Case report
Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report

https://doi.org/10.1016/j.jcm.2009.04.003Get rights and content

Abstract

Objective

This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic.

Clinical Features

The 43-year–old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis.

Intervention and Outcome

A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire.

Conclusions

Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

Introduction

Although lumbar spondylolysis is generally attributed to repetitive stress imposed by physical activity resulting in fatigue fracture of the pars interarticularis,1, 2 the etiology is likely multifactorial with elements of both inherited predisposition and repetitive trauma.3, 4, 5 One study of elite athletes found a higher prevalence of lumbar spondylolysis in sports that involve elements of lumbar hyperextension, rotation, and/or torsion against resistance.6 The prevalence of lumbar spondylolysis in the general population is estimated to be between 3% and 11.5% with a male-female ratio as high as 3:1.7, 8, 9, 10, 11, 12, 13, 14 An estimated 90% of pars defects occur at L5, and most defects at L5 are bilateral.15 According to Ravichandran,16 spondylolysis of more than 1 vertebral level in the same individual is rare, with a prevalence of multiple-level lumbar spondylolysis in the general population estimated at between 0.2% and 2.8% and with a higher prevalence among Alaskan natives estimated at 5.6%.7, 16, 17, 18

There is a paucity of literature regarding the prevalence of multiple-level lumbar spondylolysis with spondylolisthesis among military and/or veteran patient populations. A single report of 6 cases out of Taiwan between 1992 and 1998 of bilateral multiple-level lumbar spondylolysis involving Republic of China Army personnel (4 infantry and 2 from an armored unit) was published in 2001.19 Each of the Republic of China Army personnel involved denied a specific history of traumatic injury during their military service, but took part in physically demanding training including a 500-m obstacle course and long-distance marches with a full pack, which were considered to be precipitating factors.19 Surgical intervention was successfully carried out in each of the 6 cases after a minimum of 6 months of failed conservative management including bed rest, medication, bracing, or rehabilitation.19

The purpose of this report is to present a case of evaluation and conservative management of mechanical low back pain (LBP) secondary to multilevel lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran treated at the chiropractic clinic at the VA of Western New York. A review of the literature pertaining to lumbar spondylolysis and spondylolisthesis among military personnel is provided.

Section snippets

Case report

A 43-year–old United States Marine Corps veteran was referred by his primary care physician to the chiropractic clinic with chronic LBP, dull in quality, rated 4/10 on a numeric rating scale upon presentation. The patient described a history of intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. The veteran patient described an over 20-year history of LBP extending back to a fall he sustained off of an amphibious vehicle during the second of

Discussion

Although many of the studies and case reports among military personnel with spondylolysis involve parachutists, reports have also been published involving nonparachutist military personnel from the Republic of China Army,19 the Israeli Defense Forces,22, 23 the United States Army Green Berets,24 and the British Army.25 As the most commonly suspected etiologic component of spondylolysis is stress (fatigue) fracture of the pars interarticularis,1 the relationship between spondylolysis and

Conclusion

A review of the literature identified a variety of studies and case reports of lumbar spondylolysis with and without spondylolisthesis in military populations, with only 1 case series reflective of involvement at multiple levels. The case presented in this report represents a unique presentation of multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran. As with certain types of athletes, military personnel involved in parachuting and related physical

Acknowledgment

This work was conducted at and supported by the VA of Western New York Healthcare System. The authors would like to thank Dr John Taylor and Carol Simolo for their contributions to this manuscript.

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