Spondylolisthesis and Related Pathologies

Lumbopelvic Pathology

• Presentation by Adam Squires, PT, DPT, Cert SMT, Cert DN, Board Certified Specialist in Orthopedic Physical Therapy
• Focuses on understanding impairment-based classifications of low back pain and common lumbopelvic pathologies.

Definitions

• Pathology: Structural and functional deviations from normal, constituting disease, or characterizing it

• The study of the essential nature of diseases and significant structural and functional changes produced by them

• Pathology doesn't always equate to pain or limitation

• Important to understand the difference

Lumbopelvic Clinical Practice Guideline

• Published 2012, updated 2021

• Focuses on impairment-based classifications for low back pain (not pathology)

• Types included:

  • Low back pain with mobility deficits (acute, subacute, chronic)
  • Low back pain with movement coordination impairments (acute, subacute, chronic)
  • Low back pain with radiating pain (acute, subacute, chronic)

Overview of Pathology

• Serious/Systemic:

  • Spondyloarthropathies (e.g., Ankylosing Spondylitis)
  • Cauda Equina
  • Abdominal Aortic Aneurysm (AAA)
  • Cancer
  • Fracture

• Bone Pathologies:

  • Spondylolysis
  • Spondylolisthesis
  • Schmorl's Nodes

• Joint Pathology:

  • Spondylosis
  • Degenerative Joint Disease (DJD)/Osteoarthritis (OA)
  • Facet arthropathy

Ankylosing Spondylitis

• Inflammatory condition of the spine, eventually leading to spinal fusion
• Primarily affects men, starting in early adulthood (80% under 40)
• Incidence: 0.2-0.5%
• Symptoms:
  • SI joint and lumbar pain
  • Pain worsened by inactivity, improved with movement
  • Uveitis (iris and ciliary body inflammation)
  • Pain in hip and shoulder

Cauda Equina Syndrome

• Compression of the cauda equina (cauda nerve roots), often due to trauma, disc protrusion , hemorrhage, tumors, etc.
• Low incidence, 0.005-0.03% of low back pain
• Symptoms:
  • Urinary retention/incontinence
  • "Saddle anesthesia" (sensory changes in buttocks, inner thighs, perineum)
  • Loss of anal sphincter tone, leading to fecal incontinence
• Medical emergency; requires quick decompression to prevent permanent damage

Abdominal Aortic Aneurysm (AAA)

• Dilation of the abdominal aorta beyond 3 cm (1.2 inches)
• 4-8% of older men, 0.5-1.5% of older women
• Symptoms:
  • Abdominal pain, backache
• Risk factors:
  • Age, smoking, family history
• Diagnosis:
  • Palpation
  • Imaging (ultrasound, CT, MRI)

Compression Fracture

• Most common in vertebrae T8, T12, L1, and L5

• Causes:

  • Trauma (significant in young people, minor in older people)
  • Osteoporosis, postmenopausal women
  • Long-term corticosteroid use

• Symptoms:

  • Pain at fracture site
  • Limited movement

• Diagnosis:

  • X-ray

Tumors

• Primary: Rare, originates in spine
  • Osteosarcoma, Multiple myeloma
• Secondary: Common, metastasizes from other areas
  • Breast, Lung, Thyroid, Kidney, Prostate

Spondylolysis

• Fracture of pars interarticularis without vertebral displacement
• Often associated with repeated/excessive end-range extension (e.g., gymnasts, dancers)
• Symptoms: localized low back pain

Spondylolisthesis

• Pars fracture with anterior displacement of vertebral body
• Common in L5/S1 lumbar region
• Etiology:
  • Congenital
  • Arthritis
  • Trauma
  • Stress fracture
• Diagnosis:
  • X-ray

Meyerding Scale for Spondylolisthesis

• Grading system for spondylolisthesis based on percentage of vertebral displacement
  • Grade 1: 0-25%
  • Grade 2: 25-50%
  • Grade 3: 50-75%
  • Grade 4: 75-100%
  • Spondyloptosis: >100%

Schmorl's Nodes

• Disc herniation through vertebral endplate into vertebral body
• Usually asymptomatic

Degenerative Disc Disease (DDD)

• Prevalence increases with age; 88-96% asymptomatic individuals have disc degeneration between the ages of 60 and 80.
• Related pain increases every decade after age 20.
• Decrease in proteoglycans, leading to reduced water imbibition, decreased vertical height, increased facet joint loading and ligamentous laxity. Bulging of disc into canal and foramina, lig. flavum also thickens. Loss of nutrients. Strong genetic link.

Disc Herniation

• Most common location is posterolateral.
• Degeneration and breakdown of inner rings, no outer ring deformation
• Bulging beyond normal annular margin, outer rings remain intact
• Types:
  • Extrusion: Nucleus material escapes but remains in one piece; portion of broken annulus may also extrude.
  • Sequestration: Nucleus material separated from disc, annular material may also break free

Nerve Pathology

• Overview: CPG – Low back pain with radiating pain; Radiculopathy; Stenosis; Nerve Entrapment; Nerve Mechanosensitivity; "Double Crush" Syndrome.

Radiculopathy

• Prevalence: 3-5%, age-related risk factors, typically affecting men in their 40s and women in their 50s-60s
• Etiology: degenerative spondyloarthropathies, disc herniation, spondylolisthesis
• Symptoms:
  • True neurological deficits (dermatomes, myotomes, reflexes)
  • Lower motor neuron deficits
  • Pain in the area associated with the nerve root
  • +/- Limited range of motion (ROM)
  • Nerve mechanosensitivity.

Spinal Stenosis

• Narrowing of the spinal canal
• Types:
  • Central stenosis: narrowing of the spinal cord space.
  • Foraminal stenosis: narrowing of the neural foramina.
• Symptoms:
  • Bilateral leg symptoms in central stenosis
  • Unilateral symptoms in foraminal stenosis
  • Neurogenic claudication/pain with walking
  • Upper and lower motor neuron deficits.

Nerve Entrapment

• Theory: Minor injuries to nerves or connective tissues can cause adherence, shortening, and loss of elasticity. Leading to pain and paresthesia along the affected nerve
• Prevalence varies based on body area, with carpal tunnel high among others.
• Symptoms:
  • Pain and paresthesia along affected nerve.
  • +/- motor deficits
  • Absence of myotomes

"Double Crush" Syndrome

• Compression or irritation in two or more distinct area, such as sciatic nerve and L4 nerve root or piriformus

Nerve Treatment

• Nerves rely on space, movement, and blood flow.
• Treatment options include
  • Direction-specific exercises
  • Surgery
  • Injections
  • Manual therapy

Contractile Pathology

• CPG- Low back pain with mobility deficits
• Can be overlooked as pain generator in lumbar spine
• Causes:
  • Muscle strain (acute/chronic overuse)
  • Muscle spasm (protective mechanism)
• Contractile, joint, disc, or nerve injury/pain.
• Symptoms:
  • Sore, stiff
  • Aching, sharp pain
  • Localized to the lumbar musculature, decreased ROM.
• Treatment:
  • Time
  • Conservative treatment
  • Trigger point injections