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CSPE protocol 4/15/18

LumbarSpondylolysis&SpondylolisthesisLumbarspondylolysisisaunilateralorbilateraldisruption(usuallyastressfracture)ofthenarrowbridgebetweentheupperandlowerparsinterarticularis.Spondylolisthesisoccurswhenonevertebraslipsforwardinrelationtoanadjacentvertebra,usuallyinthelowestlumbarvertebralsegments(L4orL5).Spondylolisthesismayormaynotbeduetoaparsfracture.Althoughspondylolysisandspondylolisthesisareseparateentities,theyfrequentlydooccurtogetherandtheirmanagementisverysimilar.

Symptomaticspondylolysisandspondylolisthesisaregenerallyconditionsofchildhoodandyoungadulthood.

Spondylolysis

Spondylolysiscanrangefromadefect1intheparsinterarticularistoafracture2withseparationandcanbeunilateralbutisbilateralin80%ofsymptomaticcases.(Bouras2015)ThemostcommonlocationisL5(85-95%)followedbyL4(5-15%)(Malanga2016).Thepathologicalprogressionisaresponseusuallytorepetitiveloads,whichcreateastressreactioninthepars,progressingtoanincompletestressfracture,andthenacompleteparsfracture.Fromthatpoint,eithernormalhealingandunionwilloccurortheremayapermanentinactivenon-unionfilledinwithfibrotictissue.Theseearlystagesareapparentonlywithadvancedimaging.(Leone2011)Spondylolysisisestimatedtobepresentin6-13%ofthegeneralpopulation.Most,however,areasymptomatic.(Malanga2016)Intheyoungathlete,however,ithasbeenestimatedtocauseasmuchas47%oflowbackpain,comparedto5%inadultathletes(Micheli1995).Atthetimeofdetection,itisassociatedwithanteriortranslationofthevertebrae(spondylolisthesis)about25%ofthetime(Malanga2016).Theslippageisusuallyminorwithonlyabout11%ofadolescentsand5%ofadultsprogressingtomorethan10mmofslippage.(Malanga2016)Across-sectionalstudyofparticipantsintheFraminghamHeartStudy(Kalichman2009)followedanunselectedgroupofadultsaged40to80yearswithCTimagingandfoundaprevalenceoflumbarspondylolysisof11.5%.Therewasnosignificantassociationbetweenspondylolysis,observedonCTandtheoccurrenceofLBP.Theauthorsconcluded“theconditiondoesnotseemtorepresentamajorcauseofLBPinthegeneralpopulation.”1Parsdefect=occultfracture/stressreaction/stressfracture/incompletefracture.Aparsdefectmayprogresstoatruefractureoftheparsinterarticularis.Aparsdefectisnotacongenitalanomaly.2Truefracture=frankfracture/completefracture.Afracturethroughbothcorticesoftheparsinterarticularis,usuallyduetorepetitiveoverusebeginningasafatiguestressfracture.

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HISTORYTheprovidershouldsuspectacutespondylolysisinateenageroryoungadultwithlowbackpain,especiallyifheorsheisactiveinsportsthatrequirerepetitiousflexionandextensionhyperextensionortwistingandaxialloadactivities.(Bouras2015)Itismorecommoninmales(2:1)andthereisapositiveassociationwitholderteenagers(athletesunder20yearsoldin75%ofcases),andinathleteswhotrainformorethan15hoursperweek.(Malanga2016)Sportsthathavebeenimplicatedincludegymnastics,dance,wrestling,figureskating,weightlifting(particularlystandingoverheadpresses),swimming(especiallythebutterflystroke),diving,rowing,tennis(especiallyserving),soccer,baseball(especiallypitching),football(especiallylineman)andvolleyball.(Malanga2016,Perrin2016).Gymnasticsandfootballaregenerallyconsideredthehighestrisksports.(Perrin2016)Likeotherstressfractures,thepainmaycomeonabruptlyormoreinsidiouslyovertimeandonlyrelatedtocertainactivities.Abouthalfofthepatientsreportaninitiatingevent;symptomsintherestcomeongradually.(Shah2011)Thepainmaybeacuteandlancinatingintheinitialphaseandbecomedullandachyinthechronicpresentation(Malanga2016).Occasionally,evenafterthefracturehashealed,itmayremain“active”duetotissuechangesinthehealeddefectthatmakeithypersensitivetocertainloads.Severityrangesfrommildtomoderate.Patientsoftenreportdifficultyfallingtosleepduetopain(75%)andpainwhichisworsewithsittingandwithstanding(75%).Unfortunately,thesecomplaintsarenonspecificandpresentinothercompetingdiagnosesaswell.(Grodahl2016)Painassociatedwithhyperextensioninathletesisthemostcommonlyreportedhistoryandphysicalfinding.(Ledonio2017)PHYSICALEXAMINATION

• AROMisvariable.Itmaybecompletelynormal,althoughpainisfrequentlyaggravatedbyhyperextension,especiallyifitmimicsthesportingmovementthatgenerallyelicitspain.(Perrin2015).Insomepatients,thepainmayalsobeaggravatedbyextendingfromaflexedposturedandrotationorlateralflexiontothesideoflysis.Insomecases,flexionmayofferpainrelief;inothercases,itmaybelimitedbyhamstringspasm.(Malanga2016).

• Psoasmaybeshortandtightbilaterally.• Thestorktest(anorthopedictestinwhichthepatientstandsononelegandleansbackatan

angleoveronepars)isaclassictestbutonethatseveralstudieshavedemonstratedashavingpooraccuracy,failingtobeveryusefulatrulingtheconditioninorout.Itmayhavelimitedtousetoincreasesuspicionofabilateralbreak(whenthetestispositivebilaterally).(Shah2011)

• Inacutecases,focaltendernesscanbeelicitedoverthelumbarspine(Shah2011).Otherwise,theremaybenotendernesstopalpationexceptforsomediscomfortwithdeeppercussion.(Perrin2015)

• Thepresenceofskindimplingoverthespinesuggestspossiblespinabifidaocculta,whichincreasestheriskforspondylolysis.(Malanga2016)

• Neurologicalsignsareveryuncommon.

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ANCILLARYSTUDIES:DIAGNOSTICIMAGINGRadiographsaretheinitialimagingmodalityofchoice,butmoreadvancedimagingmayberequiredinavarietyofcircumstances.Advancedimagingisreportedtodetectbetween32-44%parsdefectsinpatientssuspectedofhavingspondylolysisbasedonhistoryandphysicalexamassessment.(Ledonio2017)RadiographyRadiographsmayrevealafractureattheparsinterarticularis,buttheyareofteninconclusiveinearlycases.Sensitivityandspecificityratingsfortestaccuracyarenotreadilyavailable,althoughonestudyreportedradiographstohavehighspecificityandpoorsensitivity(Ledonio2017)Inpediatricpatients,TofteetalrecommendstartingwithjusttheAPandlateralviewstoseeifadiagnosiscanbemade.Ifthesedonotrevealafracture,anAPaxiallumbosacralspotviewand/orobliqueviewsshouldbedone.Iftheseradiographsareequivocalorappearnormalbutthereremainsahighindexofsuspicion,advancedimagingmaybenecessarytoclarifythebesttreatmentapproach.Theinitialtwoviewstrategyexposesthepatientto7-9timeslessradiationdosethanbonescanning(e.g.,SPECT)andapproximatelyhalfofthatassociatedwithfour-viewplainradiographyandCT)[reportedinMalanga2016].Thetestsofchoiceiftheradiographisunclearisscanning(CTorSPECT)oranMRI.(Shah2011,Bouras2015).Eachimagingchoicehasitsownadvantagesanddisadvantages.CTSomeauthoritiessuggestthatCTisthebesttestfordiscoveringanoccultspondylolysisthatisnotreadilyapparentonplainfilmradiographs.(Dynamed2017)Although,surprisingly,formalvalidationstudieshavenotbeenperformed(Ledonio2017),CTscanningisgenerallyregardedasbeingmoresensitivefordetectingdefectsthanplainradiographsandmorespecificthansinglephotonemissionCTscans(SPECT).CTsprovideanadditionaladvantageofrevealingotherspinalpathologies(e.g.,intervertebraldiscpathology)thatarenotseenontheotherradionuclideimagingstudies.CTscanningmayhavearoleinmonitoringthestageofhealinginaparsfracture.

Oneimportantdisadvantage,especiallyinthepediatricpopulation,isthehighradiationexposure.Cancersinducedbyradiationare3-5timeshigherinchildrenthaninadults.(Ledonio2017)CTscanscannotreliablydistinguishbetweenactive(i.e.,thosethatmaybesymptomatic)andinactivelesions.(Dynamed2017)

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SPECT

ThesinglephotonemissionCTscan(SPECTscan)isthoughttobemuchmoresensitivefordetectingthepresenceofaparsdefectthanareplainradiographs.ItiscurrentlyunclearastowhetheritismoresensitivethanaregularCTinidentifyingthatadefectispresent.SPECTscansdocarrysubstantialfalsepositiveandnegativeratesthatmayrequirefurthertestingwithCTorMRI.(Ledonio2017)TheSPECTscanis,however,reportedtobethegoldstandardfordetectingoccultactive(andthereforemorelikelysymptomatic)spondylolysis.(ACR2015,Ledonio2017)Theaccumulationofradioactivelytaggeddyeemployedinthisscancanidentifyanareaofincreasedphysiologicalactivityinthebone,whichcorrelateswiththeinflammationthatoccursintheearlystageofafracture.

Therefore,SPECTcanalsobeusefulinclarifyingifafractureisactuallythecauseofthelowbackpain.InastudybyLoweetal.,apositivebonescancorrelatedwiththepresenceofLBP,whereasnegativescanswerenotcorrelatedwithpain,therebyhelpingtheproviderdifferentiateatruepaingeneratorfromanotherwiseincidentalfinding.ByassessingtheresultsofboththeplainfilmradiographandtheSPECTresults,apractitionercanplotacourseofaction.Seetablebelowforexamples.

PlainRadiograph SPECTScan Interpretation Management

Negative Negative(Nodyeuptake)

Parsdefectunlikely,seekotherdiagnosis

Furtherinvestigationofcauseofbackpainshouldbeperformed(e.g.,MRI)

NegativePositive

(Heavydyeuptake)

Earlyparsinterarticularisdefect/fracture

Conservativemanagementinformofrest,+/–bracing

Positiveforfracture

Healing(Lightdyeuptake)

Spondylolysis Conservativemanagementintheform

ofrestandbracing

Positiveforfracture Negative

Pseudoarthrosisoroldunhealedfracture

Considersurgicalinterventionforstabilizationtopreventspondylo-listhesisandtorelievepain.Considerfurtherinvestigationtoruleoutalternativepathology.

ModifiedfromMalanga2016SPECTscans,likeCTscans,alsoexposethepatienttosignificantamountsofradiation.LimitationsofaSPECTscanincludeaninabilitytodetectfracturesthathaveprogressedtochronicnonunion.Italsocannotdifferentiatespondylolysisfromfacetarthritis,infection,orneoplasmandsoCTmayneedtofollowapositiveSPECTtest.(Dynamed2017)

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MRIA2017reviewoftheliteraturereportsthatthereis“fair”evidencethatMRImaybeasaccurateasaCTscanand,becausethereisnoexposuretoionizingradiation,itmightbethepreferredinitialadvancedimagingofchoice(Ledonio2017,Leone2011,Kobayashi2013).Inaddition,MRIshouldbeconsideredforcaseswithneurologicalpresentations(which,thoughuncommon,areactuallymorelikelyassociatedwithspondylolisthesis).(Bouras2015)MRIhasbeenshowntobeusefulindetectingearlyedematousstressreactionsoftheparsarticularisevenwhenafracturelineisnotvisibleonradiographyorCT(Ledonio2017).

MANAGEMENT

Theprimaryobjectivesarepaincontrol,preventingaparsdefectfromprogressingtoafrankfracture,andpreventingslippage.Conservativecareoutcomesareusuallygood-excellentandreportedtobeashighas95%.(Kurd2007)

Thetreatmentapproachrequiresavoidingsportsoractivitiesthatrequirerepetitiveflexionandextensionandmayrequirebracing.Dynamed(2017)reportslevel3evidencethatmostpatientscanreturntosportsactivityinabout5.4-5.5months.AcuteInterventionsApplyicetotheinjuredareafor20minutes3-4timesadayalongwithpainfreeROMexercisesandstretchingofthehipflexorsandhamstringmuscles.Activitymodificationisrecommended.

Behavioralmodificationadviceshouldbegiventohelppatientsavoidhyperextensionposturesandactivities.

Physiologicalrest

Thefirstphaseoftreatmentisforthepatienttostoptheactivityorsportthatevokesthebackpainforanaverageof2-4weeks.[23,45,53]Inparticular,anyactivitiesinvolvinghyperextensionmustbeavoided.Ifplainfilmsdonotdetectafrankfracture,andadefectshowsonlyonSPECTscanandsymptomsareresolving,thepatientmaybegintoreturntoactivities.Butincasesoftruefractureorifsymptomsdonotresolverefrainingfromthesesportsactivitiesmayberequiredfor3-6months.Dynamed(2017)reportsthatthereismidlevelevidencethatstoppingsportsactivityfor≥3monthsisassociatedwithbetterpainimprovementthanstoppingsportsfor<3months.

Orthosis(bracing)

Bracingisacommonlyrecommendedintervention(Dynamed2017,Kurd2007),buthigh-levelevidenceislacking.A2009meta-analysisofchildrenandyoungadultstreatedconservativelyforspondylolysisandspondylolisthesisfoundthat83.9%ofpatientshadasuccessfulclinicaloutcomeafteratleast1year.Inthesepooledresultsfromobservationaltrials,bracingdidnotseemtoaffectpatientoutcomes.(Klein2009).NoRCTshavebeendonetoclarifytheeffectivenessofbracingsothedecisionisleftuptothepractitionerandpatients(orparents).

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PatientswithonlySPECTsignsofanoccultfracturemaynotrequireexternalbracing,althoughitremainsanoption.Bracingcanbeconsideredinpatientswhocontinuetohavesymptomsdespiteaninitialperiodofrest.Additionalindicationsfortheconsiderationofusinganexternalbracearepresenceofatruefracture,thepresenceofspondylolisthesis,orlackofpatientcompliancetoactivityrestrictions(Malanga2016).

RIGIDBRACE

AcommonapproachistoprescribearigidBostonbracetoimmobilizethepelvisandpreventhyperextension.Ifabraceisused,someauthoritiessuggestitismoreeffectiveifappliedassoonaspossible.(Shah2011)Itisgenerallyprescribedtobewornin0°lordosisfor20-23hoursadayforapproximately3-6months.Ina2015studyofchildren(ages5-14),treatmentincludedwearingabracealldayexceptatbedtime.(Leonidou2015).Thepatientisslowlyweanedoffitassymptomsresolveevenifthefracturehashealedinnonunion.(Shah2011)Oneprotocolfortheweaningprocessafter3monthsofwearwas30minutesofbracefreetimethreetimesadayforthefirstdayandthenanadditional30minutesaddedeachfollowingdayforabouttwoweeks.Patientswereallowedtosleepwithoutthebraceifsymptomswerenotexacerbated.(Kurd2007)Arepeatbonescanisusuallyperformedataround3months.(Perrin2016)Wearingarigidbraceisnottheonlybracingoption.Inonestudy,Moritaet.al.studied185adolescentswithspondylolysisandclassifiedtheparsdefectsintoearly,progressive,andterminalstages.[60]Arigid,antilordotic,modifiedBostonbracewasappliedfor23hoursperdayfor6months,followedby6monthsofweaning.Thiswascomparedtoconservativemanagement,whichincludedtheuseofaconventionalsoftlumbarcorsetfor3-6months.Follow-upradiographsshowedhealingwithouttheuseofarigidbracein73%ofthepatientsintheearlystage,in38.5%ofthoseintheprogressivestage,andin0%ofthoseintheterminalstage.[60]Formostofthesepatients,non-rigidbracingwasadequate.TheSairyoet.al.study(2012)suggeststhatpatientsyoungerthan18yearswithearlydefectsonCTscanmaybegoodcandidatesforrigidhardbracingfor3months,owingtothehighrateofunionintheirstudy.Bouras(2015)suggeststhattheathlete’scompliancewithtreatmentandrelativerestprotocolmaybemoreimportantthanwhichparticulartypeofbraceisused.PhysicalRehabilitationDynamed(2017)reportsthatthereismid-levelevidencethatalowbackphysicalrehabilitationfocusingonstabilizingbackexercisesmaydecreasepainintensityandfunctionaldisabilityinsymptomaticpatientswithisthmicspondylolysis.Therehabilitationprogramisinitiatedaftersymptomsbegintoresolveandthebonehashadsometimetorecover,butitshouldnotbedelayedtoolong.Oneretrospectivestudy(Selhorst2016)foundthatadolescentathleteswithacutespondylolysiswhowerereferredtophysicaltherapysoonerthanafter10weeksofrest,themedianperiodforfullreturntoactivitywasalmost25daysshorterthanforthosewhowaitedformorethan10weeks.Andtherewasnostatisticallysignificantdifferenceintheriskofadversereactionsseenbetweenthetwogroups.

Theexerciseprogramisessentiallythesameasfortreatmentforspondylolisthesis;seepage11.

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SpondylolisthesisSpondylolisthesisisgenerallyclassifiedascongenital(dysplasticwithabnormallyformedL5facetsbuttheparsintact);isthmic/lytic(defectinparsfromstressfracturesorboneremodelingafteratraumaticfracture;71-94%atL5);degenerative(duetofacetarthritisandremodeling);post-traumatic(damagetoposteriorelementsasopposedtothepars);andpathological(e.g.,secondarytoPaget’sdisease).(Bouras2015)Itcansometimesalsobeiatrogenicpostspinalfusionsurgeryorlaminectomies.Spondylolisthesisisalmostneverduetotrauma(Malanga2016)andmostcommonlyisisthmicinyoungpatientsanddegenerativeinolderpatients.Spondylolisthesisislikelyasymptomaticinmostadultpatients(onlyabout10%ofadultpatientswithspondylolisthesisreportedtohavesymptomsthatrequiretreatment)(Dynamed)andsoanincidentalfindingonaradiographmaybeworthchartingasacomplicatingfactor(especiallybyamanualtherapist)butmaynotberelevanttothepatient’ssymptoms.ClinicalTip:Spondylolisthesisisanunlikelycauseofbackpaininadults(especiallyafterage40)withnohistoryofsymptomsbeforeage30years;usually,anotherdiagnosismustbeidentified(e.g.,disc,strain).(Perin2016)Thereare,however,severalscenarioswherethespondylolisthesismaybecontributingtothepaingeneration:1)Whenassociatedwithacute(isthmic)spondylolysis,itisusuallyateenageroryoungadultwithanoveruseparsfractureatL5(Shah2011),2)whenthespondylolisthesisisunstable(seeCSPEprotocolLumbarFunctionalInstabilityforsignsandsymptoms),3)whenitisdegenerativeandmaybeassociatedwithspinalcanalstenosis(seeCSPEprotocolLumbarSpinalCanalStenosis),or4)whenitisassociatedwithradiculopathy.HISTORYSlippagemaypresentassociatedwithacutespondylolysisoritmaybechronicwithpainonsetoccurringovermonthsorlonger.PHYSICALEXAMINATIONFindingsareverysimilartothosefoundinspondylolysis.

• Thepatientmaystandwithincreasedflexionatthehipsandknees(PhalenDicksonsign)(Shah2011)

• Approximately60%ofpatientshavesomedegreeoffunctionalscoliosisthatunusuallyresolvesasthesymptomsresolve.(Shah2011)

• Hamstringmusclespasmisverycommon(estimatesupto80%)andcanbesignificant(Perrin2016).SpasmcancausehypolordosisandcauseinvoluntarykneeflexionduringSLR(Shah2011).

• Tendernesstodeeppalpationofthespinousprocessabovetheslip(typicallyL4)maybepresent.Thispalpationoccasionallycausesradicularpain.(Perrin2016)

• Paraspinalmusclespasmandtendernessareusuallypresent.(Perrin2016)

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• Theremaybeapalpablestepoffdefect(oftenatL4-L5junction).Inthecaseofdysplasticspondylolisthesis,thedefectmoreoftenisattheL5-S1junction.Astepdefectdiscoveredduringthephysicalhasareportedtestsensitivityrangingfrom60-88%andaspecificityof87-100%inanathletepopulation.(Grodahl2016)Anotherstudyreporteda+LRof4.6in30patientswithisthmicspondylolisthesis.(Collaer2006)

• Asupplementaryphysicalexaminationfindingintheelderlywithinstabilityisapositivepassivelegextensiontest.(Peterson2017)Bothofthepatient’slegsareliftedtoabout30cmandgentlytractioned,allowingtherelaxedlumbarspinetosettleintoextension.Apositivetestispainorfeelingofheavinessinthelowbackthatdisappearswhenthelegislowered.Ithasareported+LR8.8and–LRof0.17in38patientswithradiographicsignsofinstability.(Reiman)

• TheremaybesegmentalhypermobilitydetectedbyP-Amotionpalpation(Petersen2017).

ClinicalTip:Ina2017reviewoftheliterature,Petersensuggeststhatthefollowingcombinationofcluesmaybeuseful:intervertebralslipbyinspectionorpalpationANDsegmentalhypermobilitybyuseofmanualpassivephysiologicalintervertebralmotiontest(especiallyifitisanunstablespondylolisthesis).

DEGENERATIVESPONDYLOLISTHESISWITHSTENOSISAND/ORINSTABILITY

Eventhoughthereisnoparsfracture,thedegenerativechangesinthistypeofspondylolisthesisresultinginlossofdischeightanddegradingoftheposteriorelementsresultinslippageandmaybeunstable.Itcanevenresultinadynamicformofstenosis.Degenerativespondylolisthesisismorecommoninwomenthaninmen(5-6X)(Vibert2006),althoughmendemonstrateradiographicinstabilitymorefrequentlythanwomen.(Simmonds2015)(Seeappendixformeasurementsofinstability.)Degenerativespondylolisthesisseldomoccursbeforethe5thdecade(Simmonds2015).ThemostcommonlevelaffectedisL4slippingoverL5.Anteriortranslationupto30%ofthevertebralbodyispossible.Treatmentbeginswithconservativecare,butmayneedsurgicalstabilization.SPONDYLOLISTHESISANDRADICULOPATHY

Spondylolisthesis(eitherdegenerativeorwithaparsbreak)cancauseradiculopathybutisnotacommoncause.Inmostcases,patientsdonotcomplainofsymptomssuggestingneurologicdeficitwithlowergradesofspondylolisthesis.Radicularpainbecomesmorecommonwithlargerslips.Nerverootscanbeaffectedbythelocalexpansionofscartissueinthehealingdefectortractionedwhenthereisslippageofthevertebralbody.(Shah2011)Thelowerextremitypresentationcanberoughlydividedintotwoscenarios.1)painthatdoesnotfollowaprecisedermatome,isposition-dependent,hasnomotorsignsandmayactuallymorelikelybe

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adeepreferredpainphenomenonand2)lesscommon,classicradicularsciaticpainwithneurologicaldeficits.Thenerverootcompressioninthesecasesmaybeduetohypertrophicfibrousorosseoustissuefillingintheparsdefect.(Leone2011)Neurologicalpresentations,unsurprisingly,aremorecommoninpatientsgoingtosurgery.Inonecohortof111patientswithsymptomaticspondylolisthesisawaitingsurgery,62%hadsciatica(Möller2000).Ifsignificantlisthesisispresent,radicularsyndromes,thoughuncommon,dooccur;caudaequinasyndromeisevenararercomplication.(Shah2011)Unlikeinalumbardischerniation,theSLRisrarelypositiveevenwhenthepatientreportssciatica(sensitivityof12%comparedto80-100%indischerniations).(Möller2000)Nerverootdeficitsarenotcommon(12%inonestudy).TheL5nerverootisthemostcommonlyinvolved,followedbytheL4nerverootinmoreseverecases(withweaknessinthetibialisanteriormuscle).(Möller2000)Clinicaltip:Whenpatientspresentwithlumbarradicularsignsandsymptoms,spondylolisthesisdoesnotleadthelistofdifferentialsbutshouldbeconsidered.

ANCILLARYSTUDIES:DIAGNOSTICIMAGINGPlainfilmradiographsshouldincludeAP,lateral(tomeasureslippage),andAPaxialL/Sspotviewand/orobliqueviews(todetectparsfracture).SlippageisusuallymeasuredusingtheMeyerdingGradingSystem:GradeI(0%to25%displacement),GradeII(25%to50%displacement),GradeIII(50%to75%displacement),andGradeIV(>75%displacement).Completeor100%spondylolisthesisistermedspondyloptosis.Low-gradeisthmicspondylolisthesiscorrespondstogradesIandII,orlessthan50%listhesis.(Cochrane2012)

AlthoughMRIisnotusuallynecessary,itshouldbeorderedifthereisevidenceofatrueradicularorcaudaequinasyndrome.

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GeneralConservativeTreatmentRecommendationsKeyManagementOptions

Physiologicalrest/limitoffendingactivitiesBracingHamstringstretchesSpinalmanipulation/flexion-distractiontherapyLumbarstabilizationprogramMostpatientswithsymptomaticspondylolisthesisandchronicLBPcanbetreatedconservatively.(Dixit2017)Treatmentfocusesonbracing,initiallylimitingtheoffendingactivity,paincontrol,andthencorestrengtheningandrestorationofROM.(Shah2011)Similarlytomanagingspondylolysis,refrainingfromthesesportsactivitiesmayberequiredfor3-6months.

OralmedicationssuchNSAIDSarecommonlyprescribed,butduetoadverseeffectsshouldbeusedjudiciouslyandavoidedifpossible.Insomecasesofchronicspondylolisthesis,weightlossmayberecommendedtodecreaseventralloadonlumbarspine(Dynamed2017).

Orthosis(bracing)

Dynamed(2017)reportsthatthereislevel3evidencethatbackbracingleadstocessationinbackpaininpatientswithgrade1-2spondylolisthesis.Bracesareusuallywornfor3-6months.(Formoreinformationonbracing,seep.5.)

ManualtherapyPatientsshouldbetreatedbasedonthetotalityoftheirfindings,nottheimaging.Indicationsofspinaljointdysfunctionandmyofascialpaingeneratorsshouldbeassessedandtreatedaccordingly,asidefromacknowledgingthepresencethespondylolisthesiswhichmayormaynotbethepaingenerator.Bewareofover-emphasizingtheimportanceoftheimagingtothepatient.Highvelocity,lowamplitudemanipulationcanofferpainrelief(Cassidy1978).Patientswithspondylolisthesisrespondataratesimilartootherformsofmechanicallowbackpain,withan80%successratecomparedtoa77%successrateforgeneralnon-specificlowbackcases.(Mireau1978)Providers,however,shouldbecautiousofP-Athrustadjustmentsoverthespondylolisthesis,especiallyifthereisevidenceofinstability.Inofficestretching(e.g.,CRAC)orrelaxationtechniques(e.g.,PIR)shouldbeperformedforthehamstringsmusclesandpsoasmuscles,asindicated.Thepractitionermayfindthatthepatientgenerallytoleratesmanipulationandpatientpositioningthatfavorflexionoverextension.Examplesincludemanipulationinsideposturepromotinglumbosacralflexion(e.g.,sacralapexS-to-I),knee-cheststretches/mobilization,droptableadjustments,andpronetreatmentutilizingaflexion-biasedtable(e.g.Leadertable).

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Flexiondistractiontherapycanalsobeemployed.Asmallflexionrollisplacedunderthesegmentthathasslipped.Thespinousprocessofthevertebraaboveisliftedcephaladasthetableisflexedcausinglocaldistraction.Three20-seconddistractionsessionsareapplied,eachsessionconsistingof5-6cyclesofdistraction.Atypicaltreatmentscheduleforthistherapywouldbeabout8weeks,3timesaweek.Outcomesaremorefavorableinpatientswithstablespondylolisthesis.(Cox2011)

RehabilitationProgram

Aninitialprogramofhamstringstretchingwhilewearingthebracecanbestarted.(Shah2011,Cox2011)Stretchinghipflexorscanalsobeincorporatedasneeded.Asageneralrule,physicalrehabilitationprogramshouldnotbestarteduntilafteranadequaterestperiodandoncepainwithdailyactivitieshassubsided(Perin2016).Symptomresolutionoccursinthemajorityofpatientswithlow-gradeslips,eveniftheparsdefectdoesnotheal.Exercisetherapyisoneofthemainstaysofconservativetreatment.Exercisesincludeflexionexercises,corestabilizationexercises(includingpelvictiltsandabdominaltrunkcurls),hamstringstretching,andgeneralaerobicexercisesuchasswimmingandwalking(Hu2008,O’Sullivan1997,Cochrane2012).Ina2015studyofchildren,forexample,exercisestostrengthentheabdominalandbackmuscleswereinitiatedaftersymptomsresolved.(Leonido2015)Asthesymptomscontinuetodecrease,exercisescanbedonewithoutwearingabrace.Cross-traininginnon-extensionactivitiescanbeperformed,suchasthestationarybikeandhydrotherapy.LowBackStabilizationProgramAcomprehensiverehabilitationprogramwouldincorporatespinalstabilizationexercisesthathelpthepatientinfindingtheneutralpositionofthespine(i.e.,thepositionthatproducestheleastamountofpain).Thispositionisdependentonthespecificindividualandisdeterminedbythepelvicandspineposturethatplacestheleaststressontheelementsofthespineandsupportingstructures.Dynamiclumbarstabilizationexercisesmaybeusedtohelpprovidedynamicmuscularcontrolandtoprotectthespinefrombiomechanicalstresses,suchastension,compression,torsion,andshear.[71]Dynamed(2017)reportsthatthereismid-levelevidencesuggestingthatstabilizingbackexercisesmaydecreasepainintensityandfunctionaldisabilityinsymptomaticspondylolisthesis.ThisisbasedonasmallRCT(N=44)wherepatientswereenrolledinasupervised10-weekcorestabilityprogramwhichemphasizedisolatedtrainingofthedeepabdominalmusclesandlumbarmultifidiproximaltotheirparsdefect.Itwascomparedtoacontrolgroupmanagedbyregularamedicalpractitioner,mostpatientsperforminggeneralexercisesandsomegettingothersupervisedtherapy.(O’Sullivan1997)Improvementfavoringthestabilizationgroupwasclinicallysignificantintermsofpainreduction(VAS

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scoresdroppedto19vs.48)andimprovedOswestrydisabilityscores(15vs.25).Differencesremainedsignificantat30months.Inasmallcaseseries(N=20)comprisedofpatientsover50yearsoldwithdegenerativespondylolisthesisa6-month,home-basedtrainingprogramdecreasedpainfromaVASbaselineof63.5atto43.4andsciaticpainfrom53.7atto36.7at6-monthfollow-up.Theprogramconsistedoftheusualbasicstabilizationtracks(e.g.,bridge,sidebride,quadruped)withanemphasisonneutralpelvisandmotorcontrolofthedeepstabilizersandthediaphragm.Patientsweretodotheexercisesdaily,twiceaday,10repetitionsofeachexercise.(Nava-Bringas2014)AsmallRCTreportedthatarehabilitationprogrammayalsobeinitiatedafterfusionsurgeryandthattheresultsappeartobebetteraftera12-weekdelayasopposedtowaitingonly6-weeks.(Dynamed2017).(Formorespecificinformationonexercises,seeCSPEprotocolLowBackRehabilitation.FlexionexercisesFlexion-basedexerciseregimens(e.g.,kneetochestexercises)aregenerallyconsideredtobesuperiortoextension-basedexercisesforpainreliefforthiscondition(Jones2009;Sinaki1989)—althoughtheevidenceisactuallymixed.(Samuel2012)Twostudies(N=47each)fromtheMayoCliniccomparedflexiononlyexercisestoextensiononlyexercisesforadultswithchronicspondylolisthesisThetrendforimprovementfavoredflexiononlyoverextensiononlyexercisesat3months(27%stillwithmoderatetoseverepainvs.67%)and3years(19%vs.67%).Therewasnocontrolgroup.(Gramse1980,Sinaki1989)

Ontheotherhand,anothersmallRCT(N=56)foundthatforadultsbracingtomaintainlordoticpostureplusextensionexerciseshadbetterpainscoresafter1monthcomparedtobracingtoavoidlumbarextensionandflexionexercises.(Dynamed2017)ReturntoSportsAthletesshouldnotreturntosportuntilpainfree.Dynamed(2017)reportsthat“somecliniciansrecommendremovalfromathleticparticipationfor≥3months,particularlyforjuniorlevelorrecreationalathletes.Buthigh-levelathletescantypicallyreturntosportsoncesymptomsbecometolerableandunlikelytoaffectperformance.”Patientswithgrade2slippagearegenerallyinstructedtoavoidhyperextensionloadingofthespineevenaftersymptomsresolvewithconservativetreatment.(Perrin2016)

Kneetochestexercise:Performedtwicedaily;6repetitions,4secondholds.(Cox2011)

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PrognosisThelongtermnaturalhistoryandprognosisforspondylolisthesisandspondylolysisarefavorable,andmostpeoplewiththeseconditionsareasymptomatic.Aprospectivestudyof500firstgradechildren(Beutler2003)identified30subjectswithparsdefects.Significantprogressionofspondylolisthesisappearstobeuncommonandrarelyoccursafteradolescence.Duringa45yearfollowup,progressionofspondylolisthesisslowedwitheachdecade,andtherewasnoassociationbetweenslipprogressionandlowbackpain.Infact,therewasnostatisticallysignificantclinicaldifferencebetweenthestudypopulationandthoseofthegeneralpopulationofthesameage.Theoutcomesforconservativecareappeartobefavorableforbothspondylolysisandlowgradeisthmicspondylolisthesis(grade0-2).Goodtoexcellentresultsvarybutgenerallyrangefrom80-90%forgrades0-1and66%forgrade2(Bouras2015,Shah2011).Athletesinthiscategoryusuallyreturntofullactivityin6monthsevenwhenthereisnon-union.(Bouras2016)Infact,inKlein’smeta-analysisofobservationalstudies(2009)despitethehighrateofclinicalsuccess,mostparsdefectsdidnotshowradiographicimprovement,promptingtheauthorstooconcludethat“asuccessfulclinicaloutcomedoesnotdependonhealingofthe(radiographic)lesion.”Thepatientcanreturntofullactivitywhensymptomshaveresolvedandfollowupradiographsdocumentnofurtherprogressionofthelisthesis.Patientswithgrade2spondylolisthesisshouldcontinuetolimitactivitiesthatrequireahyperlordoticposture.Evenwithsuccessfulresolutionofsymptoms,monitoringforslippageshouldbecontinuedtobemonitoredforslippageannually.(Shah2011)SurgicalInterventionsA2013systematicreviewreportedthatfourRCTsfoundsurgicalinterventiontobemoresuccessfulthannonoperativetreatmentformanagingpainandfunctionallimitation,whileoneRCTfoundnodifferenceinfuturelowbackpainoutcomes.However,thereviewersconcludedthatnofirmconclusionscouldbemadebecauseoflimitedinvestigation,heterogeneityofstudies,lackofcontrolgroups,andbiasessuchaslackofblindingofassessors.(Garet2013)Surgeryisusuallyreservedforpatientswithseriousorprogressiveneurologicaldeficitsorneurogenicclaudicationsecondarytoinstabilitycausingadynamicstenosisassociatedwithhighgradeslippage.(Firestein2017,Shah2011)Itcanalsobeconsideredifsymptomscontinuefor>6-9monthsdespiteactivityrestrictionandbracing.Itmaybeappropriatetoadvisepatients(ortheirparents)toseekoutsecondopinionswhensurgeryisbeingconsidered.Oneprospectiveobservationalstudyof544patientsfoundalargediscordancebetweenfirstandsecondopinionsregardingtheexactdiagnosisandneedforspinalsurgery.(Lenza2017)Inthecaseofathletes,returntoplayfollowingsurgeryvariesfrom6-12monthsdependingonthesport.(Bouras2015)

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Managementofdegenerativespondylolisthesis

• Onlyabout10-15%ofpatientswithdegenerativespondylolisthesisandstenosisultimatelyundergosurgery.(Postacchini1991)

• Absoluteindicationsforsurgicalconsultationareprogressiveneurologicaldeficit(especiallymotor)andcaudaequinasyndrome.Relativeindicationsforsurgeryincludepersistentradiculopathydespiteconservativetreatment,persistentandunremittinglowerbackpainformorethan6months,lossofqualityoflifebecauseofneurogenicclaudication.(Vibert2006)

• Surgerymaybenecessaryforpatientswithstructuralinstability;optionsincludedecompressiononlyordecompressionwithfusion.

o Directsurgicaldecompressionisconsideredifsymptomshavenotrespondedtoatrialofconservativetherapyforpatientswithsymptomaticspinalstenosisassociatedwithlow-grade(<20%slippage)degenerativelumbarspondylolisthesis(weakrecommendation).(Dynamed2017)

o Decompressionalonewithpreservationofmidlinestructuresissuggestedforpatientswithlow-gradespondylolisthesis(<20%slippage)withoutforaminalstenosisasthismaybeequivalenttodecompressionwithfusion(Weakrecommendation).(Dynamed2017)Onesetofproposed(unvalidated)criteriafordecompressionalonearepatientswithdominantlegsymptomsandstablemotionunits(basedonlessthan3mmoftranslationondynamicfilmsand“restabilization”signsonradiographsuchasgrosslynarroweddiscandnofacetjointeffusiononMRI).

o Decompressionwithfusionissuggestedoverdecompressionaloneforotherpatientswithsymptomaticspinalstenosisanddegenerativelumbarspondylolisthesis(Weakrecommendation).Oneproposed(unvalidated)criteriafordecompressionwithfusion:translation>3mm(especiallyifgreaterthan5mm),fewtonosignsofrestabilization,andthepresenceoffaceteffusiononMRI.

Copyright © 2017 University of Western States

Primary Author: Ron LeFebvre DC Contributors: Owen Lynch DC Tim Stecher DC DACBR Reviewed by: Stan Ewald DC, MPH, M.Ed. Dave Panzer DC DABCO Joseph Pfeifer DC

Edited by: Ron LeFebvre, DC

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Reviewed by the Clinical Standards Protocols & Education (CSPE) Working Group (2017) • Amanda Armington, DC • Lorraine Ginter, DC • Shawn Hatch, DC • Craig Kawaoka, DC • Ronald LeFebvre, DC • Ryan Ondick, DC • James Strange, DC ReferencesACRAppropriatenessCriteria2015p8.BeutlerWJ,FredricksonBE,MurtlandA,SweeneyCA,GrantWD,BakerD.Thenaturalhistoryofspondylolysisand

spondylolisthesis:45-yearfollow-upevaluation.Spine(PhilaPa1976).2003May15;28(10):1027-35.BourasT,KorovessisP.Managementofspondylolysisandlow-gradespondylolisthesisinfineathletes.A

comprehensivereview.Eur.JSurgTraumatol.2015Jul;25Suppl1:S167-75.Epub2014Nov14.CassidyJD,PorterGE.Kirkaldy-WillisWH.Manipulativemanagementofbackpainpatientswithspondylolisthesis.J

CanChiroAssoc1978;22:15.CollaerJW,McKeoughDMetal.Lumbaristhmicspondylolisthesisdetectionwithpalpation:interraterreliability

andconcurrentcriterion-relatedvalidity.JManManipTher.2006;14(1)22-29.CoxJM.SpondylolisthesisinCoxJMLowBackPain:Mechanisms,DiagnosisandTreatment7thedLippincott

WilliamsandWilliamsPhiladelphia2011DixitR.LowbackpaininFiresteinGS,BuddRCetal.Kelley&Firestein’sTextbookofRheumatology10thedition

2017ElsevierPhiladelphiaPA,pp696-716GaretM,ReimanMP,MathersJ,SylvainJ.Nonoperativetreatmentinlumbarspondylolysisandspondylolisthesis:

asystematicreview.SportsHealth.2013May;5(3):225-32.doi:10.1177/1941738113480936.GramseRR,SinakiM,IstrupM.Lumbarspondylolisthesis:Arationalapproachtoconservativetreatment.Mayo

ClinProc1980;55:681-6.GrodahlLH,FawcettL,NazarethMet.al.Diagnosticutilityofpatienthistoryandphysicalexaminationdatato

detectspondylolysisandspondylolisthesisinathletesinlowbackpain:asystematicreview.ManTher2016;24(70:7-17.

KalichmanL,KimDH,LiL,etal.Spondylolysisandspondylolisthesis:prevalenceandassociationwithlowbackpainintheadultcommunity-basedpopulation.Spine2009;34:199–205KleinG,MehlmanCT,McCartyM.NonoperativetreatmentofspondylolysisandgradeIspondylolisthesisinchildrenandyoungadults:ameta-analysisofobservationalstudies.JPediatrOrthop.2009Mar;29(2):146-56.doi:10.1097/BPO.0b013e3181977fc5.KobayasshiA,KobayashiT,KatoKetal.Diagnosisofradiographicallyoccultlumbarspondylolysisinyoungathletesbymagneticresonanceimaging.AmJSportsMed2013;41(1):169-176.

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KurdMF,PatelD,MortonRetal.Nonoperativetreatmentofsymptomaticspondylolistheses.JSpinalDisordTech2007;20(8):560-564.LedonioCGT,BurtonDC,CrawfordCH,et.al.Currentevidenceregardingdiagnosticimagingmethodsforpediatriclumbarspondylolysis:Areportfromthescoliosisresearchsocietyevidence-basedmedicinecommittee.SpineDeformity,20179:97-101.LenzaM,BuchbinderR,StaplesMP,DosSantosOFP,BrandtRA,LottenbergCL,CendorogloM,FerrettiM.Secondopinionfordegenerativespinalconditions:anoptionoranecessity?Aprospectiveobservationalstudy.BMCMusculoskeletDisord.2017Aug17;18(1):354.doi:10.1186/s12891-017-1712-0.LitaoA.LumbosacralSpondylolysis.MEDSCAPEUpdated:Nov17,2015LoweJ,SchachnerE,HirschbergE,etal.Significanceofbonescintigraphyinsymptomaticspondylolysis.Spine

1984Sep9(6):653-5MalangaG,YoungCCetal.Parsinterarticularisinjury.Medscape,Nov6,2016.MicheliLJ,WoodR.Backpaininyoungathletes.Significantdifferencesfromadultsincausesandpatterns.ArchPediatrAdolescMed.1995Jan;149(1):15-8.MireauD,CassidyJ,etal.Acomparisonoftheeffectivenessofspinalmanipulativetherapyforlowbackpain

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2000;25(6):683-9.Nava-BringasTI,Hernández-LópezM,Ramírez-MoraI,Coronado-ZarcoR,IsraelMacías-HernándezS,Cruz-Medina

E,Arellano-HernándezA,León-HernándezSR.Effectsofastabilizationexerciseprograminfunctionalityandpaininpatientswithdegenerativespondylolisthesis.JBackMusculoskeletRehabil.2014;27(1):41-6.doi:10.3233/BMR-130417.

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chroniclowbackpainwithradiologicdiagnosisofspondylolysisorspondylolisthesis.Spine1997;22:2959-67.PerrinAE.LumbosacralSpondylolisthesis.MEDSCAPEUpdated:Feb01,2016

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Research2006;44:222-7.[expertopinion]

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APPENDIXI:RadiographicInstability

FlexionviewExtensionview

1. Thecombinedfindingsofthe2viewsabove(whicharestressviews)mustrepresentatotalsagittaltranslationof>4mmtomeetthestandardforradiographichypermobility.

2. AorBalonedoesnotindicateradiographichypermobility.

3. Thecriterionismetinthediagramabovebyaddingthelisthesisintheflexionandextensionviewsyieldingatotalsagittaltranslationof6mm.

4. Thiscriterioncouldbemetinotherways.Forexample,a1mmanterolisthesisonneutralcouldbecomea6mmanterolisthesisonflexionforatotalof5mmofsagittaltranslation.(Notshown)

Figure A. 3mm anterolisthesis

Figure B. 3mm retrolisthesis

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FlexionviewExtensionview

1. Thecombinedflexionandextensionfindings(whichwouldrequirestressviews)mustrepresentatotalsagittalrotationof>10degreeschangefromtheneutralviewtomeetthestandardforradiographichypermobility

2. CorDalonedoesnotindicateradiographichypermobility

3. Thecriterionismetinthediagramabovebyatotalsagittalrotationof16degrees.

4. Thiscriterioncouldbemetinotherways.Forexample,a0degreeangleonextensioncouldbecome12degreesofanteriorwedgingonflexion.(Notshown)

Figure C. 8 degrees of anterior disc wedging

Figure D. 8 degrees of posterior disc wedging

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APPENDIXII:QuickReferenceTableHistory • Ingeneral,lowerbacksymptomsdominate(painsometimesrefersintobuttockand

posteriorthigh).• Oftenaggravatedbyactivity(especiallylifting,weightbearing,hyperextension)andworsethroughouttheday.

• Improvedbyrestandbyflexion.• Rarely,radicularsymptomsintolowerleg;evenmorerarelycaudaequinasymptoms(withspondylolisthesisthanwithspondylolysis)

Spondylolysis• Prevalenceofsymptomaticspondylolysis:3-6%• Patientsaretypicallyteenagers• Pre-testprobabilityisashighas47%inLBPinyoungathletes• Painmaybelancinatingintheacutephase

PhysicalExamFindings

• Patientmaystandwithincreasedflexionatthehipsandknees(PhalenDicksonsign),morelikelyinspondylolisthesis

• Afunctionalscoliosisispresentin60%ofspondylolisthesiscases.• Theremaybeadimpleintheskinoverthespine,suggestingspinabifida(riskfactorforspondylolisthesis)

• AROMmaybenormal(butflexionmaybelimitedifhamstringsareinspasm);sometimesflexionprovidespainrelief

• Painmaybeaggravatedbyhyperextension(mostcommonly),rotation,orlateralflexiontothesideoflysis

• Inacutecases,focaltendernessoverthelumbarspine(morelikelyinspondylolysis)• Hamstringsfrequentlyinspasm(especiallyinspondylolysis):maycausehypolordosisandinvoluntarykneeflexionduringSLR

• Psoasmaybeshortandtightbilaterally.• Passivelegextensiontestmaybepositive(morelikelyinunstabledegenerativespondylolisthesis)

• Inspondylolisthesiscases,theremaybeapalpablestepoffdefect(oftenatL4-L5junction).

• Theremaybesegmentalhypermobility(spondylolisthesiscases).• Rarely,neurologicaldeficitsandSLRarepositive(morelikelyifsignificantlisthesisispresentandsevere)

SpecialTests • AP&lateralradiograph;APaxialL/Sspotand/orobliquesifnecessary• MRI,CT,SPECTforoccultparsfractures;andMRIifassociatedwithneurologicalsigns

ConservativeCareTreatmentOptions

Spondylolysis&initialtreatmentforSpondylolisthesis• Avoidoffendingsportsandactivitiesthatrequirerepetitiveflexionandextensionfor

2-3weekstoseeifsymptomsresolve,butmorelikely3-6months(betteroutcomesassociatedwith>3months).

• Anexternalbrace(commonbutoptional)worn23hoursadayfor3-6months.

SubacuteSpondylolysis&Spondylolisthesis• Flexionexercises(manualtherapytorelaxpsoas)• Hamstringstretching• Spinalmanipulation(sometimespositioningpatientsinflexionbias)• Flexiondistractiontherapy• Treatotherjointdysfunctionandsofttissuefindingsasappropriate• Lumbarstabilizationexercisesinneutralpelvis(oftendelayedforafewmonthsuntil

afterbraceisremoved;outcomesmaybebetterifinitiatedbefore10week).

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