spondees Flashcards
what is spondylolisthesis
Slip of one vertebral body on the other (anterior or posterior)
what is Spondylolisis
a fracture (crack or break) in the pars of a vertebrae (the pars is the area of bone between the superior and inferior articular process of the vertebrae. it can be a uni or bilateral fracture
25% of cases progress into spondylolisthesis
RF’s for spondylolysis
young athletes
M>F (2:1)
2 peak ages (between 5-7 yoa and again in teenage years)
sports with extension/rotation/loading in hyperextension (gymnastics, diving, cricket, baseball, sailing, table tennis, weight lifting, wrestling, rowing, figure skating, dancing, volleyball, soccer, tennis, rugby (esp in scrum) and American football.
people with significant lumber lordosis (Scheuermann kyphosis)
Eskimos (incidence of 20-50% vs 3-6% in general public)
genetics
spondylolysis general facts
can be unilateral or bilateral fractures (80% of symptomatic cases are Bilateral tho)
most commonly occurs at L5 (85-95% of cases), followed by L4 (10-15% of cases)
tends to start with BSI
Spondylolysis S+S’s (history)
while most cases are Asymptomatic, those who do develop symptoms typically present during pre-adolescent growth spurt.
Patients typically complain of focal LBP brought on by certain performance activities.
pain may be sharp and lancinating in acute phase but may become chronic, dull and achey over time.
pain may be located uni or bilaterally, usually along the belt line, but on occasion may radiate to the buttock proximal lower extremity.
Onset may be insidious or acute. often mild symptoms may be present for a period of time, but then symptoms may become exacerbated by a specific event
agg by movements and gets worse throughout the day: particularly spinal extension and to a lesser extent rotation.
agg by walking
pain improved with rest.
spondylolysis clinical/physical signs and symptoms?
reduced lordotic posture with excessive hamstring tightness
Phalen-dickson sign (knee flexed, hip flexed gait)
pelvic waddle gait (the hallmark of this gait abnormality includes a stiff legged gait with a short stride length due to hamstring tightness.
TTP of overlying paraspinal region with palpation potentially causing paraspinal muscle spasms
Lumber ROM reduced in flexion due to hamstring tightness.
physical examination manoeuvre “the stork test” (although this manoeuvre stress other structures other than the pars - so positive test defiantly doesn’t mean spondylolysis without context of case history/other S+S’s
perform a neuro test - there should be no near/rediculopathies with isolated spondylolysis.
rehab of spondylolisis
Treatment Options
The recommended treatment
program for spondylolysis is
usually a combination of the
following:
- For early or progressive
defects = rest/protection for the
first 4 weeks, possibly longer: no
sports participation, no physical
education class, reduce backpack
weight and avoid sleeping on
your stomach (5) - For terminal defects = a brief
period of activity reduction
prior to starting stabilization
exercises (5) - Pain medications as needed/
recommended by your physician - In addition to a calcium-rich
diet, vitamin D is essential for
bone health. Your provider may
test your vitamin D level and if
it is low, suggest that you take a
vitamin D supplement. Research
shows that vitamin D deficiency
likely exists in orthopaedic
trauma patients living in northern
latitudes.(7) In Nebraska, over 60%
of adolescents with spondylolysis
were found to have low vitamin
D levels.(8) - Rehabilitation under the
guidance of a physical therapist
or athletic trainer. Corrective
exercise training is emphasizedbeginning with gentle upper
and lower body stretching and
progressing to an individualized
core strengthening routine that
gradually builds over time. - For most people a brace is
not needed for this condition.
Clinical outcome of patients
treated with a brace to patients
treated without a brace was not
significantly different.(6) However,
if 2-4 weeks of rest/activity
restriction alone do not reduce
the pain, then a brace may be
beneficial. - On rare occasions, orthopedic
surgery should be considered
when symptoms persist, there are
associated nerve complications
or there is a progressive slippage
of the bone. In these cases,
surgery can provide additional
stabilization to the area
types of Spondylolisthesis (based on the cause of displacement)
Types of Spondylolisthesis
Based on the cause of displacement, five subtypes of spondylolisthesis are identified, they are:
Dysplastic spondylolisthesis
Isthmic spondylolisthesis
Degenerative spondylolisthesis
Traumatic spondylolisthesis
Pathologic spondylolisthesis
Dysplastic (aka congenital) spondylolisthesis
Dysplastic spondylolisthesis (Type 1) is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment. In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation.
Isthmic spondylolisthesis
translation is secondary to a lesion involving the pars interarticularis. this can be broken down into sub-types:
- subtype a (lytic): secondary to stress fracture, in most cases attributed to repeated extension and/or twisting motions
- subtype b (elongated pars): result of multiple injury/healing events leading to elongation of the pars
Traumatic spondylolisthesis (type 4)
Traumatic spondylolisthesis (Type 4)occurs after fractures of the pars interarticularis or the facet joint structure and is most common after trauma.
Pathologic spondylolisthesis (type 5)
Pathologic spondylolisthesis (Type 5) can be from systemic causes such as bone or connective tissue disorders or a focal process, including infection, neoplasm.
Iatrogenic spondylolisthesis (Type 6)
Iatrogenic spondylolisthesis (Type 6) is a potential sequela of spinal surgery. Frequently, these patients will have undergone prior laminectomy
Degenerative spondylolisthesis (Type 3)
Degenerative spondylolisthesis (Type 3) occurs from degenerative changes in the spine without any defect in the pars interarticularis. It is usually related to combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body relative to the adjacent vertebral body. Arthritis of facet joint which in turn causes weakness of ligamentum flavum leads to anterior slippage of vertebra.
S+S’s of spondylolisthesis
Patients typically have low back pain which mimics radiculopathy for lumbar spondylolisthesis and localized/radiating neck pain for cervical spondylolisthesis.
Agg: extension, direct palpation of effected segment
relieved: flexion
palpable step off (if slippage is extreme)
Phalen-Dickson sign/crouched gait
Atrophy of the muscles, muscle weakness
Tense hamstrings, hamstrings spasms
Disturbances in coordination and balance, difficulty walking
Rarely loss of bowel or bladder control.[1]
