Spondylolysis & Spondylolisthesis

Lumbopelvic Pathology

• Definition of Pathology: The structural and functional deviations from the normal that constitute disease. Also, the study of the essential nature of diseases and the structural and functional changes produced by them.
• Important Consideration: Pathology does not always correlate with pain or limitations.
• Objectives: Understand impairment-based classification of low back pain and demonstrate understanding of common lumbopelvic pathologies.

Definitions

• Lumbopelvic: Relating to the lumbar spine and pelvis.

Pathology

• Low Back Pain (LBP): Impairment-based classification for LBP (not pathology) includes low back pain with mobility deficits (acute, subacute, chronic), low back pain with movement coordination impairments (acute, subacute, chronic), and low back pain with radiating pain (acute, subacute, chronic).

Overview

• Serious/Systemic Pathology: Spondyloarthropathies (including Ankylosing Spondylitis), Cauda Equina, Abdominal Aortic Aneurysm (AAA), Cancer, and Fractures.
• Bone Pathology: Spondylolysis, Spondylolisthesis, and Schmorl's nodes.
• Joint Pathology: Spondylosis, degenerative joint disease (DJD), osteoarthritis (OA), and facet arthropathy.
• Nerve Pathology: Radiculopathy, Nerve Entrapment, "Double Crush" Syndrome, Spinal Stenosis (Central and Foraminal).
• Contractile Pathology: Muscle Strain, Acute or chronic overuse, Develop myofascial pain, Muscle Spasm, Protective mechanism (contractile, joint, disc, or nerve injury/pain).

Ankylosing Spondylitis

• Condition: Inflammatory condition of the spine eventually resulting in fusion.
• Prevalence: Predominantly affects men and typically begins in early adulthood, with 80% of cases occurring before age 40. Incidence is 0.2-0.5%.
• Symptoms: SI joint and lumbar pain, pain with inactivity that improves with movement; Uveitis (iris inflammation), Achilles enthesitis (tendon-bone inflammation), and hip/shoulder pain.
• Diagnosis: X-ray (sacroiliitis), blood test (HLA-B27).
• Treatment: Anti-inflammatories, exercise (mobility and strengthening). There is no cure.

Cauda Equina Syndrome

• Condition: Compression of the cauda equina (collection of nerve roots).
• Causes: Trauma, disc protrusion, hemorrhage, tumor.
• Incidence: 0.005-0.03% of back pain cases.
• Symptoms: Urinary retention/incontinence, "Saddle Anesthesia" (sensory changes in the buttocks, thighs, peritoneum), loss of anal sphincter tone (fecal incontinence).
• Medical Importance: A medical emergency demanding rapid decompression to avert permanent damage.

Abdominal Aortic Aneurysm (AAA)

• Condition: Dilation of the abdominal aorta exceeding 3 cm (1.2 inches).
• Prevalence: 4-8% in older men, 0.5-1.5% in older women (generally those older than 50).
• Symptoms: Abdominal pain and backache.
• Risk Factors: Age, smoking, family history.
• Diagnosis: Palpation, Imaging (Ultrasound, CT, MRI).

Compression Fracture

• Location: Most commonly in T8, T12, L1, and L5.
• Causes: Trauma (more significant in younger people), minor trauma in older people, postmenopausal women, osteoporosis, and long-term corticosteroid use.
• Symptoms: Pain at fracture site, limited motion.
• Diagnosis: X-ray.
• Treatment: Time, Kyphoplasty, Fusion.

Tumors

• Types - Primary: Rare, originates in the spine (osteosarcoma, multiple myeloma).
• Types - Secondary: Common, metastasizes from another area (breast, lung, thyroid, kidney, prostate).
• Red Flags: Unexplained weight loss, pain not relieved with rest or position change, and night pain.

Spondylolysis

• Condition: Fracture of the pars interarticularis (part of the vertebra).
• Causes: Repeated or excessive end-range extension (common in dancers and gymnasts).
• Symptoms: Pain (acute or chronic), localized to the low back.
• Diagnosis: X-ray, "Scotty Dog" collar sign.
• Treatment: Conservative, bracing, and time.

Spondylolisthesis

• Condition: Pars fracture with anterior displacement of the vertebral body, often identified with low back pain with movement coordination impairments. Most common is L5/S1.
• Etiology: Congenital, arthritis, trauma, or stress fractures.
• Diagnosis: X-ray.
• Grades: Classified by the Meyerding Scale (0-100% displacement).

Schmorl's Nodes

• Condition: Disc herniation through the vertebral endplate into the vertebral body.
• Typical Outcome: Usually asymptomatic.

Joint Pathology - Overview

• Contributing Factors: Genetics, lifestyle factors, trauma.
• Arthritic Changes: Osteophytes (bone spurs), cartilage loss, and capsule thickening.

Facet Joint

• Signs/Symptoms: Pain/stiffness reduced by movement. Local pain or referred pain. Older individuals find closed (standing, walking) positions most uncomfortable.
• Treatment: Conservative, mobility, manual therapy, injections, radiofrequency ablation.

SI Joint

• Causes: Usually related to hypermobility, common in peripartum women, and people with hypermobility and connective tissue disorders.
• Typical Symptoms: Low back pain with movement coordination impairments, stiff, sharp, tingling symptoms, localized or generalized pain, and pain exacerbated by sitting, standing, inactivity, lifting, running, or shifting weight to affected side.
• Treatments: Bracing, manual therapy, strengthening exercises, injections, RFA, and surgery.

Disc Pathology - Overview

• Prevalence: Estimated prevalence of pain related to disc herniation: 1.6-13.4% (Wong et al 2023). Degenerative disc disease (DDD) is 88-96% in people between 60 and 80 years old with degenerative disc changes. Prevalence increases with every decade starting at age 20.
• Disc Herniation: 69% of asymptomatic people between 60-80 years old have disc bulge.
• Degenerative Disc Disease (DDD): Related to decreased water imbibition in proteoglycan resulting in decreased vertical height, increased facet joint loading, ligamentous laxity, bulging into canal and foramina (stenosis), lig. flavum also thickens, and loss of nutrients.

Disc Herniation - Overview

• Types: Posterolateral (most common), degeneration (breakdown of inner rings, no outer ring deformation), prolapse (bulging beyond normal annular margin, outer rings intact), extrusion (nucleus material escapes but is still one piece), sequestration (nucleus separated free from disc).

Radiculopathy

• Prevalence: 3-5%
• Age Risk Factors: Men (40s), women (50s-60s).
• Causes: Degenerative spondyloarthropathies, disc herniation, and spondylolisthesis.
• Signs/Symptoms: True neurological deficits (Dermatomes, Myotomes, Reflexes), lower motor neuron deficits, pain localized to the area of the nerve root, and +/- Limited ROM.
• Nerve Mechanosensitivity: Nerve is sensitized to mechanical forces (e.g., stretch, compression).
• Treatment: Conservative, mobility, time, injections, and surgery.
• Spinal Stenosis: Narrowing of spinal canal and/or foramina and possible compression or irritation of the spinal cord or nerve roots. Possible impingement symptoms. Different forms can be central, foraminal, or a combination of the two.

Nerve Entrapment

• Cause: Minor injuries to either the nerve or connective tissue (adhesion, shortening, loss of elasticity)
• Result: Pain and paresthesia along the affected nerve.
• Note: Nerves can be highly sensitized with chemical irritation (inflammation).

"Double Crush" Syndrome

• Describes: Compression or irritation in 2+ distinct areas (e.g., sciatic nerve-l4 nerve root and piriformis).

Nerve Treatment

• Considerations: Space, movement, and blood flow
• Additional Considerations: Direction specific exercise? and surgery. Cardiovascular exercise.

Contractile Pathology

• CPG: Low back pain with mobility deficits, which can be overlooked as pain generators in the lumbar spine.
• Causes: Muscle strain (acute or chronic overuse, myofascial pain), Muscle spasm (protective mechanism—contractile, joint, disc, or nerve injury/pain).
• Signs/Symptoms: Sore, stiff, aching, sharp pain, and decreased ROM localized to the lumbar musculature.
• Treatment: Time, conservative care, and trigger point injections.

Test your knowledge of spondylolysis and spondylolisthesis. Questions cover diagnosis using X-rays ('Scotty Dog' sign), differences between the conditions, appropriate interventions, activity modifications, Meyerding classification, and initial treatment strategies.