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
Andrew S. Dunn DC, MEd, MSa,b,⁎, Shayne Baylisc, Danielle Ryanc
aStaff Chiropractor, VA of Western New York, Buffalo, NY 14215
bAdjunct Assistant Professor, New York Chiropractic College, Buffalo, NY 14215
cStudent, New York Chiropractic College, Buffalo, NY 14215
Received 19 February 2009; received in revised form 9 April 2009; accepted 16 April 2009
Key indexing terms:
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
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/
⁎Corresponding author. 3495 Bailey Ave, Buffalo, NY 14215, USA. Tel.: +1 716 807 8168; fax: +1 716 862 7248.
E-mail address: firstname.lastname@example.org (A. S. Dunn).
1556-3707/$ – see front matter © 2009 National University of Health Sciences.
Journal of Chiropractic Medicine (2009) 8, 125–130
distraction may serve as a safe and effective component of conservative management of
mechanical low back pain for some patients with spondylolysis and spondylolisthesis.
© 2009 National University of Health Sciences.
Although lumbar spondylolysis is generally attrib-
uted to repetitive stress imposed by physical activity
resulting in fatigue fracture of the pars interarticu-
laris,1,2the etiology is likely multifactorial with
elements of both inherited predisposition and repetitive
trauma.3-5One 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.6The 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 3:1.7-14An estimated 90% of
pars defects occur at L5, and most defects at L5 are
bilateral.15According to Ravichandran,16spondyloly-
sis 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%.7,16-18
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-
Armypersonnel (4infantry and2from anarmored unit)
was published in 2001.19Each of the Republic of China
Army personnel involved denied a specific history of
traumatic injury during their military service, but took
obstacle course and long-distance marches with a full
pack, which were considered to be precipitating
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 mechan-
ical 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 spondy-
lolysis and spondylolisthesis among military personnel
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 his 4 years as an active-duty
Marine. He denied a history of parachuting, but was
active with the physical nature of his military work and
training. The patient reported that restful sleep had at
times been impacted by his LBP. He denied bowel or
bladder dysfunction. He denied increased LBP with
cough, sneeze, or strain.
As a self-reported outcome measure, his baseline
Revised Oswestry Low Back Pain Disability Ques-
tionnaire score was 36/100.20The patient had a body
mass index of 28 kg/m2and reported strict adherence to
regular exercise while taking part in physically
demanding work and splitting wood. Active lumbar
ranges of motion were within normal limits and
nonprovocative.21Physical examination revealed that
the neurovascular integrity of the bilateral lower
extremities was maintained, as distal pulses at the
posterior tibial arteries were 2/4, motor strength rated 5/
5 for L1 through S1, sensation was intact to pinwheel
L1 through S1, and deep tendon reflexes rated 2/5 for
L4 through S1. Straight leg raise was negative to 90°
bilaterally. Orthopedic testing was largely nonprovo-
cative except for seated axial loading with lateral
bending and rotation that produced localized right-
sided LBP without radiation. Soft tissue hypertonicity
was localized to the right quadratus lumborum, with
passive end range extension loading at the lumbosacral
junction proving provocative.
Radiographs of the lumbosacral region demonstrated
a grade I spondylolisthesis of L3 in relation to L4 and a
126A. S. Dunn et al.
grade II spondylolisthesis of L4 in relation to L5
secondary to bilateral pars interarticularis defects
(Fig 1). There was marked narrowing of the L4-5
disk space with associated subchondral sclerosis. A
computed tomographic scan was ordered for further
evaluation but not obtained by the patient.
Management consisted of prone lumbar flexion/
distraction (FD) with a focus on myofascial release
directed at the right quadratus lumborum. Activity
modifications were prescribed including avoidance of
overhead activities and lumbar extension movements.
Additional exercises specific to the core were not
prescribed because the patient already adhered to an
exercise regimen inclusive of abdominal strengthening.
During the course of care, the patient provided a
subjective report of an increase in his activity level
without an associated increase in back pain severity.
After a course of care consisting of 10 treatments over
an 8-week period, LBP severity was reduced to 3/10;
and there was a 22% reduction in perceived disability
related to LBP according to a discharge Revised
Oswestry Low Back Pain Disability Questionnaire
score of 28/100. Owing to the decreased severity of
symptoms, improvement in the disability index, and
strict utilization management practices secondary to
limitations in available appointments within this clinic,
need for episodic follow-up for pain management as
appropriate and as resources allow.
Although many of the studies and case reports
among military personnel with spondylolysis involve
parachutists, reports have also been published invol-
ving nonparachutist military personnel from the
Republic of China Army,19the Israeli Defense
Forces,22,23the United States Army Green Berets,24
and the British Army.25As the most commonly
suspected etiologic component of spondylolysis is
stress (fatigue) fracture of the pars interarticularis,1the
relationship between spondylolysis and military para-
chutists is supported by the repetitive heavy axial
compression and twisting of the spine associated with
landing.26,27In a radiographic study of the lumbar
spine in military parachuting instructors (N = 74)
having performed an average of 410 jumps, Bar-Dayan
et al28concluded that parachuting predisposes to
spondylolysis and to degenerative changes of the
lumbar spine. The authors also concluded that
degenerative changes of the lumbar spine were
correlated with age and the number of jumps and that
the prevalence of spondylolysis among the sample of
parachuting instructors was 13.6%.28Furthermore, the
severity of the radiographic changes was not correlated
with either the prevalence or the severity of LBP within
this sample of parachuting instructors.28
A rare case presentation of unilateral spondylolysis
with contralateral lumbar pediculolysis at L5 was
reported in a 34-year–old military parachutist with
greater than 300 jumps over a 5-year period.29The
patient was managed with posterior interbody fusion
using carbon cages packed with iliac bone graft and
posterior transpedicular screw fixation at L5-S1. A
more common expression of this spinal condition was
presented as a collection of 3 case reports of military
parachutists with bilateral pars defects at L5 with
With regard to management for chronic spondylo-
lysis and spondylolisthesis, recommended approaches
vary from conservative management to surgical inter-
vention. Conservative management generally consists
initially of activity restriction or modification with a
graded increase in activity along with therapeutic
exercises including low-impact aerobic conditioning
and core stabilization.31Although most patients with
lumbar spondylolysis and/or spondylolisthesis respond
to conservative measures,32surgical management is
spondylolisthesis at L3 and a grade II spondylolisthesis
Spondylolysis evident at L3 and L4 with a grade I
127 Multiple-level spondylolysis in a veteran
generally indicated in patients with greater than grade
II spondylolisthesis or persistent LBP or neurologic
symptoms despite an adequate course of nonoperative
treatment.3In a recent nonmilitary report of surgical
outcomes with 5 cases of 2-level lumbar spondylo-
lysis and 2 cases of 3-level lumbar spondylolysis that
had failed conservative management, segmental wire
fixation and bone grafting were shown to be an
effective form of management for multiple-level
A review of the literature revealed only a limited
number of case reports that address chiropractic
management for lumbar spondylolysis,34-36with only
1 case report involving multiple-level lumbar spondy-
lolytic spondylolisthesis.3Spinal manipulative therapy
(SMT) directed above or below the involved spinal
region has demonstrated short-term effectiveness for
patients with lumbar spondylolysis in reducing chronic
LBP.37In the current presentation of a case of multiple-
level lumbar spondylolysis, FD was used in favor of
SMT to avoid direct manipulation of the spondylolytic
segments and the potential risk of aggravation.37
Flexion/distraction is a commonly used manual traction
procedure that is both slow and controlled, which varies
from traditional high-velocity, low-amplitude SMT.38It
is estimated that 58% of chiropractors in the United
States use FD for the management of LBP.39In a
randomized clinical trial, subjects who received FD had
significantly greater relief of chronic LBP than subjects
who received an active trunk exercise protocol, with
sustained findings at 1-year follow-up.40,41
Many cases of spondylolysis and spondylolisthesis
occur in asymptomatic patients without associated pain
or disability.9,10,12In a study by Belfi et al,42computed
tomographic scans were performed on 510 consecutive
patients for conditions unrelated to lumbar pathology,
demonstrating a 5.7% prevalence of spondylolysis and
a 3.1% prevalence of spondylolisthesis in asympto-
matic patients. Although the exact etiology of LBP in
patients with symptomatic spondylolysis and spondy-
lolisthesis remains unclear, histologic studies have
demonstrated that neural elements of the pars defect are
capable of nociceptive function and may be a source of
LBP.43,44As innervated structures within the motion
segment and associated tissues are possible pain
generators, multifactorial causes of LBP in patients
with spondylolysis and spondylolisthesis have been
The mechanisms of LBP relief with FD are theorized
to be both mechanical and neurologic in nature.46In
addition to the mechanical effects of apophyseal joint
opening and reduced intradiskal pressure associated
with FD,38,47the flexion component of FD has been
shown to inhibit lumbar spinal reflex excitability.46
This attenuation may contribute to a reduction in LBP
associated with hypertonicity and activation of para-
spinal musculature.48The stimulation of mechanor-
eceptors in apophyseal joint capsules, muscle spindles,
intervertebral disks, and spinal ligaments is further
theorized to contribute to the neurophysiologic
response with spinal manipulation and mobilization
procedures.46In the case presented, the intended goal
of manual conservative treatment with FD was the
reduction of LBP and limitations related to LBP
through the mechanical action of lumbar flexion with
a gentle distractive force, the stimulation of mechan-
oreceptor afferents, and the reduction of hypertonicity
of the paraspinal musculature. Further investigation
into this conservative treatment approach appears
warranted for this unique patient presentation.
The limitations present are consistent with case
report design in that the findings are anecdotal in
nature, should be interpreted with caution, and cannot
be generalized beyond this individual case. Although
the outcome measures were used to reflect objective
changes from baseline to discharge, the potential for
bias in obtaining or influencing outcomes cannot be
excluded because the primary author both provided the
treatments and collected outcomes in this case report.
Although the scores from the outcome measures
represent a level of improvement, the degree to
which that improvement could be considered clinically
meaningful was not specified. The concept of mini-
mally clinically important difference (MCID), consid-
ered to be a threshold value of important improvement
for an outcome measure,49should ideally be sensitive
to baseline values, the cost of involved treatments, the
risk to benefit ratio of specific management
approaches, and the nature of presenting conditions.
According to a published estimate, a 30% reduction
from baseline to discharge is considered to be the
MCID, also referred to as the minimal important
change, for commonly used back pain outcome
measures.50The authors suggest that this estimate of
MCID should perhaps be reduced in this case based
upon the long-standing nature of the complaint, the
nominal cost of care to the veteran patient, the low
level of risk with applied conservative management,
and the underlying multiple-level spondylolysis with
spondylolisthesis. Further investigation appears war-
ranted regarding the estimation of MCID for various
128A. S. Dunn et al.
conservative pain management approaches in a complex
veteran patient population with high levels of illness
burden and service-connected disability.51,52
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 demands may have a
higher incidence of lumbar spondylolysis and spondy-
lolisthesis. Conservative management is generally
considered to be the standard of care and should be
explored in its various forms for symptomatic patients
who present without neurologic deficits and with
spondylolisthesis below grade III.3The proposed
mechanisms of FD and the response to management
for the veteran patient in this case report suggest that
FD may serve as a safe and effective element of
conservative management for some patients with
mechanical LBP secondary to multiple-level lumbar
spondylolysis with spondylolisthesis.
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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