Essay: Spondylolisthesis – treatment

While surgical treatment of spondylolisthesis is often suggested, conservative treatment such as physiotherapy and bracing can serve as an alternative treatment option. A total of eight studies evaluated physiotherapy and bracing as conservative treatment option for spondylolisthesis. Specifically, the conservative approach to treating spondylolisthesis focuses on physiotherapy to strengthen muscles of the core and back, along with the application of a thoracolumbosacral brace (1,3).
 
As spondylolisthesis often results in stiffness of the hamstrings and flexion of the hips and knees, it is essential for physiotherapy to involve stabilizing the muscles of the back and stretching the muscles involved in hip flexion along with the hamstring muscles(1). Unlike the exercises that involve strengthening the core and back, exercises that involve hyperextending the lumbar spine should be excluded (1,2,3).
 
Physiotherapy involves a wide range of techniques and it can work in combination with other variables such as Pilates, cognitive, and behavioral variables (3, 5). In a study evaluating the effectiveness of conservative treatment in 44 children, Dr. Leonidou et al. found that physiotherapy and bracing was effective for most patients (1). A similar trend was noted in a study assessing the effect of Pilates on a patient with traumatic spondylolisthesis, in which Dr. Oliveira et al. reported that a three month period of Pilates improved muscle strength and flexibility, ultimately decreasing the level of pain associated with spondylolisthesis (3). Dr. Mohanty experimented with an approach that involved mobilising the thoracic spine while implementing a series of stretches and core strengthening exercises, and determined that this combination can be used to improve low back pain caused by spondylolisthesis (4). When both cognitive and behavioral fundamentals were combined with a physical therapy rehabilitation program for 10 patients, “7 out of 10” patients demonstrated significant improvement when assessing aspects of pain, injury, and confidence and “9 out of 10” patients showed significant improvement in clinical tests (5, p. 561). Overall, previous studies demonstrated the effectiveness of physical therapy as a conservative treatment for patients diagnosed with spondylolisthesis.
 
While physiotherapy serves as an efficient treatment for spondylolisthesis individually and in combination with other principles, the addition of brace is often prescribed (1). There are a variety of braces used to treat spondylolisthesis including a thoracolumbosacral brace and Boston brace. In a study on children with spondylolysis and spondylolisthesis, conservative treatment included the use of a thoracolumbosacral brace for 6 weeks to 6 months depending on their previous treatment, followed by physiotherapy (1). As a result of this combination, all displacements of patients with spondylolisthesis remained stable and did not experience further progression (1). Steiner et al. conducted a study on 67 patients with spondylolisthesis, implementing the modified Boston brace continuously for 6 months as the primary treatment (8). Out of the 67 patients that were treated, “78%” responded positively to the treatment, and were able to return to full activity with little or no pain (8, p.938). While extension exercises have been shown to increase pain in patients with spondylolisthesis, Spratt et al. recommends physicians to use short-term extension bracing as a conservative treatment for patients with low back pain associated with spondylolisthesis, after determining its significant reduction of pain in patients after a 1-month follow-up when compared to flexion bracing (6,7). These studies demonstrate bracing as a sufficient supplement to conservative treatments of spondylolisthesis.
 
Steroid Injections
 
Figure 93-4: Spinal Injections. Pg. 2196 (32)
 
In cases when physical therapy and other conservative treatments are not enough for pain relief, steroid injections and nerve blocks would be an alternative option for treatment. The antiinflammatory effects of steroids decrease leukocyte migration, the inhibition of cytokines, and membrane stabilization (11). Although the epidural steroid injections have been proven to help with pain and discomfort, complications have been reported following treatment. More dangerous, but rare, complications include hypercorticism, epidural hematoma, temporary paralysis, retinal hemorrhage, epidural abscess, chemical meningitis, and intracranial air. Other risks include headaches, vertigo, infections, and inadvertent dural punctures (9,10,11).
 
Dural punctures have been reported at a 5% risk rate for epidural steroid injections and anesthesia (11). The puncture of the dura membrane results in the loss of CSF, which causes a postdural puncture headache due to the loss of CSF. Although cases resolve on their own, dural punctures are a common complication to consider (11, 12). Epidural hematomas are another rare but common complication. A nationwide study showed 5 cases of epidural injections resulted in epidural hematoma among 707,455 cases (12). Another case described an elderly woman who underwent three months of chronic pain, weakness, and sensory loss following an epidural steroid injection. A MRI discovered a hematoma affecting the L4 nerve root. Although sensory returned and pain decreased, the patient with through extensive pain for a procedure that was meant to decrease pain (9).
 
In many studies the epidural steroids have only been found to be a short-term pain relief and haven’t been effective in preventing the need for surgery in the future (10, 13). In one study 400 patients received epidural steroid injections and after a 6 week follow up, leg and lower back pain had returned(10). A clinical trial involving 154 patients who received an epidural steroid injection were compared with 453 patients who managed pain with physical therapy. The study concluded that after three months, the epidural steroid injection only relieved short term pain and after three months lumbar pain and leg pain returned (15). Although these injections help with temporary pain, the overall risk should be considered when ultimately deciding to proceed with epidural steroid injections.
 
Operative Treatments:
 
Laminectomy
 
Figure 78-3, Benzel’s Spine Surgery. Pg 676 (33)
 
Surgical treatment, such as Laminectomy, should not be the initial prognosis for a patient diagnosed with Spondylolisthesis until nonoperative measures have initially been taken and highly considered for different grades and types of the condition. However, advanced grades are highly qualified for surgical treatment. Surgical treatment such as Laminectomy, relieves pain more efficiently than nonsurgical procedures such physical treatment/braces during a shorter period (21).
 
Dr. Weisten of The New England journal completed a study for patients of degenerative spondylolisthesis of the lumbar region with non-surgical and surgical treatment (16) . Results showed after two years of treatment and follow-up appointments, those treated surgically showed greater improvement in pain and function than those that underwent nonsurgical treatment. The protocol surgical procedures included decompressive laminectomy with or without bilateral single-level fusion.
 
Additional evidence reported by The Japanese Orthopaedic Association, includes completed surgical techniques such as laminectomy with spinal fusion to treat patients with spinal stenosis in grade I degenerative lumbar spondylolisthesis (20). Group 1 had laminectomies with decompression of the spinal canal, whereas Group 2 had just decompression surgery of the spinal canal. Group 3 completed non-operative physical therapy. The baseline JOA score of subjective low back pain was significantly higher with those who did not complete surgical treatment. However, when considering Laminectomy surgery, there are complications that should be considered. For instance, the British Medical Journal concluded that the number of patients with complications were higher in the laminectomy group (15.0% v 9.8%) versus the minimal invasive invasive surgery (22). The Scoliosis Research Society of The University of Virginia (17) found that the complication outcome rate was 10.4% when treating pediatric patients with isthmic and dysplastic spondylolisthesis with Laminectomy surgical treatment. With signs of postoperative complications and high risk factors such as age and grade level, additional surgery is typically completed and necessary (23). The European Spine Journal reported that patients that underwent Laminectomy and spinal fusion developed sympathetic pain due to advanced levels of degenerative Spondylolisthesis (18). Additional long term complications reported by The European Spine Journal such as “Axial Pain after Posterior Spine Surgery: a systematic review” reveal that patients experienced an increase in axial pain in the standing position (19). Most patients experienced pain in early postoperative stages, but the pain subsided with time. However, intractable pain may persist for up to 10 years after surgery. While Laminectomy may be an effective treatment for some patients dealing with spondylolisthesis, complications often result including lower back pain, restricted mobility, and an overall negative influence on the patient’s way of life.
 
Spinal Fusion
 
Figure 1. Outcomes of Spinal Fusion. Pg. 63. (34)
 
Another surgical procedure that can be used to treat Spondylolisthesis is spinal fusion. Just like other treatments, spinal fusions can be effective, but come with risks and complications. There are many clinical studies that show the positive effects of spinal fusion. For example, a 35-year-old patient who had complaints of lower back pain due to spondylolisthesis underwent L5-S1 posterior lumbar interbody fusion. After 41 months the vertebrates fused and pain subsided (30).
 
Although many patients have successful rates with spinal fusion treatments, complications can arise. In one study, a group of 204 patients had undergone spinal fusions. Out of the 204 subjects, 109 of the patients had high-grade spondylolisthesis and low-grade spondylolisthesis. Many surgeons have reported that In-situ posterolateral fusion is a well known treatment option (24). In a study involving the In-situ technique, the principle purpose of surgery was to relieve radicular and low back pain. Of the patients in this study, 13 indicated sciatic pain, 12 patients experienced L5 sensory deficits, and 5 patients experienced L5 combined with motor and sensory deficit (24).
Fusion has been found to be a safer and reliable treatment procedure as current procedures for for a severe slip of the spin consist of posterolateral fusion with transverse and vertical skin incision in the fascia (24). This leads to the discussion of different types of fusion such as surgical or nonsurgical procedures. The protocol for surgery includes grafting of the iliac crest with or without a posterior pedicle-screw (25). During a study that examined the results from both surgical and non-surgical treatment, primary analysis included using changes from patient’s baseline measurements to their follow-up. This study revealed that there were 75 patients that experienced complications with L4-L5 spondylolisthesis. The overall complication rate in that particular study was average at 36.76% (28).
 
Spinal Fusion has been used as a treatment for patients with severe symptomatic spondylolisthesis. Since the 1960s, most authors agreed that posterior or posterolateral intertransverse fusion was a better choice of treatment (24). For involvement and less lateral stenosis; which is abnormal narrowing of the body channel (25). The patients from this study with degenerative spondylolisthesis showed no advantage to surgery over nonsurgical treatment and showed more relief of symptoms and improvement of function.
Degenerative spondylolisthesis is a condition where one vertebra is slightly more forward than the vertebrae below it, and this condition is used as an indication for fusion surgery by many spine surgeons (26). Fusion surgery has increased since the last decade and has started to become a common treatment to help with the decompression of the neural structures to focus on minimizing future instability and deformity (26). Of the 65 million people in the United states with pain in the lumbar region of their back, approximately 151,000 of them proceed with fusion of the lumbar spine each year (27). Today surgical technology allows implants to be used with the intention to correct deformities, and manage pain and improve arthrodesis. This is done by immobilizing the spine and also allows new bony trabeculae to form from osteoblastic activity occurring in fusion (27).
Discussion
While treatment for spondylolisthesis often depends on the severity and grade, there are treatments that are more effective and efficient than others. Although steroid injections offer anti-inflammatory effects to reduce pain in cases where physical therapy does not provide adequate pain relief, there is a risk of complications including hypercorticism, epidural hematoma, temporary paralysis, retinal hemorrhage, epidural abscess, chemical meningitis, and intracranial air. Further risks of the procedure involve headaches, vertigo, infections, and inadvertent dural punctures (9, 10, 11). Similarly, laminectomy has the ability to offer patients with spondylolisthesis relief from pain; however, the lower back pain and restricted mobility that often results can negatively alter a person’s overall lifestyle (19, 21). Spinal fusion is also used to immobilize the spine and provide pain relief, but it also comes with complications.
While it is necessary for some patients to undergo surgical treatment, most patients respond to conservative treatment.For instance, conservative treatments such as physical therapy and bracing can be used to strengthen and stabilize the muscle of the core and back, working to eliminate the pain associated with spondylolisthesis without the risk that is involved with surgical and steroid treatments.
This research compared surgical and nonsurgical treatments of spondylolisthesis, revealing the best treatment based on the overall effectiveness and minimal risks to the patient. Conservative treatment such as physiotherapy should be the prescribed for patients diagnosed with spondylolisthesis, as it is a nonoperative treatment that has been shown to be effective for most patients while demonstrating minimal or no risk to the patient’s overall health and lifestyle. Although physical therapy offers relief of pain from spondylolisthesis for most patients, surgical intervention is mandatory for some patients with severe spondylolisthesis that do not demonstrate improvement with the conservative treatments that were initially prescribed. While surgical treatments pose major risks and complications, patients that must receive surgery for spondylolisthesis should proceed with spinal fusion as it seems to have the least complications when compared with other operative treatments.
Evaluating the operative and nonoperative treatments for spondylolisthesis provides patients with the information they need to determine which treatment option will be most effective for their condition and lifestyle. Additionally, it suggests the need for medical professionals to educate patients about the various options and complications that can arise while treating spondylolisthesis. Patients should be aware of both the benefits and risks associated with each treatment of spondylolisthesis prior to deciding which treatment to proceed with. This review of treatments will allow medical professionals and patients to collaborate and develop individualized treatment plans for managing spondylolisthesis.
Conclusion