(A) Diagram of spondylolisthesis of L5 over S1 caused by spondylolysis of L5. (B) Oblique plain film of the lumbar spine demonstrates a spondylolysis or pars defect on the right side at L5 (arrows). Note the intact pars at L4 (*). (C) CT bone window of a different patient shows spondylolysis defects (arrows). Although these resemble facet joints, they are more horizontal in orientation and more irregular, lacking a smooth cortical margin. (From Chen MYM, Pope TL, Ott DL. Basic Radiology. 2nd ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
PREFERRED PRACTICE PATTERN
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
A 49-year-old man employed as a high school gym teacher and coach reports a long 15+ year history of generalized lumbosacral ache, which has been getting steadily worse over the past year. Lately, this has interfered with his job since the jarring motions associated with sports increase his symptoms. He recalls falling from a 12-foot wall and landing on his buttocks when he was a teenager and also recalls several sporting injuries. He recalls returning to normal activity within 6 weeks of the fall.
Up until his early 30s, he did not experience any significant back pain; however, after age 35 years, there was a steady increase in periodic low back pain. Presently, he has pain every day, which starts as a stiff ache every morning. Getting out of bed is difficult, and he must log roll to his side to get up from supine. After a hot shower and some simple exercises, he is able to move better. Coughing and jarring movements are painful. Walking is relatively pain free on level surfaces, but painful on hills and stairs. Sitting and lying relieve pain. Getting in and out of the car is difficult and many work postures, especially bending forward aggravate the pain and you must often support yourself by leaning on an arm. The pain has not radiated into the lower extremity and is confined to the low back and buttocks. There is tenderness at L4 and L5 spinous processes, with palpable step.
Lateral lumbar spine X-ray demonstrates a 25% anterior slippage of L4 on L5 due to a defect in the L4 pars interarticularis. This is called spondylolisthesis. (From Brunicardi FC, Andersen D, Billiar T, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)