II. Definitions

  1. Spondylolisthesis
    1. Slippage of one Vertebrae over another
    2. L5 on S1 is the most common site

III. Types

  1. Degenerative Spondylolisthesis (adults)
    1. More common in women over age 40
  2. Isthmic Spondylolisthesis (children)
    1. Secondary to Spondylolysis
    2. More common in athletes (gymnastics, football)

IV. Symptoms

  1. Back pain radiates posteriorly into knees
  2. Hamstring spasms with inability to bend forward
  3. Limited Straight Leg Raise
  4. Bending, lifting or twisting provokes pain

V. Signs

  1. Loss of lumbar lordosis
  2. Flattening of buttocks
  3. Step-off at the affected spinous process (usually L5)
  4. Hamstring spasm
    1. Limited forward flexion
    2. Difficult Straight Leg Raise

VI. Imaging: Lateral Lumbosacral Spine XRay

  1. Position of posterior-inferior corner of involved Vertebrae (e.g. L5)
    1. Grading anterior slippage based on position over segment or Vertebrae immediately below (e.g. S1)
  2. Vertebrae or sacral base (e.g. top of S1) is divided into 4 sections
    1. Grade 1: <26% slippage (posterior)
    2. Grade 2: 26-50% slippage
    3. Grade 3: 51-75% slippage
    4. Grade 4: 75-100% slippage (anterior)
    5. Grade 5: >100% slippage (Spondyloptosis)
  3. Consider flexion and extension views
    1. May demonstrate instability

VII. Monitoring

  1. General
    1. Return for new neurologic symptoms or Cauda Equina Syndrome symptoms
  2. Adolescents
    1. Repeat XRay every 6 months until full adult height reached

VIII. Management

  1. Conservative management
    1. Avoid provocative activities (e.g. spine extension, squats)
    2. Encourage light activity (NOT bed rest) with Stretching
    3. Avoid heavy lifting
    4. Analgesics for pain
    5. Consider bracing
    6. Physical therapy
  2. Return to Play Guidelines
    1. Grade 1 Spondylolisthesis athletes may return to Contact Sports
    2. Grade 2 Spondylolisthesis athletes require sports medicine or spine evaluation prior to return to sports

IX. Management: Orthopedic or spine surgeon referral indications

  1. High grade slippage >50% (Grade 3 to 4)
  2. Failed medical management with persistent pain >6 months
  3. Instability (may require Spinal Fusion)

X. Prognosis

  1. Conservative, non-surgical management results in good to excellent longterm outcomes in >90% of athletes

XI. References

  1. Greene (2001) Musculoskeletal Care, p. 573-6
  2. Humphreys (2002) Am Fam Physician 65(11):2299-306 [PubMed]

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