Spondylolisthesis

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spondylolisthesis
spondylolisthesis

What is Spondylolisthesis?

First described in 1782 by a Belgian physician, the ailment known as spondylolisthesis is a condition affecting the bones of the spinal column or the vertebra. Spondylolisthesis means any kind of displacement and misalignment of the vertebra whether to the front (anterolisthesis) or towards the back (retrolisthesis), and because these vertebrae are the ones protecting the nerve bundles of the spinal cord, their misalignment can cause narrowing and impingement to these nerve endings that cause varying symptoms depending on the level of the spinal column that is injured.

In the younger generation, this condition predominantly manifests at the 5th lumbar vertebra and first sacral bone when a child receives sudden trauma to the spine or as a congenital abnormality. While in adults, spondylolisthesis usually occurs at the fourth and fifth lumbar vertebrae and is generally caused by arthritis and other degenerative or “wear and tear” diseases.

Spondylolisthesis can also be caused by the lifestyle and practices of an individual,  athletes like gymnasts and those who encounter frequent injuries due to the rough nature of the sport like rugby, wrestling, and American football are all at risk of developing spondylolisthesis because of the tremendous amount of stress that their lower backs receive. The usual cause of the condition for these people is a break or fracture in the bones of the spine when the bone finally gives in to prolonged stress or an acute traumatic injury.

Spondylolisthesis Types

There are different types of this condition depending on the cause or predisposing factor of the disease, in 1976, Wiltse et al. introduced a classification system to describe the 5 most common types of spondylolisthesis, and these are:

Isthmic spondylolisthesis:

This is a type of spondylolisthesis commonly caused by repeated trauma or an acute injury, the part of the spinal column that is most affected is the pars interarticularis. This is the foremost kind of spondylolisthesis that is not congenital in people under 50 years of age, people who develop this subtype have had their lower backs exposed to years of stress and trauma due to their occupations.

Degenerative spondylolisthesis

As its name implies, this type of spondylolisthesis is due to changes brought about by degenerative diseases, the most common of which is degenerative arthritis. This occurs because the cartilage in between the vertebra start to thin out due to years of friction, naturally, this type of spondylolisthesis is most common in the geriatric population. People with this subtype usually experience radiculopathy or neurogenic claudication because of the narrowing of the spine’s central canal at the point of the misalignment, the neurogenic claudication can be described as pain on the lower limbs that is exacerbated by movement but can be relieved by bending forwards or sitting down.

Traumatic spondylolisthesis:

Traumatic spondylolisthesis happens as a result of direct trauma to the affected vertebrae such as the neural arch but compared to the other types of spondylolisthesis, this type rarely occurs, the condition transpires when the vertebra is traumatically displaced forward.

Dysplastic spondylolisthesis:

Dysplastic means the abnormal development and growth of tissue, this type of spondylolisthesis is a congenital condition wherein there is a fault in the growth and formations of the vertebra as the fetus develops. This causes the articular processes of the vertebrae to be oriented forward and the facet joints also displaced forward instead of its normal sideways position. It has also been found out that this type of spondylolisthesis is the only one that is possibly influenced by genetic tendency

Pathologic spondylolisthesis:

Paget’s disease, metastatic carcinoma, osteoporosis, tumors, these are just some of the diseases that predispose a person to this type of spondylolisthesis. Pathologic spondylolisthesis is brought about by an abnormal displacement of the vertebrae caused by flaws in the bone structure due to the different predisposing diseases.

Spondylolisthesis Symptoms

A number of symptoms can be attributed to spondylolisthesis, the most common of which is low back pain which is exacerbated by activity and extension of the lumbar spine. The direct relationship of activity or exercise to the pain felt can be attributed to the swollen tissues being sandwiched between the bones, and as a person exercises, these tissues swell even further causing an increasing severity of pain. Other symptoms include tightening of the lower back and hamstrings leading to changes in gait and stance which is similar to a lordotic stance. The common lower back pain can sometimes be accompanied by numbness and tingling in the hamstrings and lower limbs with shocks and shooting pain that travels from the lower back to the lower leg. Normal body movements such as rising from a sitting or lying position or sitting from a standing position can become more and more difficult as the disease progresses.

Spondylolisthesis Diagnosis

This condition is diagnosed by radiography, specifically lateral X-rays that show the anterior or posterior misalignment of any of the vertebrae. Only X-rays or radiography can positively diagnose the diseases because most of its non latent symptoms are very common and may be confused with other conditions such as muscle strain or inflammation in the lower back. When numbess, weakness, and tingling of the lower limbs are present, the physician may order more diagnostic tests like and MRI or a CT scan to visualize the degree as to which the nerve bundles are impinged by the misaligned vertebrae.

Spondylolisthesis has different grades depending on the severity of the displacement of the affected vertebrae when compare to the adjacent vertebrae, these grades are as follows;

Grade I means the percentage of the displacement is up to 25 %

Grade II means the percentage of the displacement is from 26 % – 50 %

Grade III means the percentage of the displacement is from 51 % – 75 %

Grade IV means the percentage of the displacement is from 76 % – 100 %

Grade V means the percentage of the displacement is up to 100 % or when the vertebra has completely cleared the adjacent vertebra, it is also termed as spondyloptosis

Spondylolisthesis Treatment

Treatment of spondylolisthesis comes in stages of increasing intensity depending on the reaction of the patient to the treatments, the treatments given are also affected by the severity of the presentation of the condition in patients from low grade which usually entails simple low back pain and some radiculopathy, to high grade spondylolisthesis in which patients already present with gross deformity in gait and stance.

The first line of treatment can consist of any one of or a combination of 2 or all of the following more “conservative” approach to treating the disease which are PT or physical therapy, activity or lifestyle modification, and pharmacologic intervention. Physical therapy can include stretching and muscle strengthening, electric stimulations, traction, and thermal treatment.

Activity modification usually means learning techniques that lessen the pressure on the spine and having better body mechanics in doing everyday things. A number of drugs can also be used to counteract the symptoms of the disease such as NSAIDS or non steroidal anti inflammatory drugs and acetaminophen, steroids like prednisone and methylprednisone can also be used for patients complaining of severe symptoms of the disease.

Spondylolisthesis Surgery

Surgery is the last resort treatment for this condition and it usually deemed necessary if nothing else can be done to prevent the sustained worsening of the displacement of the vertebrae and the pain cannot be treated just by pharmacologic means. The two surgical procedures commonly done on spondylolisthesis patients are decompressive laminectomy and spinal fusion. Decompressive laminectomy eases pressure on the nerve by removing the part of the vertebrae which is causing direct pressure on the nerve while in spinal fusion; the vertebrae are literally fused together by a bone transplanted on the spine. Spinal fusion is the more long term and stable procedure done to alleviate pain caused by the condition.

Spondylolisthesis Exercises

As in the conservative treatments for spondylolisthesis, exercises are an integral part of the physical therapy part of treatment. The exercises in this treatment are designed to increase the strength of muscles in the lower back and abdomen to give extra stability to the spine. It is important to keep in mind that with these exercises, it can take time before the effects are felt and a slow increase in intensity is important to prevent the worsening of the condition.

References:

http://www.medicinenet.com/spondylolisthesis/discussion-372-page2.htm

http://en.wikipedia.org/wiki/Spondylolisthesis

http://www.nlm.nih.gov/medlineplus/ency/article/001260.htm

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