1. Spondylolysis and Spondylolisthesis

2. Normal Anatomy Pars interarticularis – Part of vertebra between inferior and superior articular process of the facet joint

3. Pathophysiology Spondylolysis – A fracture in the pars articularis – Usually a fatigue fracture Spondylolisthesis – A displacement of one vertebrae over another – Usually L5 anteriorly – Although can be any level and any direction – Usually occurs due to spondylolysis

4. Classification

5. Spondylolisthesis: Classification Grade 1: 0-25% vertebral slippage Grade 2: 25-50% vertebral slippage Grade 3: 50-75% vertebral slippage Grade 4: 75-100% vertebral slippage Grade 5: Complete slippage of the vertebral disc.

6. Mechanism of Injury Insidious – Isthmic Repeated microtrauma usually into extension – Wrestling – Weightlifting – Gymnastics – Dancing – Carrying a heavy back pack – Athletics – Degenerative Intervertebral disc degenerates changing joint orientation Period of instability Can cause excessive motion of the segment Causing tipping or compression of vertebrae Insidious – Pathological Weakening of posterior elements e.g metastasis – Dysplastic Congenital genetics – common in spina bifida occulta Traumatic – Hyperflexion with compression and rotation – Hyperextension

7. Associated Pathologies Spondylolisthesis Spondylolysis Degenerative Disc Disease Stenosis Spina Bifida Occulta

8. Pathophysiology Continued excessive mechanical stress (or trauma/pathology/congenital) on the posterior elements of the vertebra Causes fracture in weakest part of vertebra (pars) (Spondylolysis) Shear forces throughout the vertebral column can result in displacement (Spondylolisthesis)

9. Subjective Most commonly aged 10 – 15, Female > Male History of mechanical stress into extension – Gymnastics, dancing, athletics, weightlifting, diving Localised paraspinal pain Pain with prolonged standing and hyperextension Pain on compression +/- Radiculopathy if neural compression Leg symptoms may switch sides if central neural compression

10. Objective Hyperlordotic Pain extremes ROM Extension and Rotation Hypermobile and Vertebral Hinging Step Deformity Tight hamstrings (80%)

11. Special Tests One Legged hyperextension manoeuvre

12. Further Investigation Standing lateral oblique X ray (Scotty Dog with Collar) CT and MRI to rule out other pathologies

13. Further Investigation Standing lateral oblique X ray (Scotty Dog with Collar) CT and MRI to rule out other pathologies

14. General Management Activity modification avoiding positions of extension Manual Therapy for pain relief ONLY Treat instability Refer if neurological symptoms present without prior investigations or worsening of neurological symptoms with previous investigations

15. Conservative - Management Pain Relief – Massage, NSAID’s, Ice, Activity Modification Restore Normal Mobility – Hamstrings, Hip Extension, upper lumber and thoracic extension Restore Normal Motor Control – Anterior Core (Anti Extension) Dead Bug Over Head Pallof Press etc – Glutes, Anti Rotational Core Restore Dynamic Stability Return to Sport Specific

16. Plan B - Management Epidural steroid injection if radiculopathy is present Surgical after 6 months of conservative treatment – Decompressive lumbar laminectomy in posterior fusion