Literature review
Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review

https://doi.org/10.1016/j.ptsp.2014.12.005Get rights and content

Highlights

  • Lumbar spondylolysis and spondylolisthesis are identifiable causes of LBP in athletes.

  • This paper is the first to systematically review clinical tests to diagnose lumbar spondylolysis and spondylolisthesis.

  • Fifteen clinical tests were retrieved that had been studied to diagnose lumbar spondylolisthesis and lumbar spondylolysis.

  • The one-legged hyperextension test demonstrated low to moderate sensitivity and low specificity to diagnose spondylolysis.

  • Lumbar spinous process palpation had high specificity and was the optimal diagnostic test for lumbar spondylolisthesis.

Abstract

The aim of this paper was to systematically review the diagnostic ability of clinical tests to detect lumbar spondylolysis and spondylolisthesis.

A systematic literature search of six databases, with no language restrictions, from 1950 to 2014 was concluded on February 1, 2014. Clinical tests were required to be compared against imaging reference standards and report, or allow computation, of common diagnostic values.

The systematic search yielded a total of 5164 articles with 57 retained for full-text examination, from which 4 met the full inclusion criteria for the review. Study heterogeneity precluded a meta-analysis of included studies. Fifteen different clinical tests were evaluated for their ability to diagnose lumbar spondylolisthesis and one test for its ability to diagnose lumbar spondylolysis. The one-legged hyperextension test demonstrated low to moderate sensitivity (50%–73%) and low specificity (17%–32%) to diagnose lumbar spondylolysis, while the lumbar spinous process palpation test was the optimal diagnostic test for lumbar spondylolisthesis; returning high specificity (87%–100%) and moderate to high sensitivity (60–88) values.

Lumbar spondylolysis and spondylolisthesis are identifiable causes of LBP in athletes. There appears to be utility to lumbar spinous process palpation for the diagnosis of lumbar spondylolisthesis, however the one-legged hyperextension test has virtually no value in diagnosing patients with spondylolysis.

Introduction

Lumbar spondylolysis and spondylolisthesis are established conditions in both adolescent and adult populations and an identifiable cause of low back pain (LBP) in athletes (Garet, Reiman, Mathers, & Sylvain, 2013). The prevalence of lumbar spondylolysis differs in the literature but has been estimated to be approximately 6–8% in the general population by some authors (Brooks et al., 2010, Wiltse and Rothman, 1989), and as high as 63% in those engaging in specific sporting activities (Rossi, 1988); while the reported incidence of spondylolisthesis is suggested to comprise between 2% and 6% of LBP populations (Magora, 1976, Osterman et al., 1993).

Spondylolysis is characterised by a defect in the pars interarticularis which is proposed to be either developmental or an acquired stress fracture secondary to chronic low-grade trauma or repetitive loading (Leone, Cianfoni, Cerase, Magarelli, & Bonomo, 2011) such as that can occur in sport. Over time, stress concentration and accumulation can lead to a physis stress fracture at the vertebral body diminishing the stabilising ability of the posterior elements in the spinal segment and can progress to an isthmic spondylolisthesis (Sairyo et al., 2006). A spondylolisthesis occurs when there is a bilateral pars interarticularis defect and is often hallmarked by a forward slip of the superior vertebrae on the inferior vertebrae (Cavalier et al., 2006, McNeely et al., 2003).

The Wiltse classification system (Wiltse, Newman, & Macnab, 1976) subdivides spondylolisthesis into five aetiological categories; isthmic, dysplastic, degenerative, traumatic, and pathological (Huijbregts, 2001). Of these categories, the degenerative form is the most prevalent with isthmic spondylolisthesis more common in individuals aged less than 50 years (Logroscino, Mazza, Aulisa, Pitta, Pola, & Aulisa, 2001). Whereas the majority of individuals with spondylolysis remain asymptomatic (Haun & Kettner, 2005), symptomatic cases may present with considerable morbidity and result in focal low back pain. Symptoms may radiate into the buttock or lower limb following incidental trauma or intense athletic activities; most often associated with repeated extension and/or rotation of the lumbar spine (Morita et al., 1994, Ralston, 1998, Standaert, 2002, Standaert and Herring, 2000).

Other classification systems for spondylolisthesis define the grade of severity, such as the commonly used Meyerding system (Ganju, 2002), which categorizes the degree of vertebral slip using static lateral radiographs. Similar approaches, such as the Boxall and Taillard method, use comparable slip assessment criteria (Boxall et al., 1979, Taillard, 1954). Each of these measures quantifies the severity of spondylolisthesis and each implies the potential presence of instability.

A recent systematic review assessed the accuracy of tests to diagnose lumbar instability and included tests utilised with both spondylolysis and spondylolisthesis (Alqarni, Schneiders, & Hendrick, 2011), however, these conditions do not always lead to lumbar structural instability and current evidence suggests that translational instability (structural instability) and spondylolisthesis represent differing and separate aetiologies (Axelsson et al., 2000, McGregor et al., 2002). Translational instability is defined as abnormal translation and/or rotation around the x-, y-, and z-axes of the three-dimensional coordinates of the spine (Panjabi & White, 1978). The reported cutoff values for vertebral translatory motion employed to diagnose the presence of translational instability (structural instability) also remain somewhat contentious and very between 3 and 5 mm in the literature (Hayes et al., 1989, Knutsson, 1944, Shaffer et al., 1990).

A variety of diagnostic imaging methods are used to identify the presence of spondylolysis, including plain-film imaging, computed tomography (CT), magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and bone scintigraphy. SPECT has demonstrated the greatest sensitivity of the measures with 10–12 times more contrast than bone scintigraphy (Harvey et al., 1998, Standaert and Herring, 2000). Further estimates of the incidence of spondylolysis in the general population range from 5.9% in the general population to 30% in select populations (Sakai, Sairyo, Suzue, Kosaka, & Yasui, 2010) with a reported prevalence of 11.5% in populations with CLBP (Leonid, Kim, Li, Guermazi, Berkin, & Hunter, 2009). Since imaging is an imperfect science, linking the symptom severity and the degree of anatomical or radiographic changes is challenging (Gibson & Waddell, 2005). We cannot yet therefore determine the link between the levels of morbidity and radiographic features.

Spondylolisthesis is diagnosed radiographically through bone scintigraphy, computed tomography (CT), magnetic resonance imaging (MRI), and lateral radiographs in order to demonstrate a pars interarticularis defect and establish the percentage of vertebral slippage in the absence of translation instability (Campbell et al., 2005, Standaert and Herring, 2000). The North American Spine Society Clinical Guidelines for Multidisciplinary Spine Care report (2008) designated lateral plain-film radiographs and MRI as the most effective tools for diagnosis of spondylolisthesis with stenosis, with CT-scan demonstrating effectiveness for patients in which MRI is contraindicated. However, as with diagnosis of other low back-related conditions, a high degree of false positives (imaging findings with poor correlation to clinical symptoms) are present (Lurie, 2005).

Clinical examination findings, including specific orthopaedic tests offer advantages as initial diagnostic indicators as they may expedite diagnosis and guide initial management, while limiting the exposure of patients to the associated risks and further costs of radiology (Alqarni et al., 2011). At present, there are few pre-clinical indications that are specific to degenerative and asymptomatic lumbar spondylolisthesis, whereas patients who are symptomatic complain primarily of radiculopathy or neurogenic intermittent claudication with or without concomitant back pain. While seminal signs and symptoms that are suggested to be associated with spondylolysis and spondylolisthesis have been described in the literature (Barash, Galante, Lambert, & Ray, 1970), it is important to note that these are not unique to spondylolysis and spondylolisthesis and therefore the clinical diagnosis of these conditions based on these signs and symptoms currently remains challenging.

To our knowledge there have been no systematic reviews to date that have investigated the accuracy of clinical tests to diagnose spondylolysis and spondylolisthesis. Therefore, the aim of this paper was to systematically search and review the literature relating to clinical tests specifically for the detection of spondylolysis and spondylolisthesis in order to establish which tests have the best accuracy and utility to diagnose these conditions. We planned to qualitatively report the diagnostic accuracy of the clinical tests and describe the risk of bias of each included study.

Section snippets

Study design

This systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines throughout the research and reporting process (Moher, Liberati, Tetzlaff, & Altman, 2009). The study was exempt from Human Ethics Committee review.

Type of studies

Prospective and retrospective case control and case-based study designs were included in this review.

Type of participants

For inclusion, at least one group of participants in the studies was required to have been diagnosed with either spondylolisthesis

Study selection results

A total of 5164 articles resulted from the initial systematic literature search. After title screening, 42 articles were selected for possible inclusion in the review and after full text examination (Fig. 1), 4 articles fulfilled all eligibility criteria.

Study characteristics

Two studies (Collaer et al., 2006, Kalpakcioglu et al., 2009) used lateral radiographs as the reference standard for the differential diagnosis of a spondylolisthesis and two studies (Gregg et al., 2009, Masci et al., 2006) used MRI and SPECT

Discussion

The goals of this study were to investigate the diagnostic accuracy of clinical tests to detect spondylolysis and spondylolisthesis. We evaluated studies that investigated the clinical test's diagnostic ability when compared to imaging reference standards of bone scintigraphy (SPECT), computed tomography (CT), magnetic resonance imaging (MRI), and lateral radiographs which are capable of demonstrating the presence of a pars interarticularis defect or establishing the percentage of vertebra

Conclusion

Spondylolysis and spondylolisthesis has a high prevalence in sporting and athletic populations. This is the first systematic review to evaluate the accuracy of clinical tests to diagnose patients with lumbar spondylolysis and spondylolisthesis that used reference standard mechanisms that were not associated with translational instability. There appears to be utility to lumbar spinous process palpation for the diagnosis of lumbar spondylolisthesis, however the one-legged hyperextension test has

Conflict of interest

Dr. A.G Schneiders, the second and corresponding author, is an associate editor of the journal, Physical Therapy in Sport.

Source of support

None declared.

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