Spondylolysis and SpondylolisthesisBack pain is the most common reason that individuals seek medical attention, and there are a large number of causes for low back pain. Spinal discs are most commonly thought of when experiencing low back pain. Spondylolysis and Spondylolisthesis are two less commonly understood conditions. Spondylolysis (spon-dee-low-lye-sis) is a stress fracture to a specific location within the vertebra known as the pars interarticularis. The pars interarticularis is located between the facets, or joints of a spinal boney segment. This condition typically affects the fifth lumbar vertebra (L5), but can also affect the fourth (L4), and it can be seen on x-ray. It is the most common cause of low back pain in adolescent athletes. With increasing severity of the stress fracture, a gap at the pars develops and the normal alignment of the vertebra is lost. The front portion of the vertebra (known as the body) can slip forward. In the lower lumbar region, the vertebra angle slightly forward. Because of this angle, gravity and muscle pull are able to displace the vertebral body forward down this “slippery slope,” therefore leading to the second condition called spondylolisthesis (spon-dee-low-lis-thee-sis). Spondylolysis can be inherited, degenerative or the result of a trauma. The congenital form is a condition whereby the vertebra is either malformed, thin or weak in the pars interarticularis. Degeneration is the result of arthritis that causes the spinal joints to remodel, therefore changing their orientation and allowing for a forward slippage to occur. Traumatic changes can be the result of macro (large) or multiple micro (small) traumas that lead to a stress fracture. Overuse in the form of activities and sports that encourage a significant amount of extension or hyperextension of the spine (bending backwards) can lead to these changes in the pars interarticularis. Sports such as swimming, diving, weightlifting, football, and gymnastics can place a great deal of stress on the spine because of the amount of spinal extension they involve. Work related activities can also demand a great deal of extension on the spine. Periods of increased physical activity, particularly involving extension type activities or rapid growth spurts, can lead to a slippage of the vertebra. It has been documented in the older population that spondylolisthesis can occur without spondylolysis, and that the slippage is most commonly due to disc degeneration. Pain from these two conditions can be central and across the whole lower back, and it can often be mistaken for a muscle strain. The stress fracture to the vertebra causes the muscles of the low back to spasm in order to protect the stress fracture from worsening. The hamstring and buttock/hip (gluteal) muscles can also spasm in the same way. The hamstring muscle spasms can create an altered walking pattern as well as gluteal (buttock) atrophy due to disuse. The individual may experience a “slipping sensation” when returning to an upright position, such as standing up from a sitting position or from bending over. The symptoms can be one sided within the low back itself. With increasing severity, the individual can present with pain and altered neurological symptoms, such as pins and needles and numbness, into the back of the legs and feet in the form of sciatica. This often becomes present when the slippage is compressing the nerves. However, it is possible to have either of these two conditions and experience minimal to no symptoms and not require surgery. The diagnosis of these conditions can be made by x-ray. If a slippage is present, the amount of slippage forward will result in a grade being assigned to the spondylolisthesis. The body of the vertebra is divided in to quarters. Therefore, if the vertebra is displaced forward 25% a Grade 1 is assigned, and if the vertebra is displaced forward by 50% a Grade 2, etc. If the entire vertebral body is displaced forward it is termed a spondyloptosis. If a patient is in physical therapy and not seeing improvement, a CT scan or an MRI may be necessary to determine the severity of the pressure or pull on the spinal nerves. Treatment for these two conditions is almost always nonsurgical, in the form of physical therapy. A physician often will prescribe medications to control for pain, inflammation, and/or muscle spasms. The physical therapist will help you identify movements and postures that should be avoided to allow the stress fracture to heal. If activities or movements that created the stress fracture are continued, the pain will persist or perhaps worsen over time. By following the guidance of the physical therapist, the low back pain will begin to reduce. Some physicians may prescribe a back brace (lumbo-sacral corset) to help protect the stress fracture as it heals. In physical therapy, specific corrective stretching exercises will be prescribed when inflexibilities are identified. Core spinal stabilization exercises are then utilized to control for pain, to limit unwanted excess spinal movement thus facilitating the healing of the stress fracture, as well as attempting to prevent future recurrences of pain. Modalities can be used to assist in controlling for pain, muscle spasm, and inflammation. Spinal traction can also be used to decompress a pinched nerve when present. Traction has also been shown to create a retrolisthesis, which means that the anteriorly displaced vertebral body can be realigned through tension created in the ligaments and discs. The realigned position of the spinal segments can then be maintained when combined with corrective spinal stabilization exercises. However, in some cases certain individuals do not respond to physical therapy intervention or the slippage continues to worsen despite the efforts made in therapy. In these cases surgery, in the form of spinal fusion, may be necessary. In any case, spinal conditions such as these need to be properly understood by the patient so that the healing process can begin. The use of an x-ray can identify the boney lesion, and from there the physical therapist will use the results of the physical examination to establish a comprehensive plan of care that can facilitate a swift and complete recovery of function, resolution of pain, and the prevention of future episodes. |