Neutral view on a lumbar spine radiograph of a 55-year-old woman with a 2-year history of lower back pain.
Flexion view on a lumbar spine radiograph of the patient.
Extension view on a lumbar spine radiograph of the patient.
A 55-year-old woman presents with a 2-year history of lower back pain. Over the last 6 months, she has begun to have bilateral lower extremity pain and weakness. She has also noticed numbness in both feet and has felt unsteady while walking because of lower extremity weakness. There is no history of trauma, and the patient denies any bowel or bladder changes. Lumbar spine radiographs, including neutral, flexion, and extension lateral views, are taken. Radiographs and magnetic resonance imaging findings include facet arthropathy, disk space narrowing, and both foraminal and central stenosis. A diagnosis is made of spondylolisthesis, which is mobile by approximately 4 mm on flexion and extension views.
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The patient has a grade 1 degenerative spondylolisthesis. Spondylolisthesis is a forward slippage of one vertebral body over another. Spondylolisthesis is graded by the amount or degree that a vertebral body has slipped forward over the body beneath it. Grade 1 includes a forward slip of 0% to 25% over the inferior body; grade 2 involves a 25% to 50% slip; grade 3 is a slip of 50% to 75%; grade 4 involves a slip of >75%; and grade 5 includes slips >100%. A slip beyond grade 1 or 2 is rare.1,2
There are 6 types of spondylolisthesis: dysplastic, isthmic, degenerative, traumatic, pathologic, and postsurgical. Dysplastic or congenital abnormalities may be the result of hypoplastic facets or poorly developed pars. Symptoms of dysplastic spondylolisthesis most commonly occur at age 4 to 6 years. Isthmic spondylolisthesis is caused by spondylolysis or fracture of the pars and is one of the most common causes of lower back pain in children and adolescents. Degenerative-type spondylolisthesis is caused by a degenerative cascade that includes facet joint degeneration, intervertebral disk degeneration, and ligamentous laxity. Degenerative-type spondylolisthesis is seen most commonly in women aged more than 40 years at the L4 to L5 level. The less common traumatic, pathologic, and postsurgical types of spondylolisthesis are caused by an acute fracture other than the pars, weakened bone from disease (eg, osteoporosis, tumor), and slippage after surgery from excessive resection of supporting structures, respectively.1,2
The most common symptom of degenerative spondylolisthesis is mechanical back pain that is relieved with rest or sitting. Neurogenic claudication or buttock and leg pain while walking is also a common complaint. Flexion and extension films help determine stability of the slip. Instability is defined as 4 mm of translation or 10 degrees of angulation of motion compared with the adjacent motion segment. Conservative treatment includes oral nonsteroidal anti-inflammatory drugs, physical therapy for core strengthening, and epidural steroid injections for radicular pain. Lumbar decompression and surgical fusion may be indicated if at least 6 months of conservative treatment fails to provide relief, if there are progressive motor deficits, or if cauda equina syndrome is present. Fewer than 30% of those presenting with grades 1 and 2 spondylolisthesis will have slip progression.1
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Wheeless CR. Spondylolysis/spondylolisthesis. http://www.wheelessonline.com/ortho/spondylolysis_spondylolisthesis. Accessed December 12, 2016.
- Moore D. Degenerative spondylolisthesis. http://www.orthobullets.com/spine/2039/degenerative-spondylolisthesis. Accessed December 12, 2016.