Spondylolisthesis

Spondylolisthesis is a condition of the spine where one vertebrae slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful causing localized low back pain and sciatica.

Spondylolisthesis can be present at birth, occur in childhood as a result of injury or be present in older adults as a result of degeneration of the disc and spinal joints.

Spondylolisthesis from degeneration usually affects people over 50 years old, is more common in African Americans, and affects women more often than men. Degenerative spondylolisthesis mainly involves slippage of L4 over L5 while in patients under 20 years of age, spondylolisthesis usually involves slippage of the L5 vertebra over S1.

Back pain associated with spondylolisthesis will gradually improve in up to one-third of all patients. Worsening of symptoms is not expected in patients who don’t have neurologic symptoms at the time of diagnosis.

A condition called spondylolysis can lead to spondylolisthesis. Spondylolysis is a defect in the bony ring of the spinal column that is thought to be a stress fracture that results from repeated stress to the bony ring. Participants in gymnastics and football commonly suffer these types of stress fractures. Spondylolysis can lead to the spine slippage when a fracture occurs on both sides of the bony ring. This slippage is called spondylolisthesis.

Spondylolisthesis is graded from I through IV, with a grade 1 being mild and grade IV often causing neurological symptoms.

Symptoms
Symptoms associated with spondylolisthesis include:

• Low back pain
• Buttock pain
• Pain with standing, walking, or bending backwards
• Muscles spasms in the low back
• Sciatica nerve pain and associated symptoms
• Cauda equina in severe cases

Diagnosis
A diagnosis of spondylolisthesis is made from the results of clinical examination along with diagnostic imaging.  From these images, the extent of the slippage can be assessed along with the effect of the slippage on adjacent nerve structures.

Treatment
Most treatment for spondylolisthesis is conservative in nature and does not require surgical intervention. Medications to ease pain and reduce muscle spasm are often prescribed.

Children and teenagers who have experienced trauma resulting in a spondylolisthesis are often prescribed a rigid back brace to prevent movement and allow healing to occur.

Some patients who continue to experience symptoms are given an epidural steroid injection to reduce inflammation and ease pain.

Physical therapy is often prescribed to assist the patient with understanding their condition better and prescribing the appropriate therapeutic exercises to improve general conditioning, increase muscular flexibility, and improve trunk strength.

Back surgery is used when the spondylolisthesis is severe and when symptoms are not relieved with conservative treatment. Symptoms that cause an abnormal walking pattern, changes in bowel or bladder function, or steady worsening in nerve function require surgery.  The type of surgical procedure is dependent on your physician, your age, and your level of function. The best surgical outcomes are when a decompression procedure is combined with instrumented spinal fusion.

Following fusion surgery for spondylolisthesis, patients normally wait three to four months before beginning a rehabilitation program. This delay is needed to give the fusion a chance to start healing. Ideally, patients are able to return to their previous activities. However, some patients may need to modify or discontinue certain activities to avoid future problems.

Summary
The treatment of spondylolisthesis is based on the grade and nature of the condition.  Most patients with a diagnosis of spondylolisthesis don’t require surgery and do very well with a specifically prescribed therapeutic exercise regimen.

Written by Malton A. Schexneider, PT, MMSc