Breaking ground on spondylolisthesis treatment and the prevalence of vertebral subluxation in a pediatric population
Spondylolisthesis is a vertebral subluxation that refers to a significant shift of one vertebral body on the vertebra below. Cervical spondylolisthesis (CS) creates a scissoring effect with the structural shift of one vertebra on another resulting in a narrowing of the spinal canal.1 CS is an indicator of cervical spine instability associated with cervical spine disc degeneration and joint damage. Spondylolisthesis is detected, analyzed, measured and monitored by X-ray analysis in regard to spondylolisthesis treatment. It is considered uncommon in the cervical spine when compared to the lumbar spine and is now being recognized as an under-studied condition.2
“Cervical spondylolisthesis prevalence has been reported as low as 5.2-12%, whereas that of lumbar spondylolisthesis is 15.8-19.7%. Thus, cervical spondylolisthesis has received less attention than lumbar spondylolisthesis.”3
“Patients with severe spondylolisthesis [have] unequivocal horizontal displacement of 3.5 mm or more, a criterion established by White, et al., as suggestive of instability in the cervical spine, whereas those with moderate spondylolisthesis [have] horizontal displacement of 2.0–3.4 mm.”4 White, et al., further conclude that “the spine is unstable or on the brink of instability [when] more than 3.5 mm horizontal displacement of one vertebra in relation to an adjacent vertebra, anteriorly or posteriorly, measured on a resting lateral roentgenograms of the spine.”5
“Spondylolisthesis may present with or without pain in children and adolescents. Like scoliosis and other unstable, degenerative structural spinal conditions, progression of spondylolisthesis occurs during the adolescent growth spurt.”6 Cervical spondylolisthesis results in not only cervical pain but also radiculopathy or myelopathy as it progresses and thus should never be neglected.
Spondylolisthesis treatment for a child includes observation, limitation of activities, exercises, bracing, casting, and surgery.6 Corrective chiropractic care involving chiropractic adjustments, exercises and traction have been shown to reduce cervical spondylolisthesis.1 Regardless, restoration of global sagittal balance of the spine and pelvic alignment is paramount in the treatment of any spinal deformity.7
Spondylolisthesis is an understudied condition in pediatric populations. There does not appear to be any epidemiology study reporting on CS in pediatric populations. A recent study published in the Journal of Radiology Case Reports and indexed in PubMed of the National Library of Medicine reported on the prevalence of CS in the sagittal plane in a pediatric population.8
CS study results
A total of 342 patients’ lateral cervical radiographs were analyzed. There were 184 females and 158 males from 4-17 years of age with a mean age of 12.3 years. Seventy-three of 342 radiographs revealed the presence of a CS greater than 2.0mm (21.3%) comprised of four anterolistheses and 101 retrolistheses (105 CS in total). The greatest number of pediatric patients with CS measuring greater than 2.0 mm were between 9-16 years of age with the greatest number of CS at 10, 14 and 16 years of age (Figure 4).
Within the 73 radiographs of pediatric patients with 105 CS greater than 2.0 mm, 31 patients (42.5%) reported musculoskeletal complaints. Forty-two patients (57.5%) reported no musculoskeletal complaints. Eight of 342 radiographs revealed the presence of a CS greater than 3.5 mm (2.3%) comprised of one anterolisthesis and nine retrolistheses (10 CS in total). The greatest number of pediatric patients with CS measuring greater than 3.5 mm were between 12-14 years of age, with the greatest number of CS at 12 years of age.
Within the eight radiographs of pediatric patients with 10 CS greater than 3.5 mm, three patients (37.5%) reported musculoskeletal complaints. Five patients (62.5%) reported no musculoskeletal complaints.
Spondylolisthesis treatment and the pediatric cervical spine
The developing anatomy of the cervical spine in children increases the risk of injury of the upper cervical spine. The biomechanics of the pediatric cervical spine has the fulcrum of motion at the C2-C3 level as opposed to C5-C6 in the adult cervical spine.
“The immature spine is hypermobile because of ligamentous laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of vertebral bodies, all of which contribute to high torque and shear forces acting on the C1-C2 region. Incomplete ossification of the odontoid process, a relatively large head, and weak neck muscles are other factors that predispose to instability of the pediatric cervical spine.”9 Younger children are more likely to sustain an upper cervical spine injury located from the occiput to C3. These injuries are also associated with a high risk of neurologic damage.9
Parents, guardians and caregivers often seek health care treatment options for their children due to the presence of symptoms such as pain, discomfort or abnormal posture. However, the reality is that children and adolescents are likely to endure any number of various forms of trauma.
Birth trauma,10 unintentional falls,11 sports-related trauma,12 motor vehicle crash trauma,13 play-related trauma,14 childhood violence,15 and other trauma risks are ever-present. A major problem is that many forms of childhood trauma are not reported and underestimated.16 In some cases, only children are witness to the trauma. In other cases, the appearance of a lack of physical damage or an absence of symptoms following a trauma results in a lack of physical examination for many children following a trauma. Also, children are very resilient, which may mask underlying risks and physical injuries that become evident later.
“To remedy spine-related problems, assessments of X-ray images are essential to determine the spine and postural parameters.”17 Further investigation into the sagittal spinal alignment of children and adolescents with or without symptoms may help to identify the precursors or presence of CS calling for spondylolisthesis treatment. Studying the prevalence of spinal deformity and vertebral subluxation, such as CS, in pediatric populations educates and informs parents, guardians, caregivers, health care providers and health care policymakers to help treat and prevent degenerative spinal conditions for children and adolescents.
Additional research required
At present, pediatric CS epidemiology does not seem to be represented in research. This cross-sectional study shows that vertebral subluxation in pediatric populations needs greater attention.
This study shows that CS, even to the point of spinal instability and including multiple spinal levels, is present in children and adolescents with and without the presence of symptoms. The data presented support further investigation into the sagittal spinal alignment of children and adolescents with or without symptoms to identify the precursors or presence of CS and subsequent spondylolisthesis tretament.
Future prospective studies involving larger populations, multiple locations, long-term follow-ups, and more anthropometric and clinical data will shed more light on the epidemiology of CS and the associated functional and symptomatic effects and pathologies.
Epidemiology is the foundation of public health and influences policy decisions and evidence-based health care by identifying risks for disease and goals for preventative health care. Epidemiology discovers the causes, distribution and prevention of health problems and crises. When populations experience the effects of ill health, epidemiology helps to find solutions. The Institute for Spinal Health and Performance (ISHP) is currently exploring further the epidemiology of vertebral subluxation in pediatric, adult and geriatric populations. More incredible research is on the horizon which will help to raise chiropractic standards and awareness in health care.
The ISHP acknowledges Chiropractic BioPhysics NonProfit for their support.
CURTIS FEDORCHUK, DC, is a founder of the Institute for Spinal Health and Performance, is a peer reviewer for various scientific journals, serves on the executive board of Chiropractic BioPhysics NonProfit and the Foundation for Vertebral Subluxation, and has received multiple awards for his research. He has published chiropractic and spinal research in various peer-reviewed journals, is indexed in PubMed and collaborates on research projects with prestigious institutions such as Emory University. He can be contacted at email@example.com.
DOUGLAS F. LIGHTSTONE, DC, is a founder of the Institute for Spinal Health and Performance, a peer reviewer for various scientific journals, has published chiropractic and spinal research in various peer-reviewed journals, is indexed in PubMed, and collaborates on research projects with prestigious institutions such as Emory University. He can be contacted at drlightstone.com.