eMedicine Specialties > Physical Medicine and Rehabilitation > Lumbar Spine Disorders
Lumbar Spondylolysis and Spondylolisthesis: Treatment & Medication
Updated: Jul 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Most patients with low-grade isthmic spondylolisthesis and degenerative spondylolisthesis can be treated conservatively. If an isthmic lesion is acute, the patient should be restricted from provocative activities or sports until they are asymptomatic. Physical therapy is an integral part of the patient's rehabilitation process. The most accepted protocol includes activity and exercise that reduces extension stress.
The goals of exercise are to improve abdominal strength and increase flexibility. Since tight hamstrings are almost always part of the clinical picture, appropriate hamstring stretching is important. Instruction in pelvic tilt exercises may help reduce any postural component causing increased lumbar lordosis. Myofascial release may play a role as well in reducing pain from the surrounding soft tissues.
If conservative treatment is indicated for congenital spondylolisthesis, the above principles apply. Adequate work up must be completed for pathologic causes of spondylolisthesis prior to treating with conservative means. Traumatic spondylolisthesis most often requires surgical stabilization.
Medical Issues/Complications
Younger patients have a higher risk for progression of isthmic or congenital spondylolisthesis. Serial radiographic studies (standing lateral films only) should be performed every 6 months to follow these patients. Progression rarely occurs after adolescence. Patients with a unilateral pars defect may be prone to developing a contralateral pars defect with extension stress. Patients with degenerative spondylolisthesis are often older and have coexisting medical issues that must be taken into consideration when deciding appropriate treatment.
Surgical Intervention
Surgical treatment is indicated when any type of spondylolisthesis is accompanied by a neurologic deficit. Persistent disabling back pain after conservative management may be considered an indication. High-grade slips (greater than 50%) more commonly require surgical intervention. Traumatic spondylolisthesis is rare but almost always requires surgical stabilization.14
Other Treatment
- Bracing for acute isthmic spondylolysis/spondylolisthesis is controversial, but it has been shown in some studies to reduce symptoms and to facilitate healing. Most sources discuss use of a thoracolumbosacral spinal orthosis or modified Boston Brace for low-grade slips or for isolated spondylolytic lesions (without spondylolisthesis). Some sources advocate more extensive bracing with inclusion of most of the thorax (to the nipple line) and the thighs. Recommend use of the device for 3-6 months.15
- Steroid injections for pars pain have been advocated by some physicians. Epidural steroid injections may help radicular pain or neurogenic claudication.
- Matsudaira et al tested the effectiveness of limaprost, an oral prostaglandin E1 derivative, against that of etodolac, a nonsteroidal anti-inflammatory drug (NSAID), in improving the health-related quality of life in patients with symptomatic lumbar spinal stenosis.16 In a randomized, controlled trial, 66 patients suffering from central stenosis with acquired, degenerative lumbar spinal stenosis, along with neurogenic intermittent claudication and bilateral leg numbness related to the cauda equina, were administered a daily dose of limaprost (15 μg) or etodolac (400 mg) for 8 weeks. The results indicated that limaprost was more effective than etodolac in improving patients' physical functioning, vitality, and mental health, and in reducing pain and leg numbness.
- Treatment for degenerative spondylolisthesis may include bracing, facet or epidural steroid injections, along with the above mentioned physical therapy approach.
Medication
The goal of medication in care of spondylolysis or spondylolisthesis of any type is to mitigate pain. NSAIDs are used most commonly while narcotic analgesics are used for breakthrough pain.
Nonsteroidal anti-inflammatory medications
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Ibuprofen (Ibuprin, Motrin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Naprelan, Anaprox, Aleve)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Etodolac (Lodine, Lodine XL)
Inhibits prostaglandin synthesis by decreasing activity of the enzyme, cyclo-oxygenase, which results in decreased formation of prostaglandin precursors, which in turn results in reduced inflammation.
Adult
200-400 mg PO q6-8h prn; not to exceed 1200 mg/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia
Sulindac (Clinoril)
Decreases activity of cyclo-oxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Adult
150-200 mg PO bid or 300-400 qd; not to exceed 400 mg/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; patients whom aspirin, iodides or other NSAIDs induce hypersensitivity; gastrointestinal (GI) bleed, and renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia; caution in anticoagulation defects or are receiving anticoagulant therapy
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen (Tylenol, Feverall, Tempra, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in patients with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
Hydrocodone and acetaminophen (Vicodin, Lortab, Norcet, Lorcet-HD)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
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 |
| « Previous Page | Next Page » |
References
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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.
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].
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[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].
Magee DJ. Orthopedic Physical Assessment. Philadelphia, Pa: WB Saunders; 1997:. 398.
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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].
Further Reading
Related eMedicine articles:
Lumbar Disk Problems in the Athlete
Lumbosacral Spine Acute Bony Injuries
Lumbar Spine, Trauma
Lumbosacral Spondylolisthesis
Lumbosacral Spondylolysis
Pars Interarticularis Injury
Spinal Instability and Spinal Fusion Surgery
Spondylolisthesis
Spondylolisthesis, Spondylolysis, and Spondylosis
Spondylolysis
Clinical guidelines:
Diagnosis and treatment of degenerative lumbar spondylolisthesis. North American Spine Society - Medical Specialty Society. 2008. 133 pages. NGC:006568
Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: fusion in patients with stenosis and spondylolisthesis. American Association of Neurological Surgeons - Medical Specialty Society
Congress of Neurological Surgeons - Professional Association. 2005 Jun. 7 pages. NGC:005370
Clinical trials:
Clinical Outcomes of the Trinica(R) Anterior Lumbar Plate: Fixed Screws vs. Variable Screws
Greenwich Lumbar Stenosis SLIP Study
Pilot Study to Assess Safety/Prelimary Effectiveness of Prefix in Subjects With Degenerative Disc Disease (DDD) Undergoing Spine Fusion Surgery
Posterior Lateral Fusion (PLF) With Dynesys
Prospective Clinical Evaluation of the New Aegis Plate for Anterior Interbody Fusions
Keywords
spondylolysis, spondylolisthesis, low back pain, LBP, hamstring, disk pain, disc pain, discogenic pain, diskogenic pain, hamstrings, radiculopathy, lumbar stenosis, lumbar spinal stenosis, foraminal stenosis, pars defect, pars interarticularis, interarticularis, isthmic, nerve impingement, spondylolytic, tight hamstrings, pars fracture, spinal abnormality, spinal dysfunction
