Lumbar Spondylosis

Introduction

Lumbar spondylolysis is an anatomic defect in the pars interarticularis or isthmus. It is age-related change of the vertebrae and discs of the spine. These changes are often called degenerative disc disease and osteoarthritis. It is usually asymptomatic. However, it may cause low back pain or sciatica secondary to muscle or ligament strain, spinal or foraminal stenosis, facet degeneration or related disc degeneration and herniation. It is considered to be formed secondary to repetitive stress or trauma. Although it has been reported that genetic factors are important in the development of isthmic spondylolisthesis, predisposing anatomic factors in the formation of spondylolysis have not been clearly revealed yet.
Lumbosacral spondylolysis is most common at L5, accounting for 85% of all cases, and may be observed as high as L2.Therefore, a slip is most common at the level of L5 slipping forward on S1. Lumbosacral spondylolysis is the cause of the most common type of spondylolisthesis.

Epidemiology

Spondylolysis is more common in first-degree relatives and white (versus black) patients with a male to female ratio of about 2-3 to 1. Numerous hypothesis have been proposed on the etiology of lumbosacral spondylolysis, as follows:
• Separate ossification centers
• Fracture during postnatal life
• Stress fracture
• Increased lumbar lordosis
• Impingement of the articular process on the pars articularis
• Weakness of supporting structures
• Growth
• Pathologic changes in the pars articularis
• Dysplasia of the pars interarticularis
However, mechanical factors are widely believed to be the cause or at least the trigger of the development of lumbosacral spondylolysis, especially when congenital abnormalities are present.

Clinical presentation

• Neurogenic claudication is the main feature which include lower back pain, leg pain, numbness and motor weakness to lower extremities that become worse with walking and decrease with sitting and in supine lying position.

• Sharp shooting pain in hip and leg region.

Diagnostic Procedures

• Examining posture your posture and the amount of movement in your low back.
• X-rays: Bilateral defects are easily recognized on a lateral radiograph but unilateral lesions are usually better detected on an oblique view.
• CT Scan (computed tomography): Used to better visualization of integrity and status of the posterior vertebral elements. In progressive stage, the defect is shown as narrow but has round edges, while in a chronic or terminal stage, a wide defect is observed with hazy, blunt and sclerotic margins.

Treatment

1. If a pre-lysis defect is observed in an MRI or CT scan associated with positive bone scan, the preferred treatment is avoidance of harmful activities that would create hyperlordosis and rotational spinal loading like weight-lifting, diving, wrestling, rowing, and gymnastics.
2. Spondylolytic patients with a negative bone scan, non-union of the pars is diagnosed and the recommended initial treatment is conservative
3. Analgesics for reducing pain.
4. Lumbosacral orthosis in order to decrease lumbar lordosis.

Physical Therapy Management

Physical therapy is needed to improve your strength and flexibility. In the therapy your patient need to do ADL, so he can move on with his normal life without pain. First, the exercises you learn, may be gentle stretches or posture changes to reduce pain. Afterwards more aerobic exercises are recommend, for example cycling, swimming.
If the doctor diagnoses an acute pars fracture that has the potential to heal, it may be recommended that you wear a rigid back brace for two to three months. This usually occurs in children and teenagers who begin having back pain and see their doctor early on.

• Transcutaneous Electrical Nerve stimulation (TENS): It is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively.
• Traction: Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis.
• Spine manipulation: It is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. Manipulative therapy may function through:(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) unbuckling of motion segments that have undergone disproportionate displacement, (4) reduction of disk bulge, (5) repositioning of miniscule structures within the articular surface,

References

emedicine. (2011, 05 06). Opgehaald van lumbosacral spondylolysis: http://emedicine.medscape.com/article/95691-overview#a0101
Group, M. M. (2011). A Patient's Guide to Lumbar Spondylolisthesis. Opgehaald van Orthopod: http://www.eorthopod.com/content/lumbar-spondylolisthesis
spondylolisthesis, A. i. (2010). North american spine society .
Wilkins, L. W. (2011). Evaluation of the Relationship Between L5-S1 Spondylolysis and Isthmic Spondylolisthesis and Lumbosacral-Pelvic Morphology by Imaging via 2- and 3-Dimensional Reformatted Computed Tomography. Journal of Computer Assisted Tomography , 9-15.