Isthmic spondylolisthesis: chiropractor viewpoint
Chief complaint
Intermittent right lower extremity radiating pain exacerbated through walking 100 feet, standing extension and relieved with sitting/forward flexion.
Exam and imaging studies
Mild weakness in extending the right first digit. No signs of neural tension during SLR, and hip mobility is adequate. Plain film radiography and MRI scans show isthmic spondylolisthesis at L5-S1. Early degenerative disc disease with disc bulge and right foraminal stenosis at L4-L5 impinging the L5 nerve root.
Chiropractic treatment plan
Chiropractic management may begin with further radiographic studies. Flexion/extension and axial traction/compression radiographs will provide useful information on the stability of the L4-L5-S1 segments. If there is no evidence of instability, more aggressive chiropractic techniques can be utilized, including side posture manipulation.
Since a large majority of patients with spondylolisthesis have an associated hyperlordosis, facet syndrome and/or sacroiliac fixation, these conditions are often the cause of lower back pain rather than the spondylolisthesis. Specific chiropractic manipulation of the sacroiliac joints and the lumbar zygapophyseal joints (facet joints) above the segment with the pars defects can provide relief of pain often associated with this condition. Chiropractic manipulation of these joints may improve the biomechanical mobility of overloaded segments and thus reduce stress at the L5-S1 joint complex.
Flexion Distraction Chiropractic Manipulation may be used as treatment for the disc bulge and foraminal stenosis at L4-L5. This is a low force technique that helps improve mobility of the vertebral segments, flexibility of the annular fibers of the disc, mobility of the L5 nerve root within the IVF, decreasing the symptoms of stenosis.
A specific rehabilitation program should be developed for the patient. This program should address findings from the functional exam and improve deficits in flexibility, motor control and pain provoking movements.
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