Journal of Contemporary JCC Chiropractic Oakley and Harrison Correction of Retrolisthesis CORRECTION OF MULTILEVEL LUMBAR RETROLISTHESES BY NON-SURGICAL EXTENSION TRACTION PROCEDURES IN A PATIENT WITH CONGENITAL FUSION OF L5-S1: A CBP® CASE REPORT WITH A 13-MONTH FOLLOW-UP Paul A. Oakley1, Deed E. Harrison2 ABSTRACT posterior displacement of the superior vertebra in a functional spinal unit. The incidence of spondylolisthesis Objective: To discuss the correction of multiple in the general population is about 5-7%. (1) retrolistheses in a patient with back pain. There are many causes of spondylolisthesis, including Clinical Features: A 32-year old male sought care for congenital, degenerative, traumatic, pathologic, recurrent back pain. He had reduced lumbar spine range iatrogenic, and isthmic. The last refers to a defect of the of motion without neurologic involvement. Radiographic pars interarticularis, which then results in an anterior analysis showed multilevel pathologic retrolistheses translation subluxation over time (anterolisthesis), from L1-2 to L4-5, as well as congenital fusion of L5-S1. and most commonly occurs at L5-S1 followed by L4- 5. (2) Although most research has been conducted on Intervention and Outcome: The treatment consisted anterolisthesis, (3) spondylolisthesis subluxations in of lumbar extension traction and spinal manipulation. general are associated with back pain, central canal Following treatment, the patient experienced significant stenosis, and lateral recess or foraminal stenosis. (2) back pain relief and increased flexibility. Follow- up lumbar radiography illustrated reduction of all The quantification of spondylolisthesis is best made retrolistheses to within normal. A 13-month follow- from the lateral lumbar radiograph, using George’s up demonstrated stability of the initial multi-level line (1) or posterior tangent lines, (3) which are lines retrolisthesis subluxation corrections and the patient drawn along the posterior vertebral body margins of experienced no further pain. the affected and inferior segment. Although the ideal alignment is no translation offset (0mm), a translation Conclusion: This case illustrates that early lumbar spine offset measurement of 4.5mm or greater is considered (grade 1) retrolistheses are amenable to correction pathologic in the neutral position in the lumbar spine. via non-surgical means. This is the second case in the (4) literature showing spinal traction successfully reducing spondylolisthesis. (J Contemporary Chiropr 2020;3:137-142) Typical treatment for spondylolisthesis includes surgery when there is neurologic involvement. Non-surgical Key Indexing Terms: Spondylolisthesis; Lumbar Traction; treatment of spondylolisthesis includes pharmacological Low Back Pain intervention, activity modification and/or physiotherapy INTRODUCTION exercises for symptomatic patients (5) as well as spinal manipulation. Non-surgical structural correction Spondylolisthesis is the general term for the displacement of spondylolisthesis is virtually non-existent, and (in any direction) of a vertebra in relation to the segment specifically for retrolisthesis there is no effective non- immediately below; a retrolisthesis is specifically the surgical treatments. The only literature we could locate was a single case report by Fedorchuk et al. (6) who reported the correction of a grade 2, L4-5 anterolisthesis. 1 Private Practice, Newmarket, Ontario Canada An initial 13.3mm anterolisthesis was reduced to 2 CBP NonProfit, Inc. Eagle, ID J Contemp Chiropr 2020, Volume 3 137 Oakley and Harrison Correction of Retrolisthesis 2.4mm after 60 treatments over a period of 45 weeks by to increase lumbar lordosis in several clinical trials; (18- Chiropractic BioPhysics(R) (CBP(R)) traction methods as 22) more specifically, they have been shown to reduce well as spinal manipulation and exercises. spondylolisthesis (6). Lumbar spinal manipulation as well as mechanical massage laying supine on a PowerPlate The purpose of this case is to describe the reduction of whole-body vibration platform (23) (Performance Health multiple retrolistheses and increase in lumbar lordosis in Systems, Northbrook, IL, USA) was also performed to a male with back pain. provide pain relief. Treatments were given at a frequency of approximately 3 times per week for the duration of care. CASE REPORT An approximate 1-year follow-up was also performed. A 32-year-old male had mild, recurrent low back pain Results (LBP) as well as middle back and neck pain. The pains were aggravated after sitting too long or by bending The patient was re-assessed and reported all pain to be forward. On average, the pains were scored a 6-7/10 on a significantly reduced; the LBP was completely resolved numerical pain rating scale (NPRS: 0=no pain, 10=worst even after prolonged sitting and forward bending. pain ever), and an 8/10 when at its worst, reported to be There was an increase in overall cervical and lumbar at the end of the day. The patient scored a 34% on the flexibility to within normal limits. Score on the ODI was Oswestry Low Back Pain Disability Questionnaire [ODI 14%. Radiographic assessment showed a reduction of (7)]. The patient had not experienced previous spinal retrolisthesis subluxations, the T12-L1 reduced to 1.6mm trauma or injury. (vs. 2.3mm), L1-2 reduced to 1.4mm (vs. 4.5mm), L2-3 reduced to 3.4mm (vs. 5.9mm), L3-4 reduced to 3.0mm Range of motion assessment showed generalized, mild (vs. 5.2mm), and L4-5 reduced to 3.4mm (vs. 4.7mm). limitation for the lumbar and cervical areas. Palpation The overall lumbar lordosis remained stable (-49.6° vs. demonstrated tightness along the paraspinal muscles - 47.1°). bilaterally, in the lumbar and cervical spinal areas. Other orthopedic tests were normal or unremarkable; there was A 13-month follow-up assessment was performed. During no neurologic involvement. the 1-year time frame, the patient received infrequent ‘maintenance’ treatment sessions, approximately twice Radiographic assessment was performed and images per month, but had not been in for treatment 3 months were analyzed using the PostureRay system (PostureCo., prior to this assessment. He stated that he was well and Inc., Trinity, FL, USA). This system uses the Harrison the original neck and back pains were relatively stable, posterior tangent (HPT) method to measure the sagittal being minimal with only a mild stiffness noted after plane images. The HPT method incorporates lines drawn prolonged sitting. ROM for cervical and lumbar spine contiguous with the posterior vertebral body margins, was normal. Score on the ODI was 0%. Radiographic enabling quantification of intersegmental relative rotation angles (RRAs) at each vertebral level, an overall regional lordosis (i.e. L1-L5) or absolute rotation angle (ARA), as well as intersegmental translation values (i.e. for the measurement of spondylolisthesis). This method has been shown to be repeatable and reliable (8,9) as has standing posture. (10) The notable findings in the lumbar spine included a congenital fusion of L5-S1 (Figure 1). There was an increased lumbar lordosis L1-L5 ARA of 47.1° (vs. 40° normal (11,12)) as well as multilevel retrolisthesis subluxations at every level from T12-L1 to L4-5 (Table 1). Notably, pathologic measures of retrolisthesis (i.e. ≧4.5mm (4)) involved L1-2 (4.5mm), L2-3 (5.9mm), L3-4 (5.2mm), and L4-5 (4.7mm) intervertebral joints. Intervention and Outcome Figure 1. Lateral lumbar radiographs. Left: Initial (June 4, Treatment was aimed at increasing the lumbar lordosis by 2018) showing congenital fusion of L5-S1, as well as multilevel retrolisthesis subluxations from T12-L1 to L4-5; Middle: Post- using CBP technique protocol. (13-15) Lumbar extension treatment (Sept 19, 2018) showing dramatic reduction of all traction was performed for the purpose of reducing the retrolistheses; Right: 16-month follow-up (Oct 17, 2019) shows multilevel retrolistheses. Extension traction stretches the the maintenance of the multi-level retrolisthesis subluxation ligamentous tissues causing creep relaxation and plastic corrections. All images were performed standing in the ‘thumb- deformation. (16,17) These methods have been shown to-clavical’ position. 138 J Contemp Chiropr 2020, Volume 3 Oakley and Harrison Correction of Retrolisthesis Table 1. Intersegmental translation values at the initial, becoming irreversible.” (26) This is precise mechanism 3.5-month post-treatment, and 13-month follow-up. for the development of degenerative joint disease. Thus, *L5-S1 has congenital fusion, any difference in measurement reducing mild or early spondylolisthesis may help in due to standard error of measurement. early treatment to prevent LBP and future degenerative processes in those affected. In fact, evidence suggests Segments Initial 3.5 Month 1 Year that it may be more feasible to achieve better long-term T12-L1 -2.3mm -1.6mm -0.6mm success by providing early (and effective) treatment for L1-L2 -4.5mm -1.4mm -2.1mm spinal subluxation when diagnosed in younger patients L2-L3 -5.9mm -3.4mm -2.4mm and/or when the deformities are less severe, as logically, L3-L4 -5.2mm -3.0mm -2.5mm over time, these spinal conditions will worsen. (31-35) L4-L5 -4.7mm -3.4mm -4.1mm Since spondylolisthesis is a cause of back pain and L5-L1* -0.3mm -0.4mm -0.1mm arthritis, and since it can only be diagnosed via radiography, radiology is indicated when it is suspected. (34-38) The challenge is, of course, that it is rarely assessment revealed that the lumbar spine had remained suspected,