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Spondylolysis is a defect in the pars interarticularis. Spondylolisthesis refers to bilateral defects with anterior slippageof the superior vertebra on the inferior vertebra. The lesions are not present at birth, but about 5% of children will have the lesion by 6 years of age. It is most common in adolescent athletes, especially those involved in sports that involverepetitive back extension. Classically, this was an injury seenin gymnasts and divers. However, with increased intensityand year-round sports, the incidence is increasing. Footballinterior lineman (extension while blocking), soccer players(extension while shooting), and basketball players (extension while rebounding) are examples of athletes at higherrisk. The most common location of spondylolysis is L5, followed by L4.
Spondylolisthesis is classified according to the degree of slippage:Grade 1: less than 25% Grade 2: 25% to 50% Grade 3: 50% to 75% Grade 4: 75% to 99% Grade 5: complete displacement or spondyloptosis
The most common location of spondylolisthesis is L5 on S1.
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Patients will often complain of an insidious onset of low back pain persisting over 2 weeks. The pain tends to worsen with activity and with extension of the back and improves with rest. There may be some radiation of pain to the buttocks. A loss of lumbar lordosis may occur due to muscular spasm. Pain is present with extension of lumbar spine and with palpation over the lesion. Patients with spondylolisthesis may have a palpable step off at the lumbosacral area. A detailed neurologic examination should be done, especially because spondylolisthesis can have nerve root involvement.
Anteroposterior, lateral, and oblique radiographs of the spine should be obtained. The oblique views may show the classic Scotty dog findings associated with spondylolysis. The lateral view will allow measurement of spondylolisthesis. Unfortunately, plain radiographs do not regularly reveal spondylolysis, so advanced imaging may be needed. The most helpful form of advanced imaging among CT, bone scan, single-photon emission CT (SPECT), or MRI continues to be debated. MRI may be required in patients with neurologic deficits.
Painful spondylolysis requires activity restriction. Bracing iscontroversial but may help with pain relief. Patients benefit froman aggressive physical therapy plan to improve lower extremityflexibility and increase core strength and spinal stability. It is most beneficial to begin with flexion exercises and progress toextension exercises as tolerated. There is evidence that some patients with an acute spondylolysis can achieve bony unionand that these patients have a decreased incidence of low backpain and degenerative change in the low back as they age whencompared with spondylolysis patients with nonunion. Rarely,surgery is indicated for intractable pain and disability.
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Patients with spondylolisthesis require periodic evaluation for progression of their slippage. Treatment of spondylolisthesis is based on grading.
Grade 1: Same treatment as spondylolysis. Failure of nonoperative management may lead to surgical fusion.Grade 2: Reasonable to try nonoperative management, but if the slippage is progressing, surgical intervention may be needed. Any patient with neurologic symptoms requires surgical intervention.Grades 3 to 5: Spinal fusion is usually required to prevent further slippage or damage.
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