In general, the prognosis for these patients is quite good when the slip is of a lower grade. When the spondylolisthesis is of grade III or higher, the risks of injury to the nerves during surgery and experiencing further slipping of the spine in the future is higher than in the lower grade slips.
Surgical intervention may be needed when, patients fail to respond to nonsurgical treatments, there is progression of the slippage over 30%, the slip is grade III or higher, or when there are progressive neurological symptoms and physical deformity.
The first step in diagnosing spondylolisthesis is obtaining a complete history from the patient, followed by a detailed physical examination. If the physician is suspicious that a spondylolisthesis may be present, the next step is to confirm this with diagnostic studies.
An x-ray of the lumbar spine on a lateral view will easily confirm whether or not there is a slippage of one bone upon the other. It is often helpful to take this x-ray in a standing position as on occasion, the slip will reduce to a more neutral position when the patient is lying down (supine).
It is also helpful to have the patient obtain an extra x-ray of the lumbar spine, in the standing position, bending forward and backward. This is known as a flexion/extension x-ray. This x-ray will help to determine how much motion there is, and whether the spine is stable or unstable.
It has been found that only 10-15% of these patients go on to have spinal surgery and that most improve with nonoperative treatment. Typical nonoperative care includes rest, NSAIDS, ESIs, and a physical therapy program. Clinical significant improvements have been found with interventions that included lumbar flexion exercises and walking, but even more substantial improvement was found with the addition of manual therapy (joint mobilization and manual stretching) when performed to the lumbar spine and lower extremities. Exercise with an emphasis on spinal stabilization has been shown to provide pain relief and decreased re-occurrence of symptoms.
As the slippage progresses there is typically more irritation of the nerve root and the hamstrings become tight. This may be of benefit to a patient because of the hamstring insertion into the ischial tuberosities which would support a posterior pelvic tilt and subsequently decrease lumbar lordosis. Patients tend to walk in a more flexed position and develop increased hip flexor muscle tension. Flattening of the sacrum can be seen as the patient attempts to stop the slippage.
In 1976, Mangat and McDowall investigating the incidence of vertigo in 55 patients with cervical spondylosis, illustrated the resolution of vertigo and nystagmus with anterior cervical decompression, and suggested that abnormal afferent flow in the posterior cervical nerves in patients with cervical spondylosis lead to unstable vestibular tone, which is further upset by neck torsion.13
Isthmic and degenerative are the two types that are most common in adults. The three other types include traumatic, pathological, and dysplastic. The case study patient was a Lytic spondylolisthesis, which is always due to a fatigue fracture and is commonly seen in patients less than 50 years old.
The most common complaint in patients with vertebrobasilar insufficiency is vertigo.18,19 As the blood supply to vestibulocochlear organ, is an end artery, it is totally reliant on vertebrobasilar circulation and hence more susceptible to vertebrobasilar insufficiency20 leading to vestibular vertigo.
In the general population the incidence is between 3-10%. It is thought that athletic activities that require repeated hyperextension and rotation or repetitive combined flexion-extension predisposes athletes to develop pars defects. There are multiple types of spondylolisthesis and the exact cause is unknown.
Olszewski et al.16 examined 80 patients with radiological evidence of cervical spondylosis but with normal CT or MRI brain examination and no neurological symptoms (except cervical radicular symptoms) with 40 patients complaining of positional vertigo of at least six months durations. These patients had neuro-otological examinations and cochlear function tests to exclude other causes of vertigo and extracranial vertebral artery and carotid artery stenosis were also ruled out. All patients had transcranial doppler ultrasound with head rotations and it confirmed significant association between flow velocity in basilar artery after neck rotation and age, prevalence of vertigo and grade of radiological changes. It was also shown that vertebral artery flow velocity in neutral position was not affected by degenerative changes in cervical spine.
It usually presents as intermittent neck and shoulder pain with or without neurological deficit,5 although one-third of the patients present with headache, often in sub-occipital area radiating to vertex of the skull.8 Presentation with neurological deficit is usually divided into three clinical categories: