DOUBLE DEGENERATIVE SPONDYLOLISTHESIS



Case History


A 53 year old female patient with bilateral low back pain and radiculopathy extending down the left leg to the great toe.


Radiographic Findings


Observe the bilateral sclerosis and hypertrophy of the facets at the L4/5 and L5/S1 levels. There is a minimal anterolisthesis of L4 upon L5 and a greater degree of anterolisthesis of L5 upon the sacrum without pars defects. This represents a pseudo or degenerative spondylolisthesis and is seen most frequently in female patients but certainly occurs in male patients.

Degenerative spondylolisthesis with an intact neural arch was referred to by Junghanns as pseudo spondylolisthesis differentiating it from those with a neural arch defect. Degenerative spondylolisthesis is approximately ten times more common at L4 than seen at the L3 or L5 vertebrae and no greater than 25% anterior displacement of the L4 vertebral body occurs, with the majority involving only 10 to 15% displacement. It is six times more common in females 60 years of age or older, compared with males of the same age. It is rare in persons under the age of 50. It is three times more common in African Americans than in White with no adequate explanation to these sexual and racial disparities. Finally, degenerative spondylolisthesis is four times more likely to be found in association with a sacralized fifth lumbar vertebrae.

There is a significant association of patients with degenerative spondylolisthesis most likely at the L4 level with spinal stenosis and/or back and leg pain. Most patients with degenerative spondylolisthesis do not have leg pain, they have pain primarily in the low back and maybe in the upper buttocks. Patients with leg pain extending below the knee who also have degenerative pseudo spondylolisthesis may have an associated giant synovial cyst compressing nerve roots within the spinal canal. Synovial cysts are a complication of advanced degenerative facet arthrosis and have been referred to as the “Baker’s cyst of the spine”. Any patient with degenerative spondylolisthesis who does not respond to conservative chiropractic treatment within a reasonable period of time and has symptoms of sciatica should have an MRI scan to rule out the possibility of a giant synovial cyst.


References


Schmorl, G and Junghanns, H., The Human Spine in Health and Disease, Ed. 2, New York, Grune and Stratton, 1971.

McNab, I, Spondylolisthesis with an Intact Neural Arch; so-called Pseudo-Spondylolisthesis, J. Bone. Joint. Surg (Br) 32; 325, 1950.

Yochum Tr, et al: Reactive Sclerosis of a Pedicle Due to Unilateral Spondylolysis-A Case Study ACA J Chiro, Radiology Corner, RC September 1980.

Yochum Tr, Yochum and Rowe, LJ, Essentials of Skeletal Radiology, Chapter 5 entitled The Natural History of Spondylolysis and Spondylolisthesis, 3rd ed, Lippincott, Williams and Wilkins, 2005.