eMedicine Specialties > Physical Medicine and Rehabilitation > Lumbar Spine Disorders

Lumbar Spondylolysis and Spondylolisthesis: Differential Diagnoses & Workup

Author: Beth B Froese, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Orthopaedic Associates of DuPage Ltd
Contributor Information and Disclosures

Updated: Jul 5, 2009

Differential Diagnoses

Coccyx Pain
Lumbar Degenerative Disk Disease
Disk Herniation
Lumbar Facet Arthropathy
Diskitis
Mechanical Low Back Pain
Lumbar Compression Fracture
Overuse Injury

Other Problems to Be Considered

Osteoid osteoma (produces positive bone scan)
Spinal cord or bony malignancy

Workup

Laboratory Studies

  • Laboratory studies do not help in diagnosing spondylolytic spondylolisthesis. Workup is radiographic in nature.

Imaging Studies

  • Radiography
    • Initial workup includes anteroposterior, lateral (done while standing), and spot view radiographs of the lumbar spine and lumbosacral junction. Oblique views may provide additional information but are not obligatory. Flexion/extension views increase the sensitivity of radiographic studies and give the clinician some idea of the degree of instability that may be present. Percentage of slip and slip angle (calculated by measuring the angle formed by a line drawn from superior endplate inferiorly and the inferior endplate at the segment of involvement) are clinically valuable.
    • Radiographic studies allow visualization and grading of spondylolisthesis but may not always reveal the presence of an isolated spondylolysis (without spondylolisthesis). The 'Scottie dog' whose neck is broken can be seen on the oblique films when there is a classic spondylolysis. (See image below and Images 2, 6.)


Lumbar oblique radiograph showing the "Scottie Do...

Lumbar oblique radiograph showing the "Scottie Dog." A pars defect is seen at L5.

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Lumbar oblique radiograph showing the "Scottie Do...

Lumbar oblique radiograph showing the "Scottie Dog." A pars defect is seen at L5.



Diagram in the oblique projection shows the compo...

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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Diagram in the oblique projection shows the compo...

Diagram in the oblique projection shows the components of the vertebrae that result in the appearance of a Scottie dog with a collar.


  • Bone scan
    • Bone scan with single-photon emission computed tomography (SPECT) imaging is helpful and often helps to direct management (see image below and Image 3).
    • If the bone scan is positive, then the lesion is metabolically active. The physician may consider bracing, since healing is still in progress. A cold scan in the context of documented spondylolysis indicates that healing is complete; therefore, bracing is of limited utility.


Bone scan with single-photon emission computed to...

Bone scan with single-photon emission computed tomography (SPECT) imaging showing acute spondylolysis

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Bone scan with single-photon emission computed to...

Bone scan with single-photon emission computed tomography (SPECT) imaging showing acute spondylolysis

  • Computed tomography (CT) scan13
    • CT scan performed with 1 mm sections, including coronal and sagittal reconstructions, allows for better visualization of the spondylolytic defect.
    • CT scan not only documents the presence and severity of spondylolysis, but it can help rule out more serious causes for a positive bone scan.
    • Myelogram/CT studies are helpful in delineating the severity of central stenosis. Nerve root cut-off often is observed in the presence of radiculopathy.
  • Magnetic resonance imaging (MRI)13
    • MRI may visualize edema in the marrow around the sight of an acute spondylolytic defect.
    • MRI also is helpful in identifying the presence of nerve root compression as a result of foraminal or central canal stenosis.

Other Tests

  • Electromyography may provide 1 more modality for identifying a concomitant radiculopathy or polyradiculopathy (ie, stenosis), which may be present as a result of spondylolisthesis.

Histologic Findings

Histologic studies completed at the sight of the spondylolisthesis reveal a fibrocartilaginous mesh that often bridges the gap between the edges of the fracture sight if actual healing does not occur.

More on Lumbar Spondylolysis and Spondylolisthesis

Overview: Lumbar Spondylolysis and Spondylolisthesis
Differential Diagnoses & Workup: Lumbar Spondylolysis and Spondylolisthesis
Treatment & Medication: Lumbar Spondylolysis and Spondylolisthesis
Follow-up: Lumbar Spondylolysis and Spondylolisthesis
Multimedia: Lumbar Spondylolysis and Spondylolisthesis
References
Further Reading
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References

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

  2. 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.

  3. 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].

  4. 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].

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

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  8. 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].

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

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  11. 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].

  12. 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].

  13. 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].

  14. 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].

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

  16. [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].

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

  18. 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].

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

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

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

  23. 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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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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, 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, FAAPMR, FAAEM 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.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
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.

 
 
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