eMedicine Specialties > Sports Medicine > Spine
Lumbosacral Spondylolisthesis: Treatment & Medication
Updated: Jun 3, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
As a general rule, physical therapy should not be started until after an adequate rest period and once pain with daily activities has subsided.
The goals of physical therapy are to decrease extension stresses of the lumbar spine and to strengthen elements that promote an antilordotic posture. This consists of exercises to strengthen the abdominal muscles (eg, William flexion-type exercises) and flexibility programs to stretch the spinal extensor muscles, hamstrings, and lumbodorsal fascia.
Bracing with a thoracolumbosacral orthosis (eg, Boston antilordotic brace) may offer relief for those who do not respond to activity restrictions or whose daily activities are producing symptoms.1,16 This type of bracing is usually effective in most patients with less than 50% slippage. The brace is generally worn for 3-6 months and may be worn during activity.
If the slippage is less than 50% but the patient is symptomatic, then nonoperative therapy (eg, stretching and strengthening exercises, antilordotic brace, activity modification) is instituted.1 If pain continues to persist, then a spinal fusion is recommended.
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Resource Center Spinal Disorders
Occupational Therapy
Avoidance of heavy-duty labor or activities with repetitive lumbar extension is necessary to allow healing to occur. An occupational therapist can be very beneficial for those individuals who need instructions and compensatory strategies for activities of daily living.
Recreational Therapy
Restriction from sports and other activities that require repetitive hyperextension may be sufficient treatment in young athletes. Patients with grade 2 slippage are generally instructed to avoid hyperextension loading of the spine after symptoms resolve with conservative treatment.
Medical Issues/Complications
Younger patients require more careful observation, even if the initial symptoms resolve, because of their greater risk for progression. In an asymptomatic child with slippage up to 25% (grade 1), initially observe with radiographs every 4-6 months if younger than age 10 years, semiannually until age 15 years, then annually until the end of growth. No limitation of activities is required, but the patient is advised to avoid occupations that entail heavy labor. If the slippage is 26-50% (grade 2) and the patient is asymptomatic, then the treatment is the same as for the grade 1 slippage but with a warning against participation in contact sports or sports requiring lumbar hyperextension (eg, football, gymnastics). In general, the results of conservative management are good in most athletes with Grade I or II slips.Complications include slip progression, loss of motion segments, neurologic deficit (eg, cauda equina syndrome, radiculopathy [greatest risk with >50% slippage]), and residual deformity (following fusion of a high-grade spondylolisthesis).
Surgical Intervention
Surgery is indicated for skeletally immature patients with greater than 30-50% slippage (with or without symptoms) because they are at greater risk for progression, in the event of progressive neurologic deficit, or in those with pain persisting for more than 6-12 months that has not been relieved with rest and immobilization with any degree of slip. Spondylolysis or low-grade spondylolisthesis may be managed nonoperatively.1,2,17
Options for operative management include direct repair of the spondylolytic defect, fusion in situ, reduction and fusion, and vertebrectomy. Ideally, repair of a pars defect is for young patients with spondylolysis but no spondylolisthesis. Best results are observed in those with a lytic defect between L1 and L4. L5 defects yield less predictable results. Disc degeneration as seen on MRI is a relative contraindication. Slippage of greater than 2 mm decreases the likelihood of successful repair.
Fusion in situ at the involved level is the criterion standard of surgical treatment for most patients in whom conservative management fails. Fusion in situ is recommended for patients with persistent, symptomatic, low-grade spondylolisthesis and for patients who are not candidates for repair of the pars defect. The desire to participate in a contact sport should not be the sole indication for a fusion.
Decompression and fusion are typically performed in cases of dural sac compression with the presence of bowel or bladder dysfunction or significant motor deficits. Decompression is never performed without concomitant fusion. Pedicle screw fixation enables rapid mobilization and early ambulation after decompression and fusion. Fixation may be beneficial in repairing pseudoarthrosis and, in the face of laminectomy, in preventing further slippage while awaiting fusion.
Spondylolisthesis reduction is performed either through closed or open procedures. Reduction serves to correct lumbosacral kyphosis and to diminish sagittal translation observed in high-grade slips. Vertebrectomy may be used to treat spondyloptosis (grade 5 spondylolisthesis), as an alternative procedure to reduction or fusion in situ. The postoperative rate of permanent neurologic deficits is high (25-30%), although many are preexistent. This does not appear to be balanced by improved results; fusion in situ has achieved similar clinical outcomes with a lower complication rate.
Related Medscape topics:
Specialty Site Orthopaedics
Specialty Site Surgery
Consultations
- Sports medicine specialist
- Orthopedic surgeon, spine surgeon, or neurosurgeon if surgical intervention is considered (ie, high-grade slippage, refractory cases)
Recovery Phase
Rehabilitation Program
Physical Therapy
Antilordotic strengthening and flexibility exercises for the back and lower extremities are emphasized (progressive spinal stabilization).
Occupational Therapy
Avoidance of heavy labor or any repetitive hyperextension continues to be important. An occupational therapist can assist by completing an ergonomic evaluation and assessing subsequent workstation modifications if needed to avoid unnecessary loading of the patient's lumbosacral spine.
Recreational Therapy
Once asymptomatic, patients with grade 1 or less slippage may resume their activities as desired (as long as they remain pain free). Continue to emphasize avoidance of aggravating factors, particularly those activities that involve repetitive hyperextension of the back.
Medical Issues/Complications
Under Treatment, Acute Phase, see Medical Issues/Complications.
Surgical Intervention
Surgery is indicated if the slippage is greater than 50% or in cases of refractory symptoms or progressive neurologic deficit. For specific procedures, see Treatment, Acute Phase, Surgical Intervention.
Consultations
Consultations with specialists may be indicated as in the acute phase (eg, sports medicine specialist, orthopedic surgeon, spine surgeon, neurosurgeon).
Maintenance Phase
Rehabilitation Program
Physical Therapy
Recommend that the patient continue with his or her home exercise program, focusing on lumbar stabilization to reduce biomechanical stresses (particularly extension) in the lumbosacral spine. The program should continue to include both stretching and strengthening exercises. The athlete now starts to focus on sports-specific retraining, with attention to skill and technique refinement.
Occupational Therapy
Similar recommendations are continued in the maintenance phase as compared with the acute and recovery phases. The patient should still be instructed to avoid heavy labor or any activity that may cause repetitive hyperextension loading of the lumbar spine.
Recreational Therapy
If the patient demonstrates low-grade spondylolisthesis, he or she may continue pain-free activities as tolerated. Those with higher-grade or symptomatic spondylolisthesis must avoid aggravating activities (especially those involving repetitive hyperextension or heavy labor).
Medical Issues/Complications
Under Treatment, Acute Phase, see Medical Issues/Complications.
Surgical Intervention
Surgery is necessary only if high-grade slippage or symptoms are refractory to conservative management.
Consultations
Specialty consultations are indicated only if high-grade slippage or symptoms are refractory to conservative management.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may include leukotriene synthesis inhibition, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topic:
Resource Center Adverse Drug Events Reporting
Ibuprofen (Motrin, Ibuprin)
Available in both prescription and nonprescription strength.
Adult
400-800 mg PO q8h prn
Pediatric
10 mg/kg PO q8h prn
Aspirin, other NSAIDs, and anticoagulants may increase bleeding; methotrexate toxicity; may increase serum lithium levels; may decrease effect of furosemide and thiazide diuretics
Documented hypersensitivity; during third trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
History of upper GI disease, peptic ulcer disease, impaired renal or hepatic function, bleeding disorders, edema, hypertension, diabetes, or dehydration
Nonnarcotic analgesics
Nonnarcotic analgesics are used for control of pain but not inflammation. These drugs are not associated with any adverse gastrointestinal (GI) reactions (ie, gastritis, peptic ulcer disease).
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 prn; not to exceed 4 g/d
Pediatric
<6 years: Use pediatric forms
6-12 years: 325 mg PO q4-6h prn; not to exceed 1.625 g/d
>12 years: Administer as in adults
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
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
Hepatotoxicity is possible in patients with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding the recommended maximum dose.
More on Lumbosacral Spondylolisthesis |
| Overview: Lumbosacral Spondylolisthesis |
| Differential Diagnoses & Workup: Lumbosacral Spondylolisthesis |
 Treatment & Medication: Lumbosacral Spondylolisthesis |
| Follow-up: Lumbosacral Spondylolisthesis |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
isthmic spondylolisthesis, spondylolysis, hyperextension of the lumbar spine, lumbar spine hyperextension, hyperextended back, hyperextended spine, back pain, lower back pain, low back pain, LBP, spondylolytic spondylolisthesis, lytic spondylolisthesis, pars interarticularis stress fracture, spine stress fracture, Meyerding grading technique, Taillard method, sacral inclination, slip angle
