143. Understanding Spondylolisthesis and Its Classifications

In this episode of PTs Snacks Podcast, host we dive deep into the topic of spondylolythesis, discussing what it is, the different types, how to evaluate it, and typical treatment approaches. We explore several classifications, including dysplastic, isthmic, degenerative, traumatic, and pathologic types, and explains common symptoms and patient presentations. We also covers diagnostic tools such as radiographs and MRIs, and outlines treatment and management strategies, stressing the importance of creating a healing environment and referring patients to specialists when necessary. 

00:00 Introduction to PTs Snacks Podcast
00:21 Understanding Spondylolysis
02:57 Types of Spondylolysis
06:02 Diagnostic Imaging for Spondylolysis
07:23 Treatment Approaches for Spondylolysis
08:56 When to Consider Surgical Intervention
10:21 Conclusion and Additional Resources

Transcript

0:31

Hey everyone. Welcome to PTs Snacks podcast. This is Kasey your host, and if you're tuning in for the very first time, first of all, I just wanna say welcome. But also you should know that this podcast is meant for physical therapists and physical therapists, students who are looking to grow their fundamentals in bite-size segments of time. Today what we're gonna do is talk about spondylolysis more specifically on what it is, all the different types that can be involved, how we can evaluate for it and what we typically do for it. Now, before I do that, if you've listened to this show at least three times in, found it to be beneficial. If you wouldn't mind leaving a review, that would be so helpful wherever it is that you do listen to the podcast. But without further ado, let's go into spondylolysis. So when we are talking about spondylolysis, this is very specific to displacement of one vertebrae, but relative to its adjacent counterpart. Displacement of one vertebrae relative to its adjacent counterpart. So it could be anterior, like an anterior lysis, lateral or posterior, which would be called a retro lysis. Now there are several different types of classifications, but typically we can see this in a variety of populations, just depending on what type it is. It's most commonly. Occurring in the lumbar region, but it can also be in the cervical region and very rarely in the thoracic region, but just know that it can be there. So with these patients, it's. So with these patients, typically what they're gonna complain of is localized low back pain potentially, and I'll explain more in a second. It can be intermittent pain that may get worse, inflection and extension, just due to the fact that if you're having this type of displacement, it's probably going to manifest as a mechanical instability. At that segment, they will be tender to palpation and they may have radicular pain if the nerve roots are involved. Again, keeping in mind the natural anatomy of the spine, if there is displacement of vertebrae, it could potentially also cause compression of the nerve roots. It may improve in specific. Positions such as like lying supine. And they may also have associated symptoms with buttock pain, leg numbness or weakness. Again, if the nerve roots are compressed pain with walking and in some cases bowel or bladder dysfunction. Namely, just depending on where in the body this is affecting.'cause keep in mind, the lower lumbar nerve segments do innervate the bowel bladder. You'd also be looking for a step off deformity or maybe even exaggerated lumbar lordosis. Let's talk about zooming in a little bit more on all the different types that this can be, so that you can better build a picture of what this person looks like. So we're gonna use something called the WIL seek classification, and there are a lot of different types of spondylolysis. So if we start off with type one, we've got one that's called dysplastic. So this is from a congenital malformation in the lumbosacral spine that basically inherently causes instability in type two or isthmic. That is going to specifically be a pathology of the pars interarticularis, which is most common to occur usually L five to S one. And there's different subtypes within the ISIC type. So type two A can be from fatigue, fractures from repetitive hyperextension, so lots of sports such as wrestling, football, gymnastics, where you're repetitively in that position can cause a pathology of the pars and articular type two B. Is where potentially you have an elongated pars from microtrauma and suboptimal, suboptimal healing. And then type two C, you can see an acute traumatic fracture of the pars interarticularis. So that's all grouped under isthmic. Type three would be degenerative. So type two we may more so see in a younger individual type three degenerative, we're gonna see probably an older individual especially in postmenopausal females. So this is essentially a progressive degeneration of the intravertebral disc and facets joint, which is most commonly to L four L five, which can cause disruption to segmental stability. So that is type three, degenerative. Type four. Traumatic is where we see acute fractures or dislocations of the posterior spinal elements, excluding the pars interarticular. So think more of a motory vehicle accident. So traumatic type four is different than isthmic type two because it does not include the pars interarticularis fracture. Type five. We can also see in pathologic, and this is specific to systemic or localized disease processes like neoplasms, infections, metabolic bone disorders, et cetera. That would be type five. So as you can see, there's a lot of different causes, even though you may potentially think of a specific patient in your mind when you do hear the word spinal lysis. But it is just important to understand, hey, if I'm treating my patient, am I suspicious of some sort of mechanical instability? And could any of them fit in with this? Or maybe you already know from the imaging that they've had now. If they have not had imaging, usually the first line of defense is gonna be getting radiographs specifically in the anterior, posterior lateral and flexion extension views. And you might even see what's called a Scotty dog sign, which is a defect of the pars interarticular. And through these radiographs we can also have another type of classification called the mire ding, which is probably one of the most common ones I've seen for grading the extreme, the severity of the spondylolysis. So it's basically by how far are, by how much displacement is actually occurring. So if we're looking at grade one, the displacement is gonna be one to 25%, two. Would be 26 to 50%. A grade three would be 51 to 75%. Grade four would be 75 to a hundred percent, and grade five would be over a hundred percent. Now, other imaging that this person can benefit from would be a CT is of course, the gold standard for evaluating bony abnormalities and for pars defects. But MRIs are also really good for. Being able to have a closer look at the neural elements, disc degeneration and soft tissue injury. Now with these patients, essentially we need to be able to create a, an environment of healing. And depending on the severity of the displacement, like for instance, grade five, like over a hundred percent. Those people are probably not gonna start out in physical therapy. We're probably most likely gonna see the people with the lower grades because we are not worried about these patients quite as much for the amount of displacement that they have. What we'll typically start with is helping to basically create an environment of healing where we're calming down pain. A lot of people will start off with exercises in a neutral spine. Things where we can basically meet this patient where they're at, and then bridge the gap to where they're going. And I know I'm being very vague, but the reality is these patients, depending on who they are. Might have a very different treatment and there's a lot of different treatments out there, but essentially an understanding the role of wherever the segment in the spine is most commonly, probably the lumbar spine. Essentially making sure that we're able to do things like restoring pain-free range of motion, helping them to reduce whatever activities are causing pain and help hopefully start building them back up towards it. Or if they are, and hopefully building them back towards a certain environment or whatever things that they need to do in their day to day. But that might be an episode for a later day. Now, if these patients either have been ruled as too gross of an instability to start with physical therapy or they are failing physical therapy, they will probably get some sort of fusion. And there are a lot of different types of fusion out there, but essentially with displacement, with localized instability, the role of the fusion is to create stability. And then from that point they are rehabilitating as they would like a lumbar fusion. But from this episode, essentially you should have been able to. You should be able to communicate this to somebody and I think it's good to good practice to do that with anything that you're studying, but understanding what exactly apon lysis is, the different types of classifications that there are what they may look like in the clinic. What types of imaging this patient might get and what the potential paths for progression are for these patients. So if you are seeing someone who has not seen a physician or some sort of. Surgeons specializing in this area, and you're suspicious that this patient may not do well in therapy. Maybe they're showing signs of nerve compression, things like that. This is a good time to make sure that you help them establish an a relationship with somebody who's an expert so that you can help them to get the help that they need to. So that is all I have for you today. If you have any questions, feel free to reach out at PTs Snacks podcast@gmail.com. If you are in need of just taking more CEUs, or you're maybe studying for a specialty exam like the OCS or SCS or all the different types that are out there. Med Bridge is actually offering listeners over a hundred dollars off their year subscription just with the promo code that's down below in the show notes. So I use it for my OCS is really helpful for being able to take practice exams and things like that. I would definitely recommend it. And also if you're a student, you get an even better discount. So make sure you use the student specific promo code. Again, if you need anything, feel free to shoot me an email and I hope you guys have a great rest of your day.