Is “spondylolisthesis” a real word?
Spondylolisthesis is the name to describe when one vertebra slips over the other. It sounds like a good password, doesn’t it?
In the spine, the vertebras are aligned one on top of the other. They are held together by strong ligaments in front, in the back and inside the spine. It is important that the spine keeps its alignment to protect the spinal cord and all the nerves that exit from the spinal cord.
I am a medical doctor, and I get asked these questions very often:
Is spondylolisthesis a surgical emergency?
Is spondylolisthesis, spondylosis and spondylolysis the same?
How do I know if spondylolisthesis is the cause of my lower back pain?
My doctor told me I don’t need surgery, so what should I do to manage the pain?
Will spondylolisthesis get worse with time, and I will end up needing surgery?
Question #1. Is spondylolisthesis a surgical emergency?
The decision to undergo surgery is based on a number of different factors. It depends on the patient’s age, what caused it, how much slippage has occurred. If the patient is having symptoms or not, if the listhesis is stable or progressing, and the general condition of the patient.
You may be surprised to hear this, but the majority of people who have spondylolisthesis don’t even know as they have no symptoms at all.
Spondylolisthesis can be found in children who have some deformities of the spine. The isthmus is the bone that holds the vertebra in place. The isthmus is also called pars interarticularis. This is a tiny and thin bone that connects the back to the front of the vertebrae. If there is a fracture of the isthmus, we call this fracture spondylolysis, then, the front of the vertebra is free to move forward and this may cause spondylolisthesis. This type of spondylolisthesis is called isthmic spondylolisthesis, and it is more common in children, adolescents and young adults. In some cases, this spondylolysis (or fracture of the isthmus) is caused by a trauma or an accident, and we call this post-traumatic spondylolisthesis.
However, the most common type of spondylolisthesis is found in adults older than 50 years of age. In these cases, there is no fracture of the isthmus part. The upper vertebra will slip forward because the other structures that hold the spine in place are getting weak and degenerated, this could be degenerative disc disease, facet joint arthritis, weakened ligaments and muscles, so the vertebras start moving forward with time. This is what we call degenerative spondylolisthesis. We use the term “spondylo” to refer to the spine, and when there is degeneration of the spine we call this spondylosis. And the person will have symptoms similar to degenerative disc disease, facet joint osteoarthritis, sciatica and spinal stenosis.
Spondylolisthesis can be classified into 5 grades. We use the Meyerding grading system which is based on how much slippage occurs between the upper and lower vertebra:
Less than 25% is grade one; 26 to 50% is grade two; 51 to 75% is grade three; 76 to 100% is grade four and more than 100% is grade five (we call this spondyloptosis).
We can group grades one and two into “Low grade” and grades three, four and five into “High grade”. It is interesting to know that some people with high grades have no symptoms at all, and some people with a grade one spondylolisthesis will have a lot of pain. So, the decision to operate or not should be discussed with your surgeon based on all these factors. But rarely it is an urgency. Only if there is a risk of nerve compression or spinal cord injury you should have the surgery right away, but this is very rare with spondylolisthesis. In general, you should have enough information and enough time to decide the pros and cons of doing or not doing surgery and perhaps ask for a second opinion. Any spine surgery carries risks of complications, so it is important that you get all information you can and be prepared to ask questions.
Question #2. Is spondylolisthesis, spondylolysis, spondylosis and spondylitis the same?
Spondylo means vertebra.
Spondylolisthesis is the slippage of the upper vertebra over the lower vertebrae
Spondylolysis is the fracture of the isthmus, also called pars interarticularis. This may lead to isthmic spondylolisthesis. But there are cases of spondylolysis without spondylolisthesis.
Spondylosis is degenerative arthritis of the spine, which may lead to degenerative spondylolisthesis.
Spondylitis is inflammation of the vertebrae, and we see this in ankylosing spondylitis which is an auto-immune rheumatological disease that affects mainly the lumbosacral spine.
And there is another term, spondyloptosis is an extreme case of spondylolisthesis which is grade 5 or 100% of slippage.
Question #3. How do I know if spondylolisthesis is the cause of my lower back pain?
As I mentioned before, there are people who have degenerative spondylolisthesis, spondylolysis and spondylosis and do not have any lower back pain. They find out accidentally when they do an X-ray, CT-scan or MRI for other reasons, like to investigate a kidney stone or a gallbladder problem.
When we see a person with low-back pain we need to take a good history of the pain problem and do a complete physical examination, including a neurological exam. Then, if we suspect degenerative spondylolisthesis we can order an X-ray. If there is slippage of one vertebra over the other, we look to see if there is an isthmic fracture or spondylolysis. Usually, the lower back pain is correlated with the localization of the listhesis. So, if we see listhesis between the fifth lumbar vertebra and the first sacral vertebra, we call this L5-S1, we should see symptoms in that area and the nerves that exit at this level are the L5 nerve root, so only the skin that is innervated by L5 should be affected, and only the muscles and reflexes that are affected by L5 should be impaired. If we see that the symptoms do not correlate with the spondylolisthesis site and side, then we say that these are accidental findings and they do not explain the patient’s symptoms, therefore, there is no indication to treat the spondylolisthesis.
Question #4. My doctor told me I don’t need surgery, so what should I do to manage the pain?
Now, this is right at my ally. I’m a doctor specialist in physical medicine and rehabilitation (PM&R) or physiatry. So, when the surgeon says “to treat conservatively”, the patient could see a physiatrist for a proper plan of treatment. In physiatry, we use a multidisciplinary approach to pain management. This means that we work in teams that include: physicians, physiotherapists, psychologists, nurses, pharmacists and many others.
I usually tell my patients to remember to use their toolbox. I ask, how many tools do you have in your toolbox? Remember the 5M of conservative therapy plus IS for interventional and surgical treatments.
The 5 M conservative treatments include Medications, Mind-Body, Movement, Modalities and Manual therapies.
Medication
- Avoid narcotic medications
- NSAIDs and acetaminophen are the painkillers of choice. Use prior to activities to improve tolerance to physical exercise.
- If there is neuropathic pain, use anticonvulsants or antidepressants adjuvants.
Mind-body therapies
- Mindfulness
- Meditation
- Relaxation
- Biofeedback
- Hypnosis
- Stress reduction
Movement
- Core strengthening exercises are very important.
- Aerobic conditioning, low-impact exercises are the best. I usually recommend a stationary bike, swimming, hydro gymnastics or dance.
- If your pain is aggravated when you bend forward, then consider exercises for degenerative disk disease.
- If your pain is aggravated when you bend backwards, then consider exercises for facet joint arthritis.
- If your pain is mainly radiating to one leg, then consider exercises for sciatica.
- And if your pain is aggravated when you walk and the pain is in the back of both thighs, then consider exercises for spinal stenosis.
Modalities and lifestyle changes
- Occasionally bracing or lumbar supports might be necessary. The studies of bracing were mostly conducted with children and adolescents who had isthmic spondylolisthesis to avoid the progression of the disease.
- Acupuncture
- Electrostimulation like TENS.
- Smoking cessation is very important because smoking causes poor bone healing.
- Weight loss is very important for people with spondylolisthesis.
- Sleep hygiene is also relevant.
- Activity modification, especially around proper lifting, bending, ergonomics, avoid prolonged sitting and driving.
Manual therapies
- Spinal manipulation
- Massage therapy.
Interventional
- Facet steroid injections
- Epidural steroid injections
- Nerve blocks
Surgical
- Various types of surgical techniques
- Spinal cord stimulators
Question #5. Will spondylolisthesis get worse with time, and I will end up needing surgery?
In general, a minority of patients, that is about 1/3 of adults with degenerative spondylolisthesis will progress from a low-grade to high-grade spondylolisthesis.
Those patients who present initially to the physician with neurological symptoms will respond less favourably to conservative therapies, and will likely need surgical stabilization in the future.
Talk to your doctor about regular checkups to monitor the progression of your symptoms and to do a neurological exam. If your doctor is concerned about new symptoms or the physical exam, then they may order an x-ray to check if the spondylolisthesis is progressing.
This article is not intended to give you medical advice. Please talk to your physician or healthcare professional if you have any health issues. If you leave a comment about your own medical condition, I will not be able to provide you medical advice. But, please, leave a comment if you feel that this article has helped you to learn something new.
This article will soon be available as a YouTube video on my channel: https://www.youtube.com/c/DrAndreaFurlan
