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BETHANY NAVAJEEVAN COLLEGE OF PHYSIOTHERAPY

THIRUVANANTHAPURAM- 695015
(Affiliated to the University of Kerala)

SPONDYLOLISTHESIS

By

D J. JINO ALEX VIII Semester BPT 2005-2006 Batch

BETHANY NAVAJEEVAN COLLEGE OF PHYSIOTHERAPY


THIRUVANANTHAPURAM- 695015
(Affiliated to the University of Kerala)

Register Number.. This is to certify that this project of Bonafide record work is done by, final year BPT in partial fulfillment of the requirements for BACHELOR OF PHYSIOTHERAPY DEGREE and submitted to the University of Kerala during the year April 2010. Principal Project guide

Internal examiner

External examiner

DEDICATED TO LORD JESUS & MY PARENTS

ACKNOWLEDGEMENT
I am grateful to Almighty Lord for His graces and blessings which enabled me to fulfill the work assigned to me. My sincere gratitude to Dr.D.P SUBHASH CHANDRA BOSE MBBS, DPMR, D ORTHO, MS ORTHO, our principal who extended his valuable guidance and advices for the fulfillment of my project. I express my heartfelt gratitude to our Co coordinator/HOD Mr. PREMLAL G.R BSc, MPT for his valuable instructions and spending his valuable time for achieving this task. I am deeply indebted to my project Guide Mr.J ANAND JIM. MPT, who extended his efficient guidance, his valuable suggestions and help for the collection of material required for the successful completion of my project. My sincere thanks to all our lectures, Mr.DEEPU.B MPT, Mr.SIVAPRASAD G. MPT, Miss.CHITHRA PRASAD MSc Physiology for their encouragement and help. I would like to thank Dr.V. K. PODIYAPPAN MBBS, DPH, Dr. ANEESH NINAN MBBS MD, Dr. SANTHOSH KUMAR MBBS, MD for their timely assistance during the course of the project. I also thank our college Librarian Sr.POORITHA SIC who helped me in the collection of materials required for my project. I am also thankful to all our non teaching staffs and all the hospital faculty members for their co operation. I am very much thankful to our college management for providing us all facilities for finishing the project. I also take this opportunity to thank my loving parents and all my friends for their love and encouragement.

INDRODUCTION
Spondylolisthesis describes the anterior displacement of vertebrae or the vertebral column in relation to the vertebrae below. It was first described in 1782 by a Belgian obstetrician Dr. Herbinaux. The term spondylolisthesis was coined in 1854 by Killian, from the Greek Spondyl for vertebrae and Olisthesis for slip. The slip commonly occur in the lumbar spine. Studies reported a prevalence of 4.4% in children aged 6 years, with prevalence increasing 5.4% by adulthood. In same study prevalence of spondylolisthesis was reported to be 2.6% and 4.0% respectively. Dysplastic spondylolisthesis represents approximately 14-21% of cases of spondylolisthesis. Eskimos have a reported incidence of spondylolisthesis in adults of almost 50% which is presumed to result from a combination of genetic and environment factors. Mortality has never been reported in spondylolisthesis but is not common. White population is affected more frequently with spondylolisthesis than is the black population. Eskimos also have a high incidence. The degenerative form has a higher prevalence in the black population. Spondylolisthesis has a 2:1 male female predominance. The congenital and degenerative forms of spondylolisthesis have a female male predominance of 2:1 and 5:1 respectively. Spondylolisthesis is not present at birth. Its appearance develops with increasing age, in keeping with the presumed pathogenesis relating to increasing activity and spinal loading. Spondylolisthesis mainly classified into five different types by the Wiltse classification system. They are,

a) Dysplastic b) Isthmic c) Degenerative d) Traumatic e) Pathologic a) Dysplastic It is a true congenital spondylolisthesis but it is seen rarely.
It occurs because of malformation of the lumbo-sacral with small

incompetent, facet joints. In which congenital bony anomalies of the lumbosacral junction allow the slipping or listhesis occur. It progress rapidly and is often associated with more severe neurological deficits. It is difficult to treat because of poorly developed transverse process and posterior elements. b) Isthmic Other ways called spondylolytic spondylolisthesis. It is a commonest form of spondylolisthesis.

It is mainly due to spondylolytic defects and a lack of normal

bony continuity in each pars inter articularis or isthmus. c) Degenerative It is a disease of the older adult commonly seen those who are above 65 years old. Develops as a result of facet arthritis like degenerative diseases.

Most slips are asymptomatic, but can worsen the symptoms of neurological claudication when associated with lumbar spinal stenosis. d) Traumatic It is a very rare condition. It may be associated with acute fracture of the inferior facet or pars inter articularis. e) Pathologic It is rarely seen. It occur due to the damage of the posterior elements from Pathologic spondylolisthesis is reported in the case of metastases or metabolic bone disease. pagets disease of bone, Albers-schonbergs disease of bone, osteogenic imperfecta, giant-cell tumours and tumour metastases.

ANATOMY OF VERTIBRAL COLUMN


The vertibral column resembles a curved rod, composed of 33 vertebrae and 23 intervertebral disks. The vertebral column is divided into five regions. Cervical, thoracic, lumbar, sacral and coccyx. The vertebrae increase in size from the cervical to the lumbar regions and then decrease in size from the sacral to the coccygeal regions. Twenty four of the vertebrae in the adult are distinct entities. Seven vertebrae are located in the cervical region, 12 in the thoracic region, and five in the lumbar region. Five of the remaining nine vertebral are fused to form the sacrum and the remaining four constitute the coccygeal vertebral. (1) Cervical Vertebrae There are seven cervical vertebrae which form the upper part of the spine between the skull and the chest. These are generally small and delicate. Their spinous processes are short with the exception of second and seventh vertebrae, which have palpable spinous processes. (2) Thoracic Vertebrae There are 12 thoracic vertebrae which are found between the upper chest and lower back. The 12 thoracic bones and their transverse process have surfaces that articulate with the ribs. Body of the vertebrae are roughly heart shaped and are about as wide antero-posteriorly as they are
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in the transverse dimension. Vertebral foramina are roughly circular in shape. Lumbar There are five lumbar vertebrae which form the lower back and are the largest and strongest of the vertebrae. They are the source of attachment of may strong back muscles. Lumbar vertebrae are very robust in construction, as they must support more weight than other vertebrae. They allow significant flexion and extension moderate lateral flexion and a small degree of rotation. Sacrum Five sacral vertebrae fused together from the sacrum which is triangular in shape and connects the spine to the pelvis. The sacrum also provides support for the spine. Coccyx A small triangular bone which is formed by fusion of four rudimentary coccygeal vertebrae. It is other ways called tail bone or caudal bone.

Typical Vertebrae
A typical vertebrae is comprised of several components including, Vertebral Body Main anterior bony part of the vertebra. It faces the front of the body (anterior) and is the weight-bearing segment of the vertebrae. It is cylindrical in shape. And it is the largest portion of vertebrae.
Pedicles

To short stalks that project off of the right and left sides of each vertebral body and function as attachment sites for muscles and ligaments of the spine. They also make up the sides of the neural arch.
Laminae

Flat bones that arise from the posterior part of the vertebrae. They form the roof of the spinal cord and protect the spinal cord.
Neural Arch

Arises from the body of the vertebrae and forms a circle of bone around the canal through which the spinal cord passes. A neural or vertebral arch is composed of a floor at the back of the vertebrae, walls (pedicles) and a roof where two laminae join. Vertebral Foramen It is also called spinal canal opening formed by the Centrum anteriorly and the vertebral arch posteriorly. It is an enclosed space through which the spinal cord passes. Processes: Bony projections from the back of the vertebrae that function as important attachment sites for spinal muscles and ligament. There are three processes.
1)

Spinous processes: A projection from the posterior, midline Superior and inferior articulating processes: There is a

region of the neural arch.


2)

pair of each of these processes on each side of the neural arch. The superior processes project upward and the inferior processes project downward.
3)

Transverse Processes: Processes that project outward from

each side of the vertebrae and are located between the superior and inferior processes. Facet Joints:

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A joint formed by the two inferior articulating processes interconnecting with the superior process of the vertebrae below, like the link of a chain. Each vertebrae have two facet joints. The joint provide stability while allowing the movement. Pars Interacticularis: A thin isthmus of bone that forms a bridge and connects the upper and lower facet joints of contiguous vertebrae. The pars is very thin with poor blood supply which makes it vulnerable to stress fractures. Intervertebral Disks A flat cartilaginous disk that sits between the vertebrae and allows the spine to bend, stretch and twist. It also act as a shock absorber for any movement of the spine. The upper and lower surfaces of vertebral bodies are covered with hyaline cartilaginous plates. The intervertebral disks intervene between these plates by nucleus pulposus in the center and annulus fibrosus at the periphery. Annulus fibrosus is made up of concentric laminae of collagen fibres. The arrangement is vertical on the posterior side. Nucleus pulposus is made up of cartilage cells embeded in gelatinous mucoidal mass having about 80% of water. This water content of the disk diminishes with advancing age. Its position is variable. It is central in cervical and thoracic region and shifted posteriorly in lumbar region. In the frontal plane, the vertebral column bisects the trunk when viewed from the posterior aspect. When viewed from the sagital plane, the curves are evident. The curve of the vertebral column of a baby in fetal life exhibits one long curve that is convex posteriorly, where as the secondary curves develop in infancy. However, in the column of an adult, four distinct antero-posterior curves are evident. The two curves, thoracic and sacral
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curves, that retain the original posterior convexity through out life are called primary curves, where as the two curves, cervical and lumbar curves, that show a reversal of the original posterior convexity are called secondary curves. Curves that have a posterior convexity (anterior concavity) are referred to as kyphotic curves; curves that have anterior convexity (posterior concavity) are called lordotic curves. The secondary or lordotic curves develop as a result of the accommodation of the skeleton to upright posture.

BIOMECHANICS
The lumbosacral articulation is formed by the fifth lumbar vertebra and first sacral segment. The first sacral segment, which is inclined slightly anteriorly and inferiorly forms an angle with the horizontal called the lumbosacral angle. The lumbosacral angle is determined by measuring the angle formed by a line drawn parallel to the superior aspect of the sacrum and a horizontal line. Normal lumbosacral angle is 300. The size of the angle varies with the position of the pelvis and affects the superimposed lumbar curvature. An increase in this angle will result in an increase in lordosis of the lumbar curve and will increase the amount of shearing stress at the lumbosacral joint. There are mainly two forces are act on the lumbar region, compression and shear forces. Compression One of the primary functions of the lumbar region is to provide support for the weight of the upper part of the body in the static as well as in dynamic situations. The increased size of the lumbar vertebral bodies and disks in comparison with their counterparts in the other regions helps
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the lumbar structures support the additional weight. The lumbar region must also withstand the tremendous compressive loads produced by the muscle contraction. The percentage of compressive load can change with altered mechanics; with increased extension or lordosis, the zygapophyseal joint will assume increased compressive load. Also, with degeneration of the intervertebral disk, the zygapophyseal joints will assume increased compressive load. Changes in position of the body will change the location of the bodys live of gravity and thus change the force acting on the lumbar spine. Lumbosacral loads during in the erect standing posture were in the range of 0.82 to 1.18 times body weight, where as lumbosacral loads during level walking were in the range of 1.41 to 2.07 times body weight (an increase of 56.3%) Shear force In the upright standing position, the lumbar segments are subjected to anterior shear forces caused by the lordotic position, the body weight, and ground reaction forces. This anterior shear or translation of the vertebra is resisted by direct impaction of the inferior zygapophyseal facets of the superior vertebrae against the superior zygapophyseal facets of the adjacent vertebra below. The effectiveness of the zygapophyseal joint in providing resistance to anterior translation during flexion depends on the extent to which the inferior vertebras superior facets lie in the frontal plane and face posteriorly. The more that the superior zygapophyseal facets of an adjacent inferior vertebrae face posteriorly the greater the resistance they are able to provide to forward displacement because the posteriorly facing facets lock against the inferior facets of the adjacent superior vertebra.

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Movements occur in Lumbar Region The lumbar region is capable of movement in flexion, extension, lateral flexion, and rotation. The lumbar zyapophyseal facets favour flexion and extension. Flexion of the lumbar spine is more limited than extension and, normally, it is not possible to flex the lumbar region to form a kyphotic curve. The amount of flexion varies at each interspace of the lumbar vertebrae, but most of the flexion takesplace at the lumbosacral joint. During flexion and extension, the greatest mobility of the spine occurs between L4 and S1 which is also the area that must be most weight. Rotation in this region, is more limited because of the shape of the zygapophyseal joints.

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AETIOLOGY
The main aetiological factor is a weakness at the pars inter articularis of the laminae of the 5th lumbar vertebrae.The weakness is due to the spondylolytic effect on the pars interarticularis or by degenerative diseases which affecting the facet joints. Fracture of the inferior facet or pars interarticularis due to traumatic injury to the spine also result spondylolisthesis.

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PATHOLOGY
In the common lytic type spondylolisthesis the pars interarticularis is in two pieces and the gap is occupied by fibrous tissue: behind the gap the spinous process, lamina and inferior articular facet remain as an isolated segment. With stress, the vertebral body and superior facets in front of the gap may subluxate or dislocate forwards, carrying the superimposed vertebral column; the isolated segment of neural arch maintains its normal relationship to the sacral facets. When there is no gap, the parts interarticualris is elongated or the facets are defective. The degree is slip is measures by the amount of overlap of adjacent vertebral bodies and is usually expressed as a percentage. With forwards slipping there may be pressure on the duramater and cauda equina, or on the emerging nerve roots, these roots may also be compresses in the narrowed-intervertebral foramina. Disk prolapse is liable to occur. Dysplastic Spondylolisthesis: In the dysplastic type congenital anomalies of the vertebral arch and or facet occurs at the lumbosacral junction. Leisions in these categories include dysplastic facets that may have an axial or horizontal or sagittal orientation. Leisions may occur as a result of the failure of vertebral body formation. The end result is that the facet do
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not lock in, and forward slipping is allowed. The pars may remains intact, develop poorly, elongate or even lyse. Isthmic It affects the region of the pars interarticularis, which is roughly the region of the junction of the pedicle and lamina, where the articular and transverse processes of the vertebrae arise. A defect at this point functionally separates the vertebral body, pedicle and superior articular process from the inferior articualr process and remainder of the vertebra. Thus the defect cleaves the vertebrae into two parts. The portion of the vertebrae posterior to the detect remains fixed, and the anterior portions are free to potentially slip forward relative to the posterior structures and spine below. Degenerative Long standing inter segmental instability leads to degenerative spondylolisthesis. Osteoarthritic changes develop in the facet joints. Erosive and eburnation changes occur, which may lead to abnormal alignment of the articualr surfaces. Other factors include abnormalities of the ligamentous structures and intervertebral disk, such as loss of disk height. Traumatic spondylolisthesis: Traumatic forces may effect parts of the spine and result in a spondylolisthesis. For instance, fractures may be seen in the articualr processes, through the facet joints and also fractures through pars intearticularis. Subluxation or dislocation of the facet joint may occur. Associated ligamentous injury should always be considered, such
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injuries can occur if the traumatic force involves the disk anterior and posterior longitudinal ligaments, interspinous ligament, supraspinous ligament and the capsule and ligaments of the facet joints, causing facet-joint instability. Any one or more of these mechanism may result in spondylolisthesis. Pathologic spondylolisthesis: Neoplasm or infection may involve the pars interarticularis, facets or pedicles. Malignancy, such as metastasis from primary. Breast, prostate and lung carcinoma as well as myeloma, do occur in the posterior elements infections such as blood-borne staphylococcal osteomyelitis also occur.

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RISK FACTORS
Age: Progression is highly likely during adolescent growth spurts.

The younger the age at onset of a vertebral leision, the higher the probability of slip progression.
Gender:

Females are four times more likely to develop

spondylolisthesis than males. Pregnancy may be a risk factor. Osteoarthritis in older people can lead to degenerative spondylolisthesis. Traumatic injury. Spondylolysis. Activity in sports o Gymnastics o Diving o Football o Pole voulting o Weight lifting o Wrestling
o High jumping

o Dancing

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Back pain: Investigation into generalized back may uncover existent but possibly asymptomatic

pain

spondylolisthesis.

SIGNS AND SYMPTOMS


The patient will typically experience generalized pain in the lower back along with intermittent shocks of shooting pain beginning in the buttock traveling downward into the back of the thigh and sometimes on lower leg. Sciatica that extends below the knee and may be felt in the feet. Sometimes symptoms include tingling and numbness. Sitting and trying to stand up may be painful and difficult. Hamstring tightness or weakness. Shortened appearance of the trunk and lumbar hyperlordosis. Tenderness and irregularities in bony alignment that may be felt or palpated. Posture The posture will typically give the appearance that the individual leans forward slightly or that they are suffering from lordosis. In more advanced cases, that gait of the individual may change to give the appearance of more of a waddle than a walk, where the individual rotates the pelvis more due to the decreased mobility in the hamstrings. A
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result of the change in gait is often a noticeable atrophy in gluteal muscle due to lack of use.

DIAGNOSIS
On Examination There is often a visible or palpable step above the sacral crest due to the forward displacement of the spinal column. There may be increased lumbar lordosis. There may be evidence of stretching of the sciatic nerve, as found by the straight leg raising test. X-Ray Examination X-ray shows the severity or magnitude of forward Oblique views of x-ray are taken to show the And also shows greater degree of spinal slippage of vertebrae. defect in the pars inter articularis known as Dog or Terrier sign. instability. According to the x-ray the spondylolisthe is classified into different grades, called Meyerding grading system. The system categorizes severarity based upon measurements on lateral x-ray of the distance from the posterior edge of the adjacent inferior

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vertebral body. This distance is taken reported as a percentage of the total superior vertebral body length. Grade- I Grade-II Grade-III Grade-IV 0-25% of slip 25-50% of slip 50-75% of slip 75-100% of slip

Over 100% is, when the vertebrae completely falls of the supporting vertebrae. Computerised Axial Tomography [CAT Scan] Very effective in the diagnosis of facet joint changes, stenosis and presence or absence of bony structures around healed microfractures of the pars as well as cracks, unhealed microfactors and the degree of severity of spondylolytic defect. Magnetic Resonance Imaging [ MRI] This is not as effective in visualizing bony detail but has the advantage of avoiding use of radiation. MRI is effective in visualizing,

Soft tissue structures and their relationship to the vertebrae. If adjacent disks have suffered damage such as wear and Signs of oedema around the spondylolytic defect. Nerve root compression.

tear because of slippage.


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PROGNOSIS
Dysplastic Spondylolisthesis: Appears at an early age, often goes on to a severe slip and carries a significant risk of neurological complications. Isthmic Spondylolisthesis: Less than 10% displacement is usually asymptomatic, does not progress after adulthood, does not predispose the patient to later back problems and is not a contraindication to strenous work. With slips of more than 25% there is an increased risk of back ache in later life. Degenerative It is rare before the age of 50 years, progress slowly and seldom exceeds 30% displacement.

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ASSESSMENT
1) Demographic Data Name: Age:
Dysplastic spondylolisthesis - congenital one Isthmic - under 50 years of age

Degenerative spondylolisthesis and pathologic spondylolisthesis can occur at any age. Sex Spondylolisthesis has a 2:1 male-female predominance Congenital and degenerative forms of spondylolisthesis have female-male predominance of 2:1 and 5:1 respectively. Occupation More prevalent in people with strenuous occupation. Chief complaints:

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Generalized pain in the lower back. Intermittent shocks of shooting pain beginning in the buttock traveling downward into the back of the thigh and sometimes on lower by. Sitting and trying to stand up may be painful and difficult. Sometimes patient have tingling and numbers sensation. Mechanism of Injury Dysplastic spondylolisthesis occurs due to the malformation of the lumbosacral with small, incompetent facet joints. Isthmic spondylolisthesis occurs due to spondylolytic defects in the each pars interarticularis. Degenerative spondylolisthesis occurs due to the degenerative defects like facet arthritis.
Traumatic s spondylolisthesis occurs due to the acute fracture of

the inferior facet or pars inter articularis. Pathologic spondylolisthesis occurs due to the damage of posteriorelements from metastases or metabolic bone disease. Site of pain Patient will typically experience generalized pain in the lower back. Intermittent shocks of shooting pain beginning in the buttock traveling downward into the back of the thigh and sometimes on lower leg. Which movement is painful Sitting and trying to stand up may be painful and difficult.

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OBSERVATION

Body type: Gait In advanced stage, the individual may give the appearance of waddling gait. Where the individual rotates the pelvis more due to decreased mobility in the hamstrings. Attitude: Posture: The posture will be typically give the appearance that the individual leans forward slightly or that they are suffering from lordosis. Step Deformity

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The step occurs because the spinous process of one vertebra becomes prominent. When either vertebra above or the affected vertebra slips forward on the one below.

EXAMINATION Active movement: Active movements are performed with the patient standing. The examiner is looking for differences in range of motion and patients willingness to do the movement. Active movements of the Lumbar spine
Forward flexion Extension Lateral flexion Rotation

400 to 600 200 to 350 1500 to 200 30 to 180

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During forward flexion, returning to neutral from flexion, or side flexion, possible to see an instability jog. An instability job is a sudden movement shift or rippling of the muscles during active movement. Similarly, muscle twitching during movement or complaints of something slipping out during lumbar spine movement may indicate instability. Passive movement In the lumbar spine, passive movements are very difficult to perform because of he weight of the body. If active movements are full and pain free, over pressure can be attempted with care.

Special tests: Test for Neurological dysfunction Slump Test The slump test has become the most common neurological test for the lower limb. The patient is seated on the edge of the examining table with the legs supported, the hips in neutral position (i.e., no rotation, abduction, or adduction), and the hands behind the back. The examination is performed in sequential steps. First, the patient is asked to slump the back into thoracic and lumbar flexion. The examiner then uses one arm to apply overpressure across the shoulders to maintain flexion of the thoracic and lumbar spines. While this position is held, the patient is asked to actively flex the cervical spine and head as far as possible. (i.e., chin to chest) the examiner then applies over pressure to maintain flexion of all three parts of the spine (cervical, thoracic, and lumbar) using the hand of the same arm to maintain overpressure in the cervical spine.
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With the other hand, examiner then holds the patients foot in maximum dorsiflexion. While the examiner holds these positions, the patient is asked to actively straighten the knee as much as possible. The test is repeated with the other leg and then with both legs at the same time. If the patient is unable to fully extend the knee because of pain, the examiner releases the overpressure to the cervical spine and the patient actively extends the neck. If the knee extends further, the symptoms decrease with neck extension, or if the positioning of the patient increases the patients symptoms, then the test is considered positive for increased tension in eh neuromenigeal tract. Some clinicians modify the test to make the knee extension of eh test passive. Once the patient is positioned with the three parts of the spine in flexion, the examiner first passively extends the knee. If symptoms do not result, then the examiner passively dorsiflexes the foot. A positive test would indicate the same lesion. Straight Leg Raising Test It is also known as Lasegues test. It is one of the most common neurological tests of lower limb. It is a passive test, and each leg is tested individually with the normal leg being tested first. With the patient in the supine lying position, the hip medially rotated and adducted, and the knee is extended, the examiner flexes the hip until the patient complains of pain or tightness in the back or back of leg. Prone Knee Bending Test It is also known as Nachlas test . Here the patient lies prone while the examiner passively flexes the knee as far as possible so that the patients heel rests against the buttock. At the same time , the examiner should ensure that the patients hip is not rotated. If the examiner is unable to flex the patients knee past 90 because of a pathological condition in the hip, the test may performed by passive extension of the hip while the

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knee is flexed as much as possible. Unilateral neurological pain in the lumbar area, buttock, or posterior thigh may indicate an L2 or L3 lesion The test also stretches the femoral nerve. Pain in the anterior thigh indicate s tight quadriceps muscles or stretching of the femoral nerve. Test for Lumbar instability Specific lumbar Spine Torsion Test: This test stresses specific levels of the lumbar spine. To do this, the specific level must be rotated and stressed. An example would be testing the integrity of left rotation on L5S1. The patient is placed in a right side lying position with the lumbar spine in slight extension (slight lordosis). To achieve rotation and side bending, the examiner grasps the right arm and pulls it upward and forward at 450 angle until movement is felt at the L5 spinous process. This locks all the vertebrae above L5. The examiner then stablizes the L5 spines process by holding the left shoulder back with the examiners elbow while rotating the pelvis and sacrum forward until S1 starts to move with the opposite hand. Minimal movement should occur, and a normal capsular tissue stretch should be felt when L5S1 is stressed by carefully pushing the shoulder back with the elbow and rotating the pelvis forward with the other arm/hand. This test position is a common position used to manipulate the spine, so the examiner should take care not to overstress eh rotation during assessment. In some cases, when doing the test, the examiner may hear a click or pop. This is the same pop or click that would be heard with a manipulation. Farfan Torsion Test This nonspecific test stresses the facet joints, joint capsule, supraspinous and interspinous ligaments, neural arch, the longitudinal
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ligaments, and the disc. The patient lies prone. The examiner stabilizes the ribs and spine (at about T12) with one hand and places the other hand under the anterior aspect of the ilium. The examiner then pulls the ilium backward causing the spine to be rotated on the opposite side producing torque on the opposite side. The test is said to be positive if it reproduces all or some of the patients symptoms. The other side is tested for compression. Lateral Lumbar Spine Stability Test The patient is placed in side lying with the lumbar spine in neutral. The examiner places the forearm over the side of the thorax at about the L3 level as an example. The examiner then applies a downward pressure to the transverse process of L3, which produces a shear to the side on which the patient is lying for vertebra below L3 and a relative lateral shear in the opposite direction to the segments above L3. The production of the patients symptoms indicates a positive test. Test of Anterior Lumbar Spine Instability The patient is placed in side lying with the hips flexed to 700 and knees flexed. The examiner palpates the desired spinous processes. By pushing the patients knees posteriorly with the body along the line of the femur, the examiner can feel the relative movement of the L5 spinous process on L4. Normally, there should be little or no movement. Other levels of the spine may be tested in a similar fashion. A problem with the test is that the examiner should endure that the posterior ligaments of the spine are relatively loose or relaxed. This can be controlled by altering the amount of hip flexion. With greater hip flexion, the posterior ligaments tighten more from the bottom (sacrum) up.

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Test of Posterior Lumbar Spine Instability The patient sits on the edge of the examining table. The examiner stands in front of the patient. The patient places the pronated arms with elbows bent on the anterior aspect of the examiners shoulders. The examiner puts both hands around the patient so the fingers rest over the lumbar spine and with the heels of the hands gently pull he lumbar spine into full lordosis. To stress L5 on S1, the examiner stabilizes the sacrum with the fingers of both hands and asks the patient to push through the forearm while maintaining the lordotic posture. This produces a posterior shear of L5 on S1. Other levels of the spine may be tested in a similar fashion. Segmental Instability Test The patient lies prone with the body on eh examining table and the legs over the edge resting on the floor. The examiner applies pressure to the posterior aspect of the lumbar spine while the patient rests in this position. The patient then lifts the legs off the floor, and the examiner again applies posterior compression to the lumbar spine. If pain is elicited in the resting position only, the test is positive, because the muscle action masks the instability. Radiological examination: X-Ray X-ray shows the severarity or magnitude of forward slippage of vertebrae. Oblique views of X-ray are taken . It show the defect in the pars inter articularis known as terrier sign or scottish dog wearing neck collar. And also shows greater degree pf spinal instability.
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Computerised Axial Tomography It shows any degenerative changes in the facet joint, bony anormalies and mirofractures in the pars. And also helps to diagnose the severarity of spondylolytic defect. Magnetic Resonance Imaging (MRI) It shows any degenerative changes in the adjacent inter vertebral discs. Nerve root compression.

MANAGEMENT
Treatment of spondylolisthesis is wide ranging from observation to surgical stabilization of the spine. Determining the appropriate treatment plan is most dependent on the age of the patient, the type of slip, and the symptoms experienced by the patient. Aim of treatment Relieve pain Strengthen and stabilize the spine. Principles: For a mild symptomless spondylolisthesis no treatment is required. When symptoms are mild they are adequately relieved by conservative methods such as a brace and spinal exercises. When symptoms are

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moderately severe or more especially if these hamper with the activity of the patient an operation may be required. Methods Management consists of conservative and operative methods. Conservative methods consist of rest and external support to the affected segment, medical therapy and physical therapy. External support is given by the help of bracing. I) Life style modification It is important for the patient with spondylolisthesis to become educated about their conditions and to take steps to minimize their symptoms and protect themselves from further slip progression. These steps include, Reducing or eliminating activities that cause pain. Bed rest during acute episodes of pain. Maintaining proper weight. Limiting lumbar extension movements. II) Bracing Bracing forms an important part of conservative management. Antilordotic total contact thoraco-lumbosacral moulded brace is fabricated in the corrected position of lordosis. Brace provide additional support to the spine and in some cases also decrease pain and muscle spasm. III) Medical Therapy Medications are available to reduce pain, inflammation and muscle spasm.

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Non steroidal anti-inflammation drugs (NSAIDs) and steroids like cortisone are used to reduce inflammation. Analgesis are used to relieve pain and muscle relaxants are used to reduce muscle spasm. IV) Physical Therapy Physical therapy utilizes a variety of modalities such as ultrasound, electric stimulation, massage and thermal therapy to help relieve muscular spasms. Manual tissue and joint mobilizing types of therapy can be used to help increase tissue flexibility. Physical therapy excels in the use of muscular strengthening exercises to build stability to weaken tissue. It should be noted that irritated muscles can become further damaged with strengthening exercises that are premature to the healing of the area.

Ultrasound
Ultrasound is an extremely effective way to stimulate proper tissue healing. The sound waves to break down unwanted scar tissue, increase circulation to the area, and help relax the musculature, This can be extremely beneficial in the case where the spondylolisthesis has caused soft tissue irritation to the back. Hot packs Hot packs are useful for increasing circulation and there by loosening up the muscle tissue. Ice packs Ice can be used in the initial 72 hours of an injury to reduce inflammation and numb the pain associated with the spondylolisthesis.

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TENS Transcutaneous electrical nerve stimulation is helps to reduce pain. It is used mainly presence of radiating pain. SPINAL STABILITY EXERCISE To maintain spinal stability three inter-related systems have been proposed. Passive support is provided by inert tissue, while active support is provided by inert tissues, while active support is from the contractile tissues. Sensory feedback from both systems provides co-ordination via the neural control centres. Where the stability provided by one system reduces, the other systems may compensate. Thus the proportion of load taken by the active system may increase to minimize stress on the passive system through loadsharing. Instability of the lumbar spine occurs when there is a decreased stiffness (resistance to bending) of a spinal segment. As a result, excessive movement occurs even under minor loads.

Control Neural

Passive (Spinal column)

Active Muscular

The spinal stabilizing system consisting of three interrelating systems


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Spinal Stability Programme The stablizers of the lumbo-pelvic region are the deep abdominals, the gluteals and inter segmental muscles of the spine especially multifidus. These muscles often function poorly after injury and may be incorrectly recruited as a result of intense training activities, which leads to muscle imbalance. When this happens the mobilizers muscles of the lumbopelvic region (rectus abdominis, hip flexors and hamstrings) often dominate movements with the stabilizers being poorly recruited. The focus of the back stability programme, therefore, is to reduce the dominance of the mobilizer muscles and enhance the function of stabilizers. The lumbar stabilization programme is divided into three overlapping stages. In stage I the therapist helps the patient to gain voluntary control of the stabilizing muscles, and then helps to build up their holding capacity. In stage II, dynamic work augments the static activities begun with stage I, and controlled movements are used within mid-range only. In stage III, the speed of muscle contraction is enhanced (through proprioceptive training) in an attempt to redevelop the automatic nature of stabilization. PHASE-I (Re-Education) The initial aim of the programme is to gain voluntary control over the stabilizing muscles. The process starts with the abdominal hollowing exercise. The patient begins traditionally in a prone kneeling position with the spine in its neutral midrange) position-(slight Lordosis). The action is to pull the abdominal wall in, and hold the position for two seconds initially building to 5,10 and eventually 30 seconds, breathing normally. Initially the action may be demand high levels of muscle work to facilitate learning, the
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eventual aim is to use minimal muscle activity. A useful teaching point is to contract the abdominal muscles as hard as possible and then to relax by half and then half again. The therapist should monitor the ribcage to ensure that is does not move substantially. Once this has been achieved the holding capacity of these muscles is built up until the patient can maintain the contraction for 10 repetitions, each held for 10 seconds. PHASE-II [Building Stability Control] The second phase is to use the now stable base for movements of the arm and legs. The patient performs the hollowing action and while maintaining the neutral lumbar position, one leg is straightened, sliding the head along the ground. The action of the hip flexors in this case tries to tilt the pelvis forwards (iliacus) and increase the lordosis (psoas). The abdominal muscles must work hard to stabilize the pelvis and lumbar spine against this pull. A number of other movements may be used including the bent knee fallout, which works for rotatory stability, and bridging actions which combine abdominal work with gluteal actions. PHASE-III [Reduced Attention] More complex activities can now be used which draw the subjects attention away form the spine and into the environment. The aim now is to use proprioception to monitor the position and stability of the spine so that stability becomes more automatic and less attention demanding. Resistance training appropriate to individual sporting requirements may be used. The correct relationship between lumbar alignment and pelvic alignment must be rigorously maintained. A convex contour of the abdominal wall (doming or bow-stringing) indicates that the deep abdominals are failing to maintain stability against the pull of rectus
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abdominis. A maximally flexed or extended lumbar spine indicates that mid-range (active) stability has been lost and joint approximation and inert tissue stretch are providing passive stability only. During stage II, dynamic movements of the spine are also used. Now the aim is to maintain both static (neutral position) and dynamic (lumbopelvic rhythm) alignment. Actions such as the trunk curl and hip hinge are useful, as are more traditional lumbar exercises-involving rotation. A variety of additional movements may be used with the aim in each case maintaining correct alignment of the spine and building holding capacity. Side support movements work the quadratus lumborum and trunk side flexers which are important stabilizers in single handed carrying tasks especially. Lumbar Stabilisation Stage Muscle Re-education Single isolated movements Slow and precise Focus attention of body part Use visualization and cueing Method Perform abdominal hollowing, 4 point kneeling, standing, prone lying or supine lying. Build holding time until person who able to maintain contraction for 20-30 seconds breathing normally or to perform 10 reps Building stability control Limb movements Maintain neural position holding each for 10 seconds. Supine lying heel slide, bent knee fall out Prone lying leg raise

Frontal sagital and transverse 4 point kneeling leg and arm movements. plane motions.

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Standingabduction. Reduced attention Perform secondary

single

flexion

or

movements Throwing/ catching. Machine weight activities. Free weight activities.

while maintaining stability. Functional actions. balance action.

Bending lifting, sports specific Balance board, swiss gym ball.

SURGICAL MANAGEMENT
Surgery is indicated there is neurological deficit or if the pain is disabling or if the slip progresses rapidly. Spinal Fusion The spine is fused in situ, ie without correcting the slip. Posterior, postero-lateral or anterior fusion may be performed. However posterolateral fusion is common. Postero-lateral fusion Postero lateral fusion (PLIF) is a type of spine surgery that involves approaching the spine from the back (posterior) of the body to place bone graft material between two adjacent vertebrae (interbody) to promote bone growth that joins together, or "fuses," the two structures (fusion). The bone graft material acts as a bridge, or scaffold, on which new bone can grow. The ultimate goal of the procedure is to restore spinal stability.
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Posterior Fusion Posterior is the most common type of fusion surgery for the low back. A fusion is a surgical procedure that joins two or more case vertebrae together into one solid bone. The procedure is called a posterior fusion because the surgeon works on the back, or posterior, of the spine. Anterior Fusion Anterior fusion is an operation done on the front of the lower spine. Fusion surgery helps two or more bones grow together into one solid bone. Fusion cages are new devices, essentially hollow screws filled with bone graft, that help the bones of the spine heal together firmly. Surgeons use this procedure when patients have symptoms from disc degeneration, disc herniation, or spinal instability Reduction of listhesis and spinal fusion In this surgery the slip is reduced and fuse the spine posteriorly. The spine is stabilized internally with the help of rods of plates. Post operatively the patient is nursed in bed for 4-6 weeks, after which a lumbo-sacral corset is given and the patient is mobilized. Some surgeons prefer a plaster jacket up to a period of 3 months after surgery. Physical Therapy Management During Immobilization Deep breathing and arm movements encouraged with ankle and foot movements. Assisted knee movements. Hip flexion, when given, should not be taken beyond 60 degrees. Isometric to the glutei. During mobilization

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A plaster of paris jacket is applied by 2 weeks after the operation. The jacket continues for a very long time, sometimes even up to 6 months or till the fusion is evident. Therefore, total mobilization with the jacket to be instituted immediately. Educating and guiding the patient to perform functional activities forms an important part of the management. After the removal of jacket gradual mobilisation of the spine is started. Mobilisation is initiated in conservative management and progressed till total functional independence is achieved. It may take 7-8 months to regain full function.

CASE STUDY ONE

Demographic Data
Name Age Sex Occupation Chief Complains Intermittent low back pain
Pain in the right hip region and radiating to back fo right thigh.

- Madhan Mohan - 47 - Male - Driver

Pain while weight lifting Site of Pain Lumbar region Radiating pain on right hip and back of thigh
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Aggavating Factors Prolonged standing and sitting is pain full ON OBSERVATION Body type Gait Posture ON EXAMINATION Active range of motion Forward flexion Extension Side flexion Passive range of motion Forward flexion Extension Side flexion SPECIAL TESTS Slum Test SLR Prone Knee Bending ON PALPATION An step is palpable over the L5-S1 region MANAGEMENT Aims
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- built - Lurching gait - Slightly looping forward

- Pain ful - Limited - Limited

- Pain ful - Limited - Limited

- Positive - Painful - Positive

Reduce pain Reduce inflammation Strengthen and stabilize the spine TREATMENT To reduce pain and inflammation
Ultrasound, TENS, Hot packs, Cold packs, IFT

To strengthen and stabilize the spine Teach spinal stabilization exercise programe.

CONCLUSION
Spondylolisthesis describes the anterior displacement of vertebrae or the vertebral column in relation to the vertebrae below. Spondylolisthesis is not present at birth. Its appearance develops with increasing age, relating to increasing activity and spinal loading.Spondylolisthesis is mainly occur due to the failure of the posterior stability of spine. Spondylolisthesis has a 2:1 male-female predominance but the congenital and degenerative form of spondylolisthesis have a femalemale predominance of 2:1 and 5:1 respectively. The main clinical features of spondylolisthesis is severe low back ache, sitting and standing may painful and an radiating pain that start from buttock and extened to lower leg.

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The treatment of spondylolisthesis is wide ranging and the treatment plan is depened on the age of the patient, type of slip and symptoms experienced by the patient. Conservative treatment is use to reduce pain and inflammation and surgical treatment is use to reduce the slip and fuse the vertebrae. Physical therapy management is designed to increase the stability of the spine by spinal stabilization exercise programe

REFERENCES
1. B D Chaurasia; Human Anatomy, Fourth edition. 2. The Lumbar Spine and Back Pain, Jayson & Dixon, Fourth edition 3. Tidys Physiotherapy, Edited by Stuart B. Porter, Thirteenth edition. 4. Carolyn Kisner and Lynn Allen Colby; therapeutic ExerciseFoundation and Techniques,Forth edition. 5. David J. Magi; Orthopaedic Assesment.
6. John Ebnezar; Essential of orthopaedics for Physiotherapist, First

edition.
7. Essentials of Orthopaedics and Applied Physiotherapy, Jayanth

Joshi & Prakash Kotwal. 8. Claytons Electrotherapy, Foster&Palastanga, Eight edition. 9. WWW physio work. Com.
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10.WWW. Physio advisor. com


11. WWW en. Wikipedia.org 12. WWW. Emedicine. Medspace. Com. 13. WWW. Medicinenet. Com. 14. WWW. Spineuniverse. Com.

15. WWW nismat. org

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