A Non-Surgical Approach for Correction of Double-Retrolisthesis of the Lower Lumbar Spine and a Single Cervical Spine Retrolisthesis: A Case Report
Retrolistheses of L2 on L3 and L3 on L4 with congential sacralisation of L5 on S1. Retrolisthesis of C3 on C4.
55-year old male with a fifteen-year history of chronic low back pain following a road traffic collision. The patient was referred to us after failing 15 years of manual therapies including osteopathy and sports therapy.
Upon his presentation at the clinic, the patient scored 40/100 on the Oswestry Low Back Pain Disability Questionnaire (Revised) and 59/150 on the Pain Disability Questionnaire (specifically, 3/60 psychological and 56/90 on functional rating). Physical examination revealed reduced lumbar spine range of motion in extension and lateral flexion bilaterally with pain during active motion. Pain on palpation of the L5 spinal segment on the left-side. Muscle spasm of the lumbar erector spinae muscles bilaterally, gluteus maximus and piriformis on the left-side. Reduced active and passive range of motion of the patients’ cervical spine in extension and rotation bilaterally was noted with pain on palpation of the C2-3 spinal segments on the right-side, and C3-4 on the left-side. The patients’ vital signs showed grade 3 hypertension measuring 183/131mm Hg[1–3], his pulse was 84 beats per minute (BPM), O2 saturation was 98%, body temperature was 37.4C and his deep tendon reflexes were +2 and symmetrical bilaterally.
The current case report presents the successful outcomes of a 55-year-old male who followed CBP® protocols for his chronic low back pain. This case demonstrates how the treatment interventions had positive effects on his pain, disability, physical, social and psychological functioning. It also showed the positive improvements in the structural alignment of his cervical and lumbar spine regions. Of note, the alignment of the lumbar segments improved dramatically and shows restoration of stability of the lumbar spine. However, the ARA of the lumbar spine improved by only 1.2% (from -49.9 to -49.3). This lack of improvement is likely to be the combined result of the patients’ pelvic morphology and the sacralisation of the L5 segment. The pelvic incidence (PI) and Posterior Tangent Pelvic Incidence Angle (PTPIA) are both high meeting the criteria of a Type 4 classification (high grade PI) and therefore hyper-lordosis would expected to be normal with this configuration. Another worthwhile area of discussion is the aetiology of retrolisthesis and adjacent segmental disease (ASD). It was hypothesised in this case that the retrolisthesis of the lumbar segments may have been secondary to the congenital sacralisation of the L5/S1 complex, thus resulting in adjacent segmental disease and buckling of the column. However, the true nature of this phenomenon is still unknown, it has been suggested that adjacent segmental disease can result from “any factor that changes normal loading at the adjacent level may have an influence on the development of ASD” . There is significant research relating adjacent segmental disease as a post-surgical complication following fusion, regardless of surgical method[45–50]. Paraspinal muscle damage, either traumatic or iatrogenic and altered biomechanics have been suggested as possible mechanisms of ASD. Therefore, the presence of sacralisation in this case may play a contributory role but without additional evidence from the literature, this will remain hypothetical.
The use of spinal manipulative therapy, combined with exercises and spinal traction resulted in the none-surgical correction of retrolistheses of both cervical and lumbar spine segments. These outcomes resulted in significant physical, psychological, social functioning of the patient and a dramatic reduction in his blood pressure. Thus reducing his risk of morbidity and mortality related issues with grade 3 hypertension.