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 to reduce any postural component causing increased lumbar lordosis. Myofascial release may play a role 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. [2]
A literature review by Longo et al suggested that in patients with high-grade spondylolisthesis, surgical treatment with reduction followed by arthrodesis may be more beneficial than arthrodesis in situ. The report was based on eight studies, involving a total of 165 operations in which reduction was performed prior to arthrodesis and 101 surgeries in which patients underwent arthrodesis in situ, with no reduction performed. The investigators found that in the patients treated first with reduction, the percentage of slippage and slip angle and the frequency of pseudarthrosis were significantly lower than in the arthrodesis in situ patients. Moreover, there was no significant difference between the two groups with regard to the prevalence of neurologic deficits. [20]
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. [21]
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. [22] 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 and facet or epidural steroid injections, along with the above-mentioned physical therapy approach.
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Radiograph of the lumbosacral junction showing a grade 1 spondylolytic spondylolisthesis at L5-S1.
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Lumbar oblique radiograph showing the "Scottie Dog." A pars defect is seen at L5.
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Bone scan with single-photon emission computed tomography (SPECT) imaging showing acute spondylolysis
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Axial computed tomography (CT) scan shows bilateral spondylolysis. Note elongation of the spinal canal at this level.
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Grade 4 traumatic spondylolisthesis.
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Diagram in the oblique projection shows the components of the vertebrae that result in the appearance of a Scottie dog with a collar.
