A 28-year-old male professional player presented complaining of central low back pain. This has developed over a period of four months. There was no significant referral of pain. His symptoms appeared related to activity and seemed to be getting worse over time. He described having had multiple short-lived bouts of pain over his lifetime but that these had never been bad enough for him to seek medical attention.
On examination there was a mild, generalised restriction in his lumbar ROM and mild tenderness in the midline over the low lumbar region. He did not have any focal neurological signs, evidence of radicular pain or other abnormalities.
A standing lateral x-ray image of the lumbar spine shows that there is anterolisthesis of L5 on S1 secondary to previous L5 pars fractures. Lumbar alignment is otherwise maintained. There is also marked disc height loss at the L5-S1 level. With the patient lying supine (for the MR imaging) displacement is less with approximately 12 mm of forward shift of L5 relative to S1. This is again shown to be associated with bilateral L5 pars defects. There is generalised bulging of the margin of the uncovered posterior portion of the L5-S1 disc that causes mild narrowing of the central spinal canal at this level. There is also bilateral L5-S1 neural foraminal narrowing.
This player has been successfully managed with education, a short course of analgesics and a rehabilitation programme. This programme involved manual therapy, progressive core stability and a reduced training load for several weeks. He reported experiencing some occasional low back pain but that this is back to his “normal” level and that it is not having any significant impact on his life.
The Wiltse Classification is the most commonly used classification system used to describe the aetiology of spondylolisthesis. There are five major aetiologies: degenerative, isthmic, traumatic, dysplastic and pathologic. The extent of the slip can also be graded. The Meyerding classification divides the superior endplate of the vertebrae below into quarters (and five grades). The grade depends on the location of the posteroinferior corner of the vertebrae above. A grade I slip has moved between 0-25% while a grade V slip (also known as spondyloptosis) has a greater than 100% slip. Isthmic spondylolisthesis, as illustrated in this case, is the most common cause in paediatric and adolescent patients and results from defects in the pars interarticularis. It is common for this to go undiagnosed and to present in adulthood. Spondylolistheses are common radiological findings and are not always associated with symptoms. It is estimated that between 7-8% of patients have developed a spondylolisthesis by the age of 18 years and that up to 18% of adult patients may have this finding on MRI scan. The L5-S1 level is the most common level.
In the majority of cases, isthmic spondylolisthesis can be managed with time and rehabilitation. Analgesics, progressive strengthening and other physiotherapy techniques are effective in most cases. Approximately 10-15% of younger patients with low-grade spondylolisthesis, as well as a greater percentage with higher grade slips, will fail non-surgical treatment.
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