minished touch sensation on the lateral aspect of the left thigh and medial calf. .... inducing too much rotation into the lumbar spine, has been shown to be an ...
Dysplastic spondylolisthesis: a report of two cases Dale Mierau, BSPE, DC J David Cassidy, DC, BSC, FCCS(C) Ken Yong-Hing, MB, FRCS(C) Two adolescent females presented with longstanding low-back pain and leg pain. They both had lumbosacral dysplastic spondylolisthesis. One girl responded to a course of spinal manipulation while the other did not and went on to surgical intervention. Spondylolisthesis should be suspected in young patients with persistent low-back pain unresponsive to conservative treatment. KEY WORDS: spondylolisthesis, manipulation, chiropractic
Les deux adolescentes qui se sont presentees avaient depuis longtemps des maux de jambes et des douleurs au bas du dos. Elles avaient toutes deux une spondylolistesis lombosacree dysplastique. Une des adolescentes a reagi favorablement a' une session de manipulation de la colonne vertebrale, tandis que l'autre a du subir une intervention chirurgicale. La spondylolistesis devrait toujours etre soup onnee chez les jeunes patients presentant des douleurs persistantes dans le bas du dos et ne reagissant pas aux traitements conservateurs. MOTS CLES: spondylolistesis, manipulation, chiropractie
Introduction
Case reports:
Low-back pain with or without leg pain, in a child or adolescent, that persists for longer than one month and is resistant to conservative treatment, should be thoroughly investigated. Such investigations will often disclose spondylolisthesis of the lower lumbar spine. In children, the principle types of spondylolisthesis are the dysplastic and isthmic types. ' Dysplastic, or congenital spondylolisthesis is due to hypoplasia of the upper sacrum or arch of L5 which permits a forward slip of L5 on the sacrum to occur.2 In lytic spondylolisthesis, the lesion is in the pars interarticularis which may be elongated but intact, or fractured.2 The defect in isthmic spondylolisthesis, is usually not present at birth and seldom appears before the age of four. Between the ages of five and seven, the incidence rises sharply. Slipping generally occurs before the age of twenty with the period of most rapid slip between the ages of ten and fifteen.3 The slip in isthmic spondylolisthesis rarely increases after the age of twenty. In dysplastic spondylolisthesis, the upper sacrum or neural arch of L5 is insufficient to withstand the anterior shear force at the lumbosacral level and the last moveable vertebrae slips forward on the one below. If the pars interarticularis remains unchanged and the ring is intact, the slip cannot exceed 35 percent or cauda equina pressure might result.2 However, in some cases, the pars may elongate and allow further slip. There is often spina bifida of SI or L5. Wynne-Davies and Scott reported that eleven of- twelve patients with dysplastic spondylolisthesis had either spina bifida occulta and/or some other lumbosacral segmental defect.' There is little information on sex ratio between male and female patients with the dysplastic form, however, seven males and five females were in the WynneDavies and Scott series. They also showed that one in three relatives will be affected (33 percent) indicating a strong genetic component to dysplastic spondylolisthesis. From the Department of Orthopaedics, University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan Address reprint requests to Dr. D. Mierau, 4th Avenue Chiropractic Clinic, 208 - 119 4th Ave. S., Saskatoon, Saskatchewan, S7K 5X2 D Mierau, JD Cassidy, K Yong-Hing 1985
The Journal of the CCA/Volume 29 No. 3/September 1985
Case 1 Miss K.E. is a 15-year-old girl who, for eighteen months, had intermittent "soreness" in the left leg. She pointed to the posterior thigh, posterior calf and ankle. The pain was brought on by exercise, sports and prolonged sitting and relieved by avoiding the above activities and lying down. Six months prior to her presentation at our clinic, she had a fall which was followed by an increase in left lumbosacral and left buttock pain. In addition to the pain, she felt that the left leg fell asleep frequently. She denied weakness and required no analgesics. She had not lost any school and had not been in bed for more than a few hours because of pain. Before her fall, chiropractic manipulations had decreased her back and leg pain substantially. However, manipulations did not help her after her fall. On examination, this sexually mature 15-year-old was tender over the spinous processes and interspinous ligaments of the thoracolumbar spine and also at the lumbosacral junction. Straight leg raising was 90 degrees on the right and 60 degrees on the left with a positive bowstring test over the lateral popliteal nerve, and a positive ankle dorsiflexion test. Both ankle jerks were absent, even with reinforcement. The knee jerks were present and symmetrical. There was diminished touch sensation on the lateral aspect of the left thigh and medial calf. Motor power in the lower extremities was noted at 5/5 for all muscle groups. Her posture and leg lengths were within normal limits. X-rays of her lumbar spine showed an L5-S 1 spondylolisthesis. L5 had slipped forward more than 50 percent of the anteroposterior diameter of S1. (FIG. la) She also had an L5 spina bifida occulta. (FIG. lb) Oblique views of the lumbosacral junction did not demonstrate a spondylolysis. A CT scan of the lumbosacral spine showed considerable disruption of the normal architecture of the neural arch. The posterior elements were bilaterally hypoplastic. Bilateral pars defects were also seen. These multiple bony abnormalities are in keeping with combined dysplastic and isthmic spondylolisthesis. (FIG.2) A diagnosis of bilateral S1 nerve root entrapment secondary to a grade III L5-S 1 dysplastic spondylolisthesis was made. After consultation with another orthopaedic specialist the decision was made to proceed with an operation. At operation the L5-S 1 dysplastic spondylolisthesis was confirmed. Both S1 nerve roots were
131
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Figure 1(a,b): a) Lateral view of the lumbar spine shows a grade III spondylolisthesis of L5 on SI.
b) AP view of the lumbar spine shows spina bifida at L5 with inadequate development of the posterior arches of L5 and 51.
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Figure 3 (a,b): a) AP view of the lumbar spine shows spina bifida at L5 and SI with inadequate development of the posterior arches at both levels. b) Lateral view of the lumbar spine shows a grade I spondylolisthesis of L5 on S I with inadequate development of the posterior element of L5 and S 1.
132
Case 2 One year ago, while playing volleyball, Ms. C.H. injured her low back. She felt a sharp jab in her lumbosacral region which took a week or so to improve. She did not, however, completely recover and continued to have recurrent back pain. This trouble was aggravated by activity, sitting and relieved by rest. She had been seen by an American chiropractor who aggravated her condition with prone lumbar manipulation. He did not x-ray her back. On examination, she was a fit looking 14-year-old with good pos-
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Figure 2: A lumbosacral C-T Scan shows considerable disruption of the norrnal architecture of the posterior arch of L5 and S1. Bilateral
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tight, taking a sharp bend around the SI vertebral body. The right L5 nerve was compromised around the pedicle of L5. The SI nerves were decompressed along with the right L5 nerve. A posterolateral L5 to sacrum fusion was then done. Her post-operative progress was uneventful.
pars defects are also seen. These abnormalities are consistent combined dysplastic and isthmic spondylolisthesis. ture. There was a painful palpable step at L5-S I. Both sacroiliac joints were tender and immobile. The range of motion of the lumbar spine was restricted on extension and forward flexion, and she complained of a "catch" upon rising from the forward flexed position. Straight leg raising was limited bilaterally to 70 degrees by hamstring spasm. Sensory, motor and reflex examination of the lower limbs were un-
remarkable. X-rays of her lumbar spine revealed a grade I dysplastic spondylolisthesis with a spina bifida occulta of L5. (FIG.3a,b) No pars defect was seen.
The diagnosis in this case was dysplastic L5 spondylolisthesis complicated by bilateral sacroiliac syndrome. A regimen of daily side posture manipulations to her sacroiliac joints and stretching of her hamstrings rendered her pain free in two weeks. Straight leg raising at the end of treatment was 90 degrees. The percentage of improvement was rated as 80 to 90 percent. She has been evaluated monthly for nine months after the cessation of treatment and has remained symptom-free.
The Journal of the CCA/Volume 29 No. 3/September 1985
Dysplastic spondylolisthesis
Discussion Spondylolisthesis should be suspected in young patients with persistent low-back pain unresponsive to conservative treatment. The typical findings in a patient with lumbar spondylolisthesis are found in table 1. Sciatic scoliosis might be present secondary to lumbar muscle spasm produced by irritation of neural elements due to pressure or traction. Leg pain and/or numbness with or without weakness of the muscles of the foot signals L5 or S1 nerve root involvement. Spondylolisthesis is a radiographic diagnosis. The lumbar lateral view will show a break in the posterior vertebral body line indicating the forward slip of one vertebra on the vertebrae below. (FIG. 1) A break in the pars interarticularis might also be visible on the lateral view. The lumbar AP view will show the mal-development of the posterior arches of the involved vertebrae. Hypoplasia of the posterior elements is suggestive of dysplastic spondylolisthesis. (FIG.2) Oblique views of the lumbar spine are frequently necessary to visualize and confirm a pars defect. The slip is measured as a percentage of the amount of slip in millimeters divided by the widest part of S 1. The degree of slip varies. The younger the child the greater the risk of progressive slippage. A high degree of slip may be seen in a young child with a dysplastic or isthmic spondylolisthesis. The likelihood of further slip is greatest between ten and fifteen years and falls off dramatically after the cessation of growth. The risk of increasing or severe slip in girls is at least four times that of boys.2 Spondylolisthesis in a young athlete with a pars defect rarely exceeds 25 percent of the sacrum. I A painless, non-progressive spondylolisthesis in a child or adolescent requires no more than a home-exercise program to strengthen the abdominal muscles and stretch the hamstring muscles. Regular check-ups are warranted because progressive slip might occur. Patients with back pain and spondylolisthesis without progressive slip or neurological deficit should have a generous trial of conservative treatment. This treatment should include rest and avoiding the activities that aggravate the pain along with a daily home-exercise program to strengthen the abdominal muscles and stretch the hamstrings. Sit-ups, with the knees and hips flexed to at least 60 degrees, will strengthen the abdominal muscles. Toe touching, in the standing position, should be avoided as a method of stretching the hamstrings, since this can produce forced hyperflexion of the lumbar spine. A safe and effective method of stretching the hamstrings has
been documented by the principle author.3 Sacroiliac joint dysfunction and pain is common in people with spondylolisthesis.5'6 Also, Mierau et al found a high association between sacroiliac dysfunction and low back pain in children.8 A two-week course of daily, specific manipulations of the sacroiliac joints with the patient in side posture, without inducing too much rotation into the lumbar spine, has been shown to be an effective treatment for low-back pain associated with spondylolisthesis. 5'6 It has been our experience that lumThe Journal of the CCA/Volume 29 No. 3/September 1985
Table I: Examination findings in patients with spondylolisthesis 1 increased lumbar lordosis. 2 palpable step between the spinous processes of the lower lumbar vertebrae which may be tender. 3 decreased straight leg raise due to nerve root tension or hamstring muscle spasm. 4 neurological deficit due to nerve root compression in the lower lumbar spine.
bar spondylolisthesis is a contraindication for prone manipulation of the lumbar spine. If a trial of daily manipulations specifically directed at the sacroiliac joints renders the patient painfree, it can be assumed that the back pain was due to a sacroiliac syndrome.6'78 It might be that sacroiliac dysfunction places extra stress on the spondylolisthesis and causes pain. Relief of the sacroiliac dysfunction removes the strain resulting in a decrease in pain. If conservative measures fail to control the pain or if there is evidence of slip progression or neurological deficit, arrangements should be made for the patient to be seen by an orthopaedic specialist. Persistent symptoms more often require an operation in the child than the adult because symptoms appearing so early in life mean many years of trouble at an age when the child wishes to engage in strenuous activities.2 Furthermore, the results of surgery for these cases is much better than in the adult.7 The older the individual is when symptoms begin, the more likely he will be willing or able to cut down his activities and live with his discomfort. In the absence of progressive slip or neurological deficit, several months or a year should elapse before contemplating an operation. This will allow ample time for the symptoms to settle on their own or for conservative management to be instituted and completed. In addition, conservative treatment can help to rule out other causes for symptoms.
Conclusion Spondylolisthesis should be suspected in a young patient whose back and/or leg pain does not subside in four to six weeks. These patients should be given a generous course of conservative treatment which includes daily specific manipulations to the sacroiliac joints over a period of two weeks. Prone lumbar manipulation should be avoided in cases of spondylolisthesis. Patients with progressive neurological deficit or progressive slip and those who do not respond to a generous dose of conservative treatment should be referred on to an
orthopaedic specialist. Two girls with dysplastic spondylolisthesis were seen in our office. One did well with a two-week course of manipulations to her sacroiliac joints and an exercise program, while the other showed no improvement after a course of treatment and was referred on to an orthopaedic specialist. She subsequently underwent a decompression and fusion. 133
Dysplastic spondylolisthesis
Acknowledgements The authors wish to thank Drs. R. Martsinkiw and H. Armstrong for the referral of two very interesting cases. In addition, we would like to thank the department of Medical Photography at the University of Saskatchewan for the reproduction of the x-ray images and Ms. Kari Frydenlund for typing.
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References I Wynne-Davis R, Scott J H S. Inheritance and spondylolisthesis; a radiographic family survey. J Bone Joint Surg (Br) 1979; 61B: 301305. 2 Wiltse L L. Spondylolithesis and its treatment. In: B E Finneson. Low back pain. Philadelphia: J B Lippincott, 1973. 3 Milne R A, Mierau D R. Hamstring distensibility in the general
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population: relationship to pelvic and low back stress. J Manip Physio Ther 1979; 2:3. Cassidy J D. Progressive two level isthmic spondylolisthesis: a case report. JCCA 1980; 24(2): 70-71. Cassidy J D, Potter G E, Kirkaldy-Willis W H. Manipulative management of back pain in patients with spondylolisthesis. JCCA 1978; 22 (1): 15-20. Kirkaldy-Willis W H. Manipulation. In Kirkaldy-Willis W. Managing low-back pain. New York: Churchill Livingstone, 1983. Laurent L E, Einola S. Spondylolisthesis in children and adolescents. Acta Orthop Scand. 1961; 31:45-64. Mierau D R, Cassidy J D, Hamin T L, Milne R A. Sacroiliac joint dysfunction and low-back pain in school-age children. J Manip Physio Ther. 1984;7(2): 81-84.
CHAIRMAN,
DEPARTMENT OF
@ACADEMIC DEAN The Canadian Memorial Chiropractic College is currently seeking an Academic Dean. Candidates must hold a first
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firt a phirofesstioa Preference dregrene/diplomwill be chiropractic.
given to candidates with experience in a post-secondary teaching institution who are familiar with curriculum and faculty development. Evidence of scholarly or outstanding professional activity will be required. The initial appointment will be for 5 years. Salary is negotiable.
Application and resume should be sent to:
The President Canadian Memorial Chiropractic College 1900 Bayview Avenue, Toronto, Ontario M4G 3E6 134
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ROENTGENOLOGY
Applications are now being accepted for the fulltime position of Chairman of the Department of Roentgenology. The successful applicant should be a Doctor of Chiropractic (DC) with certification in Roentgenology, (FCCR/DACBR) and have experience with both undergraduate and postgraduate teaching. Duties include responsibility for the administration of the undergraduate and postgraduate residency programmes in roentgenology, direction of clinical X-ray facilities, and development of roentgenology related research. Salary is competitive with other chiropractic institutions and is commensurate with credentials and experience. A benefit plan is available for full-time faculty members. Please send curriculum vitae with current telephone number and the names and addresses of two references to: Glen R. Engel, DC, FCCS(C) Director, Division of Clinical Sciences Canadian Memorial Chiropractic College 1900 Bayview Avenue, Toronto, Ontario M4G 3E6 The Journal of the CCA/Volume 29 No. 3/September 1985
