Spondylolisthesis

Causes of sciatica

What is a spondylolisthesis?

The spine comprises of many bones known as vertebrae. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally (figure 1). These joints are designed to support body weight and enable spinal movement.

A spondylolisthesis refers to the slipping of one vertebra forward on another. This typically occurs due to defects in the bone which usually develop during childhood and is most commonly seen in children between the ages of 9 and 14. The defect is due to an absence of a section of bone on each side of the vertebral column which assists in holding the vertebra in alignment. This section of bone is known as the 'pars interarticularis' (figure 1). Although uncommon, a spondylolisthesis may also occur due to stress fractures in each pars interarticularis. This may occur due to excessive athletic or sporting activity involving repetitive hyperextension of the spine.

A spondylolisthesis is graded according to the degree of slip of the vertebra relative to the vertebra below. A Grade I slip indicates a slip of less than 25%, Grade II – 50%, Grade III – 75% and Grade IV > 75%.

Signs and symptoms of a spondylolisthesis

Patients with this condition generally experience an increase in pain during activities that straighten or extend the spine (figure 2), especially if these activities are repetitive, excessive, or, maintained for long periods of time. Conversely, activities that bend the spine (e.g. sitting) tend to ease symptoms. It is important to note, that many patients with a Grade I spondylolisthesis may experience no symptoms and be completely unaware of the defect. Patients with a Grade II spondylolisthesis or higher, however, more commonly experience lower back pain with or without associated leg pain.

Diagnosis of a spondylolisthesis

X-ray investigation is usually required to confirm diagnosis of a spondylolisthesis. This is best performed in the position that reproduces the patient's pain.

Treatment for a spondylolisthesis

Treatment of patients with this condition is determined by the severity of symptoms and grade of injury. Typically, treatment involves rest from aggravating activity combined with abdominal and lower back strengthening exercises. Once the patient is pain-free, a gradual increase in activity and exercise can occur provided symptoms do not increase. Wearing an appropriate brace during activity may be helpful. If symptoms do recur upon resuming sport, then that activity should be ceased. Patients with a Grade III or IV spondylolisthesis should avoid high speed or contact sports altogether.

Alternative exercises placing minimal force through the lower back should also be performed to maintain fitness provided they do not increase symptoms. Better activities include: cycling, cross trainer, rowing, water running and clinical Pilates. Patients should also perform flexibility, strengthening and core stability exercises to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Contributing factors to the development of symptoms of a spondylolisthesis

There are several factors that may contribute to the development of symptoms in patients with this condition. These need to be assessed and corrected with direction from a physiotherapist and may include:

• poor posture
• poor core stability
• muscle weakness
• poor flexibility
• joint stiffness

Technique adjustment should also be made to restrict the amount of extension during sporting activity.

Physiotherapy for a spondylolisthesis

Physiotherapy treatment for patients with this condition is vital to hasten the healing process and ensure a safe return to activity. Treatment may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• bracing
• mobilization
• dry needling
• education
• activity modification advice
• biomechanical correction
• clinical Pilates
• hydrotherapy
• exercises to improve flexibility, strength and core stability
• a gradual return to activity program

Other intervention for a spondylolisthesis

Despite appropriate physiotherapy management, a small percentage of patients with this condition fail to improve adequately or deteriorate. When this occurs, other intervention may be required. This may include further investigations such as X-rays, CT scan or MRI, or assessment from a specialist. Although it is rare for a slip to progress, spinal fusion surgery may be indicated if there is evidence of progression. The treating physiotherapist can advise if this may be required and can refer to the appropriate medical authority if it is warranted clinically.

Exercises for a spondylolisthesis

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Rotation in lying

Begin this exercise lying on your back, knees bent, feet flat and together as demonstrated (figure 4). Gently take both knees from side to side as far as possible and comfortable without increasing your symptoms. Repeat 10 times.

Figure 4 – Rotation in lying

Knees to chest 

Begin this exercise lying on your back with your knees bent as demonstrated (figure 5). Take both knees towards your chest as far as possible and comfortable provided there is no increase in symptoms. Repeat 10 times.

Figure 5 – Knees to chest