Spondylolisthesis is the slippage of one vertebral body in respect to the adjacent vertebral body causing mechanical or radicular symptoms or pain. It can be due to congenital, acquired or idiopathic causes. Spondylolisthesis is graded based on the degree of slippage of one vertebral body on the adjacent vertebral body.
Spondylolisthesis is commonly classified as one of five major etiologies: degenerative, isthmic, traumatic, dysplastic or pathologic. Degenerative spondylolisthesis occurs from degenerative changes in the spine without any defect in the pars interarticularis and is usually related to combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body in relation to the adjacent vertebral body. Isthmic spondylolisthesis results from defects in the pars interarticularis. The cause of isthmic spondylolisthesis is undetermined, but a possible etiology includes microtrauma in adolescence related to sports such as wrestling, football, and gymnastics where repeated lumbar extension occurs. Traumatic spondylolisthesis occurs after fractures of the pars interarticularis or the facet joint structure and is most commonly seen after trauma. Dysplastic spondylolisthesis is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment. In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation. Pathologic spondylolisthesis can be from systemic causes such as bone or connective tissue disorders or a focal process including infection, neoplasm or iatrogenic origin. Additional risk factors for spondylolisthesis include a first-degree relative with spondylolisthesis, scoliosis or occult spinal bifida at the S1 level.
Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the cervical spine and rarely, except for trauma, in the thoracic spine. Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese. Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males. Dysplastic spondylolisthesis is more common in the pediatric population with females more commonly affected than males. Current estimates for prevalence are 6-7% for isthmic spondylolisthesis by the age of 18 years and up to 18% of adult patients undergoing MRI of the lumbar spine. Grade I spondylolisthesis accounts for 75% of all cases. Spondylolisthesis most commonly occurs at the L5-S1 level with anterior translation of the L5 vertebral body on the S1 vertebral body. The L4-5 level is the second mose common location for spondylolisthesis.
Any process that can weaken the supports keeping vertebral bodies aligned can allow spondylolisthesis to occur. As one vertebra moves in relation to the adjacent vertebrae, local pain can occur from mechanical motion or radicular or myelopathic pain can occur due to compression of the exiting nerve roots or spinal cord respectively. Pediatric patients are more likely to increase spondylolisthesis grade when going through puberty. Older patients with lower grade I or II spondylolisthesis are less likely to progress to higher grades over time.
Patients typically have intermittent and localized low back pain for lumbar spondylolisthesis and localized neck pain for cervical spondylolisthesis. The pain is exacerbated by flexing and extending at the affected segment as this can cause mechanic pain from motion. Pain may be exacerbated by direct palpation of the affected segment. Pain can also be radicular in nature as the exiting nerve roots are compressed due to the narrowing of nerve foramina as one vertebra slips on the adjacent vertebrae, the traversing nerve root (root to the level below) can also be impinged through associated lateral recess narrowing, disc protrusion, or central stenosis. Pain can sometimes be improved in a positional manner such as laying supine. This improvement is due to the instability of the spondylolisthesis that reduces with supine posture thus relieving the pressure on the bony elements as well as opening the spinal canal or neural foramen. Other symptoms associated with lumbar spondylolisthesis include buttock pain, numbness or weakness in the leg(s), difficulty walking and rarely loss of bowel or bladder control.
Anteroposterior and lateral plain films, as well as lateral flexion-extension plain films, are the standard for the initial diagnosis of spondylolisthesis. One is looking for the abnormal alignment of one vertebral body to the next as well as possible motion with flexion and extension which would indicate instability. In isthmic spondylolisthesis, there may be a pars defect which is termed the "Scotty dog collar." The "Scott dog collar" shows a hyperdensity where the collar would be on the cartoon dog which represents the fracture of the pars interarticulars. Computed tomography (CT) of the spine provides the highest sensitivity and specificity for diagnosing spondylolisthesis. Spondylolisthesis can be better appreciated on sagittal reconstructions as compared to axial CT imaging. MRI of the spine can show associated soft tissue and disc abnormalities, but it is relatively more difficult to appreciate bony detail and a possible pars defect on MRI.
For grade I and II spondylolisthesis treatment typically begins with conservative therapy including nonsteroidal anti-inflammatory drugs (NSAIDs), heat, light exercise, traction, bracing and/or bed rest. Approximately 10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment and need surgical treatment. No definitive standards exist for surgical treatment. Surgical treatment includes a varying combination of decompression, fusion with or without instrumentation or interbody fusion. Patients with instability are more likely to require operative intervention. Some surgeons recommend a reduction of the spondylolisthesis if able as this not only decreases foraminal narrowing but also can improve spinopelvic sagittal alignment and decrease the risk for further degenerative spinal changes in the future. The reduction can be more difficult and riskier in higher grade and impacted spondylolisthesis.
Meyerding’s classification of spondylolisthesis is the most commonly used classification. It is based on the percentage of anterior translation relative to the adjacent level. Grade I spondylolisthesis is 1-25% slippage, grade II is up to 50% slippage, grade III is up to 75% slippage, and grade IV is 76-100% slippage. If there is more than 100% slippage, it is known as spondyloptosis or grade V spondylolisthesis.
Subclasses of isthmic spondylolisthesis are subtype A (stress fractures of the pars), subtype B (elongation of the pars without overt fracture), subtype C (acute fracture of the pars).
Subclasses of pathologic spondylolisthesis are subtype A (systemic causes) and subtype B (focal processes).
An interprofessional team consisting of a specialty trained nurse, physical therapist, and an orthopedic surgeon or neurosurgeon will provide the best outcome and long-term care of patients with degenerative spondylolisthesis. The team should encourage weight loss as weight reduction may reduce symptoms and increase the quality of life. [Level V]
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