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High-grade spondylolytic spondylolisthesis.

Case Presentation

A 28-year-old female presented to the World Spine Care (WSC) clinic in Moca, Dominican Republic with a 10-year history of intermittent lower back pain (LBP) and parasthesia into the right lower leg and foot. The pain, which was rated as a six out of 10, was described as a "dull ache" and was generally worse when rising from bed first-thing in the morning. Standing up after prolonged sitting was also provocative. Exercise at the gym, walking, and performing yoga were described as palliative. Recent diagnostic imaging investigations had revealed a high-grade lumbosacral spondylolisthesis (Figures 1-3). The patient had consulted numerous surgeons and other medical specialists and was told that she would be unable to have children because of her spondylolisthesis and would eventually be confined to a wheelchair if she did not have surgery. There were no signs or symptoms of cauda equina syndrome. The patient was in good general health and did not take medications. Because chiropractic treatment had provided relief in the past, she visited the WSC Moca clinic for a second opinion.

On examination, the patient was of normal weight and her gait was unremarkable. The lumbosacral lordosis was increased. Range of motion of the lumbar spine was full and pain-free, with the exception of mild lower back pain on passive end-range extension. Bilateral Kemp's test (1) provoked mild LBP but the straight leg raise, slump, and femoral nerve stretch tests were negative. Neurologic examination of the lower limbs, including motor, reflex, sensory, vibratory, and Rhomberg's testing, was normal except for absent Achilles tendon reflexes (graded as 0) bilaterally. Mid-thigh and calf muscle circumferences were symmetric bilaterally with no evidence of atrophy. A non-tender midline 'step defect' was palpated at the lumbosacral junction and mild pain was elicited with the application of posterior-to-anterior pressure over this region. Palpation also revealed hypertonicity of the quadratus lumborum and lumbosacral erector spinae muscles, bilaterally. Milgram's test (1) (i.e. bilateral active straight leg raise test, performed with the patient supine) severely provoked the chief LBP complaint and elicited patient apprehension. Further radiographic imaging including dynamic views of the lumbar spine were obtained. The flexion radiographs revealed instability of the spondylolisthesis (Figure 4). Based on clinical and imaging findings, a diagnosis of chronic unstable grade 4 spondylolytic spondylolisthesis was made.


Table 1 lists the radiologic grading and etiological classification systems for spondylolisthesis. (2,3) The key imaging features for high-grade spondylolytic spondylolisthesis are listed in Table 2. According to the Meyerding classification (2), high-grade spondylolistheses are characterized by an anterior vertebral slippage of 50% or greater (i.e. grades 3, 4, and 5). The incidence of isthmic (spondylolytic) spondylolisthesis in the general adult population ranges between 3.7% and 8%; (9) however, the epidemiology of high-grade spondylolisthesis is unknown. To date, the evidence concerning the long-term prognosis and optimal (i.e. conservative versus surgical) management of patients with high-grade spondylolisthesis also remains insufficient and controversial. (4-9) Moreover, clinical symptoms in such patients often do not correlate with the degree of slip. (10) Several authors advocate for surgical intervention (e.g. fusion, with or without slip reduction) regardless of patient symptoms, in order to prevent further slippage and or symptom progression. (7,8) Others have suggested however that non-surgical management can be considered, particularly in asymptomatic or minimally symptomatic cases. (5-8) Regarding natural history, the risk of slip progression is greater in skeletally immature children and adolescents than it is in adults. (8,10) As such surgery is rarely indicated for this reason in adults. (8)

In the current case, the patient underwent a trial of conservative therapy, including spinal manipulation (to the thoracic and upper lumbar spine), soft-tissue trigger-point therapy and Active Release Techniques[R] (to the lumbosacral and thoracolumbar paraspinal muscles), and home-based spinal stabilization exercises (i.e. cat-camel mobilizations, bird-dogs, side-bridges, and crunches). The patient was also encouraged to continue with her weekly exercise activities (e.g. walking, gym exercise, and yoga). After nine visits (over five weeks) the patient had no functional limitations and her pain severity was reduced to a two out of 10. Furthermore, there were no adverse treatment effects during the course of her care.

Indications for surgery in patients with spondylolisthesis are listed in Table 3. With a greater than 10% reported risk of complications including neurologic injury with surgical intervention (6,8,11), some authors have indicated that non-surgical treatment may be suitable for patients in the absence of functional limitations or neurologic impairment. (5-8) In the current case, the patient had clinical and radiologic evidence of instability but no significant functional limitations, postural deformities, gait abnormalities, or progressive neurologic signs or symptoms. Her LBP symptoms also responded favourably to a short-course of conservative treatment. She was advised to return for chiropractic treatment as needed, or for re-evaluation should any neurologic signs or symptoms develop. As the patient was planning on getting married later in the year, the news that her spondylolisthesis would have no bearing on her ability to have children after all came as a welcome surprise.

Key Messages

* Published cases involving high-grade spondylolisthesis are rare within the chiropractic literature

* Indications for surgery in such patients include slip progression, significant deformity and postural imbalance, neurologic deficit and/or cauda equina syndrome, and imaging confirmed radiculopathy unresponsive to conservative treatment

* Conservative therapy may be considered as a first line treatment option in patients with high-grade spondylolisthesis who present with minimal neuromusculoskeletal symptoms


(1.) Evans RC. Illustrated Essentials in Orthopedic Physical Assessment. St. Louis: Mosby; 1994.

(2.) Meyerding HW. Spondylolisthesis. Surg Gynecol Obstet. 1932; 54:371-377.

(3.) Wiltse LL, Newman PH, Macnab I. Classification of spondylosis and spondylolisthesis. Clin Orthop Relat Res. 1976; 117:23-29.

(4.) DeWald CJ, Vartabedian JE, Rodts MF, Hammerberg KW. Evaluation and management of high-grade spondylolisthesis in adults. Spine. 2005; 30(6 Suppl):S49-S59.

(5.) Bourassa-Moreau E, Mac-Thiong JM, Joncas J, Parent S, Labelle H. Quality of life of patients with high-grade spondylolisthesis: minimum 2-year follow-up after surgical and nonsurgical treatments. Spine J. 2013; 13(7):770-774.

(6.) Lundine KM, Lewis SJ, Al-Aubaidi Z, Alman B, Howard AW. Patient outcomes in the operative and nonoperative management of high-grade spondylolisthesis in children. J Pediatr Orthop. 2014; 34(5):483-489.

(7.) Xue X, Wei X, Li L. Surgical versus nonsurgical treatment for high-grade spondylolisthesis in children and adolescents: a systematic review and meta-analysis. Medicine. 2016; 95(11):e3070.

(8.) Kasliwal MK, Smith JS, Kanter A, Chen CJ, Mummaneni PV, Hart RA, Shaffrey CI. Management of high-grade spondylolisthesis. Neurosurg Clin N Am. 2013; 24(2):275-291.

(9.) Kreiner DS, Baisden J, Mazanec DJ, Patel RD, Bess RS, Burton D, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis. Spine J. 2016; 16(12):1478-1485.

(10.) Haun DW, Kettner NW. Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management. J Chiropr Med. 2005; 4(4):206-217.

(11.) Fu KM, Smith JS, Polly DW Jr, Perra JH, Sansur CA, Berven SH, et al. Morbidity and mortality in the surgical treatment of six hundred five pediatric patients with isthmic or dysplastic spondylolisthesis. Spine. 2011; 36(4):308-312.

Peter C. Emary, DC, MSc (1)

Stefan A. Eberspaecher, DC (2)

John A. Taylor, DC, DACBR (3)

(1) Private Practice, Cambridge, ON

(2) World Spine Care, Dominican Republic Clinic Supervisor, Patronato Cibao de Rehabilitation, Moca, Provincia Espaillat, Republica Dominicana

(3) Professor and Coordinator of Diagnostic Imaging, Chiropractic Department, D'Youville College, Buffalo, NY, World Spine Care Consultant

Corresponding author: Peter C. Emary (1) Private Practice, 201C Preston Parkway, Cambridge, ON N3H 5E8, Canada e-mail:

Consent: The patient has provided written consent to having her personal health information, including diagnostic images, published.
Table 1. Radiologic grading and etiologic classification systems for

Radiologic (Meyerding (2)) grading system

* Grade 1 (slippage of 1% to 25%)
* Grade 2 (slippage of 26% to 50%)
* Grade 3 (slippage of 51% to 75%)
* Grade 4 (slippage of 76% to 100%)
* Grade 5 (slippage of >100%) (i.e. spondyloptosis)

Etiologic (Wiltse (3)) classification

* Type 1:  Dysplastic    Congenital defect of the neural arch
* Type 2:  Isthmic       Pars interarticularis defect (3
                         a) Stress (fatigue) fracture (most
                         common type, present in this
                         b) Elongated pars
                         c) Acute pars fracture
* Type 3:  Degenerative  Facet joint osteoarthrosis
* Type 4:  Traumatic     Acute fracture of the vertebral arch
                         other than the pars
* Type 5:  Pathological  Insufficiency fracture as a result of
                         bone weakening diseases
* Type 6:  Iatrogenic    Fracture secondary to spinal surgery
                         such as laminectomy

Table 2. Key imaging features of high-grade spondylolytic (isthmic Type
2a) spondylolisthesis

Key imaging features

* Spondylolysis: pars interarticularis stress (fatigue) fracture
  that usually occurs during childhood or early adolescence
* Most common at L5
* Anterior displacement of the vertebral body and corresponding
  posterior displacement of the neural arch resulting in
  characteristic palpable "step defect" (see Figure 1)
* Bowline of Brailsford on frontal radiograph (see Figure 2)
* Trapezoidal shape of listhetic vertebral body and
  corresponding "rounding" of the subjacent sacral base (see
  Figure 4) (These are signs of chronic, longstanding vertebral
  body displacement.)
* Vertebral body translation >4.5 mm observed on dynamic
  flexion-extension radiographs suggests radiologic instability
  (see Figure 4)

Table 3. Indications for surgery in patients with spondylolisthesis

Surgical indications (8)

* Slip progression
* High-grade spondylolisthesis with significant lumbosacral
  kyphotic deformity and sagittal imbalance
* Neurologic deficit
* Low back pain unresponsive to conservative treatment
* Radicular pain and nerve root compression documented on
  imaging studies unresponsive to conservative treatment
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Author:Emary, Peter C.; Eberspaecher, Stefan A.; Taylor, John A.
Publication:Journal of the Canadian Chiropractic Association
Article Type:Case study
Date:Aug 1, 2017
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