Lumbosacral Spondylolisthesis Treatment & Management

 

 

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, Williams 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. ^{[2, 25]} 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. ^[2] If pain continues to persist, then a spinal fusion is recommended.

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 1 or 2 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 in the following settings ^{[25, 26]} :

• 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.
• For patients with any degree of slip who have pain persisting for more than 6-12 months that has not been relieved with rest and immobilization.

Spondylolysis or low-grade spondylolisthesis may be managed nonoperatively. ^{[2, 3]}

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 magnetic resonance imaging (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. ^{[27, 28]}

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 high rate of deficits does not appear to be balanced by improved results; fusion in situ has achieved similar clinical outcomes with a lower complication rate.

Consultations

The following specialists might be consulted:

• Sports medicine specialist

• Orthopedic surgeon, spine surgeon, or neurosurgeon if surgical intervention is considered (ie, high-grade slippage, refractory cases)

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.

Surgical intervention

Surgery is indicated if the slippage is greater than 50% or in cases of refractory symptoms or progressive neurologic deficit.

Consultations

Consultations with specialists may be indicated as in the acute phase (eg, sports medicine specialist, orthopedic surgeon, spine surgeon, neurosurgeon).

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

Recommendations similar to those in the acute and recovery phases are continued in the maintenance phase. 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).

Surgical intervention

Surgery is necessary only if high-grade slippage is present or if symptoms are refractory to conservative management.

Consultations

Specialty consultations are indicated only if high-grade slippage is present or if symptoms are refractory to conservative management.

Return to play

In general, the athlete is ready to return to play once the following are demonstrated ^[29] :

• Full, pain-free range of motion

• Normal strength

• Appropriate aerobic fitness

• Adequate spinal awareness and mechanics

• Performance of sports-related skills without pain

Patients with a slippage equal to or less than grade 1 may resume desired activities once they are asymptomatic. Patients with a grade 2 or greater slippage are generally instructed to avoid hyperextension loading of the spine after symptoms resolve with conservative treatment.

Complications

Possible complications include slippage progression, neurologic deficit, and disc degeneration adjacent to the previously fused segments.

Prevention

Avoiding activities that involve repetitive hyperextension is important for preventing spondylolisthesis. Continuous flexibility and strengthening exercises are recommended to minimize excessive forces on the lumbosacral spine. If overweight, the athlete is encouraged to achieve his or her ideal weight to reduce stress on the lumbar spine.

Prognosis

The prognosis of spondylolisthesis is benign in most cases, and the problem can usually be managed nonoperatively. Surgical correction, when necessary, is usually successful in eliminating symptoms, and the union rate following surgery has been estimated at approximately 75% (depending on the degree of slippage and the surgical technique used).

Education

Patients need to be educated regarding which activities to avoid and which exercises should help minimize the forces that aggravate the condition, and how to identify the typical signs of complications. In their chosen sport, proper technique should be emphasized along with avoidance of abrupt increases in training frequency.

Medical/legal pitfalls

Medicolegal issues may arise in cases of missed diagnoses (especially if they result in permanent symptoms), improper treatment, or poor postoperative outcomes.