Lumbar Spondylolysis and Spondylolisthesis Clinical Presentation

  • Author: Beth B Froese, MD; Chief Editor: Rene Cailliet, MD   more...
 
Updated: Jan 18, 2012
 

History

  • Isthmic spondylolisthesis
    • Symptoms often occur around the time of an adolescent growth spurt.
    • Some report acute onset of focal low back pain during activity, while others have more insidious onset.
    • Radiating pain may extend to the buttocks or thigh. Pain may be more significant and have mechanical characteristics with higher grades of spondylolisthesis.
    • In most cases, patients do not complain of symptoms suggesting neurologic deficit with lower grades of spondylolisthesis. Radicular pain becomes more common with larger slips. Complaints of radiating pain below the level of the knee associated with numbness and tingling in a dermatomal distribution would suggest the presence a radiculopathy resulting from either the foraminal stenosis that occurs with spondylolisthesis or a concomitant herniated disk. Nerve root impingement from the fibrocartilaginous bar that forms at the sight of the lysis may occur. High degrees of spondylolisthesis may present with neurogenic claudication or symptoms suggesting cauda equina impingement.
    • The patient's pain usually is provoked by activity, particularly back extension activities.
    • Patients with acute spondylolysis tend to demonstrate poor tolerance of activities requiring excessive spine loading, including running and jumping. Sitting usually is better tolerated.
    • A large percentage of patients with spondylolysis are asymptomatic. Progression of a spondylolisthesis also may occur without symptoms.
  • Degenerative spondylolisthesis
    • The pain begins insidiously and may be achy in character. Pain is located in the low back and posterior thighs.
    • Neurogenic claudication may be present as well, with lower extremity symptoms being made worse with activity and better with rest.
    • Symptoms are often chronic and progressive, although patients may experience periods of remission.
  • Dysplastic spondylolisthesis: Symptoms present much like isthmic spondylolisthesis, but neurologic compromise is more likely.
  • Traumatic spondylolisthesis
    • Patients present with acute pain associated with trauma.
    • If a slip is severe enough, cauda equina compression may occur and present with classic symptoms including bowel and bladder dysfunction, radicular symptoms, or neurogenic claudication.
  • Pathologic spondylolisthesis: Symptoms may be insidious in onset and associated with radicular pain/claudication.
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Physical

  • Isthmic spondylolisthesis
    • Hamstring tightness is observed almost universally, even in low-grade spondylolisthesis.
    • Lumbar spasm may be present.
    • A palpable step-off is noted with slips equal to or greater than grade 2.
    • With higher degrees of spondylolisthesis, an increased lumbosacral kyphosis is seen (50% or greater) along with a compensatory thoracolumbar lordosis. Truncal shortening may be present. With severe slips, the rib cage may rest on the iliac crest.
    • Dermatomal weakness may be present if a radiculopathy or an element of stenosis is present.
    • A waddling gait may be noted secondary to hamstring tightness producing a shortened stride length.
    • If spondylolisthesis is not present, spondylolysis presents with paraspinal spasm, pain provocation with lumbar spine extension, and tight hamstrings.
  • Degenerative spondylolisthesis
    • These patients present with less prominent physical findings. Pain often is provoked with lumbar spine extension.
    • If lumbar stenosis is present, then reflexes may be diminished. Radicular findings also may be present.
  • Congenital/dysplastic spondylolisthesis: Physical findings are similar to those described above for isthmic spondylolisthesis.
  • Traumatic and pathologic spondylolisthesis
    • These patients also present with similar findings.
    • A good neurologic evaluation is important.
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Causes

  • A genetic predisposition to isthmic spondylolisthesis is believed to be linked with patients having a thin pars or subtle hypoplastic facet joints. Family members have a reported incidence of 28-69%. Activities requiring lumbar extension stress increase the risk. Patients with spina bifida occulta are known to have a higher occurrence.[14]
  • Degenerative spondylolisthesis is caused by facet degeneration accompanied by disk degeneration most commonly at the level of L4-L5. Some studies identify sagittally oriented facets as more prone to arthritic change.
  • Congenital spondylolisthesis is due to dysplastic sacral or lower lumbar segments. Dysplastic facets or abnormal orientation of the facet joints are the cause for spondylolisthesis.
  • Traumatic spondylolisthesis is rare. In theory, severe hyperextension stress placed on the pars could produce fracture and instability. One should keep in mind that hyperflexion-distraction forces can cause facet dislocation and spondylolisthesis.
  • Pathologic spondylolisthesis can occur as a result of any bone lesion that might weaken the posterior elements. Generalized skeletal diseases including osteomalacia, syphilitic disease, and Von Recklinghausen disease are some reported causes. Bony destructive lesions, including tumor or infection, are other potential causes.
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Contributor Information and Disclosures
Author

Beth B Froese, MD  Consulting Staff, Department of Physical Medicine and Rehabilitation, Orthopaedic Associates of DuPage, Ltd

Beth B Froese, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Curtis W Slipman, MD  Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

References

  1. Niggemann P, Kuchta J, Beyer HK, Grosskurth D, Schulze T, Delank KS. Spondylolysis and spondylolisthesis: prevalence of different forms of instability and clinical implications. Spine (Phila Pa 1976). Oct 15 2011;36(22):E1463-8. [Medline].

  2. Wiltse LL. Spondylolisthesis: classification and etiology. Symposium of the Spine. Am Acad Orthop Surg. 1969;143.

  3. Grobler LJ, Wiltse LL. Classification, and nonoperative and operative treatment of spondylolisthesis. In: Frymoyer's The Adult Spine: Principles and Practice. 2nd ed. Philadelphia, Pa: Lippincott; 1997:1865-921.

  4. Huang KY, Lin RM, Lee YL, et al. Factors affecting disability and physical function in degenerative lumbar spondylolisthesis of L4-5: evaluation with axially loaded MRI. Eur Spine J. Jun 14 2009;[Medline].

  5. Beutler WJ, Fredrickson BE, Murtland A, et al. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine. May 15 2003;28(10):1027-35; discussion 1035. [Medline].

  6. d'Hemecourt PA, Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med. Oct 2000;19(4):663-79. [Medline].

  7. Comstock CP, Carragee EJ, O'Sullivan GS. Spondylolisthesis in the young athlete. The Physician and Sportsmedicine. 1994;22(12):39-46.

  8. Rossi F. Spondylolysis, spondylolisthesis and sports. J Sports Med Phys Fitness. Dec 1978;18(4):317-40. [Medline].

  9. Sairyo K, Katoh S, Sasa T, et al. Athletes with unilateral spondylolysis are at risk of stress fracture at the contralateral pedicle and pars interarticularis: a clinical and biomechanical study. Am J Sports Med. Apr 2005;33(4):583-90. [Medline].

  10. Kruse D, Lemmen B. Spine injuries in the sport of gymnastics. Curr Sports Med Rep. Jan-Feb 2009;8(1):20-8. [Medline].

  11. Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. Feb 2004;86-A(2):382-96. [Medline].

  12. Oh JY, Liang S, Louange D, Rahmat R, Hee HT, Kumar VP. Paradoxical motion in L5-S1 adult spondylolytic spondylolisthesis. Eur Spine J. Jun 15 2011;[Medline].

  13. Peterson JB, Wenger DR. Asymmetric spondylolisthesis as the cause of childhood lumbar scoliosis--can new imaging modalities help clarify the relationship?. Iowa Orthop J. 2008;28:65-72. [Medline]. [Full Text].

  14. Wynne-Davies R, Scott JH. Inheritance and spondylolisthesis: a radiographic family survey. J Bone Joint Surg [Br]. Aug 1979;61-B(3):301-5. [Medline]. [Full Text].

  15. Sairyo K, Sakai T, Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing. J Bone Joint Surg Br. Feb 2009;91(2):206-9. [Medline].

  16. Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am. Jul 1999;30(3):487-99, ix. [Medline].

  17. Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine. Dec 1985;10(10):937-43. [Medline].

  18. [Best Evidence] Matsudaira K, Seichi A, Kunogi J, et al. The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis. Spine. Jan 15 2009;34(2):115-20. [Medline].

  19. Magee DJ. Orthopedic Physical Assessment. Philadelphia, Pa: WB Saunders; 1997:. 398.

  20. McGregor AH, Cattermole HR, Hughes SP. Global spinal motion in subjects with lumbar spondylolysis and spondylolisthesis: does the grade or type of slip affect global spinal motion?. Spine. Feb 1 2001;26(3):282-6. [Medline].

  21. Rothman RH, Simeone FA. Spondylolisthesis. vol 1. 1992:913-69.

  22. Simper LB. Spondylolysis in Eskimo skeletons. Acta Orthop Scand. Feb 1986;57(1):78-80. [Medline].

  23. Standaert CJ, Herring SA, Halpern B, King O. Spondylolysis. Phys Med Rehabil Clin N Am. Nov 2000;11(4):785-803. [Medline].

  24. Weinstein JN, Rydevik BL, Sonntag VKH, eds. Essentials of the Spine. New York, NY: Raven Press; 1995:. 195-230.

  25. Whitesides TE Jr, Horton WC, Hutton WC, et al. Spondylolytic spondylolisthesis: a study of pelvic and lumbosacral parameters of possible etiologic effect in two genetically and geographically distinct groups with high occurrence. Spine. Mar 15 2005;30(6 Suppl):S12-21. [Medline].

 
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Radiograph of the lumbosacral junction showing a grade 1 spondylolytic spondylolisthesis at L5-S1.
Lumbar oblique radiograph showing the "Scottie Dog." A pars defect is seen at L5.
Bone scan with single-photon emission computed tomography (SPECT) imaging showing acute spondylolysis
Axial computed tomography (CT) scan shows bilateral spondylolysis. Note elongation of the spinal canal at this level.
Grade 4 traumatic spondylolisthesis.
Diagram in the oblique projection shows the components of the vertebrae that result in the appearance of a Scottie dog with a collar.
 
 
 
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