Spondylolysis & spondylolithesis

[Maeghan L]

NB: This is general advice that can not cover all eventualities.

Both spondylolysis & spondylolithesis can be missed on normal x-ray views of the lumbar spine and as such are a commmonly missed diagnosis. Medical imaging techniques that will pick them up include;- MRI & an 'oblique view lumbar spine x-ray'. The latter is taken at a specific angle and not routinely done unless specifically requested by GP and justified as to why (i.e. suspected 'spondylo'), as it invloves a higher doseof radiation.

Spondylolithesis can be a progression of a spondylolysis – literal meaning ‘broken vermassageplanetra’, but don’t panic. These by enlarge remain stable with the occasional ‘flare up’ and can usually be helped with osteopathic treatment. In the long term maintaining good muscle tone of the correct muscle groupsis key.

The difference is that a spondylolithesis invloves a degree of forward slippage on the vertebral body and these are graded by the amount and nature of the slippage.

As far as I know the only surgical procedure is that of fusion. Usually fusing it with the vertebra below, which can be the sacrum, but it’s not without risk and some suffer long term pain or worse. On checking a recent orthopaedic book - there is mention of ‘re-fusing’ the separation of the vertebral arch to the vertebral body. No research references were given, so would consider with caution and use the maxim of surgery as last resort.

The break or separation occurs somewhere in the bony arch at the back of the vertebra allowing it to become separated with the vertebral body (the larger weight bearing component, the main part). This separation can allow the vertebral body (usually L4 or L5, one of the lower 2 lumbar vertebrae) to slip forward on occasions, causing pain locally in the lumbar area or a variety of symptoms & signs in the buttocks, leg/s or worse.

This would be evident on an MRI as the vertebral body having slipped forward (anterior in medical speak) and can allow the rear portion of the vertebra (vertebral arch) to be further back (posterior) and cause the spinous process to be more pronounced than normal.

The ‘worse’ category, fortunately quite rare, includes; numbness over the sacrum (central back of pelvis), crotch area (including genitalia), problems with bladder &/or bowel function that is not just due to constipation from pain killers. This is only usually in the elderly where severe degeneration of the lumbar spine has occurred or following a severe trauma.

If any of the above, then go straight to A & E. Don’t faff waiting to speak to GP or NHS online.

The more common variety, as said, tend to remain stable most of the time and include a congenital deformity (lack of full formation of the vertebral arch) or more commonly from a lumbar spine extension injury. A trauma involving being bent backwards (i.e. diving injury), a fall flat on the back (from being thrown from a horse, climbing incident, etc). At the time the latter may only involve a few weeks of low back ache &/or pain, but can flare up many years later, long after the original trauma is forgotten and with little warning.

General advice;


Avoid excessive extension on the lumbar spine, including extension lumbar spine exercises that are often given by physiotherapists for low back pain. These usually involve lying on the front and pushing upper body up with arms. Sorry, but I've seen several people where this has been the case. Extension of the lumbar spine can cause further forward slippage of the vertebra in question and exacerbate the problem.
Flexion stretching exercises may help – pulling knees to chest, whilst lying on back. Less likely to help whilst standing due to gravity & possible ‘pinching’ of vertebra.
Rhythmic traction may help with lumbar spine flat or in flexion. Lying on back with an assistant gently rhythmically pulling on legs at an angle between 15 & 60 degrees upwards. Up to about

 

[faybybaby]

Thanks for that Andrew! I'm a trainee Physio and your account of those 2 conditions is more comprehensive and makes much more sense than any of the text books I've read!

Thanks again!

 

[ShaZoloiuu]

No probs.

It started as a general advice to a patient & then went on a bit.

Always good to keep these in mind when taking case history & treating.

Andrew.