine slippage whena fracture occurs on both sides of the bony ring. This slippage iscalled spondylolisthesis. The slippage is graded from I through IV,one being mild, IV often causing neurological symptoms. Theback section of the bony ring separates from the main vertebralbody, so the injured vertebra is no longer connected by bone to
the one below it. In this situation, the facet joints can't providetheir normal support.
A traumatic fracture in the bony ring can lead to slippage whenthe fracture goes completely through both sides of the bony ring.
The facet joints are no longer able to provide a buttress, allowingthe vertebra with the crack in it to slip forward. This is similar towhat happens when spondylolysis (mentioned earlier) occurs onboth sides of the bony ring, but in this case it happens all at once.
Degenerative changes in the spine (those from wear and tear)can also lead to spondylolisthesis. The spine ages and wearsover time, much like hair turns gray. These changes affect the
structures that normally support healthy spine alignment.Degeneration in the disc and facet joints of a spinal segmentcauses the vertebrae to move more than they should. Thesegment becomes loose, and the added movement takes anadditional toll on the structures of the spine. The disc weakens,
pressing the facet joints together.
http://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_cause02.jpg7/28/2019 Spondylolisthesis and PLIF.pdf
23/107
Inside Me..Eventually, the support from the facet joints becomes ineffective,and the top vertebra slides forward.
Symptoms
What does the condition feel like?
An ache in the low back and buttock areas is the most commoncomplaint in patients with spondylolisthesis. Pain is usually worsewhen standing, walking, or bending backward and may be easedby resting or bending the spine forward. Leaning on a counter top,piece of furniture, or shopping cart are common waysto alleviate
Spasm is also common in the low back muscles. The
(reduce) the symptoms.
hamstringmuscleson the back of the thighs may become tight.
The pain can be from mechanical causes. Mechanical pain iscaused by wear and tear on the parts of the spine. When thevertebra slips forward, it puts a painful strain on the disc and facet
joints.
Slippage can also cause nerve compression. Nerve compressionis a result of pressure on a nerve. As the spine slips forward, thenerves may be squeezed where they exit the spine. This conditionalso reduces space in the spinal canal where the vertebra hasslipped. This can put extra pressure on the nerve tissues inside
the canal. Nerve compression can cause symptoms where thenerve travels and may include numbness, tingling, slowedreflexes, and muscle weakness in the legs.
http://www.eorthopod.com/content/hamstring-injurieshttp://www.eorthopod.com/content/hamstring-injurieshttp://www.eorthopod.com/content/hamstring-injurieshttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_symptom01.jpghttp://www.eorthopod.com/content/hamstring-injurieshttp://www.eorthopod.com/content/hamstring-injuries7/28/2019 Spondylolisthesis and PLIF.pdf
24/107
Inside Me..Nerve pressure on the cauda equina (mentioned earlier), thebundle of nerve roots within the lumbar spinal canal, can affectthe nerves that go to the bladder and rectum. When this happens,bowel and/or bladder function can be affected. The pressure may
causelow back pain, pain running down the back of both legs,and numbness or tingling between the legs in the area you wouldcontact if you were seated on a saddle.
Diagnosis
How do doctors diagnose the problem?
Diagnosis begins with a complete history and physical exam.Your doctor will ask questions about your symptoms and howyour problem is affecting your daily activities. Your doctor will alsowant to know what positions or activities make your symptomsworse or better.
Next the doctor examines you by checking your posture and theamount of movement in your low back. Your doctor checks to seewhich back movements cause pain or other symptoms. Your skinsensation, muscle strength, and reflexes are also tested.
Doctors will usually order X-rays of the low back. The X-rays aretaken with your spine in various positions. They can be used tosee which vertebra is slipping and how far it has slipped.
If more information is needed, your doctor may order computedtomography (a CT scan). This is a detailed X-ray that lets thedoctor see slices of the body's tissue. If you have nerve problems,the doctor may combine the CT scan withmyelography. To dothis, a special dye is injected into the space around the spinal
canal, the subarachnoid space. During the
http://www.eorthopod.com/content/low-back-painhttp://www.eorthopod.com/content/low-back-painhttp://www.eorthopod.com/content/low-back-painhttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_diagnosis01.jpghttp://www.eorthopod.com/content/low-back-pain7/28/2019 Spondylolisthesis and PLIF.pdf
25/107
Inside Me..CT scan, the dye highlights the spinal nerves. The dye canimprove the accuracy of a standard CT scan for diagnosing thehealth of the nerves.
Your doctor may also order a magnetic resonance imaging
Treatment
(MRI)scan. The MRI machine uses magnetic waves rather than X-raysto show the soft tissues of the body. It can help in the diagnosis ofspondylolisthesis. It can also provide information about the healthof nerves and other soft tissues.
What treatment options are available?
Nonsurgical TreatmentStudies have not been done yet to determine the best treatmentfor this condition. Conservative care is preferred, especially whenthe vertebra hasn't slipped very far. Most patients with symptomsfrom degenerative spondylolisthesis do not need surgery andrespond well to nonoperative care. Medications may beprescribed to help ease pain and muscle spasm. In some cases,the patient's condition is simply monitored to see if symptoms
improve.
Your doctor may ask that you rest your back by limiting youractivities. This is to help decrease inflammation and calm musclespasm. You may need to take time away from sports or otherstrenuous activities to give your back a chance to heal.
If your doctor diagnoses an acute pars fracture that has thepotential to heal, it may be recommended that you wear a rigid
back brace for two to three months. This
http://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesisCAT_Lumbar_Pars_Fx.jpg7/28/2019 Spondylolisthesis and PLIF.pdf
26/107
Inside Me..usually occurs in children and teenagers who begin having back
pain and see their doctor early on. X-rays may show afresh fracture of the pars area of the vertebra on one, or both,sides. A CT scan or bone scan may be recommended todetermine if the fracture is likely to heal. If so, a brace isrecommended. X-rays or a CT scan may be ordered in six to eightweeks to see if the fracture is healing. IF not, the brace will bediscontinued.
Some patients who continue to have symptoms are givenanepidural steroid injection(ESI). Steroids are powerful anti-inflammatories, meaning they reduce pain and swelling. In anESI, medication is injected into the space around the lumbar
nerve roots. This area is called the epidural space. Some doctorsinject only a steroid. Most doctors, however, combine a steroidwith a long-lasting numbing medication. Generally, an ESI isgiven only when other treatments aren't working. But ESIs are notalways successful in relieving pain. If they do work, they may onlyprovide temporary relief.
Patients often work with a physical therapist. After evaluating yourcondition, your therapist can assign positions and exercises to
ease your symptoms. Your therapist can design an exerciseprogram to improve flexibility in your low back and hamstrings andto strengthen your back and abdominal muscles.
http://www.eorthopod.com/content/epidural-steroid-injectionshttp://www.eorthopod.com/content/epidural-steroid-injectionshttp://www.eorthopod.com/content/epidural-steroid-injectionshttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_treatment02.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_treatment01.jpghttp://www.eorthopod.com/content/epidural-steroid-injections7/28/2019 Spondylolisthesis and PLIF.pdf
27/107
Inside Me..The use of a stationary bike can promote aerobic conditioning andputs you in the optimal position to open the spaces where thenerve roots exit. This type if exercise program can aid in reducingthe painful symptoms.
Surgery
Surgery is used when the slip is severe and when symptoms arenot relieved with nonsurgical treatments. Symptoms that cause anabnormal walking pattern, changes in bowel or bladder function,or steady worsening in nerve function require surgery.Deterioration of symptoms is common in patients with a history ofsignificant neurologic symptoms who don't have surgery to correct
the problem.
If a reasonable trial of conservative care (three months or more)does not improve things and/or your quality of life is significantlyreduced, then surgery may be the next best solution. The maintypes of surgery for spondylolisthesis include
laminectomy(decompression)
posterior fusionwith or without instrumentation
posterior lumbar interbody fusion
Laminectomy
When the vertebra slips forward, the nearby nerves that exit the
spine can become pinched or irritated. In addition, the size of thespinal canal in the problem area shrinks, placing pressure on thenerves inside the canal. To fix this, the lamina of the bony ring isremoved to ease pressure on the nerves. The procedure to
remove the lamina and release pressure on thenerves is called laminectomy.
http://www.eorthopod.com/content/cervical-laminectomyhttp://www.eorthopod.com/content/cervical-laminectomyhttp://www.eorthopod.com/content/posterior-lumbar-fusionhttp://www.eorthopod.com/content/posterior-lumbar-fusionhttp://www.eorthopod.com/content/posterior-lumbar-interbody-fusionhttp://www.eorthopod.com/content/posterior-lumbar-interbody-fusionhttp://www.eorthopod.com/content/lumbar-laminectomyhttp://www.eorthopod.com/content/lumbar-laminectomyhttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_surgery01.jpghttp://www.eorthopod.com/content/lumbar-laminectomyhttp://www.eorthopod.com/content/posterior-lumbar-interbody-fusionhttp://www.eorthopod.com/content/posterior-lumbar-fusionhttp://www.eorthopod.com/content/cervical-laminectomy7/28/2019 Spondylolisthesis and PLIF.pdf
28/107
Inside Me..Decompression alone is usually not advised. Studies show muchbetter results when the operation is combined with a fusion of theinvolved vertebrae (see below).
Posterior Fusionwith Instrumentation
A spinal fusion
In this procedure, the surgeon lays small grafts of bone over the
back of the problem vertebrae.
is normally done immediately after laminectomyfor spondylolisthesis. The fusion procedure is designed to fusethe two vertebrae into one bone and stop the slippage fromworsening. The fusion is used to lock the vertebrae in place andstop movement between the vertebrae, easing mechanical pain.When combined with laminectomy surgery (mentioned earlier),fusion helps relieve nerve compression.
Sometimes fusion isdone just with bone graft material. This is a fusion without fixation(non-instrumentation).Instrumentation
Outcomes are improved when decompression is combined withfusion (compared with decompression alone). Fusion andfunctional improvement are even better when spinalinstrumentation is used. There are fewer long-term problems with
is the use of metal plates orscrews to stabilize the segment during healing. Most surgeonscombine fusion with instrumentation to prevent the two vertebraefrom moving. This protects the graft so it can heal better andfaster.
http://www.eorthopod.com/content/posterior-cervical-fusionhttp://www.eorthopod.com/content/posterior-cervical-fusionhttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_surgery03.jpghttp://www.eorthopod.com/sites/default/files/images/lumbar_spondylolisthesis_surgery02.jpghttp://www.eorthopod.com/content/posterior-cervical-fusion7/28/2019 Spondylolisthesis and PLIF.pdf
29/107
Inside Me..pain and pseudoarthrosis
SOURCE:
(formation of movement or false jointswithin the fusion).
http://www.eorthopod.com
Spondylolisthesis
Spondylolisthesis is the displacement of one vertebra on top of another. This
displacement can occur when there is significant acute damage to the area,
from a contact sports injury say, or as a result of more chronic issues such
as cervicaldegenerative disc disease, osteoarthritis, and other cervical spinal
issues. Unchecked, degenerative spondylolisthesis can lead tocervical spinal
stenosis(Kalichman, 2008).
Physicians usually classify spondylolisthesis according to its cause, with the
most common being degenerative spondylolisthesis. This is caused by
chronic degenerative changes in the ligaments, facet joints, bones, and
cartilage that hold the spinal/vertebral column in position. This degeneration
can lead to spondylolisthesis as the vertebral column loses its ability to stay
together and the vertebrae slip out of position. Isthmic spondylolisthesis is
the result of spondylolysis; a defect in the pars interarticularis (part of the
vertebrae) most commonly caused by repetitive microtrauma in childhood
through activities such as gymnastics, diving, soccer, football, and wrestling
(Standaert, 2000).
http://www.eorthopod.com/http://www.eorthopod.com/http://www.eorthopod.com/http://www.painneck.com/degenerative-disc-diseasehttp://www.painneck.com/degenerative-disc-diseasehttp://www.painneck.com/degenerative-disc-diseasehttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/degenerative-disc-diseasehttp://www.eorthopod.com/7/28/2019 Spondylolisthesis and PLIF.pdf
30/107
Inside Me..
Traumatic spondylolisthesis is due to direct trauma inflicted upon the
vertebrae causing a fracture of the pedicle, lamina, or facet joints and
allowing the front of the vertebrae to move forward.Cervical
spondylolysis
Understanding the cause means that the correct treatment can be applied,
such as adequate rest from the microtrauma-inducing sport, analgesics,
anti-inflammatories, physical therapy, or surgery in cases where significant
damage has occurred and conservative treatment has proved ineffective.
Spondylolysis normally does not require surgical intervention, unless it
progresses into spondylolisthesis. The use of a brace may be helpful in
reducing neck pain in the meantime. Identifying the exacerbating activity is
key to preventing future occurrences of the condition, meaning that correct
posture, and core muscle strengthening, along with neck strengthening
exercises are key to a positive outcome. In the case of lumbar or
can lead to spondylolisthesis by altering the normal structure
of the vertebral column and causing vertebral displacement. Congenital
abnormalities of the facet joints can lead to spondylolisthesis, as the
vertebrae are allowed to slip out of place. The condition is referred to as
dysplastic spondylolisthesis. A further classification is pathological
spondylolisthesis, where a defect of the bone, or a tumour causes the slip to
occur.
cervical
spine surgery, typically a spinal fusion is the procedure used to correct
spondylolisthesis.
Causes of Spondylolisthesis
http://www.painneck.com/spondylosishttp://www.painneck.com/spondylosishttp://www.painneck.com/spondylosishttp://www.painneck.com/spondylosishttp://www.painneck.com/surgeryhttp://www.painneck.com/surgeryhttp://www.painneck.com/surgeryhttp://www.painneck.com/surgeryhttp://www.painneck.com/surgeryhttp://www.painneck.com/spondylosishttp://www.painneck.com/spondylosis7/28/2019 Spondylolisthesis and PLIF.pdf
31/107
Inside Me..
There are five major types ofspondylolisthesis, all with different causes. The
most common is degeneration of the components of the vertebral column
and spine - degenerative spondylolisthesis. These structures, when
healthy, maintain the spines correct position, allowing for strength and
flexibility of movement. As these components degrade, through chronic wear
and tear they lose their ability to stay supple and strong, making shifts in
the spinal structure more likely, including the slippage of the vertebrae as
occurs in spondylolisthesis. Cartilage calcification and degeneration,
ligaments stretching and tearing,bone spursor osteophyte growth, and
changes in the shock absorbing and cushioning qualities of the intervertebral
discs means that the vertebra can slide forward (or backward in the case of
retrolisthesis), and cause deformity of the spine, with associated pain,
paraesthesia,pinched nerves, numbness, muscle weakening, and impaired
mobility.
Degeneration with age is not, however, the only cause of spondylolisthesis.
Congenital abnormalities such as misshapen bones in the spinal column, or
problems with the pelvic incidence (tilt), can also
http://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/bone-spurshttp://www.painneck.com/bone-spurshttp://www.painneck.com/bone-spurshttp://www.painneck.com/pinched-nervehttp://www.painneck.com/pinched-nervehttp://www.painneck.com/pinched-nervehttp://www.painneck.com/pinched-nervehttp://www.painneck.com/bone-spurshttp://www.painneck.com/spondylolisthesis7/28/2019 Spondylolisthesis and PLIF.pdf
32/107
Inside Me..
cause excess pressure on the spinal column leading to slippage of the
vertebrae and spondylolisthesis (Labelle, 2004). This is known as dysplastic
spondylolisthesis.
Isthmic spondylolisthesis is a further classification, used to describe the
condition that results fromspondylolysis. This is a condition where repetitive
microtrauma causes defects in the pars interarticularis, a specific part of the
vertebrae, which may develop into spondylolisthesis if the vertebrae slip
forward due to this defect. Spondylolysis is commonly caused in adolescents
and children by activities such as gymnastics, football, wrestling, and diving.
With appropriate rest and possible use of a brace it should correct itself
without developing into spondylolisthesis.
Specific injury or damage to the vertebrae through complications of
surgery,epidural injections, assault, or accidents, such aswhiplash, can
cause traumatic spondylolisthesis. These types of injury can result in
fractures of the lamina, facet joints, or pedicle, and allow the vertebrae to
slide forward. The final class is pathologic spondylolisthesis
Symptoms of Spondylolisthesis
. This is
where the vertebrae slip forward due to an abnormal growth such as a
tumour or bone growth. The specific pathology of the spondylolisthesis
requires careful diagnosis in order to apply appropriate treatment.
In some cases the patient may be asymptomatic and only discover
thespondylolisthesisby chance when having an x-ray conducted for an
unrelated reason. Many cases involving children cause no, or few,
symptoms. Other patients suffer extreme
http://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolisthesis-referencehttp://www.painneck.com/spondylolsishttp://www.painneck.com/spondylolsishttp://www.painneck.com/spondylolsishttp://www.spinalstenosis.org/injections.phphttp://www.spinalstenosis.org/injections.phphttp://www.spinalstenosis.org/injections.phphttp://www.painneck.com/whiplashhttp://www.painneck.com/whiplashhttp://www.painneck.com/whiplashhttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/whiplashhttp://www.spinalstenosis.org/injections.phphttp://www.painneck.com/spondylolsishttp://www.painneck.com/spondylolisthesis-reference7/28/2019 Spondylolisthesis and PLIF.pdf
33/107
Inside Me..
symptoms, involving persistent,severe neck pain, back and spine, with
radiating pain down the legs and arms. Pain may be worsened when
hyperextending (arching) the back, making some activities such as yoga or
pilates potentially unsuitable for those with spondylolisthesis. In general,
however, these activities would be excellent for maintaining back and neck
health.
Some patients may experience neurological symptoms, such as intermittent
claudication or vesicorectal disorder; in most cases these patients will
requirespine surgeryto correct the slippage and compression on spinal
structures.Pinched nervesin the cervical spine may lead to weakness and
numbness in the arms and shoulders, along with paraesthesia.Pain in
neckand head can occur, depending on the location of the slippage and
which nerves are being impinged upon. Symptoms of spondylolisthesis may
share commonalities with symptoms of bulging or herniated discs, spinal
stenosis, andcervical arthritis, as well as the issues found with severe
osteophyte growth in the spine. If the patient experiences numbness in the
genital area, or loses bladder or bowel control then they should seek medical
help immediately as they may be signs of cauda equina syndrome which is
considered a medical emergency.
http://www.painneck.com/severehttp://www.painneck.com/severehttp://www.painneck.com/severehttp://www.painneck.com/surgeryhttp://www.painneck.com/surgeryhttp://www.painneck.com/surgeryhttp://www.painneck.com/pinched-nervehttp://www.painneck.com/pinched-nervehttp://www.painneck.com/pinched-nervehttp://www.painneck.com/http://www.painneck.com/http://www.painneck.com/http://www.painneck.com/http://www.painneck.com/cervical-arthritishttp://www.painneck.com/cervical-arthritishttp://www.painneck.com/cervical-arthritishttp://www.painneck.com/cervical-arthritishttp://www.painneck.com/http://www.painneck.com/http://www.painneck.com/pinched-nervehttp://www.painneck.com/surgeryhttp://www.painneck.com/severe7/28/2019 Spondylolisthesis and PLIF.pdf
34/107
Inside Me..
As there are numerous blood vessels in the cervical area, including the
arteries and veins leading up to the head, it is possible that spondylolisthesis
can cause compression of these blood vessels. This may occur upon
movement, with patients experiencing light-headedness upon rotation or
flexion of the neck and head. If this occurs it is essential to seek medical
assistance immediately as it may lead to blackouts, falls, and accidents as
circulation to the brain is impaired.
Physical signs of theslippage of the vertebraecan, in extreme cases, include
deformity of the back and neck, withstiffness of the neck, pain on rotation,
flexion, and extension, and an abnormal tilt to the posture. Those with
spondylolisthesis of the lumbar area may experience tightness in their
hamstrings, sciatic nerve pain, and numbness in the legs and buttocks; the
latter is a sign of cauda equina syndrome and
http://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/stiffnesshttp://www.painneck.com/stiffnesshttp://www.painneck.com/stiffnesshttp://www.painneck.com/stiffnesshttp://www.painneck.com/spondylolisthesis7/28/2019 Spondylolisthesis and PLIF.pdf
35/107
Inside Me..
should be thoroughly investigated.
Diagnosis of Spondylolisthesis
In general it will not be possible for a physician to observe outward signs
ofspondylolisthesisupon examining a patient. Taking a history of
symptoms, and a detailed record of trauma and activities such as contact
sports, the physician will recommend further tests and scans as they see fit.
They may also ask patients to conduct some simple stretches, rotation
orflexion of the neck, and to apply resistance during gentle pressure on
their hands, shoulders, and head from the physician. The production, or
relief, of pain from these physical tests can be enlightening as to the
aetiology of theirspine condition, and also make it easier for the physician to
estimate the specific area which is damaged so as to scan that area.
Commonsymptoms of spondylolisthesis, such as tight hamstrings, muscle
spasms, and pain, may overlap with other conditions, such as muscle
strain,disc herniation,spinal stenosis, and diabetic neuropathy, making it
extremely important to obtain the correct diagnosis prior to commencing
treatment.
http://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/spondylolisthesishttp://www.painneck.com/exerciseshttp://www.painneck.com/exerciseshttp://www.painneck.com/exerciseshttp://www.painneck.com/conditionshttp://www.painneck.com/conditionshttp://www.painneck.com/conditionshttp://www.painneck.com/spondylolisthesis-symptomshttp://www.painneck.com/spondylolisthesis-symptomshttp://www.painneck.com/spondylolisthesis-symptomshttp://www.painneck.com/herniated-dischttp://www.painneck.com/herniated-dischttp://www.painneck.com/herniated-dischttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/cervical-spinal-stenosishttp://www.painneck.com/herniated-dischttp://www.painneck.com/spondylolisthesis-symptomshttp://www.painneck.com/conditionshttp://www.painneck.com/exerciseshttp://www.painneck.com/spondylolisthesis7/28/2019 Spondylolisthesis and PLIF.pdf
36/107
Inside Me..
Grades of Spondylolisthesis
X-rays taken from the side (lateral) can identify slippage of vertebra relative
to the adjacent vertebrae. The degree of slippage can be calculated and is
graded as follows: Grade 1 is a slip of up to 25%, grade 2 is a slip of 26%-
50%, grade 3 is a slip of 51%-75%, and grade 4 76%-100%. Grade 5 is
known as spondyloptosis and is where the vertebra has slipped off the next
vertebra completely.
MRI or CT scans can be helpful in identifying any stenosis of the spine that
may be causing neck, back, andshoulder pain, andradiating painto the
extremities. Paraesthesia, numbness, and weakness indicate nerve
problems, possibly with a pinched nerve such as can occur in disc herniation.
If aspinal fusionsurgical procedure is being considered then a PET scan can
ascertain whether the defective bone site has active bone growth occurring.
This will affect the likely healing of the patients spine post-surgery, making
http://www.painneck.com/shoulderhttp://www.painneck.com/shoulderhttp://www.painneck.com/shoulderhttp://www.painneck.com/radiculopathyhttp://www.painneck.com/radiculopathyhttp://www.painneck.com/radiculopathyhttp://www.spinalstenosis.org/fusion.phphttp://www.spinalstenosis.org/fusion.phphttp://www.spinalstenosis.org/fusion.phphttp://www.spinalstenosis.org/fusion.phphttp://www.painneck.com/radiculopathyhttp://www.painneck.com/shoulder7/28/2019 Spondylolisthesis and PLIF.pdf
37/107
Inside Me..
decisions about the effectiveness of certain treatments simpler.
Treatment of Spondylolisthesis
Conservative Treatment
Conservative treatment is the usual therapeutic course for patients with
spondylolisthesis. In small children, where the slip is normally quite minor,
the usual therapeutic plan is simple observation and restriction of boisterous
activities. More significant slips pose a threat of progressive complication
and justify the use of more invasive treatment methods. NSAIDs and
analgesics are likely to be used, alongside physical therapy, and the
condition will be monitored closely. If treatment is unsuccessful after six
months or so, or if an acute exacerbation occurs, then surgery may be
required.
If intermittent claudication and other neurological symptoms are present
then the need for surgical intervention is more likely. Favored treatment
plans for minor cases involve the use of analgesics and NSAIDs, or
alternative supplements for those concerned with the potential side-effects
of pharmaceutical medications. Epidural steroid injections and selective
nerve root blocks may be used to provide relief from the condition and break
the cycle of inflammation often found in spondylolisthesis. If the patient has
adequate rest and refrains from any exacerbating activities, it is possible
that the combination of anti-inflammatories, physical therapy and flexion
strengthening exercises can alleviate, or even correct, the problem.
Exercises to strengthen the core abdominal muscles are also likely to benefit
a patient with spondylolisthesis as these may
7/28/2019 Spondylolisthesis and PLIF.pdf
38/107
Inside Me..
help correct underlying postural issues and alleviate some pressure on the
spine. The use of a hyperextension brace may also assist those with isthmic
spondylolisthesis as it can help to extend the lumbar spine and promote
healing.
Surgical Treatment
Surgery varies depending on the type of spondylolisthesis. Isthmic
spondylolisthesis patients are likely to have repair work done on the portion
of the vertebrae that is defective, most notably the pars interarticularis.
Healthy post-surgical healing is likely to occur if an MRI or PET scan reveals
active bone at the defective site. In this procedure the scar tissue will be
removed and a bone graft put in place with screws to hold it across the
defect, thus encouraging the re-knitting of the bone. Those patients with
neurological symptoms will likely undergo a decompression procedure to
make the foramina through which the nerves exit the spine more spacious.
Decompression surgery is often conducted alongside fusion to reposition the
vertebrae correctly and hold them in place with plates. In some cases the
vertebrae are fused in the position they have moved to, to prevent further
slippage. This is done in cases where moving the vertebrae back has an
increased risk of further nerve damage.
Source: http://www.painneck.com
http://www.painneck.com/http://www.painneck.com/http://www.painneck.com/7/28/2019 Spondylolisthesis and PLIF.pdf
39/107
Inside Me..
Spondylolisthesis -DegnerativeSpondylolisthesis occurs when one vertebra slips forward over thevertebra below. Degenerative spondylolisthesis often affects thelumbar (low back) spine, often at L4-L5 (4th and 5th lumbar vertebrallevels). Degenerative changes in vertebral structure may cause jointsbetween vertebrae to slip forward creating a spondylolisthesis.Sometimes spinal stenosis develops with spondylolisthesis.Degenerative spondylolisthesis is more common in older femalepatients over age 60.
SymptomsSome people with spondylolisthesis are symptom-free.Spondylolisthesis may be discovered when the patient has a lumbar x-ray for back pain or another problem. Symptoms may include:
Low back pain Sciatica
Muscle spasms Leg weakness Tight hamstring muscles Irregular gait or a limp
An accurate diagnosis of spondylolisthesis can be made by aphysician with expertise in spinal disorders. This may include thefollowing steps.
Medical history
The doctor asks you about your symptoms, severity, treatments tried,and the results.
Physical examinationThe physician examines you for movement limitations, balance
problems, and pain. He tests your reflexes,
7/28/2019 Spondylolisthesis and PLIF.pdf
40/107