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Lumbar Spondylolisthesis
Mike Bazarnicki
Objective: The objective is to describe the case of a 20 year old NCAA division III female
swimmer who sustained a grade I lumbar spondylolisthesis slippage at L5. Background: The
athlete walked into the athletic training clinic complaining of reinjuring an injury to the lower
back. Athlete described that the back has been injured for 3 years. The athlete said it was
reinjured while she was doing squats. She says the pain is a 10 out of 10. The initial diagnosis
of the injury was grade I spondylolisthesis. Differential Diagnosis: Spondylolysis was the first
differential diagnosis listed. Facet Joint dysfunction could also be another differential diagnosis.
Treatment: The athlete was originally told to rest and take non-steroidal anti-inflammatory
drugs as the initial treatment until swelling and pain went down. After that ultra sound, deep
tissue massages, increasing flexibility, strength, core stability, and exercises that help regain full
range of motion. Uniqueness: The athlete has been having the back problems for 3 years now.
The athlete’s spondylolysis progressed into spondylolistheses. Conclusion: Spondylolysis
needs to be caught early and treated correctly therefore spondylolisthesis doesn’t occur. Key
Words: Spondylolisthesis, Spondylolysis, Lumbar Spine,
Lumbar Spondylolisthesis: Case Study
The vertebral column is divided into four columns, the cervical spine, thoracic spine,
lumbar spine, and the sacrum and the coccyx.1-3 The lumbar spine consists of 5 vertebrae they are
listed L1-L5. The lumbar vertebrae are the largest because they bear the most weight in the
spine.1-2 Each vertebrae consists of multiple parts as seen in Figure A and Figure B, that all serve
specific purposes. In the lumbar spine, like the cervical and thoracic spines, consists of a
vertebral body.1 These bodies are positioned anteriorly and its primary function is weight
bearing.1-2 Follow the vertebral body and go posterior, there you will find a projecting structure,
this is the sight of the pedicles, each vertebra contains two pedicles.1 The pedicles help form the
anterior section of the neural arch.1 The laminae are posterior to the pedicles.1 The laminae help
form the posterior portion of the neural arch as well as protect the spinal cord.1 The transverse
processes are located laterally from the laminae.1,3 They serve as attachment sites to the intrinsic
muscles and ligaments of the spine.1,3 The spinous process is the most posterior projection of
each vertebrae.1 They project at a downward angle which helps restrict extension of the spine as
well as serves as an attachment sight of muscles and ligaments of the spine.1 There are two
articulating surfaces that arise from the lamina.1,3 The articulating surfaces are called she superior
facets and the inferior facets.1,3 The superior facets of the vertebrae attach to the inferior facets of
the vertebrae above, this attachment creates the facet joints.1,3 In the lumbar spine the facet joints
function is to assist in flexion, extension, and rotation of the spine as well as protect against shear
forces.1-3 The pars interarticularis arises from the laminae and is intermediate to the superior and
inferior facets of the vertebrae.1,3 The pars interarticularis is a common spot for fractures.1,3 In
between each vertebrae lies an intervertebral disks which made up by the nucleus pulposus and
annulus fibrosus. The nucleus pulposus is the center of the disk that is made up of a jellified
liquid. The annulus fibrosis is the outer layer of the disk and it is made up of collagen that forms
a weave pattern.
Spondylolisthesis in the Lumbar spine most commonly affects the L5 and is an anterior
slippage of the vertebra below it.3-6 It is a result to defects or damage to the pars interarticularis.16
It is most common in women and adolescents. Spondylolisthesis most often affects women and
adolescents.3-6 The three most common types of sponylolisthesis that you see are congenital,
isthmic, and degenerative spondylolisthesis.4 Congenital spondylolisthesis is characterized by an
abnormal bone formation that causes the slippage that is present at birth.3-6 Degenerative
spondylolisthesis is characterized by age and it’s the wearing down of the vertebra that causes
the slippage.4-6 Isthmic spondylolisthesis, which is the most common in sports, occurs as a result
of spondylolysis, which is characterized by fractures to the pars interarticularis.3-6 Spondylolysis
and spondylilisthesis go hand in hand. Spondylolysis is classified as an overuse injury that
occurs due to repetitive back extension.5-6 Spondylolysis is characterized by stress fractures to
the pars interarticularis.5-6 Once these occur the continuous repetitive motions will cause the
vertebrae slippage causing spondylolisthesis.3-6 There are 4 grades that correspond to the amount
of slippage that takes place.4-4 Grade I is a slippage from 1% to 25%, grade II is a slippage of
26% to 50%, grade III is a slippage of 51% to 75%, and grade IV is a slippage of 76% to 100%.46
In Figure C you can see the deformity.
Spondylolisthesis is an injury that is not always detected; often time’s patients will have a
slippage but will have no signs and symptoms.3-6 This usually occurs in grade I slippage and
grade II slippage.3-6 The most common mechanism for spondylolisthesis is repetitive back
extension, which in swimming occurs frequently with the athlete diving into the pool and
performing flip turns.4-6 The most common signs and symptoms of this injury are low back pain,
quadriceps weakness, hamstring weakness, and pain in the gluteal muscles.3 Often times when a
patient has a slippage, they may walk like they are waddling due to pain and discomfort.3
A 20 year old, female, division III came into the Athletic Training Clinic complaining of
lower back pain. She explained that during her senior year of high school she started noticing
the lower back pain and during her freshman year of college the pain got worse. The athlete also
said that the doctors diagnosed her with a nerve impingement and she did physical therapy in
Tampa and in the Rowan Athletic Training Clinic, and explained after doing rehab that the pain
comes and goes. She then explains that she re-injured her lower back doing squats right before
coming into the Athletic training clinic. She describes that the pain is a 10 out of 10 at the time
of the evaluation. During swimming the athlete complains of sharp pain while pushing off the
board when diving into the pool. Upon evaluation of the back there was no noticeable swelling,
ecchymosis, or deformities. During palpations the posterior superior iliac spine, posterior
inferior iliac spine, L5 transverse processes, and L5 facet region were all positive for point
tenderness. For soft tissue palpations the transverse process ligament was positive for point
tenderness. Active, passive, and resistive ranges of motion were all tested. For active range of
motion flexion, extension, lateral flexion, and rotation were full with mild to no pain. During
passive range of motion flexion, lateral flexion, and rotation were all full with no pain.
Extension however, was limited due to pain. With resistive range of motion both rotation to the
right and extension were limited with pain. Manual muscle tests were not performed due to pain.
Circulation was found to be within the normal limits. Neurological tests for dermatomes and
myotomes were found to be within normal limits. There were a multitude of special tests done,
the ones that were found to be negative were bilateral straight leg raise, unilateral straight leg
raise, SI distraction, long sit, valsalva maneuver, Patrick’s test, and McKenzie flexion. The
special tests that tested positive were stork standing, SI compression, and McKenzie extension.
The three of them all tested positive for pain. Functional tests were not performed due to pain.
The initial impression of the pathology was either spondylolysis or grade I spondylolisthesis, and
the athlete was instructed to rest for a few days to see if the pain would subside then, depending
on the pain in a few days would either get x-rays or begin the rehabilitation process.
After a couple of days the athlete said that her back pain had not gone away, however,
she now said that her pain was at a 6 out of 10. It was decided that it wasn’t necessary for her to
get x-rays. Although x-rays weren’t taken, the athletic trainers still believed the pathology to be
grade I spondylolisthesis.
There are several signs to tell that the pathology is a grade I spondylolisthesis. The
athlete has been complaining of lower back pain since she was in high school that got worse
when she was a freshman in college. She was instructed to do physical therapy and that helped
her cope with the pain, even though the athlete described her pain after that as it would “come
and go”. As a swimmer she continually is extending her back, which that repetitive trauma could
have led to spondylolysis. The athlete also said that she reinjured it while doing squats.
Therefore, with the spondylolysis present while continuing to participate in activities she caused
a slippage of 1% to 25% meaning a grade I slippage. Although the athlete was never referred to
a physician to receive x-rays or a CT scan to confirm the injury, it is still the best diagnosis that
could be made.
In this specific case the athlete has been non compliant. There are however, many
different ways to treat spondylolisthesis, these treatment options vary based on the severity of the
slippage.3-6 In grade I and grade II the initial treatment option would be a period of rest while
taking non-steroidal anti-inflammatory drugs.3-6 Along with that the athlete can use ice over the
lumbar spine to reduce swelling.3-5 This can help relieve pain and swelling if there is any present.
Throughout the rehab process the athletic trainer can administer a deep tissue massage, which
helps reduce spasms to the muscles while they try to adapt to the slippage that took place.3
Ultrasound can also be used to increase the vascular supply to decrease spasms.3 Rehabilitation
should consist of exercises that improve flexibility, strength, core stability, and range of
motion.3-6 The main muscle groups that need improved flexibility include the hamstrings and the
quadriceps.3 The goals of the rehabilitation program are to have the athlete to be able to go back
to activity pain free and to regain full range of motion.3 The initial rehabilitation program should
avoid doing exercises that involve back extension, because extension of the back will aggravate
the injury and event potentially cause more slippage.4-6 If it is a grade III or grade IV slippage
and conservative treatments do not work then surgery will be required.5 The surgery fuses the
lumbar spine with the sacrum to prevent any more slippage.5
In order for the athlete to return to play a few key things need to happen. First the athlete
needs to regain their full range of motion with out any pain.4-6 Along with that the athlete needs
to regain full strength and neuromuscular control.3-6 Also the athlete needs to be able to perform
sport specific movements without any pain.3-6 These sport specific movements include running,
jumping, diving into the pool, performing flip turns, and be able to perform proper swimming
strokes.
I believe it is important for people to know about my case study because if it goes
misdiagnosed it can cause a lot of problems. On top of things it is most prevalent in adolescents,
which is something we need to know since we will be potentially working in high school. The
unique thing about this is the fact that the athlete has been injured for over three years. Which
means she had spondylolysis that turned into spondylolisthesis.
First, I learned a great amount about the lumbar spine just from doing research. On top
of that I learned about multiple injuries while doing my research, especially about spondylolysis
and spondylolisthesis. The best thing about the case study is that I got to improve my writing
skills for the future by writing this case study.
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References
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http://www.spineuniverse.com/conditions/spondylolisthesis/anatomy-spondylolisthesis
Accessed December 3, 2014
Cleveland Clinic. HealthHub. October 19, 2009. Available
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Spondylolisthesis. Accessed December 3, 2014
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KnowYourBack.org. KnowYourBack.org. . Available
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