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Frequency Evaluation of Early Pregnancy in Spondylolisthesis: A Cross Sectional Study on Iranian Females

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Shahrbanoo Kazemi 1 , Seyedeh Zahra Emami Razavi 2 , Mohaddeseh Azadvari 3 , * , Farid Rezaei Moghadam 4

1 Specialist of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran

2 Assistant Professor, Specialist of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran

3 Assistant Professor, Specialist of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran

4 Associate Professor, Specialist of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Imam Reza Hospital, Tehran, Iran

How to Cite: Kazemi S, Emami Razavi S Z, Azadvari M, Rezaei Moghadam F. Frequency Evaluation of Early Pregnancy in Spondylolisthesis: A Cross Sectional Study on Iranian Females, Arch Neurosci. 2018 ; 5(1):e15162. doi: 10.5812/archneurosci.15162.

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Archives of Neuroscience: 5 (1); e15162
Published Online: January 3, 2018
Article Type: Research Article
Received: June 12, 2017
Revised: October 2, 2017
Accepted: November 26, 2017
DOI : 10.5812/archneurosci.15162
Frequency Evaluation of Early Pregnancy in Spondylolisthesis: A Cross Sectional Study on Iranian Females
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Abstract

Background: Spondylolisthesis is a common skeletal disorder that is rather prevalent among human beings occurring at various areas of spinal cord particularly with higher prevalence in lumbosacral area. There are several risk factors contributing to the occurrence of spondylolisthesis especially in the lumbosacral area including multiple pregnancies, early age pregnancy, etc. The current study aimed at investigating the pregnancy history of females afflicted with spondylolisthesis and probing the relationship of such factors with spondylolisthesis.

Methods: Females with low back pain, afflicted with spondylolisthesis, and diagnosed based on the medical scanning were included in the study. The exclusion criteria comprised affliction with acute diseases, rheumatologic diseases such as rheumatoid arthritis, and history of direct trauma to their cords. The patients were then, examined and the related questionnaires were filled in by the authors. The results were analyzed using SPSS version 20.0.

Results: A total of 113 females with the mean age of 53.79 (SD = 10.79) years were studied; 74.3 % of the patients had a history of pregnancy prior to 20 years old. The spondylolisthesis most commonly observed in L4-L5 intervertebral area (49.6%), and grade I had the highest frequency (82.3%).

Conclusions: Early age and multiple pregnancies were considered important risk factors increasing the likelihood of developing spondylolisthesis. Provision of appropriate education about time for the first pregnancy and number of pregnancies, training, and raising public awareness can help to reduce this risk factor.

Keywords

Spondylolisthesis Pregnancy Low Back Pain

Copyright © 2018, Archives of Neuroscience. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Spondylolisthesis is a common skeletal disorder, which refers to the slippage of the upper vertebra on the lower one. This might happen in anterior or posterior spondylolisthesis forms (1). Spondylolisthesis does not usually have a clear symptom; however, it is one of the important causes of back pain and disability in the low back area.

Spondylolisthesis usually occurs in the lumbosacral area because of 2 reasons including spondylolysis and degenerative diseases (2). In the spondylotic cases, a fracture usually occurs in the pars interarticularis manifested initially in childhood and early adulthood (3, 4). In the degenerative cases, however, perfect spondylolisthesis occurs in the posterior lumbar vertebra. Whereas there are diverging opinions about the causes of this disorder, the degenerative type usually does not occur at ages earlier than 50 years. It seems that the facet joints and discs degenerative changes due to aging are related to this disorder (5).

There are a number of risk factors considered to cause spondylolisthesis especially in the lumbosacral area, including age increase (6, 7), the increase of sagittal alignment angle, reduction of the diameter of para-spinal muscles (8, 9), increase of sacrum slope, and increase of the alignment of L1 to S1 (10).

L4 and L5 are the most commonly vertebrae afflicted with spondylolisthesis (9). There are various reports on the prevalence of spondylolisthesis in different communities. The prevalence among females ranges from 6% in Taiwan to 25% in the US, and among males, from 3% in Taiwan to 31% in the US (6, 10-14).

Unfortunately, there is no accurate statistics about the prevalence of spondylolisthesis in Iran. Listhesis is 3 to 4 times more frequent among females than males. In addition, the prevalence of spondylolisthesis is 3 times more in black females than the white ones (1).

The precise reason of higher prevalence of spondylolisthesis among females is unknown. However, it is very likely that this higher prevalence is due to factors such as pregnancy, ligament laxity, total oophorectomy, and post-menopause posture (15-17).

Elderly females have a more limited disc space when compared with the same age males. These degenerative changes make females more prone to degenerative spondylolisthesis (18, 19).

Numerous physiological changes and development happen during pregnancy in a female including ligament and joint laxity of this area (20) as the results of relaxin hormone (21). The precise effects of this hormone are still unknown; however, it increases the level of collagenase (22). The collagenase influences the anolous collagen in lumbar intervertebral discs, leading to increased risk of spondylolisthesis (23, 24).

In females with pregnancy experience, there is considerable laxity in the pelvis when compared with nulliparous ones. This, of course, occurs over the first pregnancy, and does not get intensified over the subsequent pregnancies (25). The ligament laxation has long-term effects on the joints, even years after delivery. On the other hand, the relaxin hormone is likely to influence the stability of facet joints; thereby resulting in rotation of vertebra on each other (26).

Another issue considered as a risk factor for spondylolisthesis is the increased lumbar lordosis during pregnancy. This theory, however, is rejected by some researchers. These researchers believe that the extension happening in the hip joint during pregnancy compensates for the increased lordosis. Therefore, the lordosis angle does not undergo considerable changes during pregnancy (27).

The most important factor contributing to the increased risk of degenerative spondylolisthesis in pregnancy, particularly in multiple pregnancies, is the laxation of anterior abdominal muscles, which is more noticeable in multipara females than nulliparous females and males (28-30).

Investigations showed that the most prevalent area for anterolisthesis is L4-L5, and for retrolisthesis is L3-L4 and L5-S1 (13).

The Meyerding classification model is used to categorize spondylolisthesis:

Grade 0, no slip; grade I, ≥ 5% and < 25%; grade II, 26% - 50%; grade III, 51% - 75 %; grade IV, 76% - 100 %; and grade V, complete slippage (30).

Based on the conducted studies, it seems that early age pregnancy, particularly below 20 years, along with multiple pregnancies can seriously increase the risk of spondylolisthesis. To date, no study investigated this issue in Iran. Therefore, the current study aimed at investigating the risk factors in spondylolisthesis in females afflicted with it.

2. Methods

A total of 113 female patients with spondylolisthesis referring to the physical medicine and rehabilitation clinic were included in the study. The inclusion criteria were female gender, and confirmed affliction with spondylolisthesis in lumbosacral X-ray or magnetic resonance imaging (MRI). The exclusion criteria comprised affliction to severe diseases such as rheumatologic diseases, and history of malignancy. The patients were examined by a specialist in physical medicine and rehabilitation. The related demographic questionnaires including age, trauma history, weight, and height were filled in and pregnancy and delivery information was also recorded. The data were analyzed with SPSS version 20.0

3. Results

In the current study, 113 females with the mean age of 53.79 (SD: 10.79) years were enrolled. The demographic information and the maternity records of the patients are demonstrated in Tables 1 and 2. The median for pregnancies was 4, and the mode was 5.

Table 1. The Demographic Information and Maternity Records of the Participants
VariablesMinimumMaximumMeanStd. Deviation
Age30.0082.0053.7910.79
BMI20.6937.1128.233.98
Pregnancy number1.0011.004.172.01
Table 2. The Demographic Information and Maternity Records of the Participants
VariablesNumberPercentage
First delivery
Below 20 year8474.3
Above 20 year2925.7
Job
Employee2421.2
Housewife8978.8
History of trauma
Yes108.8
No10391.2

About 74.3% of the patients had a history of birth delivery below the age of 20 years. In addition, 89 patients (78.8%) were housewives and the rest had other jobs; 8.8% of the patients had a history of direct trauma to their cords.

The area with highest frequency of listhesis in the results was L4-L5 (49.6%), followed by L5-S1 ranked the second with a frequency of 40.7%. The third frequency belonged to 2 vertebrae including L5-S1, and L4-L5 with 1.8% of the total frequency.

In the current study, the most frequent grade of spondylolisthesis was grade I with 82.3%. However, 7.3% of the patients had vertebrae spondylolisthesis grade II and above (Table 3).

Table 3. Frequency of Spondylolisthesis in Patients, According to Their Grading
VariablesGrade IGrade IIGrade IIIGrade IV
Frequency931910
Percentage82.316.80.90

4. Discussion

The study by Lai-Chang showed that in elderly males and females, lower height, higher body mass index (BMI), higher hip and spine BMD (bone mass measurement), and degenerative clinical arthritis increased the risk of spondylolisthesis. In the current study, the mean age and BMI of the patients were 53.79 (± 10.79) years and 28.23 (± 3.98) kg/m2 respectively, classified as elderly and overweight patients.

The study by Paul, probing the role of pregnancy on the occurrence of spondylolisthesis, reported that females with pregnancy experiences had significantly higher affliction rates to spondylolisthesis compared with males and nulliparous females (9). In the current study, the average delivery was 4, which can be indicative of this fact.

Studies reported the most frequent occurrence of spondylolisthesis in anterolisthesis of L4-L5 (13). Similarly, in the current study, the most frequent occurrences of listhesis were in L4-L5, and then in L5-S1.

In the study by Lai-Chang, 97% of the patients were afflicted with grade I listhesis, and 2.7% had grade II (1). Likewise, in the current study, a similar trend was observed as a substantial majority of the patients (82.3%) were afflicted with grade I listhesis, and 16.8 % of them had grade II.

In the current study, 74.3% of the patients had a history of pregnancy prior to age 20 years. In other studies there were no comments on this conception.

4.1. Implications for Practice

Based on the results of the current study, a correlation was observed between the early age pregnancy, multiple pregnancies, higher BMI, aging, and the rate of spondylolisthesis.

4.2. Conclusion

Due to the limitations of the current study, it cannot be concluded that the early pregnancy can be considered as a risk factor for spondylolysthesis. It is necessary to design other forms of research such as a case-control study, but community, especially females, awareness of pregnancy health including avoiding early and multiple pregnancies can be helpful and may reduce the risk of low back pain and improve community health.

References

  • 1.

    He LC, Wang YX, Gong JS, Griffith JF, Zeng XJ, Kwok AW, et al. Prevalence and risk factors of lumbar spondylolisthesis in elderly Chinese men and women. Eur Radiol. 2014;24(2):441-8. doi: 10.1007/s00330-013-3041-5. [PubMed: 24126641].

  • 2.

    Wiltse LL, Newman PH, Macnab I. Classification of spondylolisis and spondylolisthesis. Clin Orthop Relat Res. 1976;(117):23-9. [PubMed: 1277669].

  • 3.

    Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am. 1984;66(5):699-707. [PubMed: 6373773].

  • 4.

    Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D. The natural history of spondylolysis and spondylolisthesis: 45 year follow up evaluation. Spine (Phila Pa 1976). 2003;28(10):1027-35. doi: 10.1097/01.BRS.0000061992.98108.A0. [PubMed: 12768144].

  • 5.

    Rosenberg NJ. Degenerative spondylolisthesis. Predisposing factors. J Bone Joint Surg Am. 1975;57(4):467-74. [PubMed: 1141255].

  • 6.

    Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34(2):199-205. doi: 10.1097/BRS.0b013e31818edcfd. [PubMed: 19139672].

  • 7.

    Herkowitz HN. Spine update. Degenerative lumbar spondylolisthesis. Spine (Phila Pa 1976). 1995;20(9):1084-90. [PubMed: 7631240].

  • 8.

    Love TW, Fagan AB, Fraser RD. Degenerative spondylolisthesis. Developmental or acquired?. J Bone Joint Surg Br. 1999;81(4):670-4. [PubMed: 10463743].

  • 9.

    Sanderson PL, Fraser RD. The influence of pregnancy on the development of degenerative spondylolisthesis. J Bone Joint Surg Br. 1996;78(6):951-4. [PubMed: 8951013].

  • 10.

    Denard PJ, Holton KF, Miller J, Fink HA, Kado DM, Yoo JU, et al. Lumbar spondylolisthesis among elderly men: prevalence, correlates, and progression. Spine (Phila Pa 1976). 2010;35(10):1072-8. doi: 10.1097/BRS.0b013e3181bd9e19. [PubMed: 20393398].

  • 11.

    Chen JC, Chan WP, Katz JN, Chang WP, Christiani DC. Occupational and personal factors associated with acquired lumbar spondylolisthesis of urban taxi drivers. Occup Environ Med. 2004;61(12):992-8. doi: 10.1136/oem.2003.011775. [PubMed: 15550605].

  • 12.

    Jacobsen S, Sonne-Holm S, Rovsing H, Monrad H, Gebuhr P. Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study. Spine (Phila Pa 1976). 2007;32(1):120-5. doi: 10.1097/01.brs.0000250979.12398.96. [PubMed: 17202902].

  • 13.

    Vogt MT, Rubin D, Valentin RS, Palermo L, Donaldson W3, Nevitt M, et al. Lumbar olisthesis and lower back symptoms in elderly white women. The Study of Osteoporotic Fractures. Spine (Phila Pa 1976). 1998;23(23):2640-7. [PubMed: 9854764].

  • 14.

    Kauppila LI, Eustace S, Kiel DP, Felson DT, Wright AM. Degenerative displacement of lumbar vertebrae, A 25 year follow up study in Framingham. Spine (Phila Pa 1976). 1998;23(17):1868-73. [PubMed: 9762744].

  • 15.

    Porter RW, Hibbert C. Vertebral displacement in spondylolisthesis. Clin Biomech. 1989;4(1):58-63. doi: 10.1016/0268-0033(89)90069-7.

  • 16.

    Imada K, Matsui H, Tsuji H. Oophorectomy predisposes to degenerative spondylolisthesis. J Bone Joint Surg Br. 1995;77(1):126-30. [PubMed: 7822369].

  • 17.

    Wang YX, Griffith JF, Ma HT, Kwok AW, Leung JC, Yeung DK, et al. Relationship between gender, bone mineral density, and disc degeneration in the lumbar spine: a study in elderly subjects using an eight-level MRI-based disc degeneration grading system. Osteoporos Int. 2011;22(1):91-6. doi: 10.1007/s00198-010-1200-y. [PubMed: 20352410].

  • 18.

    Wang YX, Griffith JF. Effect of menopause on lumbar disk degeneration: potential etiology. Radiology. 2010;257(2):318-20. doi: 10.1148/radiol.10100775. [PubMed: 20959546].

  • 19.

    Wang YX, Griffith JF, Zeng XJ, Deng M, Kwok AW, Leung JC, et al. Prevalence and sex difference of lumbar disc space narrowing in elderly chinese men and women: osteoporotic fractures in men (Hong Kong) and osteoporotic fractures in women (Hong Kong) studies. Arthritis Rheum. 2013;65(4):1004-10. doi: 10.1002/art.37857. [PubMed: 23335175].

  • 20.

    Abramsom D, Roberts SM, Wilson PD. Relaxin of the pelvic joints in pregnancy. Surg Gynecol Obstet. 1934;58:595-613.

  • 21.

    Zarrow MX, Holmstrom EG, Salhanick HA. The concentration of relaxin in the blood serum and other tissues of women during pregnancy. J Clin Endocrinol Metab. 1955;15(1):22-7. doi: 10.1210/jcem-15-1-22. [PubMed: 13221624].

  • 22.

    Mazoujian G, Bryant-Greenwood GD. Relaxin in breast tissue. Lancet. 1990;335(8684):298-9. [PubMed: 1967759].

  • 23.

    Harris HJ J. Variation in extension of the metacarpo phalangeal and interphalangeal joints of the thumb. J Bone Joint Surg (Br). 1949;31:547-59.

  • 24.

    Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32(5):413-8. [PubMed: 4751776].

  • 25.

    Saugstad LF. Persistent pelvic pain and pelvic joint instability. Eur J Obstet Gynecol Reprod Biol. 1991;41(3):197-201. [PubMed: 1936503].

  • 26.

    Gunzburg R, Hutton WC, Crane G, Fraser RD. Role of the capsulo-ligamentous structures in rotation and combined flexion-rotation of the lumbar spine. J Spinal Disord. 1992;5(1):1-7. [PubMed: 1571606].

  • 27.

    Ostgaard HC, Andersson GB, Schultz AB, Miller JA. Influence of some biomechanical factors on low-back pain in pregnancy. Spine (Phila Pa 1976). 1993;18(1):61-5. [PubMed: 8434326].

  • 28.

    Omatsu Y. Basal metabolism in pregnancy. Kobe J Med Sci. 1957;27:21-6.

  • 29.

    Beimborn DS, Morrissey MC. A review of the literature related to trunk muscle performance. Spine (Phila Pa 1976). 1988;13(6):655-60. [PubMed: 3051439].

  • 30.

    Meyerding HW. Spondyloptosis. Surg Genacool Obstet. 1932;54:371-7.

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