CE ARTICLE
Spondylolysis and spondylolisthesis: What the primary care provider should know Robert Metzger, DNP, APRN, FNP-BC (Family Nurse Practitioner)1 & Susan Chaney, EdD, RN, FNP-C, FAANP (Professor)2,3 1
Orthopedic Spine Clinic, Parkland Health and Hospital System, Dallas, Texas Texas Woman’s University, T. Boone Pickens Institute of Health Sciences - Dallas Center, Dallas, Texas 3 HOMES Program, Parkland Health and Hospital System, Dallas, Texas 2
Keywords Spondylolysis; spondylolisthesis; low back pain; nurse practitioner; primary care. Correspondence Robert Metzger, DNP, APRN, FNP-BC, Orthopedic Spine Clinic, Parkland Health and Hospital System, 4900 Harry Hines Blvd, Dallas, TX, 75235. Tel: 214-590-9801; Fax: 214-590-2773; E-mail: [email protected] Received: April 2012; accepted: May 2013 doi: 10.1002/2327-6924.12083 To obtain CE credit for this activity, go to www.aanp.org and click on the CE Center. Locate the listing for this article and complete the post-test. Follow the instructions to print your CE certificate. Disclosures The authors report no financial interests or potential conflicts of interest.
Abstract Purpose: To provide nurse practitioners (NPs) with an overview of spondylolysis and spondylolisthesis, including the pathophysiology and etiology, incidence and prevalence, clinical presentation, diagnosis and differentials, management, and prognosis for these conditions. Data sources: Selected research, reviews, and clinical articles, and the authors’ experience. Conclusions: Spondylolysis and spondylolisthesis are two common and confusing diagnoses identified by healthcare providers in the treatment of low back pain. Symptoms can vary depending on the degree of disarticulation with radiculopathy occurring in advanced grades of spondylolisthesis. Standing, lateral lumbosacral radiographs remain the gold standard for diagnosis. The majority of patients will improve with conservative treatments. Surgical options are warranted after 6 months of failed conservative treatments for patients with radiculopathy, neurogenic claudication, progressive neurological deficits, high-grade slips, or bladder and bowel symptoms. Implications for practice: NPs can distinguish these diagnoses and perform appropriate conservative management prior to referral to specialists for surgical evaluation. NPs are important providers in interdisciplinary care by assisting patients with both psychosocial and physical management of their back pain.
In the evaluation of patients with low back pain (LBP), spondylolysis and spondylolisthesis are two common and confusing diagnoses identified by many healthcare providers. Hence, it is important for nurse practitioners (NPs) to differentiate between these two diagnoses. Spondylolysis is defined as a unilateral or bilateral defect along the isthmus, more commonly known as the pars interarticularis (Tsirikos & Garrido, 2010). Spondylolisthesis is the actual displacement of a vertebral body in correlation to the underlying vertebra (Denard et al., 2010).
Pathophysiology and etiology Spondylolysis, which remains unnoted in newborns, is believed to occur with the onset of upright and bipedal posturing. Genetics also plays a role in spondylolysis with a familial tendency and a parallelism with spina bifida occulta (Tsirikos & Garrido, 2010). Predisposition for
spondylolysis includes athletic activities, such as gymnastics, football, wrestling, and weightlifting (Kalichman & Hunter, 2008). The majority of cases are related to excessive mechanical stress on the lower aspects of the lumbar spine. Frequency increases with flexion and extension range of motion. These stresses cause a fracture or defect within the weakest link of the vertebra, the pars (see Figure 1). Shear forces on the vertebral column, resulting in spondylolisthesis, can occur once there is disturbance and weakening of the pars (Tsirikos & Garrido, 2010). Spondylolisthesis consists of five distinct types that include dysplastic, isthmic, degenerative, pathologic, and traumatic (Denard et al., 2010). Congenital dysplasia, Type I, can occur at the L5 neural arch or the sacrum (Lamartina, Zavatsky, Petruzzi, & Specchia, 2009). Isthmic spondylolisthesis occurs in relation to spondylolysis and indicates posterior destabilization (Niggermann
C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 5–12
C 2013 American Association of Nurse Practitioners
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Figure 1 Lateral radiographic image of spondylolysis at the L5 segment. Note the space on the posterior aspect at the L5-S1 disc space.
Figure 2 Lateral radiographic image of spondylolisthesis between L4 and L5. Notice the difference between the posterior borders of the vertebrae.
et al., 2011). Degenerative spondylolisthesis (DS) is typically seen with degenerative changes noted in the intervertebral disc segment and/or the facet joints without a defect in the vertebral ring (see Figure 2). DS is indicative of instability in the motion segment with a gliding forward of the entire top vertebra, including the body and the posterior elements, which are the neural arch and processes (Denard et al., 2010; Kalichman & Hunter, 2008; Watters et al., 2009). Pathologic spondylolisthesis includes posterior element incompetence from a pathologic process, such as metastasis (Lamartina et al., 2009). Traumatic spondylolisthesis occurs infrequently and is associated with an acute fracture of the posterior elements (Jindal, Pruthi, Garg, & Sharma, 2012; Lamartina et al., 2009). The two major causes of spondylolisthesis are isthmic and degenerative. Isthmic, which is described above, commonly occurs at the L5-S1 segment. This type is typically asymptomatic in the pediatric population because of skeletal immaturity. However, adult patients with isthmic spondylolisthesis experience symptoms more repeatedly (Agabegi & Fischgrund, 2010). With a six to nine times increase in frequency at the L4-L5 segment over other levels, degenerative causes are the second main cause of spondylolisthesis (Kalichman & Hunter, 2008).
DS can be multicausal and related to continued unsteadiness of the lumbar motion segment. Anatomical causes include degenerative disc disease, facet arthropathy, ligamentous hyperlaxity, and decreased muscular stabilization (Kalichman & Hunter, 2008). Injury mechanisms for traumatic spondylolisthesis are hyperflexion, especially with compression and rotation, as well as hyperextension (Jindal et al., 2012). Risk factors for spondylolisthesis include female sex, African-American ethnicity, joint laxity, anatomical predisposition, and increasing age of more than 50 years (Kalichman & Hunter, 2008).
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Incidence and prevalence The incidence of spondylolysis is 4.4% in children aged 6, increasing to between 6% and 11.5% in adult Caucasians (Jones & Rao, 2009; Kalichman et al., 2009; Niggermann et al., 2011; Tsirikos & Garrido, 2010). After the age of 18, minimal changes in incidence occur throughout the adult years. The progress toward spondylolisthesis varies ethnically with prevalence of 2% among African Americans and up to 54% among Native Americans and Eskimos. The ratio is 2:1 for males-to-females in regards to spondylolysis and isthmic spondylolisthesis (Kalichman et al., 2009; Tsirikos & Garrido, 2010).
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Female patients are more likely to have spondylolytic progression to spondylolisthesis; additionally, the ratio of spondylolisthesis categorized as degenerative favors women 3:1 (Kalichman et al., 2009; Tsirikos & Garrido, 2010). Development of isthmic spondylolisthesis will occur in 50%–75% of spondylolytic patients (Jones & Rao, 2009). Children are more often affected by developmental types of spondylolisthesis such as dysplastic or isthmic; whereas, adults tend to suffer from degenerative, traumatic, and pathological (Tsirikos & Garrido, 2010).
Clinical presentation Presentation of spondylolysis and spondylolisthesis include lower lumbar pain that is increased by prolonged standing and hyperextension. Symptoms can vary depending on the degree of disarticulation with radiculopathy and anatomical deformity, such as a step off, occurring in advanced grades of spondylolisthesis. Common lower extremity findings consist of bilateral hamstring tightness in almost 80% of patients, posterior buttock pain extending to the knees upon standing or walking, and possible neurological changes along the L5 or S1 dermatomes that are indicative of nerve root impingement. Scoliosis has been documented in almost 47% of spondylolisthesis patients (Jones & Rao, 2009; Tsirikos & Garrido, 2010). DS frequently has symptoms of neurogenic claudication, vesicorectal disorder, and radiculopathy. LBP, described as a recurrent, episodic event, remains the most usual complaint of DS patients. Changes in posture from supine to erect increases pain levels throughout the day. Altered gait, unexplained weakness with falls, and cold feet are other symptoms (Kalichman & Hunter, 2008).
Diagnosis Detailed history and physical examination remains the best approach to diagnosing and planning treatment for spondylolysis and spondylolisthesis (Watters et al., 2009). Specific details regarding pain should include location, severity, duration, quality, and exacerbating or alleviating factors. Other aspects to explore include precipitating leisure or occupational risks (Jones & Rao, 2009). Diagnostics are used to confirm the clinical diagnosis. Overall, a standing, lateral, and lumbosacral X-ray remains the gold standard for evaluating spondylolysis and spondylolisthesis (Jones & Rao, 2009; Niggermann et al., 2011; Watters et al., 2009). Defects, although not always visualized, can be noted on lateral X-ray. Oblique radiographs, which show an appearance of a Scottie dog (see Figure 3) with a collar, can be used for suspected yet poorly visualized pars defects (Kalichman & Hunter,
Figure 3 Oblique radiographic image of spondylolysis in the lumbar spine. As you glance down the spinal column, notice the appearance of a Scottie dog. The bottom dog (L4-5) appears to have a collar in place, which indicates the pars defect.
Table 1 Meyerding’s classification of spondylolisthesis Grade of Spondylolisthesis
Percentage of Slip
Grade I Grade II Grade III Grade IV Grade V (spondyloptosis)
0–24 25–49 50–74 75–99 100
2008; Tsirikos & Garrido, 2010). If there is concern for movement at the defect or spondylolisthesis, flexion and extension films can be obtained. Measurement of spondylolisthesis is carried out with a grading system utilizing radiographic images. Meyerding’s classification (see Table 1) has been the standard system employed and grades the degree of slip from I to IV (Kalichman & Hunter, 2008; Tsirikos & Garrido, 2010). One can grade the degree of slip by dividing the inferior vertebral body into fourths (see Figure 4e) and examining how many quarters the superior body moves over the inferior body (e.g., grade I equals a zero to 25% shift). Napoleon’s sign is labeled grade V (spondyloptosis) and is a complete slip of L5 on S1 (Kalichman & Hunter, 2008; Tsirikos & Garrido, 2010). Further descriptions include low grade, which is a shift less than 50%, or high grade, which is greater than 50% (Agabegi & Fischgrund, 2010). 7
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cause neuroforaminal and spinal stenosis frequently accompany spondylolisthesis (Herkowitz, 2010; Kalichman & Hunter, 2008).
Management
Figure 4 Meyerding’s classification for grading the degree of spondylolisthesis. (a) Grade I, (b) Grade II, (c) Grade III, (d) Grade IV, and (e) normal vertebra with inferior body divided into quarters used to determine measurement of slip. Adapted from Meyerding (1932). Copyright 1932 by the American College of Surgeons. Reprinted with permission.
More expensive tests can be used if there are other concerns, such as neurogenic claudication, radiculopathy, or metastatic disease. Computed tomography (CT) scanning can be used for detailed evaluation of bony anatomy and is the most precise for evaluation of spondylolysis (Kalichman et al., 2009). Magnetic resonance imaging (MRI) is preferred for patients with neurological concerns, with CT myelography preferred in patients with contraindications for MRI. Preoperative evaluation warrants these additional studies (Kalichman & Hunter, 2008; Watters et al., 2009).
Differential diagnosis By far the most common differential diagnosis is LBP. Osteoarthritis, a prominent finding on imaging, can be responsible for a variety of diagnoses, such as facet arthropathy, intervertebral disc degeneration, and scoliosis, all possible occurrences independent of and in conjunction with spondylolisthesis. One of the main things to consider with differential diagnoses is the nerves be8
Tsirikos and Garrido (2010) state that treatment options depend on the age, remaining development, degree of spondylolisthesis, and severity of symptoms of the patient. The majority of patients with symptoms will improve with conservative treatments. Nonsteroidal antiinflammatories (NSAIDs) are the mainstay of treatment (Jones & Rao, 2009; Kalichman et al., 2009). Treatment with muscle relaxants is considered feasible for patients with muscular pain. In cases of severe pain, narcotic analgesics can be used for a short duration. According to Kalichman and Hunter (2008), neither of these treatments is more effective than acetaminophen or NSAIDs based on well-controlled studies. Activity modification of 1–2 days should be considered and longer periods highly recommended for manual laborers or adolescent athletes (Agabegi & Fischgrund, 2010; Jones & Rao, 2009). Physical therapy treatment includes preferably lumbar flexion exercises. Long-term relief has been established with core stabilization exercises for the lower abdominal, lumbar muscles, hamstrings, and hip flexors. Low impact aerobic exercises, such as cycling, elliptical training, swimming, and walking, are highly recommended. Weight reduction, despite minimal effect on neurological concerns, is suggested for improvement of LBP (Agabegi & Fischgrund, 2010; Kalichman & Hunter, 2008). According to Jones and Rao (2009), the use of massage, heat, or ultrasound lack beneficial evidence for treatment of isthmic spondylolisthesis. Chiropractic adjustments lack continued benefit but can provide short-term relief for patients (Kalichman & Hunter, 2008). Epidural steroid injections used for axial pain lack benefit; however, they are recommended for patients with radicular symptoms and are an appropriate alternative for patients with significant comorbidities (Jones & Rao, 2009; Kalichman & Hunter, 2008). Other injections commonly performed include localized treatment at the pars defect or facet joints and selective nerve root blocks (Agabegi & Fischgrund, 2010; Kalichman et al., 2009). Surgical treatments are suggested after 6 months of failed conservative treatment in cases with radiculopathy or neurogenic claudication, progressive neurological deficits, progressive or high-grade slips, or bladder and bowel symptoms (Agabegi & Fischgrund, 2010; Kalichman & Hunter, 2008; Tsirikos & Garrido, 2010). Any grade III or above symptomatic spondylolisthesis is a consideration for surgical planning. Immediate surgical
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intervention is indicated in cauda equina syndrome and traumatic spondylolisthesis to restore neurologic function (Lim, Hee, & Liu, 2009). The standard surgical procedure for spondylolisthesis is a decompressive lumbar laminectomy with instrumented posterior fusion (Herkowitz, 2010; Watters et al., 2009). Smoking cessation is highly encouraged as this is a risk factor for pseudoarthrosis (Agabegi & Fischgrund, 2010).
Prognosis An increase in vertebral displacements from one grade to another is limited with estimates at only 5%. These changes are noted to decrease with patient age and increase in patients with higher levels of disc degeneration (Jones & Rao, 2009). The majority of patients will do well with conservative management if no neurological symptoms are present. However, symptomatic patients may continue with neurologic functional decline (Kalichman & Hunter, 2008; Watters et al., 2009) with decreased outcomes depending upon the time from presentation to surgery, especially in traumatic spondylolisthesis (Lim et al., 2009). Radcliff et al. (2011) noted that outcomes showed no difference in DS between surgical or nonsurgical management and the duration of symptoms. Should surgery be warranted, in approximately 10%–15% of cases, outcomes are improved with a solid surgical fusion and, which is usually very successful (Agabegi & Fischgrund, 2010; Herkowitz, 2010; Kalichman & Hunter, 2008). The following case study illustrates the presentation and evaluation of a patient with LBP, a condition commonly seen by NPs in primary care.
B.C. described his LBP as a constant, dull, burning pressure that goes across his lower lumbar segments. Pain continued into his bilateral lower extremities anteriorly to his knees. He also had symptoms of numbness medially in his left lower extremity from the knee to his ankle. All of these symptoms have gradually worsened over the past couple of years. B.C. underwent physical therapy and stated continued use of independent home exercise program that provided him with some relief. He denied any spinal injections. He reported a history of some urinary incontinence, which has been occurring infrequently since his accident. He denied any bowel incontinence. Difficulties with walking for prolonged distances and sitting for prolonged lengths of time were described. He uses a cane for ambulatory assistance when needed. Medication management included a history of NSAIDs, antineuropathic agents, skeletal muscle relaxants, and opioid analgesics. At the time of his visit, he had weaned himself from narcotic pain relievers. His pain was rated at a 6 of 10 using the pain visual analogue scale.
Past medical/surgical history (PMH/PSH) B.C.’s PMH included pneumonia, bipolar disease, asthma, depression, hiatal hernia, and transischemic attacks (TIAs) that occurred approximately six to eight times in 1979 to 1980. His surgical history was positive for a left knee operation, bilateral inguinal hernia repairs, a right hand surgery, esophagogastroduodenoscopy, and tendon repair in his left lower extremity. Health maintenance procedures of electrocardiogram and colonoscopy had been performed and normal.
Case Study
Immunizations, allergies, and current medications
Chief complaint (CC)
All adult immunizations were up to date. He had an allergy to varenicline. Current medications consisted of zolpidem 10 mg, one tablet at bedtime as needed (PRN); aspirin 325 mg daily; albuterol inhaler, two puffs every 6 h PRN; lithium 300 mg, one tablet four times per day; fluticasone/salmeterol dry powder inhaler 100/50 mg, one inhalation every 12 h; tizanidine hydrochloride 4 mg, one tablet every 12 h PRN; and a daily multivitamin.
LBP.
History of present illness (HPI) B.C. is a 50-year-old Anglo, non-Hispanic male. He stated his symptoms began over 8 years ago when he described being knocked off of a three-story building, landing onto his left foot, and subsequently his tailbone. He was immediately treated at another hospital where he was diagnosed with a fracture in his spine and a dislocation. B.C. denied requiring any medical or surgical intervention at the time of his injury. He had progression of symptoms in his left lower extremity and eventually required operative procedures on his leg and knee.
Family history B.C.’s father has a history of diabetes and hypertension. His mother has history of hypertension. His paternal grandfather has history of cancer. His paternal uncle has history of coronary artery disease.
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Social history B.C. was a single male with no children. He was educated at the high school level. He admitted to smoking half a pack per day of cigarettes for the past 38 years. He quit drinking alcohol in 1980. He denied any recreational drug use. He is currently unemployed and not receiving any disability.
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except in the bilateral patellar, which were one out of three.
Differential diagnosis The differential diagnosis for this patient includes lumbago, osteoarthritis, facet arthropathy, and lumbar stenosis with claudication.
Review of systems
Diagnostic testing
Pertinent positives included pulmonary with asthma without wheezing, musculoskeletal with LBP, difficulty walking, and neurological with numbness and burning in his lower extremities. In addition, he was positive for a psychological history of bipolar disease.
B.C. had anterior, posterior, and lateral views of his lumbar spine taken on the date of his initial examination. There were five lumbar segments present with pedicles well-visualized. Narrowing was noted at the L5-S1 disk space with presence of L5 pars defects and grade II spondylolisthesis. No vertebral fractures were noted. Imaging previous MRI of the lumbar spine demonstrated disc degeneration at L5-S1 with a grade II spondylolisthesis and bilateral neuroforaminal stenosis at the L5-S1 segment. No mention of his spondylolysis was noted on the radiologist report. Based on the history and physical examination, B.C. clearly was having issues of LBP with evidence of neurogenic claudication. B.C.’s lateral X-ray showed evidence of lumbar disc degeneration, bilateral L5 spondylolysis, and a grade II spondylolisthesis. His MRI confirmed neuroforaminal stenosis that would account for lumbar radiculopathy. All of these findings confirmed these conditions as his diagnoses.
Physical examination B.C.’s affect was calm and he was in no acute distress. All questions were answered appropriately and with clear speech. He was 66 inches in height, weight of 145 pounds, and body mass index (BMI) of 25. Vital signs measured included a tympanic temperature of 97.5◦ Fahrenheit, a pulse of 73 beats per minute, blood pressure of 123/80 mmHg, and respirations of 16 breaths per minute. He overall was well-developed, well-nourished, and appropriate for his age. Examination of his head, eyes, nose, and throat revealed a normocephalic, atraumatic head. His extraocular muscles were intact and oropharynx clear. His neck showed no signs of jugular vein distention, thyromegaly, or cervical lymphadenopathy, and trachea was midline. Pulmonary respirations were equal and unlabored. Pulses remained two plus and equal in all extremities on cardiovascular exam. Musculoskeletal examination demonstrated an antalgic gait pattern with a limp using his left lower extremity. Tandem gait was normal but he did have difficulties with tiptoe and heal walking with the left lower extremity. Both of these maneuvers were intact in the right lower extremity. Muscle strength testing was five of five in his bilateral upper and lower extremities. His sensation was grossly intact throughout. He had negative straight leg raise tests bilaterally, as well as negative Spurling’s signs bilaterally. Tenderness was noted over the lower lumbar segments on palpation. Full range of motion was present in both the cervical and lumbar spines. Neurological examination revealed him to be alert and oriented times three. He had a negative Romberg’s sign, negative bilateral Hoffman’s sign, negative bilateral clonus, and negative Babinski’s signs. His deep tendon reflexes were two plus and equal in all of his extremities 10
Plan Continued conservative treatments were discussed with the patient by NP as a plan of care. Because B.C. had previous treatments of physical therapy and continued use of an independent home exercise program, the NP discussed referral for spinal injections. B.C. mentioned concerns that spinal injections would just be a “BandAid” treatment. The NP educated B.C. regarding the purpose of injections and probable surgical interventions. After this detailed discussion, a referral was made for B.C. to the pain management clinic for evaluation of injection therapies. However, B.C. still desired further discussion regarding his surgical options, so an appointment with the surgical residents was made. The NP reviewed and discussed medication management for B.C.’s diagnosis. Prescriptions for etodolac, an anti-inflammatory, and pantoprazole, as prophylactic treatment for reflux and medication-induced gastritis, were provided. As the patient was actively weaning from his narcotic pain medication, a script for tramadol, a nonnarcotic analgesic, was written. Patient education against
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long-term opioid treatment was provided by the NP. Coping strategies, such as diversion and endurance, were discussed with the patient to assist with his LBP especially in relation to his depression. Maintaining an optimistic outlook can decrease progression to chronic LBP. Smoking cessation was also encouraged because the patient was smoking a half pack per day of cigarettes.
Follow-Up Follow-up with the orthopedic spine clinic to further discuss his surgical options after 3 months revealed that B.C.’s symptoms were unchanged. His medication management had changed with the scheduled use of acetaminophen every day for his pain. Besides denying any urinary or bowel incontinence, he also denied any urinary retention. No changes were noted in his physical exam from his initial evaluation. The resident physician discussed at length with B.C. the surgical options of lumbar decompression with posterior spinal instrumentation. After this discussion, B.C. stated he was not interested in surgical intervention and would like to continue nonsurgical treatments.
Continued care Interdisciplinary care continued with B.C. having an evaluation with the pain management clinic following the surgical consultation. At this visit, it was noted that he was using two NSAIDs for pain: ibuprofen 200 mg 4– 16 per day and naproxen 250 mg 4–8 per day. He denied any evidence of dark, tarry stools but did admit to intermittent heartburn that was relieved with use of an antacid. He had used a transcutaneous electrical nerve stimulation (TENS) unit at home with moderate benefit. He continued to deny any chiropractic manipulations or acupuncture. The pain clinic physician scheduled B.C. for an epidural steroid injection at the L5-S1 segment. Consideration for a left sacroiliac joint injection was also described. Recommendation of the pain clinic physician should B.C. fail injection therapy, was additional follow-up in the orthopedic spine clinic for surgical planning. B.C. was advised to decrease his NSAID and acetaminophen use. Continuance of home exercise program was encouraged. He was instructed to follow-up in the pain management clinic in 3 months. No further appointments in either clinic have occurred to date.
Conclusion As evidenced in this case study, NPs as primary care and specialty providers can evaluate patients with spondylolysis and spondylolisthesis. Through performance of appro-
priate history, physical, and diagnostics, appropriate diagnosis can be determined. Conservative treatment options can be discussed with patients and administered prior to referral to other specialty care. NPs are important providers in assisting patients with both psychosocial and biophysical management of their LBP. Through employment of psychosocial interventions, such as adaptive coping techniques, NPs can also assist patients with decreasing depression and avoiding disability. According to Heymans et al. (2010), interdisciplinary care that includes NPs in the management of LBP can help patients to better manage their conditions and avoid the development of chronic LBP. NPs can recommend continued independent home exercise programs to further decrease pain and increase patient functioning. In conclusion, through evaluation of patients with LBP, spondylolysis and spondylolisthesis are two common and confusing diagnoses encountered by many healthcare providers. Hence, it is important for NPs to differentiate between these two diagnoses. Based on the information in this case study, NPs can understand the importance of evaluation and diagnosis of spondylolysis and spondylolisthesis. With this information, NPs can better distinguish between these two diagnoses, order appropriate diagnostics, and perform appropriate conservative management treatments prior to referral to specialists for surgical evaluation.
References Agabegi, S., & Fischgrund, J. (2010). Contemporary management of isthmic spondylolisthesis: Pediatric and adult. Spine Journal, 10, 530–543. doi:10.1016/j.spinee.2010.02.023 Denard, P., Holton, K., Miller, J., Fink, H., Kado, D., Marshall, L., & Yoo, J. (2010). Back pain, neurogenic symptoms, and physical function in relation to spondylolisthesis among elderly men. Spine Journal, 10, 865–873. doi: 10.1016/j.spinee.2010.07.004 Herkowitz, H. (2010). Degenerative lumbar spondylolisthesis: A surgeon’s perspective of 30 years in practice. Spine Journal, 10, 916–917. doi:10.1016/jspinee.2010.08.026 Heymans, M., Van Buuren, S., Knol, D., Anema, J., Van Mechelen, W., & De Vet, H. (2010). The prognosis of chronic low back pain is determined by changes in pain and disability in the initial period. Spine Journal, 10, 847–856. doi:10.1016/j.spinee.2010.06.005 Jindal, R., Pruthi, M., Garg, S., & Sharma, R. (2012). Traumatic L4–5 spondylolisthesis: Case report and literature review. European Journal of Orthopaedic Surgery and Traumatology, 22, 61–64. doi:10.1007/s00590–011–0773–2 Jones, T., & Rao, R. (2009). Adult isthmic spondylolisthesis. Journal of the American Academy of Orthopaedic Surgeons, 17(10), 609–617. Kalichman, L., & Hunter, D. (2008). Diagnosis and conservative management of degenerative lumbar spondylolisthesis. European Spine Journal, 17, 327–335. doi:10.1007/s00586–007–0543–3 Kalichman, L., Kim, D., Li, L., Guermazi, A., Berkin, V., & Hunter, D. (2009). Spondylolysis and spondylolisthesis: Prevalence and association with low back pain in the adult community-based population. Spine, 34(2), 99–205. Lamartina, C., Zavatsky, J., Petruzzi, M., & Specchia, N. (2009). Novel concepts in the evaluation and treatment of high-dysplastic
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spondylolisthesis. European Spine Journal, 18(Suppl 1), S133–S142. doi:10.1007/s00586–009–0984-y Lim, C., Hee, H., & Liu, G. (2009). Traumatic spondylolisthesis of the lumbar spine: A report of three cases. Journal of Orthopaedic Surgery, 17(3), 361– 365. Meyerding, H.W. (1932). Spondylolisthesis. Surgical, Gynecology, & Obstetrics, 54, 371–377. Niggermann, P., Kuchta, J., Beyer, H., Grosskurth, D., Schulze, T., & Delank, K. (2011). Spondylolysis and spondylolisthesis: Prevalence of different forms of instability and clinical implications. Spine, 36(22), E1463–E1468. doi:10.1097/BRS.0b013e3181d47a0e
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Radcliff, K., Rihn, J., Hilibrand, A., Dilorio, T., Tosteson, T., Lurie, J., . . . Weinstein, J. (2011). Does the duration of symptoms in patients with spinal stenosis and degenerative spondylolisthesis affect outcomes? Spine, 36(25), 2197–2210. doi:10.1097/BRS.0b013e3182341edf Tsirikos, A., & Garrido, E. (2010, June). Spondylolysis and spondylolisthesis in children and adolescents. Journal of Bone & Joint Surgery [Br], 92-B(6), 751–759. doi:10.1302/0301–620X.92B6.23014 Watters, W., Bono, C., Gilbert, T., Kreiner, D., Mazanec, D., Shaffer, W., . . . Toton, J. (2009). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine Journal, 9, 609–614. doi:10.1016/j.spinee.2009.03.016
Spondylolysis and spondylolisthesis: What the primary care provider should know Robert Metzger, DNP, APRN, FNP-BC (Family Nurse Practitioner)1 & Susan Chaney, EdD, RN, FNP-C, FAANP (Professor)2,3 1
Orthopedic Spine Clinic, Parkland Health and Hospital System, Dallas, Texas Texas Woman’s University, T. Boone Pickens Institute of Health Sciences - Dallas Center, Dallas, Texas 3 HOMES Program, Parkland Health and Hospital System, Dallas, Texas 2
Keywords Spondylolysis; spondylolisthesis; low back pain; nurse practitioner; primary care. Correspondence Robert Metzger, DNP, APRN, FNP-BC, Orthopedic Spine Clinic, Parkland Health and Hospital System, 4900 Harry Hines Blvd, Dallas, TX, 75235. Tel: 214-590-9801; Fax: 214-590-2773; E-mail: [email protected] Received: April 2012; accepted: May 2013 doi: 10.1002/2327-6924.12083 To obtain CE credit for this activity, go to www.aanp.org and click on the CE Center. Locate the listing for this article and complete the post-test. Follow the instructions to print your CE certificate. Disclosures The authors report no financial interests or potential conflicts of interest.
Abstract Purpose: To provide nurse practitioners (NPs) with an overview of spondylolysis and spondylolisthesis, including the pathophysiology and etiology, incidence and prevalence, clinical presentation, diagnosis and differentials, management, and prognosis for these conditions. Data sources: Selected research, reviews, and clinical articles, and the authors’ experience. Conclusions: Spondylolysis and spondylolisthesis are two common and confusing diagnoses identified by healthcare providers in the treatment of low back pain. Symptoms can vary depending on the degree of disarticulation with radiculopathy occurring in advanced grades of spondylolisthesis. Standing, lateral lumbosacral radiographs remain the gold standard for diagnosis. The majority of patients will improve with conservative treatments. Surgical options are warranted after 6 months of failed conservative treatments for patients with radiculopathy, neurogenic claudication, progressive neurological deficits, high-grade slips, or bladder and bowel symptoms. Implications for practice: NPs can distinguish these diagnoses and perform appropriate conservative management prior to referral to specialists for surgical evaluation. NPs are important providers in interdisciplinary care by assisting patients with both psychosocial and physical management of their back pain.
In the evaluation of patients with low back pain (LBP), spondylolysis and spondylolisthesis are two common and confusing diagnoses identified by many healthcare providers. Hence, it is important for nurse practitioners (NPs) to differentiate between these two diagnoses. Spondylolysis is defined as a unilateral or bilateral defect along the isthmus, more commonly known as the pars interarticularis (Tsirikos & Garrido, 2010). Spondylolisthesis is the actual displacement of a vertebral body in correlation to the underlying vertebra (Denard et al., 2010).
Pathophysiology and etiology Spondylolysis, which remains unnoted in newborns, is believed to occur with the onset of upright and bipedal posturing. Genetics also plays a role in spondylolysis with a familial tendency and a parallelism with spina bifida occulta (Tsirikos & Garrido, 2010). Predisposition for
spondylolysis includes athletic activities, such as gymnastics, football, wrestling, and weightlifting (Kalichman & Hunter, 2008). The majority of cases are related to excessive mechanical stress on the lower aspects of the lumbar spine. Frequency increases with flexion and extension range of motion. These stresses cause a fracture or defect within the weakest link of the vertebra, the pars (see Figure 1). Shear forces on the vertebral column, resulting in spondylolisthesis, can occur once there is disturbance and weakening of the pars (Tsirikos & Garrido, 2010). Spondylolisthesis consists of five distinct types that include dysplastic, isthmic, degenerative, pathologic, and traumatic (Denard et al., 2010). Congenital dysplasia, Type I, can occur at the L5 neural arch or the sacrum (Lamartina, Zavatsky, Petruzzi, & Specchia, 2009). Isthmic spondylolisthesis occurs in relation to spondylolysis and indicates posterior destabilization (Niggermann
C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 5–12
C 2013 American Association of Nurse Practitioners
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Figure 1 Lateral radiographic image of spondylolysis at the L5 segment. Note the space on the posterior aspect at the L5-S1 disc space.
Figure 2 Lateral radiographic image of spondylolisthesis between L4 and L5. Notice the difference between the posterior borders of the vertebrae.
et al., 2011). Degenerative spondylolisthesis (DS) is typically seen with degenerative changes noted in the intervertebral disc segment and/or the facet joints without a defect in the vertebral ring (see Figure 2). DS is indicative of instability in the motion segment with a gliding forward of the entire top vertebra, including the body and the posterior elements, which are the neural arch and processes (Denard et al., 2010; Kalichman & Hunter, 2008; Watters et al., 2009). Pathologic spondylolisthesis includes posterior element incompetence from a pathologic process, such as metastasis (Lamartina et al., 2009). Traumatic spondylolisthesis occurs infrequently and is associated with an acute fracture of the posterior elements (Jindal, Pruthi, Garg, & Sharma, 2012; Lamartina et al., 2009). The two major causes of spondylolisthesis are isthmic and degenerative. Isthmic, which is described above, commonly occurs at the L5-S1 segment. This type is typically asymptomatic in the pediatric population because of skeletal immaturity. However, adult patients with isthmic spondylolisthesis experience symptoms more repeatedly (Agabegi & Fischgrund, 2010). With a six to nine times increase in frequency at the L4-L5 segment over other levels, degenerative causes are the second main cause of spondylolisthesis (Kalichman & Hunter, 2008).
DS can be multicausal and related to continued unsteadiness of the lumbar motion segment. Anatomical causes include degenerative disc disease, facet arthropathy, ligamentous hyperlaxity, and decreased muscular stabilization (Kalichman & Hunter, 2008). Injury mechanisms for traumatic spondylolisthesis are hyperflexion, especially with compression and rotation, as well as hyperextension (Jindal et al., 2012). Risk factors for spondylolisthesis include female sex, African-American ethnicity, joint laxity, anatomical predisposition, and increasing age of more than 50 years (Kalichman & Hunter, 2008).
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Incidence and prevalence The incidence of spondylolysis is 4.4% in children aged 6, increasing to between 6% and 11.5% in adult Caucasians (Jones & Rao, 2009; Kalichman et al., 2009; Niggermann et al., 2011; Tsirikos & Garrido, 2010). After the age of 18, minimal changes in incidence occur throughout the adult years. The progress toward spondylolisthesis varies ethnically with prevalence of 2% among African Americans and up to 54% among Native Americans and Eskimos. The ratio is 2:1 for males-to-females in regards to spondylolysis and isthmic spondylolisthesis (Kalichman et al., 2009; Tsirikos & Garrido, 2010).
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Female patients are more likely to have spondylolytic progression to spondylolisthesis; additionally, the ratio of spondylolisthesis categorized as degenerative favors women 3:1 (Kalichman et al., 2009; Tsirikos & Garrido, 2010). Development of isthmic spondylolisthesis will occur in 50%–75% of spondylolytic patients (Jones & Rao, 2009). Children are more often affected by developmental types of spondylolisthesis such as dysplastic or isthmic; whereas, adults tend to suffer from degenerative, traumatic, and pathological (Tsirikos & Garrido, 2010).
Clinical presentation Presentation of spondylolysis and spondylolisthesis include lower lumbar pain that is increased by prolonged standing and hyperextension. Symptoms can vary depending on the degree of disarticulation with radiculopathy and anatomical deformity, such as a step off, occurring in advanced grades of spondylolisthesis. Common lower extremity findings consist of bilateral hamstring tightness in almost 80% of patients, posterior buttock pain extending to the knees upon standing or walking, and possible neurological changes along the L5 or S1 dermatomes that are indicative of nerve root impingement. Scoliosis has been documented in almost 47% of spondylolisthesis patients (Jones & Rao, 2009; Tsirikos & Garrido, 2010). DS frequently has symptoms of neurogenic claudication, vesicorectal disorder, and radiculopathy. LBP, described as a recurrent, episodic event, remains the most usual complaint of DS patients. Changes in posture from supine to erect increases pain levels throughout the day. Altered gait, unexplained weakness with falls, and cold feet are other symptoms (Kalichman & Hunter, 2008).
Diagnosis Detailed history and physical examination remains the best approach to diagnosing and planning treatment for spondylolysis and spondylolisthesis (Watters et al., 2009). Specific details regarding pain should include location, severity, duration, quality, and exacerbating or alleviating factors. Other aspects to explore include precipitating leisure or occupational risks (Jones & Rao, 2009). Diagnostics are used to confirm the clinical diagnosis. Overall, a standing, lateral, and lumbosacral X-ray remains the gold standard for evaluating spondylolysis and spondylolisthesis (Jones & Rao, 2009; Niggermann et al., 2011; Watters et al., 2009). Defects, although not always visualized, can be noted on lateral X-ray. Oblique radiographs, which show an appearance of a Scottie dog (see Figure 3) with a collar, can be used for suspected yet poorly visualized pars defects (Kalichman & Hunter,
Figure 3 Oblique radiographic image of spondylolysis in the lumbar spine. As you glance down the spinal column, notice the appearance of a Scottie dog. The bottom dog (L4-5) appears to have a collar in place, which indicates the pars defect.
Table 1 Meyerding’s classification of spondylolisthesis Grade of Spondylolisthesis
Percentage of Slip
Grade I Grade II Grade III Grade IV Grade V (spondyloptosis)
0–24 25–49 50–74 75–99 100
2008; Tsirikos & Garrido, 2010). If there is concern for movement at the defect or spondylolisthesis, flexion and extension films can be obtained. Measurement of spondylolisthesis is carried out with a grading system utilizing radiographic images. Meyerding’s classification (see Table 1) has been the standard system employed and grades the degree of slip from I to IV (Kalichman & Hunter, 2008; Tsirikos & Garrido, 2010). One can grade the degree of slip by dividing the inferior vertebral body into fourths (see Figure 4e) and examining how many quarters the superior body moves over the inferior body (e.g., grade I equals a zero to 25% shift). Napoleon’s sign is labeled grade V (spondyloptosis) and is a complete slip of L5 on S1 (Kalichman & Hunter, 2008; Tsirikos & Garrido, 2010). Further descriptions include low grade, which is a shift less than 50%, or high grade, which is greater than 50% (Agabegi & Fischgrund, 2010). 7
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cause neuroforaminal and spinal stenosis frequently accompany spondylolisthesis (Herkowitz, 2010; Kalichman & Hunter, 2008).
Management
Figure 4 Meyerding’s classification for grading the degree of spondylolisthesis. (a) Grade I, (b) Grade II, (c) Grade III, (d) Grade IV, and (e) normal vertebra with inferior body divided into quarters used to determine measurement of slip. Adapted from Meyerding (1932). Copyright 1932 by the American College of Surgeons. Reprinted with permission.
More expensive tests can be used if there are other concerns, such as neurogenic claudication, radiculopathy, or metastatic disease. Computed tomography (CT) scanning can be used for detailed evaluation of bony anatomy and is the most precise for evaluation of spondylolysis (Kalichman et al., 2009). Magnetic resonance imaging (MRI) is preferred for patients with neurological concerns, with CT myelography preferred in patients with contraindications for MRI. Preoperative evaluation warrants these additional studies (Kalichman & Hunter, 2008; Watters et al., 2009).
Differential diagnosis By far the most common differential diagnosis is LBP. Osteoarthritis, a prominent finding on imaging, can be responsible for a variety of diagnoses, such as facet arthropathy, intervertebral disc degeneration, and scoliosis, all possible occurrences independent of and in conjunction with spondylolisthesis. One of the main things to consider with differential diagnoses is the nerves be8
Tsirikos and Garrido (2010) state that treatment options depend on the age, remaining development, degree of spondylolisthesis, and severity of symptoms of the patient. The majority of patients with symptoms will improve with conservative treatments. Nonsteroidal antiinflammatories (NSAIDs) are the mainstay of treatment (Jones & Rao, 2009; Kalichman et al., 2009). Treatment with muscle relaxants is considered feasible for patients with muscular pain. In cases of severe pain, narcotic analgesics can be used for a short duration. According to Kalichman and Hunter (2008), neither of these treatments is more effective than acetaminophen or NSAIDs based on well-controlled studies. Activity modification of 1–2 days should be considered and longer periods highly recommended for manual laborers or adolescent athletes (Agabegi & Fischgrund, 2010; Jones & Rao, 2009). Physical therapy treatment includes preferably lumbar flexion exercises. Long-term relief has been established with core stabilization exercises for the lower abdominal, lumbar muscles, hamstrings, and hip flexors. Low impact aerobic exercises, such as cycling, elliptical training, swimming, and walking, are highly recommended. Weight reduction, despite minimal effect on neurological concerns, is suggested for improvement of LBP (Agabegi & Fischgrund, 2010; Kalichman & Hunter, 2008). According to Jones and Rao (2009), the use of massage, heat, or ultrasound lack beneficial evidence for treatment of isthmic spondylolisthesis. Chiropractic adjustments lack continued benefit but can provide short-term relief for patients (Kalichman & Hunter, 2008). Epidural steroid injections used for axial pain lack benefit; however, they are recommended for patients with radicular symptoms and are an appropriate alternative for patients with significant comorbidities (Jones & Rao, 2009; Kalichman & Hunter, 2008). Other injections commonly performed include localized treatment at the pars defect or facet joints and selective nerve root blocks (Agabegi & Fischgrund, 2010; Kalichman et al., 2009). Surgical treatments are suggested after 6 months of failed conservative treatment in cases with radiculopathy or neurogenic claudication, progressive neurological deficits, progressive or high-grade slips, or bladder and bowel symptoms (Agabegi & Fischgrund, 2010; Kalichman & Hunter, 2008; Tsirikos & Garrido, 2010). Any grade III or above symptomatic spondylolisthesis is a consideration for surgical planning. Immediate surgical
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intervention is indicated in cauda equina syndrome and traumatic spondylolisthesis to restore neurologic function (Lim, Hee, & Liu, 2009). The standard surgical procedure for spondylolisthesis is a decompressive lumbar laminectomy with instrumented posterior fusion (Herkowitz, 2010; Watters et al., 2009). Smoking cessation is highly encouraged as this is a risk factor for pseudoarthrosis (Agabegi & Fischgrund, 2010).
Prognosis An increase in vertebral displacements from one grade to another is limited with estimates at only 5%. These changes are noted to decrease with patient age and increase in patients with higher levels of disc degeneration (Jones & Rao, 2009). The majority of patients will do well with conservative management if no neurological symptoms are present. However, symptomatic patients may continue with neurologic functional decline (Kalichman & Hunter, 2008; Watters et al., 2009) with decreased outcomes depending upon the time from presentation to surgery, especially in traumatic spondylolisthesis (Lim et al., 2009). Radcliff et al. (2011) noted that outcomes showed no difference in DS between surgical or nonsurgical management and the duration of symptoms. Should surgery be warranted, in approximately 10%–15% of cases, outcomes are improved with a solid surgical fusion and, which is usually very successful (Agabegi & Fischgrund, 2010; Herkowitz, 2010; Kalichman & Hunter, 2008). The following case study illustrates the presentation and evaluation of a patient with LBP, a condition commonly seen by NPs in primary care.
B.C. described his LBP as a constant, dull, burning pressure that goes across his lower lumbar segments. Pain continued into his bilateral lower extremities anteriorly to his knees. He also had symptoms of numbness medially in his left lower extremity from the knee to his ankle. All of these symptoms have gradually worsened over the past couple of years. B.C. underwent physical therapy and stated continued use of independent home exercise program that provided him with some relief. He denied any spinal injections. He reported a history of some urinary incontinence, which has been occurring infrequently since his accident. He denied any bowel incontinence. Difficulties with walking for prolonged distances and sitting for prolonged lengths of time were described. He uses a cane for ambulatory assistance when needed. Medication management included a history of NSAIDs, antineuropathic agents, skeletal muscle relaxants, and opioid analgesics. At the time of his visit, he had weaned himself from narcotic pain relievers. His pain was rated at a 6 of 10 using the pain visual analogue scale.
Past medical/surgical history (PMH/PSH) B.C.’s PMH included pneumonia, bipolar disease, asthma, depression, hiatal hernia, and transischemic attacks (TIAs) that occurred approximately six to eight times in 1979 to 1980. His surgical history was positive for a left knee operation, bilateral inguinal hernia repairs, a right hand surgery, esophagogastroduodenoscopy, and tendon repair in his left lower extremity. Health maintenance procedures of electrocardiogram and colonoscopy had been performed and normal.
Case Study
Immunizations, allergies, and current medications
Chief complaint (CC)
All adult immunizations were up to date. He had an allergy to varenicline. Current medications consisted of zolpidem 10 mg, one tablet at bedtime as needed (PRN); aspirin 325 mg daily; albuterol inhaler, two puffs every 6 h PRN; lithium 300 mg, one tablet four times per day; fluticasone/salmeterol dry powder inhaler 100/50 mg, one inhalation every 12 h; tizanidine hydrochloride 4 mg, one tablet every 12 h PRN; and a daily multivitamin.
LBP.
History of present illness (HPI) B.C. is a 50-year-old Anglo, non-Hispanic male. He stated his symptoms began over 8 years ago when he described being knocked off of a three-story building, landing onto his left foot, and subsequently his tailbone. He was immediately treated at another hospital where he was diagnosed with a fracture in his spine and a dislocation. B.C. denied requiring any medical or surgical intervention at the time of his injury. He had progression of symptoms in his left lower extremity and eventually required operative procedures on his leg and knee.
Family history B.C.’s father has a history of diabetes and hypertension. His mother has history of hypertension. His paternal grandfather has history of cancer. His paternal uncle has history of coronary artery disease.
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Social history B.C. was a single male with no children. He was educated at the high school level. He admitted to smoking half a pack per day of cigarettes for the past 38 years. He quit drinking alcohol in 1980. He denied any recreational drug use. He is currently unemployed and not receiving any disability.
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except in the bilateral patellar, which were one out of three.
Differential diagnosis The differential diagnosis for this patient includes lumbago, osteoarthritis, facet arthropathy, and lumbar stenosis with claudication.
Review of systems
Diagnostic testing
Pertinent positives included pulmonary with asthma without wheezing, musculoskeletal with LBP, difficulty walking, and neurological with numbness and burning in his lower extremities. In addition, he was positive for a psychological history of bipolar disease.
B.C. had anterior, posterior, and lateral views of his lumbar spine taken on the date of his initial examination. There were five lumbar segments present with pedicles well-visualized. Narrowing was noted at the L5-S1 disk space with presence of L5 pars defects and grade II spondylolisthesis. No vertebral fractures were noted. Imaging previous MRI of the lumbar spine demonstrated disc degeneration at L5-S1 with a grade II spondylolisthesis and bilateral neuroforaminal stenosis at the L5-S1 segment. No mention of his spondylolysis was noted on the radiologist report. Based on the history and physical examination, B.C. clearly was having issues of LBP with evidence of neurogenic claudication. B.C.’s lateral X-ray showed evidence of lumbar disc degeneration, bilateral L5 spondylolysis, and a grade II spondylolisthesis. His MRI confirmed neuroforaminal stenosis that would account for lumbar radiculopathy. All of these findings confirmed these conditions as his diagnoses.
Physical examination B.C.’s affect was calm and he was in no acute distress. All questions were answered appropriately and with clear speech. He was 66 inches in height, weight of 145 pounds, and body mass index (BMI) of 25. Vital signs measured included a tympanic temperature of 97.5◦ Fahrenheit, a pulse of 73 beats per minute, blood pressure of 123/80 mmHg, and respirations of 16 breaths per minute. He overall was well-developed, well-nourished, and appropriate for his age. Examination of his head, eyes, nose, and throat revealed a normocephalic, atraumatic head. His extraocular muscles were intact and oropharynx clear. His neck showed no signs of jugular vein distention, thyromegaly, or cervical lymphadenopathy, and trachea was midline. Pulmonary respirations were equal and unlabored. Pulses remained two plus and equal in all extremities on cardiovascular exam. Musculoskeletal examination demonstrated an antalgic gait pattern with a limp using his left lower extremity. Tandem gait was normal but he did have difficulties with tiptoe and heal walking with the left lower extremity. Both of these maneuvers were intact in the right lower extremity. Muscle strength testing was five of five in his bilateral upper and lower extremities. His sensation was grossly intact throughout. He had negative straight leg raise tests bilaterally, as well as negative Spurling’s signs bilaterally. Tenderness was noted over the lower lumbar segments on palpation. Full range of motion was present in both the cervical and lumbar spines. Neurological examination revealed him to be alert and oriented times three. He had a negative Romberg’s sign, negative bilateral Hoffman’s sign, negative bilateral clonus, and negative Babinski’s signs. His deep tendon reflexes were two plus and equal in all of his extremities 10
Plan Continued conservative treatments were discussed with the patient by NP as a plan of care. Because B.C. had previous treatments of physical therapy and continued use of an independent home exercise program, the NP discussed referral for spinal injections. B.C. mentioned concerns that spinal injections would just be a “BandAid” treatment. The NP educated B.C. regarding the purpose of injections and probable surgical interventions. After this detailed discussion, a referral was made for B.C. to the pain management clinic for evaluation of injection therapies. However, B.C. still desired further discussion regarding his surgical options, so an appointment with the surgical residents was made. The NP reviewed and discussed medication management for B.C.’s diagnosis. Prescriptions for etodolac, an anti-inflammatory, and pantoprazole, as prophylactic treatment for reflux and medication-induced gastritis, were provided. As the patient was actively weaning from his narcotic pain medication, a script for tramadol, a nonnarcotic analgesic, was written. Patient education against
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long-term opioid treatment was provided by the NP. Coping strategies, such as diversion and endurance, were discussed with the patient to assist with his LBP especially in relation to his depression. Maintaining an optimistic outlook can decrease progression to chronic LBP. Smoking cessation was also encouraged because the patient was smoking a half pack per day of cigarettes.
Follow-Up Follow-up with the orthopedic spine clinic to further discuss his surgical options after 3 months revealed that B.C.’s symptoms were unchanged. His medication management had changed with the scheduled use of acetaminophen every day for his pain. Besides denying any urinary or bowel incontinence, he also denied any urinary retention. No changes were noted in his physical exam from his initial evaluation. The resident physician discussed at length with B.C. the surgical options of lumbar decompression with posterior spinal instrumentation. After this discussion, B.C. stated he was not interested in surgical intervention and would like to continue nonsurgical treatments.
Continued care Interdisciplinary care continued with B.C. having an evaluation with the pain management clinic following the surgical consultation. At this visit, it was noted that he was using two NSAIDs for pain: ibuprofen 200 mg 4– 16 per day and naproxen 250 mg 4–8 per day. He denied any evidence of dark, tarry stools but did admit to intermittent heartburn that was relieved with use of an antacid. He had used a transcutaneous electrical nerve stimulation (TENS) unit at home with moderate benefit. He continued to deny any chiropractic manipulations or acupuncture. The pain clinic physician scheduled B.C. for an epidural steroid injection at the L5-S1 segment. Consideration for a left sacroiliac joint injection was also described. Recommendation of the pain clinic physician should B.C. fail injection therapy, was additional follow-up in the orthopedic spine clinic for surgical planning. B.C. was advised to decrease his NSAID and acetaminophen use. Continuance of home exercise program was encouraged. He was instructed to follow-up in the pain management clinic in 3 months. No further appointments in either clinic have occurred to date.
Conclusion As evidenced in this case study, NPs as primary care and specialty providers can evaluate patients with spondylolysis and spondylolisthesis. Through performance of appro-
priate history, physical, and diagnostics, appropriate diagnosis can be determined. Conservative treatment options can be discussed with patients and administered prior to referral to other specialty care. NPs are important providers in assisting patients with both psychosocial and biophysical management of their LBP. Through employment of psychosocial interventions, such as adaptive coping techniques, NPs can also assist patients with decreasing depression and avoiding disability. According to Heymans et al. (2010), interdisciplinary care that includes NPs in the management of LBP can help patients to better manage their conditions and avoid the development of chronic LBP. NPs can recommend continued independent home exercise programs to further decrease pain and increase patient functioning. In conclusion, through evaluation of patients with LBP, spondylolysis and spondylolisthesis are two common and confusing diagnoses encountered by many healthcare providers. Hence, it is important for NPs to differentiate between these two diagnoses. Based on the information in this case study, NPs can understand the importance of evaluation and diagnosis of spondylolysis and spondylolisthesis. With this information, NPs can better distinguish between these two diagnoses, order appropriate diagnostics, and perform appropriate conservative management treatments prior to referral to specialists for surgical evaluation.
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spondylolisthesis. European Spine Journal, 18(Suppl 1), S133–S142. doi:10.1007/s00586–009–0984-y Lim, C., Hee, H., & Liu, G. (2009). Traumatic spondylolisthesis of the lumbar spine: A report of three cases. Journal of Orthopaedic Surgery, 17(3), 361– 365. Meyerding, H.W. (1932). Spondylolisthesis. Surgical, Gynecology, & Obstetrics, 54, 371–377. Niggermann, P., Kuchta, J., Beyer, H., Grosskurth, D., Schulze, T., & Delank, K. (2011). Spondylolysis and spondylolisthesis: Prevalence of different forms of instability and clinical implications. Spine, 36(22), E1463–E1468. doi:10.1097/BRS.0b013e3181d47a0e
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Radcliff, K., Rihn, J., Hilibrand, A., Dilorio, T., Tosteson, T., Lurie, J., . . . Weinstein, J. (2011). Does the duration of symptoms in patients with spinal stenosis and degenerative spondylolisthesis affect outcomes? Spine, 36(25), 2197–2210. doi:10.1097/BRS.0b013e3182341edf Tsirikos, A., & Garrido, E. (2010, June). Spondylolysis and spondylolisthesis in children and adolescents. Journal of Bone & Joint Surgery [Br], 92-B(6), 751–759. doi:10.1302/0301–620X.92B6.23014 Watters, W., Bono, C., Gilbert, T., Kreiner, D., Mazanec, D., Shaffer, W., . . . Toton, J. (2009). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine Journal, 9, 609–614. doi:10.1016/j.spinee.2009.03.016
