Aging and spondylolisthesis

Introduction

Spondylolisthesis occurs when one vertebra slips forward over the vertebra below. Degenerative spondylolisthesis often affects the lumbar (low back) spine, often at L4-L5. Degenerative changes in vertebral structure may cause joints between vertebrae to slip forward creating a spondylolisthesis and more common in older female patients over age 60.

Why it occurs in women?

- Bones are typically smaller and lighter

- Loss of bone mass accelerates as estrogen level declines, especially in first five to eight years after menopause

- Women make up 80% of patients with osteoporosis

- Excessive dieting or eating disorders can contribute to bone loss

Anatomy

-Pars Interarticularis: Area between the superior and inferior facets

-Lumbar Spine: L1-L5, Vertebral body, Disc, Nucleus pulposus, Annulus fibrosis,  Pedicles, Laminae, Facet Joints.

Any injury, degeneration or trauma to the motion segment ( facet joints and dics) may lead to :

Spondylosis – degenerative of IVD

Spondylolysis – a defect in the pars interarticularis

Spondylolisthesis – a forward displacement of one vertebra over another

Retrolisthesis – backward displacement of one vertebra to another

There are 3 stages of injury to the pars interarticularis

1) Stress reaction

2) Fracture (spondylolysis)

3) Slippage (spondylolisthesis)

If fracture gap at the pars widen, the condition can be known as spondylolisthesis. Widening of the gap leads to the fifth lumbar verterbra shifting forward on the part of the pelvic bone called the sacrum. Standing lateral spine x rays able to determine the amount of forward slippage.

What is spondylolisthesis?

Defined as when one vertebra slips forward over the vertebra below it (http://www.neurospine.org/Spondylolisthesis_2.html)

Pathological conditions characterized by Ferrari, Vanti & O’ Reilly (2012):

- Slipping of a vertebral body, compared with the underlying one

- Following structural and/or degenerative changes of the spine

- Pain is exacerbated by repetitive extension, rotation, return from a flexed position and sudden activities

- Pain is relieved by resting

- Patient may report radicular symptoms in one or both legs

Types of spondylolisthesis

• Congenital: present at birth, abnormal bone formation, abnormal arrangement and high risk of slipping
• Isthmic: Result of spondylolysis, small fractures in vertebra, fractures weaken the bone and it slip out of place
• Degenerative: Most common, the disc, the cushion between vertebral bones lose water, less spongy and less able to resist movement by vertebrae.
• Traumatic: Injury leads to spinal fracture. slippage
• Pathological : Spine is weakened by disease (osteoporosis)

Degenerative spondylolisthesis

• Commonest cause of lumbar spondylolisthesis above age 50 years old.
• Neural arch is intact, slip occurs because of degenerative changes in the facet joints with associated disc degeneration. It shows a more sagittal orientation of facet joints in lower lumbar spine, which is a congenital variation.
• Hence, facet joint transmit body weight anteriorly rather than inferiorly
• Inverterbral disc at this level starts to show premature degenerative changes
• Degree of slip is usually mild
• Even a small progression in the slip can result in cauda equina compression
• Affects the L4/5 level most commonly (9x common than other level), and 4x common in women
• Osteoarthritic changes seen are synovitis, cartilage degeneration, and osteophytes.

Pathophysiology

With  aging, high stresses and motion produce degeneration of the interverterbral disc.

Loss of water content in the nucleus pulposus and disc height.

As disc in anterior column deteriorates, it loses its ability to resist motion in affected spinal segment.

Result: unstable verterbral segment moves forward and narrows the spinal canal or nerve roots = nerve compression exist.

Grading of spondylolisthesis

- Based on Meyerding grading system

- Percentage of slippage through the x-ray

          Grade 1       :         0-25%

          Grade 2       :         25%-50%

          Grade 3       :         50%-75%

          Grade 4       :         75%-100%

          Grade 5       :         100 % (considered spondyloptosis; the vertebra  completely falls of supporting the vertebra)

Sign  & Symptoms

- Low back pain and tenderness

- Buttock pain

- Lumbosacral tenderness

- Protruding abdomen

- Thigh and leg pain and/or weakness

- Spasm of hamstring : if slipped vertebra is pressing on nerve, pain might spread down the leg to the foot

- Hamstring tightness :cause the person to walk with short strides and with knee slightly bent.

Diagnosis

• X ray: Done on a lateral side of lumbar x-ray. Example: vertebra above the arrow is not in line with vertebra below it, it is slipped forward
• CT scan or MRI can be done also in obtain  : the anatomy in great details

Treatment

1-Conservative-about 80% people will improve in 6 weeks of treatment.

2-Factors need to be considered for conservative:

- Age and overall health of the person

- Extent of the slip

- Severity of the symptoms

3-Aims in conservative treatment:

- To reduce irritation of the nerve and disc

- To improve physical condition of patient

- To give protection to spine & indirectly will improve spine function

4-Example of conservative treatments:

• Rest
• NSAIDs (ibuprofen)
• Analgesic drugs: Epidural steroid injections
• Education : emphasize on wearing lumbar corset, brace or back support and comfortable position
• Physical therapy/ exercises : Strengthen the abdominal and/ or back muscles, Minimizing bony movement of spine
• Modifications of ADL so less stress is put on lower back

Physical therapy:

Assessment: Detect major problem of patient, SLR show positive result

Treatment:

- Pain management (U/S, TENS, H/P, C/P, Traction, Manual/Hands on skills)

- Gentle stretches exercises & posture changes

- Improve flexibility, strength, endurance

Advice:

- Avoid driving

- Prolonged sitting

- Excessive lifting and flexion of the trunk

Operative: Indicated :

- If vertebra continue to slip

- Pain is not relieved by conservative treatment

Goal:

1) To relieve the pain associated with an irritated nerve

2) To stabilize spine where vertebra has slipped out of place

3) To increase the person’s ability to function

Most common:

- Decompressive laminectomy

- Removing the part of bone that is pressing on the nerves. However, removing a piece of bone can leave the spine unstable.

- Spinal fusion, provided stability, piece of bone is transplanted to the back of spine,as the bone heals, it fuse with the spine.

- Creating a solid mass of bone, keep the spine from moving and stabilizing it.

An example of plan of treatment of physiotherapy

1-Pain management: Hot pack

Aim: to reduce pain and muscle spasm

pt. position: prone lying

Procedure: apply hot pack at lower back

Dosage: 20 minutes

2-Stretching exercise:

a) Trunk rotation

Aim: to stretch & mobilize trunk.

Pt. position: crook supine lying

Procedure: bring both knee down to the right & to the left

Dosage: 5 reps/set x hold 15 sec x 2 set

b) Knee to chest

Aim: to stretch & mobilize trunk.

Pt. position: crook supine lying

Procedure: bring one knee to the chest and hold

Dosage: 5 reps/set x hold 15 sec x 2 set ; alternate legs

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c) Hamstring stretch

Aim: to increase flexibility of muscles.

Pt. position: long sitting

Procedure: using a towel placed on pt’s foot, pt hold each end of the towel and pull leg straightly, do for both legs

Dosage: 5 reps/set x hold 15 sec x 2 set ; alternate legs

3) Strengthening exercise:

a) Pelvic tilt

Aim : to strengthen back muscles

pt position : crook supine lying

procedure : tighten stomach muscle and pull lower back to the bed

Dosage : 5 reps/set x hold 8 sec x 2 set

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b) SLR in 1 plane

Aim : to strengthen bilateral lower limb muscles

pt position : crook supine lying

procedure : One knee is bent, another knee is lift up and extension

Dosage : 5 reps/set x hold 8 sec x 2 set ; alternately

4.  Pt education

- Do not hold breath while doing exercises

- Pamphlet of back education is given

- Importance of each exercise

- Joint protection program

- Practice a good posture while lifting heavy object, bend hip & knee, maintain straight back

- Do not twist the trunk while lifting heavy loads with foot planted on the ground as it will give more stressed on the spine

5. Home exercise program

- Do exercise regularly, minimal 2 session per set

- If pain increased after doing all the exercises, stop the exercises immediately and seek medical attention.