5-Minute Emergency Consult

Spondylolysis/spondylolisthesis

Description

  • Spondylolysis:
    • Bony defect at the pars interarticularis (the isthmus of bone between the superior and inferior facets)
    • Can be unilateral or bilateral
    • Bilateral form has a much higher likelihood of slippage or spondylolisthesis than the unilateral form
  • Spondylolisthesis:
    • The slipping forward of one vertebra upon another
    • Spondylolysis can contribute to spondylolisthesis, which is noted in ∼5% of the population. It is 2–4 times more common in males.
    • Of those with spondylolysis, 50% will have some degree of spondylolisthesis develop during their lifetime, and 50% of those will be symptomatic:
      • Literature does not associate athletic activity with increased slippage.
    • Spondylolisthesis predisposes to nerve root impingement and frequently sciatica.
  • Classification:
    • Type 1—dysplastic: Congenital defect of the neural arch or intra-articular facets is often associated with spina bifida occulta.
    • Type 2—isthmic: Stress fracture from repetitive microtrauma through the neural arch
    • Type 3—degenerative: Long-standing segmental instability
    • Type 4—traumatic
    • Type 5—pathologic: Leneralized or focal bone disease.
    • Spondylolisthesis is divided into four grades based on degree of slippage (Meyerding grading system):
      • Grade I: Up to 25% of the vertebral body width
      • Grade II: 26%–50% of vertebral body width
      • Grade III: 51%–75% of vertebral body width
      • Grade IV: 76%–100% of vertebral body width
    • The most common location for spondylolisthesis is L5 displaced on the sacrum (85%–95%), followed by L4 on L5.

Pediatric Considerations
  • Spondylolysis is one of the most common causes of serious low back pain in children, although it is most often asymptomatic.
  • Symptoms most often present during adolescent growth spurt from age 10–15 yr.
  • Seen commonly in athletic teens; particularly in sports involving back hyperextension (eg, gymnastics, diving, football).
  • Acute symptoms are related to trauma.

Etiology

Unknown; theories include congenital pars anomalies, alterations in bone density, and recurrent subclinical stress injury.

Signs and Symptoms

History

  • Onset often gradual, unless traumatic
  • Often associated with feeling of stiffness or spasm in paravertebral muscles
  • Pain in the back and proximal legs aggravated by standing and walking
  • Sitting or forward bending relieves pain.
  • Pain occurs after varying amounts of exercise, with standing, or with coughing:
    • Aggravating factors can include repetitive hyperextending movements.
    • Alleviating factors can include rest, although the course is variable and slow and usually requires sitting or stooping positions.
  • Systemic/neurologic symptoms: minimal, unless there is significant trauma or “slip.”

Physical Exam
  • Hyperlordotic posture:
    • Trunk may appear shortened.
    • Rib cage approaches iliac crests.
  • Hamstring tightness:
    • Knees flexed to allow patient to stand upright
  • Only “typical” finding is one-legged hyperextension:
    • Standing on one leg and leaning backward reproduces pain on ipsilateral side.
  • Palpation may reveal step-off with a prominent spinous process of L5 in significant spondylolisthesis.
  • Neurologic exam is usually normal:
    • If abnormal, pain and sensorimotor loss is in a dermatomal distribution.
    • Consider herniation or spondylolisthesis.

Pediatric Considerations
  • Spondylolysis in a child <10 yr is rare; these patients should be watched for:
  • Constant pain lasting several weeks
  • Pain occurring spontaneously at night
  • Pain that interferes repeatedly with school, play, or sports
  • Pain associated with marked stiffness, limitation of motion, fever, or neurologic signs
  • Pain at the lumbosacral junction

Diagnostic Tests and Interpretation

Lab
There are no required laboratory studies.

Imaging

  • Lumbosacral spine radiographs:
    • Lateral and oblique radiographs of spine most helpful.
    • Spondylolysis will manifest as a radiolucent defect in the pars interarticularis, visible as a “collar” or “broken neck” on the oblique view “Scottie dog”:
    • Secondary radiographic signs may include sclerosis of the contralateral pedicle and spina bifida occulta at the level of the spondylolysis.
    • Majority (80%–95%) found at L5–S1 level, 15% at L4–L5.
    • Spondylolisthesis will manifest as forward slipping of one vertebral body on another (seen on lateral view).
  • Single photon emission computed tomography (SPECT)—better specificity for linking back pain to spondylolysis.
  • CT scan:
    • Pathology more clearly demonstrated than on plain films
    • Can identify other spinal pathology
    • Plays an important role for orthopedics in management decisions through identification of new stress fractures and healing of old stress fractures.
    • If a CT scan is obtained in the ED, sagittal reconstructions should be performed and the CT scanner should be at minimum a 16-slice scanner.
    • Outpatient evaluation unless history of recent trauma.
  • MRI—exact role not yet clarified in literature:
    • Useful for defining root impingement and foraminal narrowing.
    • May be useful in the assessment of acuity of abnormality.
    • Can identify alternate pathologic diagnoses.

Pediatric Considerations
  • Lower threshold for ordering imaging studies.
  • Progressive slipping more likely to occur than in adults.

Differential Diagnosis

  • Tuberculosis (Pott disease)
  • Discitis
  • Bone or spinal cord tumor
  • Pyelonephritis
  • Retroperitoneal infection
  • Injury to muscles or joints of back
  • Congenital hip dislocation
  • Rickets
  • Ruptured intervertebral disc
  • Vascular claudication
  • Osteomyelitis
  • Osteoid osteoma

Pre Hospital

Spinal precautions are not needed unless there is a history of recent trauma.

Initial Stabilization/Therapy

Vigorous attempts at traction should not be pursued.

Ed Treatment/Procedures

  • Pain control and muscle relaxants as clinically needed
  • Supportive therapy if symptoms are mild
  • Restrict activities if repetitive trauma is likely aggravating cause (eg, sports) for 3–6 wk, followed by reintroduction of activity when asymptomatic.
  • Consider antilordotic braces (controversial) or physical therapy.
  • Orthopedic consult or referral if symptoms are moderate to severe or unresponsive to supportive care
  • Surgical intervention typically consists of spinal fusion in the flexed position:
    • 50% of symptomatic patients with spondylolisthesis may require surgery.
  • All symptomatic patients with grade III or IV spondylolisthesis should probably undergo surgery.
  • Exercises are not of proven benefit.

Pediatric Considerations
  • Activity restriction is not necessary if minimal or no symptoms.
  • Literature suggests good outcome for young athletes with conservative treatment.

Medication

  • Muscle relaxants:
    • Example—methocarbamol: 1,000–1,500 mg PO q.i.d. (peds: safety and effectiveness for children <12 yr of age not established)
    • Diazepam: 2–10 mg PO t.i.d. – q.i.d.
    • Cyclobenzaprine: 5–10 mg PO t.i.d. (peds: safe for ages >15 yr old)
  • NSAIDs:
    • Example—ibuprofen: 200–800 mg PO t.i.d.–q.i.d. (peds: 5–10 mg/kg PO q6h)
  • Opioids (doses can vary on oral medications):
    • Example—morphine sulfate: 0.1 mg/kg up to 2- to 4-mg increments IV.
    • Acetaminophen/hydrocodone: 5/500 mg 1–2 tabs PO q.i.d.
    • Acetaminophen/oxycodone: 5/325 mg 1–2 tabs PO q.i.d.
    • Acetaminophen/codeine: 300/30 mg 1–2 tabs PO q.i.d. (peds: 0.5–1 mg/kg codeine PO q4–6h; max 60 mg per dose codeine; 1g per dose, 75 mg/kg/day up to 4 g/day >3 yr old)

Disposition

Admission Criteria

  • Inability to walk
  • Inability to cope at home due to pain or social situation
  • New or progressive neurologic deficit

Discharge Criteria
  • Orthopedic follow-up arranged
  • Social support system in place
  • Pain control
  • Patient education

Pediatric Considerations
Close follow-up is mandatory.

Additional Reading

  • Castillo M, Mukherji S. Spinal imaging: Overview and update. Neuroimaging Clin N Am. 2007;7(1):92–93.
  • Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med. 1997;25(2):248–253.
  • Debnath UK, Freeman BJ, et al. Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg. 2003;85(2);244.
  • Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports. 2004;14(6):337.
  • Miller SF, Congeni J, Swanson K. Long-term functional and anatomical follow-up of early detected spondylolysis in young athletes. Am J Sports Med. 2004;32(4):928.
  • Nachemson A. Newest knowledge of low back pain. Clin Orthop. 1992;279:8.
  • Satndaert CJ. Spondylolysis. Phys Med Rehab Clin North Am. 2000;11(4):785–801.
  • Skinner H. Disorders, diseases and injuries of the spine. In: Current Diagnosis and Treatment in Orthopedics. Norwalk, CT: Appleton & Lange, 1995:206–211.
  • Vitek G. Spine conference spondylolysis and spondylolisthesis. Ortho News Mag. May 1995. Available at: http://www.nmis.com/onm/html/sponconf-spon.htm.
  • Weinstein J, Wiesel S. Lumbar and lumbosacral spondylolisthesis In: The Lumbar Spine: The International Society for the Study of the Lumbar Spine. Philadelphia: Saunders, 1990:471–545.

ICD-9

  • 738.4 Acquired spondylolisthesis
  • 756.11 Congenital spondylolysis, lumbosacral region
  • 756.12 Spondylolisthesis, congenital

SNOMED

  • 240221008 spondylolysis (disorder)
  • 80712009 congenital spondylolysis of lumbosacral region (disorder)
  • 274152003 spondylolisthesis (disorder)
  • 13236000 congenital spondylolisthesis (disorder)

Authors

Lisa G. Lowe Hiller


© Wolters Kluwer Health Lippincott Williams & Wilkins

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