NUR IZZATTY BINTI SUHAIMI

57179211269
PUAN AZLINDAHANI BINTI
OTHMAN
SPONDYLOLISTHESIS
SEMESTER 6

DEFINITION
SPONDYLO : SPINE
LISTHESIS : SLIP FORWARD
Spondylolisthesis occurs when one vertebra slips forward onto the vertebrae below it. This
produces both a gradual deformity of the lower spine and also a narrowing of the vertebral
canal. It is often associated with pain. This is most common level that a spondylolisthesis occurs
is at L5/S1.

ANATOMY OF SPINE
Vertebrae
Vertebrae are the 33 individual bones that interlock with each other to form the spinal column.
The vertebrae are numbered and divided into regions: cervical, thoracic, lumbar, sacrum, and
coccyx (Fig. 2). Only the top 24 bones are moveable; the vertebrae of the sacrum and coccyx
are fused. The vertebrae in each region have unique features that help them perform their main
functions.
Cervical (neck) - the main function of the cervical spine is to support the weight of the head
(about 10 pounds). The seven cervical vertebrae are numbered C1 to C7. The neck has the
greatest range of motion because of two specialized vertebrae that connect to the skull. The first
vertebra (C1) is the ring-shaped atlas that connects directly to the skull. This joint allows for the
nodding or yes motion of the head. The second vertebra (C2) is the peg-shaped axis, which
has a projection called the odontoid, that the atlas pivots around. This joint allows for the sideto-side or no motion of the head.

Thoracic (mid back) - the main function of the thoracic spine is to hold the rib cage and protect
the heart and lungs. The twelve thoracic vertebrae are numbered T1 to T12. The range of
motion in the thoracic spine is limited.
Lumbar (low back) - the main function of the lumbar spine is to bear the weight of the body.
The five lumbar vertebrae are numbered L1 to L5. These vertebrae are much larger in size to
absorb the stress of lifting and carrying heavy objects.
Sacrum - the main function of the sacrum is to connect the spine to the hip bones (iliac). There
are five sacral vertebrae, which are fused together. Together with the iliac bones, they form a
ring called the pelvic girdle.
Coccyx region - the four fused bones of the coccyx or tailbone provide attachment for
ligaments and muscles of the pelvic floor.

PATHOPHYSIOLOGY
Pathophysiology base on type of spondylisthesis:
TYPE:
1. Congenital spondylolisthesis - Congenital means "present at birth." Congenital
spondylolisthesis is the result of abnormal bone formation.
2. Isthmic spondylolisthesis - This type occurs as the result of spondylolysis, a condition
that leads to small stress fractures (breaks) in the vertebrae.
3. Degenerative spondylolisthesis - This is the most common form of the disorder. With
aging, the discs , the cushions between the vertebral bones (lose water, becoming less
spongy and less able to resist movement by the vertebrae.)
4. Traumatic spondylolisthesis - in which an injury leads to a spinal fracture or slippage
5. Pathological spondylolisthesis - which results when the spine is weakened by disease
such as osteoporosis an infection, or tumor.

Spondylolisthesis is graded according to the amount that one vertebral body has slipped
forward on another:
Grade I Less than 25 percent slip
Grade II Between 25 and 50 percent slip
Grade III Between 50 and 75 percent slip
Grade IV More than 75 percent slip

Grade V This means that the upper vertebral body has slid all the way forward off the front of
the lower vertebral body. This is a special situation that is called a spondyloptosis and is very
rare.

CAUSES OF SPONDYLOLISTHESIS
In children, spondylolisthesis is usually due to a birth defect in that area of the spine, or the
result of a sudden injury.
In adults, it is most commonly caused by age-related wear of the spine or a degenerative
disease such as arthritis.
Other possible causes in adults are:
1. a bone disease
2. a fracture as a result of a sudden injury
3. a stress (hairline) fracture as a result of sustained pressure on the spine - commonly
seen in gymnasts and weight lifters.

SYMPTOMS OF SPONDYLOLISTHESIS

Spondylolisthesis may not cause any symptoms for years or after the slippage has occurred. If
you do have symptoms, they may include:
1.
2.
3.
4.

low back pain

buttock pain
numbness, tingling, pain, muscle tightness or weakness in the leg (sciatica)
increased sway back

These symptoms are usually aggravated by standing, walking, running or sports that involve
hyperextension. eg gymnastics, cricket and other activities, while rest will provide temporary
relief.

CLINICAL FEATURES

Pain with back motion,particularly extension cause radiation

Increased lumbar lordosis
Tight hamstring & hip muscles
Impaired sensation,strength and muscle reflexes with root injury.

DOCTORS MANAGEMENT
1. Medical History and Physical Examination
After knowing the symptoms and medical history, doctor will examine back. Looking at the back
and pushing on different areas to see if it hurts.Doctor may have to bend forward, backward,
and side-to-side to look for limitations or pain.
2.

Imaging Tests
X-rays
Magnetic resonance imaging (MRI).
Computed tomography (CT). These scans are more detailed than X-rays and can create
cross-section images of your spine.

Nonsurgical Treatment
1) Physical therapy and exercise.
Specific exercises can strengthen and stretch your lower back and abdominal muscles.

2) Medication.
Pain medications, such as acetaminophen or NSAIDs (e.g. ibuprofen, COX-2 inhibitors)
or oral steroids to reduce inflammation in the area.
3) Steroid injections.
Cortisone is a powerful anti-inflammatory. Cortisone injections around the nerves can
decrease swelling.

Surgical treatment

Laminectomy. Removing the pressure involves opening up the spinal canal.

Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the
painful vertebrae.

PHYSIOTHERAPYS MANAGEMENT

Modalities : ultrasound, electric stimulation, hot packs, cold packs, and manual

"hands on" therapy to reduce pain and muscle spasms.

Stretching exercise: to improve posture and help to reduce back pain or leg
symptoms.

Strengthening exercise: strengthening the muscles that support spine and will
help to keep back and upper body stable. Keeping these muscles strong can

relieve back pain and prevent further injury.

Developing your back and stomach muscles will help stabilize your spine and
support your body.

Stretching exercise
Knee to chest
Using gymball
Pelvic tilt
-

Strengthening exercise
Bird dog exercise
Bridging exercise
Abdominal bracing
Abdominal crunch
Dead bug exercise

A)PATIENT PARTICULAR.
NAME: Mdm. M
AGE: 67 years old

SEX: Female
D.O. REFEREL: 13 April 2014
D.O. ASSESMENT: 13 April 2014
DR. : L4, L5 Spondylolisthesis
DR. MX: Conservative management:
1)Medication
2)Refer To Physio
INVESTIGATION: X-ray done on 12 april 2014
:-result : L4, L5 spondylolisthesis.
B)SUBJECTIVE ASSESMENT.
C/O: Pain at Rt. Lower back until Rt. Lower leg and numbness at Rt. big toe.
PAIN ASSESMENT
PAIN SCALE

0/10 : Rest
2/10 : During Assessment
5/10 : Aggravating
PAIN AREA : Rt. Lower back, Rt. Lower leg and Rt. Big toe.

NATURE OF PAIN: Aching pain at Rt. Lower back

AGGRAVATING: 5/10 : No specific movement.
EASE: Oilment.
24 HOURS SYMPTOMS: a.m :
p.m :
on-off
night:
IRRITABILITY: Medium
PRESENT HX
Current pain at Rt lower back when went to vacation to Bandung on 21/3/2014 till
24/3/2014. After back from vacation, she went to clinic near by her son house at KL.
Doctor give medication management.
PAST HX: H/o fall from stairs about ten years ago. Her buttock crashing on the
ground. She never go to get treatment .

PAST MEDICAL HX: NIL

SURGICAL HX: NIL
MEDICATION HX: Pain killer and oilment.
FAMILY HX: NIL
SOCIAL HX
OCCUPATION: Ex-staffnurse
NATURE OF JOB: Office hour 9 a.m to 5 p.m
ALLERGIC BACKGROUND: NIL
MARITAL STATUS: Married and have 3 children.
HOME ENVIRONMENT: Double storey. (not disturb pain)
HOBBY: Gardening.

ALCOHOLIC/SMOKING: NIL.

PRE-MORBID
Do all activity with no pain and doesnt disturb

POST-MORBID
Disturb while praying

activity.
C)OBJECTIVE ASSESMENT
GENERAL OBSERVATION: A women with moderate body size came to department
independently without using assistant device accompany with her daughter. Pt look
healthy.
GAIT : Normal
POSTURE OBSERVATION.
Anteriorly
-Ear level symmetry
-Sh. level is symmetry for both side
-Elbow crest symmetry

Laterally
-No kyphotic posture noted
-No lordotic noted
Posteriorly
-Ear level symmetry
-Shoulder level symmetry
-Scapula level symmetry
-Pelvic level symmetry
LOCAL OBSERVATION: 1) Redness at Rt. Lower back and Rt lower limb.
2) Swelling at Rt. Lower back and Rt lower limb.
3)Scar at Rt. Lower back and Rt lower limb.
4)Bony deformity form at Rt. Lower back and Rt lower limb.
5)Muscle wasting at Rt. Lower back and Rt lower limb.
PALPATION: 1) Tenderness over lumbar region.
2)Warmness over lumbar region.
3)Muscle spasm at Rt lower back.

ROM (TRUNK)
MOVEMENT

STARTING

ACTIVE (CM)

PASSIVE (CM)

FLEXION

POSITION (CM)
66

8 with ERP

5 with ERP

EXTENSION
66
52 with ERP
RT. SIDE FLEXION
66
40 with ERP
LT. SIDE FLEXION
66
43 with ERP
RT. SIDE ROTATION
56
42 with ERP
LT. SIDE ROTATION
56
41 with ERP
INTERPRETATION: Limited ROM of extension of trunk due to pain.

54 with ERP
33 with ERP
37 with ERP
40 with ERP
39 with ERP

MUSCLE POWER (TRUNK)

MOVEMENT
MUSCLE POWER
FLEXION
5/5 within range
EXTENSION
5/5 within range
RT. SIDE FLEXION
5/5 within range
LT. SIDE FLEXION
5/5 within range
RT. SIDE ROTATION
5/5 within range
LT. SIDE ROTATION
5/5 within range
INTERPRETATION: Muscle power of trunk is 5/5. Normal.
Passive Accessory Intervertebral Movement (PAIVM)
Central
L1
L2
Mobile with no pain
L3
L4
L5
Hypomobile with localized pain grade 2
S1
SPECIAL TEST
1) Straight leg raise positive with tight hamstring over Rt. side of leg
2) Slump test positive with hamstring tightness over Rt. Side of leg
INTERPRETATION: Positive SLR and Slump test d/t hamstring tightness over the left
leg at 70 degree.
NEUROLOGICAL TEST
Hot and cold intact

PHYSIOTHERAPY IMPRESSION
1) Pain over Rt. Lower back till Rt. Lower limb d/t pathological changes.
2) Decrease Range Of Motion of extension of trunk d/t pain.

3) Muscle spasm at Rt. Lower back d/t over used.

SHORT TERM GOAL
1) To reduce pain at Rt. Lower back till Rt. Lower limb 1/12
2) To increase range of motion of extension of trunk 1/12
3) To reduce muscle spasm at Rt. lower back 1/12
LONG TERM GOAL
1) To optimize functional activity.
2) To prevent any recurrent condition.
PLAN OF TREATMENT
1) Pain management
Hot pack
IFT
Ultrasound
2) Therapeutic exercise
3) Home exercise program
INTERVENTION
1) Pain management
Hotpack
-Patients position : pr. Lying
-Hot pack is applied over lower back and Rt. calf
-Duration : 20 mins

IFT
-Patients position : pr.lying
-Modulated IFT is applied lower back and Rt. calf
-Duration : 15 mins

Ultrasound
-Patients position: pr.lying
-u/s is applied at lower back and Rt. Calf
-Intensity: 1mhz, 0.8wcm3, 5 minutes each.

2) Therapeutic exercise

Straight leg raise exs.

-Patients position: sup.ly
-Patient was asked to do exs by lift up Rt. Leg straight but not over than Lt.
leg.
-Repetition: 10 reps , 3 sets

Piriformis stretch
-Patients position: sup.ly

-Patient was asked to bend one leg and another leg cross over the bend leg.
Active pull the bend leg toward chest.
-Repetition : 10 reps, hold 10 sec, 3 sets

Trunk Flexion Stretch (sustained flexion)

-Patients position: kneeling
-Tuck in chin and arch back. Slowly sit back on heels, dropping shoulders
towards floor.
-Repetition: 10 reps, hold 10 sec, 3 sets.

Cat and Camel Exercise

-Patients position: kneel on hands and knees.
-Ask pt to do arch back , letting head drop slightly. Keep abdomen and
buttock muscles tightened.
-Holds 10 sec, 10 reps
-Let back sag towards floor while keeping arms straight and weight evenly
distributed between legs and arms.
-Hold for 10 sec, 10 reps.

HOME EXERCISE PROGRAMME

Advice to apply hot pack on back at home for 15min when needed to reduce

pain.
Advice to avoid lifting heavy weights + proper lifting technique demonstrated.
Advice and teach patient on how to wake up from bed and lying down on bed.
Ask pt to continue exercises at home as been taught for 3x/day.
Pamphlet of back care is given.
EVALUATION
-Pt cooperates well when the treatment given.
-Pt complaint that her pain reduce from 2/10 to 0/10.
REASSESSMENT
-Reassess pain scale of patient next visit
-Reassess range of motion of trunk next visit
FOLLOW UP (24/4/2014)
S-c/o reduce pain at Rt. Lower back.
-Pain at Rt lower leg.
-Numbness at Rt big toe.
-Pain scale: 4/10
O- GENERAL OBSERVATION: A women with moderate body size came to
department independently without using assistant device accompany with her
daughter. Pt look healthy.

GAIT : Normal
POSTURE OBSERVATION.
Anteriorly
-Ear level symmetry
-Sh. level is symmetry for both side
-Elbow crest symmetry
Laterally
-No kyphotic posture noted
-No lordotic noted
Posteriorly
-Ear level symmetry
-Shoulder level symmetry
-Scapula level symmetry
-Pelvic level symmetry
LOCAL OBSERVATION:
1) Redness at Rt. Lower back pain and Rt lower limb.
2) Swelling at Rt. Lower back pain and Rt lower limb.
3)Scar at Rt. Lower back pain and Rt lower limb.
4)Bony deformity form at Rt. Lower back pain and Rt lower limb.
5)Muscle wasting at Rt. Lower back pain and Rt lower limb.
PALPATION:
1) Tenderness over lumbar region.
2)Warmness over lumbar region.
3)Muscle spasm at Rt lower back.

ROM (TRUNK)
MOVEMENT

STARTING POSITION

FLEXION
EXTENSION
RT. SIDE FLEXON
LT. SIDE FLEXON
RT. SIDE ROTATION
LT. SIDE ROTATION

(CM)
66
66
66
66
56
56

ACTIVE
(CM)

PASSIVE
(CM)

5 with ERP
45 with ERP
38 with ERP
40 with ERP
42 with ERP
41 with ERP

0
42 with ERP
33 with ERP
35 with ERP
40 with ERP
39 with ERP

INTERPRETATION: Limited ROM of extension due to pain.

MUSCLE POWER (TRUNK)

MOVEMENT
FLEXION
EXTENSION
RT. SIDE FLEXON
LT. SIDE FLEXION
RT. SIDE ROTATION
LT. SIDE ROTATION
INTERPRETATION: Muscle power of trunk is 5/5. Normal.

MUSCLE POWER
5/5 within ERP
5/5 within ERP
5/5 within ERP
5/5 within ERP
5/5 within ERP
5/5 within ERP

A1)Pain over Rt. Lower back till Rt. Lower limb d/t pathological changes.
2)Decrease Range Of Motion of extension of trunk d/t pain.
3)Muscle spasm at Rt. Lower back d/t over used.

P1)

Pain management
Hot pack
IFT
Ultrasound
2) Therapeutic exercise
3) Home exercise program
I1)Pain management
Hotpack
-Patients position : pr. Lying
-Hot pack is applied over lower back and Rt. calf
-Duration : 20 mins
IFT
-Patients position : pr.lying
-Modulated IFT is applied lower back and Rt. calf
-Duration : 15 mins
Ultrasound
-Patients position: pr.lying
-u/s is applied at Rt. Calf
-Intensity: 1mhz, 0.8wcm3, 5 minutes .
2)Therapeutic exercise

Straight leg raise exs.

-Patients position: sup.ly
-Patient was asked to do exs by lift up Rt. Leg straight but not over than Lt.
leg.
-Repetition: 10 reps, hold 10 sec, 3 sets

Piriformis stretch
-Patients position: sup.ly
-Patients was asked to bend one leg and another leg cross over the bend
leg. Active pull the bend leg toward chest.
-Repetition : 10 reps, hold 10 sec, 3 sets.

Bridging
-Patients position: cr. Ly.
-Bridging 10 reps, hold 10 sec.

Mckenzie
-Patients position : pr. Lying.
-Patients was asked to do exs by using lower arm.
-Repeat for 10 reps, in 3 sets.

Trunk Flexion Stretch (sustained flexion)

-Patients position: kneeling
-Tuck in chin and arch back. Slowly sit back on heels, dropping

shoulders towards floor.

-Repetition: 10 reps, hold 10 sec, 3 sets.

Cat and Camel Exercise

-Patients position: kneel on hands and knees.
-Ask pt to do arch back , letting head drop slightly. Keep abdomen and

buttock muscles tightened.

-Holds 10 sec, 10 reps
-Let back sag towards floor while keeping arms straight and weight
evenly distributed between legs and arms.
-Hold for 10 sec, 10 reps.

HOME EXERCISE PROGRAMME

Advice to apply hot pack on back at home for 15min when needed to

reduce pain.
Advice to avoid lifting heavy weights + proper lifting technique
demonstrated

Advice and teach patient on how to wake up from bed and lying down

on bed.
Ask pt to continue exercises at home as been taught for 3x/day
Pamphlet of back care is given.

EVALUATION
Pt cooperates well when the treatment given
Pt claim that her pain decrease to 0/10

REFERRENCES
1) Raj, P.P. et al (2008). Intervertebral Disc : Anatomy, Physiology, Pathophysiology and
Treatment, World Institute of Pain, Vol. 8, Issue 1, 18-44.
2) Hertling, D., & Kessler, R. M. (2006). Management of Common Muskuloskeletal
Disoders: Physical Therapy Principles & Methods.Philadelphia: Lippincott Williams &
Wilkins.

3) Kraemer, J. (2008). Intervertebral Disk Disease: Causes, Diagnosis, Treatment &

Prophylaxis. 3rd ed. Philadelphia. Pg 195-200
4) Jeong H, You J, Sohn H, Park S. (2013) Radiologic evaluation of degeneration in
isthmic and degenerative spondylolisthesis. Asian Spine J.;7(1):25-33.
5) Kovacs FM, Royuela A, Jensen T, Estremera A, Amengual G, Muriel A, et al. (2009)
Agreement in the interpretation of magnetic resonance images of the lumbar spine.
Acta Radiol.;50(5):497-506.

CONCLUSION
Spondylolisthesis may sound like a common case, but the impact may be severe to some
people. It may affect patient daily activities or some serious cases, prohibit the patient from
moving.