Under the Knife of Spondylolisthesis

Under the Knife of Spondylolisthesis

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     Imagine you are sitting in a doctor’s office waiting for a report on your condition. Your symptoms are pain that spreads across your lower back that doesn’t go away, spasms that stiffen the back and tighten the hamstrings, and numbness in the lower extremities. Upon examination and after x-rays, the doctor sits down in the room and tells you of a condition you have called spondylolisthesis. Spondylolisthesis.....??? What is that.....??? Spondylolisthesis is the forward slippage of one vertebra on the vertebrae beneath it. This forward slippage can be the result of many causes and is classified based on the reason for the slip (American Academy for Orthopaedic Surgeons, p 1). Most cases of the disease occur in the low lumbar spine with the most common spinal levels being either L5-S1 or L4-L5. Depending on the cause of the disease, it can be classified as one of six different types. The types are congenital, isthmic, degenerative, traumatic, pathological, and post-surgical. When faced with spondylolisthesis the question of how to deal with the condition arises. The options to treat the condition are small in number. One can either choose conservative treatment or a more radical decision of surgery. Here our controversy arises: to have surgery or to choose another route. This is a much more difficult decision than it may seem due to the fact that most of the routes come to a dead end. Conservative treatments only alleviate the symptoms; they do not correct the slippage. We should now go on to the different types of spondylolisthesis, their symptoms, and their treatments.

     This form of spondylolisthesis is caused by an abnormality of the bones of the spine. An individual is born with an abnormality of the arch in back of the spine. This abnormality most commonly occurs at the L5-S1 levels of the spine and usually includes the joints that connect one vertebra to another at the back of the spine. These joints are called facet joints (Ullrich, p 1). Due to the nature of the bones, the normal ability of the spine to keep proper alignment is lost as vertebral body of L5 slips forward on S1. As diagnostic technology has improved (MRI’s and CT Scans) this once thought rare occurrence is becoming identified more and more with each new advancement in the field. Two orthopedic authorities, Winter & Moe, quote a percentage of 14-21% of all cases of spondylolisthesis are caused by an abnormal bone formation known as dysplasia.

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In most patients, this becomes evident in the adolescent years. Usually the patient the patient has or has had a history of hyperextension activities. The most common include gymnastics, soccer, football lineman, diving, weight lifting, and volleyball. Most adolescents with spondylolisthesis are asymptomatic (without symptoms) and pain-free. However, the most common cause for back pain in adolescents is spondylolysis and listhesis (Ullrich, p 1). Back pain is the most common complaint, but leg pain (or sciatica) is also very common. A patient with leg pain may have impaired ability to lift the foot and big toe due to nerve root impingement. A patient may walk with a foot drop but this occurrence is a rare one. If the slip has occurred at a different level in the spine, a different pattern of pain, numbness, and weakness will occur. A thorough examination with x-rays will reveal different findings depending on the severity of the slip. Most children with this form of spondylolisthesis most usually have tight hamstrings. Other findings will depend on the amount of slippage and are best founded by a qualified physician.
     As there are different treatments for this we will go over each one separately. The first line of treatment includes: 1) rest, activity modification, and anti-inflammatories. Patients, who may be involved in hyperextension activities, should discontinue any of those activities. In addition, exercises such as hamstring stretching should be introduced to relieve muscle spasm and provide pain relief. Physical Therapy for abdominal strengthening should be involved to help stabilize the mobile junction for secondary support. Even though some low-grade slip cases may improve with these conservative measures the problem still remains unresolved. Although these few may feel improved, these conservative measures will not change the status of the slip. 2) Another treatment is through bracing. A brace can be used with patients who have an acute condition, significant pain, or those who haven’t shown improvement through other measures. The brace can either be a thoraco lumbar sacral orthosis or can include a thigh cuff. The device limits the motion in the area of injury. It allows the tissues to heal without extra inflammation while increasing pain relief. The thigh cuff reduces lumbosacral motion when locked by immobilizing the pelvis. 3) A cast can become the next level of treatment; it includes the body and one or both legs. It is successful in immobilizing the structures around the injured area and thereby provides greater support. 4) Surgery is the last choice in the treatment process. In-patients with slips from 0-50%, fusion of the one level involved is usually undertaken. Fusion is the binding together of two or more bones to make one bone. In higher-grade slips, two levels usually are required for fusion (Ullrich, p 1). Surgery of this nature requires a hospital stay of 2-4 days followed by a rehabilitation program after which the patient will return to normal function within 6-9 months. Success rate of this surgery rank at 97%. The patient further benefits from the aspect of surgery by having the condition completely eliminated rather than just dealing with the symptoms.

     Isthmic spondylolisthesis is caused by a defect in a part of the bone called the pars interarticularis. The pars bone connects the upper joint of one vertebra to the lower joint (Ullrich, p 2). Due to this pars defect, the vertebrae are allowed to slip forward out of its alignment. This usually occurs with L5 slipping over S1. Isthmic spondylolisthesis is usually caused by a stress fracture of the pars. This condition can be painful in itself even without the slippage. This fracture is thought to occur due to repetitive stress through the pars. The type of stress occurs when one bends backwards. Usually the patient is born with some minor abnormality of the pars, which can contribute to the episode of the fracture. The symptoms and treatment of isthmic spondylolisthesis is the same as the congenital form.

     This form of spondylolisthesis is a forward slippage due to arthritis of the spine. Stenosis (a narrowing of the canals, which carry the spinal nerves) is highly associated with this type. The cause in which the vertebrae slips is as follows: first, as the disc in front of the spine ages it loses water and loses some of its ability to resist motion. As a result, the joints increase in size and develop extra soft tissue and bone to compensate. The tissue and bone then impinges on the nerve roots and actually weaken the joints in the back of the spine. This causes the slippage. Due to all the structures and joints in the back of the spine being intact and no pre-existing dysplasia, the amount of slippage is limited by the bony restraints. The most common region for this type is L4-L5 region. The reason being, L5-S1 has secondary restraints keeping slippage at minimum. Symptoms that exist are again low back pain and problems with numbness in the lower extremities. Conservative measures of treatment consist of: activity restrictions, medications, injections, bracing, or physical therapy. All of these conservative measures may make the patient feel better, but it is only masking a problem that cannot be fixed through this treatment. The second option is surgery to correct the slippage through fusion of the two vertebrae together. Surgery, as above, corrects the alignment of the slippage thereby relieving all symptoms and restoring function without restriction.

     Traumatic spondylolisthesis is a slip of a vertebrae caused by a fracture in the spine, usually at a facet joint. This type presents with the same symptoms of all types above as well as treatment.

     This type is caused by destruction of the posterior aspect of the spine through either a tumor or infection or abnormal bone such as in osteoporosis. The disruption of the bone allows the slippage (Ullrich, p 2). This is rare type that may involve chemotherapy and other medical interventions.

     This form of spondylolisthesis is the rarest of all types due to such a high success rate in all surgeries performed. This problem only occurs in 3 % of all surgeries including malpractice. In this case the surgery does not perform as it should and the patient must have the problem solved in another manner.

     In conclusion, although most patients fear going “under the knife”, the outcome is usually a successful one. A patient must take into consideration all options and discuss them with their medical doctor before making any decisions. However, from review of the information in this report, surgery may be the best option for a large part of the population with this disease. When you consider the idea that one can return to normal function after surgery, why not take the plunge? Caution must be taken when making any kind of medical decision in a hasty manner. There are always options to be considered since all cases a different. Spondylolisthesis can be a devastating and life changing disease if not handled in a proper manner. However, with careful treatment and a dedicated patient, one can return to levels of previous function.

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