Spondylolisthesis

A 7-year-old boy presented with a request for an excuse from gym class. The parents reported that he had experienced back pain 6 months earlier, for which he saw a chiropractor. After several adjustments, he awoke one morning with difficulty moving his right leg.

The chiropractor referred the child to physical therapy, which he underwent 2 to 3 times weekly for 6 months. His leg flexibility improved but did not return to normal. He had difficulty walking and keeping up with classmates in gym class. His gym teacher wanted to accommodate the boy but needed a physician’s excuse to legally excuse him.

The child had no history of illness, surgery, or trauma. Musculoskeletal examination revealed hips that were very tight and resistant to flexion. He could flex his knees to only about 45°. Upon standing, the boy leaned forward, and his knees were in flexion because his hamstrings were tight. He walked on his toes.

Neurologic examination revealed mild bilateral nystagmus, intact cranial nerves, and deep tendon reflexes present equally in both knees and ankles.

Brain and lumbar spine computed tomography (CT) and magnetic resonance imaging (MRI) scans were obtained. The results of the brain scans were normal, but the lumbar CT (A) and MRI (B) scans revealed spinal stenosis and a bulging herniated disk at L5-S1 with grade 2 spondylolisthesis at the same level. The boy was referred to a pediatric orthopedic spine specialist; 2 weeks later, surgery was performed for reduction of the herniated disk and fusion of the L5-S1 joint.

It is estimated that 20% to 25% of pediatric cases of the condition are grade 2 spondylolisthesis.² The majority of cases of spondylolisthesis are congenital and asymptomatic.¹ However, the prevalence of symptomatic cases is unknown and merits further study.

The Centers for Disease Control and Prevention reported in 2007 that 2.8% of children in the United States had used chiropractic manipulation in the past 12 months.³ A review of the literature by Gouveia and colleagues⁴ concluded that there are not enough data concerning the incidence or prevalence of adverse events related to chiropractic interventions.

Although we cannot prove causation in this case, the timing of the patient’s symptoms highly suggests that spinal manipulation caused or aggravated his disk herniation. Were it not for the school’s policy on gym accommodation requiring a physician’s note, this patient’s condition may not have been detected.