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Bracing for Spondylolisthesis

The spine or vertebral column consists of a series of vertebrae held together to give support for the spinal cord and nerves arising from it.

Each vertebra consists of an anterior vertebral body, and a posterior bony ring with two superior facets and two inferior facets that articulate with the neighboring vertebrae. These articulations form the posterior facet joints that provide stability to the spine.

In spondylolysis, there is a defect in the pars interarticularis (which literally means the "piece between the articulations"). So spondylolysis means a defect in the thin isthmus of bone connecting the superior and inferior facets, and could be unilateral (involving one side) or bilateral (involving both sides). Although the defect can be found at any level, the commonest vertebra involved is the 5th Lumbar vertebra (or L5).



In cases of bilateral spondylolysis, the posterior articulations can no longer provide the posterior stability, and anterior slipping of the L5 vertebra over the sacrum could result.

Spondylolysis is the commonest cause of spondylolisthesis, and is sometimes referred to as isthmic spondylolisthesis, since the defect is in the isthmus. But there are other causes of spondylolisthesis. Any infection or tumor affecting the posterior bony ring including the facet joints, can also cause instability and spondylolisthesis.

Spondylolisthesis is the term used to describe when one vertebra slips forward on the one below it. This usually occurs because there is a spondylolysis in the vertebra on top. There are two main parts of the spine that keep the vertebrae aligned - the disc and the facet joints. When a spondylolysis occurs, the facet joint can no longer hold the vertebra back. The intervertebral disc may slowly stretch under the increased stress and allow the upper vertebra to slide forward. In the vast majority of cases, the stretching only allows a small amount of forward slip

.

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There is a special type of spondylolisthesis in teenagers where the forward slipping is extremely severe. This can lead to the upper vertebra slipping completely off the lower vertebra.

Spondylolisthesis is important because it can be a cause of low back pain. Just because you have it does not mean that you will necessarily ever have problems with your back. However, you are at a higher risk than the normal population of developing chronic low back pain. This condition can cause typical mechanical and/or compressive (or neurogenic) type back pain symptoms.

The forward slip of the vertebra also makes the spinal canal smaller, leaving less room for the nerve roots.

There is usually pain across the small of the back and into the buttocks. If there are compressive symptoms, there may be pain down the leg to the foot, numbness in the foot, and possibly weakness in trying to raise the foot.

For Grades 1 and 2, conservative treatment is usually instituted. This will be similar to treatment for spondylolysis, except for use of a rigid Lumbosacral orthosis LSO or thermoplastic brace), and intensive physical therapy to strengthen the back and abdominal muscles, as well as stretching exercises for the tight hamstring muscles. X-rays (lateral views only) are done every 3 to 6 months to check on the severity of the slip. If the patient responds to conservative treatment, the pain resolves, the hamstring tightness improves, and the patient may return to limited sports. Gymnastics, weight-lifting and football should be avoided. If the pain does not improve, or if follow-up X-rays demonstrate further slip, surgery may be needed.

Surgery consists of fusing the L5 to the S1 vertebrae to prevent further slipping. Depending on the degree of slip and other factors, your surgeon may fuse the vertebrae "as is", or fuse the vertebrae after attempting to reduce the slip. This latter technique entails significant risk to the spinal nerves, and will have to be taken into consideration in the pre-operative planning.
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