Physiotherapist

1. Spondylolisthesis
(spondylo = spine, listhesis = slippage)
PRESENTED BY
Divya Singh
MPT(Orthopedics) 2nd year

2. • Definition
• Anatomy
• Lumbo-sacral biomechanics
• Pathology
• Mode of Injury
• Predisposing factors
• Types of lesthisis
• Clinical presentation
• Diagnosis
•

3. • Radiological finding
• Management
• a) Conservative
• b) surgical

8. Spondylolisthesis
• Forward displacement of a vertebrae over the one
below it is called as antero-listhesis.
• In case if the displacement is backwards it is called
as Retro-listhesis.
• Commonest level of listhesis is L5-S1 & L4-L5.
(Rarely seen in lower cervical region also).
• Responsible anatomical factor is LS articular
surface & the biomechanical factor is the shear
stresses acting at LS junction.

11. LS Junction Biomechanics
• LS junction – The first sacral segment is directed
slightly downward, so that the discal surface of S1
forms an angle with an imaginary horizontal line &
this angle is called as LS angle.
• Increased anterior Pelvic tilt (as in case of obesity)
= Increased LS angle = Increase L lordosis =
Increased shear forces acting at LS junction =
predisposition for Displacement of one vertebrae
over another.
• Correlation = Rx

12. LS Junction Stabilization
• LS junction – between a mobile (Lumbar) & a
least mobile segment (sacral), makes the it prone
for injury.
• Junction between lumbar lordosis & sacral
kyphosis, makes the LS junction prone for
abnormal shear stresses.
• Bone check mechanism - Forward displacement
or translation of one vertebrae over another is
normally prevented by engagement of its
articular processes with that of the vertebrae
below. Disc and the major longitudinal ligaments
also helps to some extend in this check
mechanism.
• Role of Inter-transverse ligament (illio-lumbar
ligament of LS junction)

13. Inter-transverse or
Iliolumbar Ligament

14. PATHOLOGY
• Forward displacement or translation of one
vertebrae over another is normally prevented
by engagement of its articular processes with
that of the vertebrae below. (Bone check
mechanism)
• Disc and the major longitudinal ligaments
also helps to some extend in this check
mechanism.
• Any defect in this check mechanism will lead
to S-listhesis.

15. Cont.
• Resultant segmental instability
• Altered position of slipped vertebrae
changes its relative position with adjacent
vertebrae & surrounding soft structures,
creating abnormal mechanical stresses
over them.
• Clinical pictures correlates with the degree
of displacement (Nerve root compression,
central canal stenosis or spinal cord
injury)

16. PIA stresses
• Pars-inter-articularis - as the name suggest
it is the part of vertebrae bridging the supe
rior & inferior articular projections of a ve
rtebrae.
• There are two main theories on what caus
es the increased stresses on pars interartic
ularis:
1) Repeated Hyperextension and
2) Repeated Hyperflexion

17. Mode Of Injury
• The mechanism involves repeated bendin
g stresses around the thinnest part of the v
ertebrae (pars interarticularis) eventually r
esulting in a break in the vertebra i.e. Spon
dylolysis.
• In more severe cases, the involved vertebr
a may slip forward, ie. Spondylolisthesis

19. Predisposing Factors
• Physical/ mechanical shear stresses to LS
spine
• Repeated forcefull flexion & extension
• Direct/ indirect trauma
• increasing LS angle – such as
Obesity / Pregnancy/ Poor posture

20. Spondylolysis Spondylolisthesis

21. Pelvic cross syndrome
& LS angle

22. Spondylolisthesis
Traumatic
Congenital
or
Dysplastic
Acquired
Isthemic Degenerative Pathological

25. ISTHEMIC
• Commonest category (50% of cases) fracture
or lesion of the pars inter-articularis.
• Sub-types -
1. Acute # of PIA (Single episode of trauma)
2. Lytic or Fatigue # of PIA(repeated stress)

26. OTHER TYPE
2. Degenerative – Due to degeneration of discs and
facet joints. common in old age and in females. A
slow process thus usually does not produces any
acute symptoms. (Adaptation).
3. Pathological – Generalized or localized bone
disease.
4. Traumatic – violent trauma (Young-Adult)

27. Clinical Presentation
1. Majority of cases may remain asymptomatic
initially.
2. Commonest initial complaint is Back pain with or
without radiation.
3. Pain aggravated by Standing and walking.
(extension- shear forces)
4. Flexion Bias. Pain reduces with flexion, sitting, rest.
5. Increased lumbar lordosis, with a +ve Step sign -
Palpable Step of forward displacement of vertebrae.
6. Degenerative changes in other articular structures
over a period of time.
7. Depending upon the severity of displacement & the
level of displacement, the neurological symptoms
may appear, like lateral foramen stenosis, central
canal stenosis or even Spinal cord compression.

35. Radiological Findings
1. Lateral view LS spine
• Grading system. (AP width of Vertebral body)
2. Oblique view LS spine (Bw lateral & posterior
view) shows the defect in pars-inter-articularis
1. Scotty Dog appearance of normal PIA.
2. Scotty Dog wearing a collar in case of # or
defect of PIA (A defect in PIA without slipping
of vertebrae) - Spondylolysis
3. Scotty dog head separated from the neck (A
defect in PIA with slipping of vertebrae) -
Spondylolisthesis

38. Spondylolysis
Scotty Dog
wearing a collar

40. MRI FINDING

41. Grades of Listhesis
• Using the lateral view X-ray, the listhesis can be
graded according to the degree of severity.
• The Myerding grading system measures the
percentage of vertebral slip forward over the body
beneath.
• The grades are as follows:
Grade 1: 25 % Mild to moderate central canal
stenosis
Grade 2: 25 % to 50 % Severe stenosis,
Grade 3: 50 % to 75 %
Grade 4: 75 % to 100 %

44. Physiotherapy
a) Pain relief (Levels of pain modulation)
b) Back care Ergonomic advises such as –
• Keeping a Bolster under the knee in supine
position,avoid prolonged standing or walking,
• Weight reduction.
• Activity restrictions (no heavy lifting,
• excessive bending/twisting/stooping etc that
causes stress to lumbar spine).
• Postural education.
• Spinal Braces - LS belt/ corset/ frame

53. Surgery
• Aim
1. Pars interarticularis repair
2. Reduction of the listhetic deformity
3. Decompression +/- fusion
Options
1. Inter body fusion
2. Inter-transverse fusion
• with or without internal fixations
Post operative PT & Bracing

54. Surgery
• Severe cases not responding to
conservative management & showing
symptoms of neurological compromise
such as Spinal cord compression requires
Operative management

58. Reference

59. Thank you