Spondylolisthesis involves the displacement of a vertebra, one of the bones in the spinal column, causing it to shift forward and become misaligned. This displacement can happen at any point along the spine, though it is most frequently observed in the lower back, known as the lumbar spine. While some individuals may not experience any noticeable symptoms, others might encounter varying degrees of back and
leg discomfort, ranging from mild to intense.
Gaining a grasp of the mechanics of your spine can enhance your comprehension of spondylolisthesis. You can delve deeper into the anatomy of the spine by exploring Spine Basics. Spondylolisthesis is a
spinal ailment primarily associated with lower
back pain. It emerges when one of the vertebrae, the skeletal components comprising the spine, shifts out of its original position and moves onto the vertebra situated below it.
Typically, nonsurgical interventions are effective in alleviating the associated symptoms. Surgical procedures tend to yield positive outcomes in the majority of cases where severe spondylolisthesis is present.
What is spondylolisthesis?
Spondylolisthesis is a condition characterized by instability in the spine, leading to excessive movement of the vertebrae. This results in the displacement of a vertebra, causing it to shift from its proper position onto the vertebra located below. This displacement has the potential to exert pressure on nerves, potentially giving rise to lower back pain or leg discomfort.
The term ‘spondylolisthesis’ (pronounced as spohn-di-low-less-THEE-sis) originates from the combination of Greek words: ‘spondylos,’ meaning ‘spine’ or ‘vertebra,’ and ‘listhesis,’ signifying ‘slipping,’ ‘sliding,’ or ‘movement.’
Anatomical Context of spondylolisthesis
The spine consists of a series of small bones called vertebrae, arranged in a stacked formation that creates the natural curves of the back. These vertebrae are interconnected to form a protective canal housing the spinal cord. Intervertebral disks, which possess flexibility, are located between the vertebrae. These disks function as shock absorbers during activities such as walking or running. Spondylolisthesis manifests when a vertebra within the spine shifts forward and becomes dislodged from its original position. This destabilization of the spine can result in pain and may even expedite the development of bone spurs or arthritis.
Causes of Adult Spondylolisthesis:
One of the primary factors leading to spondylolisthesis among young athletes is the excessive extension of the spine. Genetic factors might also contribute, as certain individuals are naturally endowed with thinner vertebral bones. In the case of older adults, the gradual impact of daily activities on the spine and the intervertebral disks (which serve as cushions between the vertebrae) can give rise to this condition.
The causes and types of spondylolisthesis are diverse. Among adults, the two most prevalent forms are degenerative spondylolisthesis and spondylotic/congenital spondylolisthesis. Several factors can contribute to the development of adult spondylolisthesis in the low back, including:
Degenerative Spondylolisthesis
As we progress through the aging process, the natural wear and tear on our bodies initiates changes within the spine. Over time, the intervertebral disks that reside in the spine undergo a reduction in height, becoming rigid and desiccated. This process leads to their weakening, and they may even start to bulge. As these disks lose height, the
ligaments and joints responsible for maintaining the proper alignment of our vertebrae begin to lose their strength.
In certain individuals, this sequence of events can introduce instability, potentially culminating in the development of degenerative spondylolisthesis. As the degeneration of the spine persists, the ligaments positioned along the back of the spine might begin to buckle, resulting in the compression of nerves. Simultaneously, the progression of slippage within the spine can contribute to the narrowing of the spinal canal.
Ultimately, this narrowing and buckling contribute to the compression of the spinal cord, a condition known as spinal stenosis. This phenomenon of spinal stenosis is frequently observed in patients diagnosed with degenerative spondylolisthesis. Among those affected, women exhibit a higher propensity for degenerative spondylolisthesis in comparison to men. Furthermore, this condition becomes increasingly prevalent in individuals aged 50 and above. Research has also indicated a heightened occurrence among the African American population.
Spondylolytic Spondylolisthesis (Isthmic Spondylolisthesis)
Another prevalent contributor to spondylolisthesis is the occurrence of a stress fracture, commonly referred to as a crack, within a vertebra. This type of fracture typically arises in the pars interarticularis region of the lower (lumbar) spine, leading to a classification known as isthmic spondylolisthesis. In numerous instances of spondylolytic spondylolisthesis, the fracture of the pars (also termed spondylolysis) emerges during adolescence and remains unnoticed until adulthood.
Subsequent to this, the natural degeneration of spinal disks that occurs with age can place stress on the previously sustained pars fracture, resulting in the forward slippage of the vertebra. It’s important to note that while the stress fracture may contribute to the slip, the progression of the slip is rarely significant or worsens considerably over time. Manifestations of isthmic spondylolisthesis typically manifest in middle age.
The occurrence of a pars fracture leads to the disconnection between the front (vertebra) and back (lamina) portions of the spinal bone.
Consequently, only the front portion slips forward, which diminishes the likelihood of spinal canal narrowing compared to other forms of spondylolisthesis, such as DS, where the entire spinal bone shifts forward. However, as individuals with isthmic spondylolisthesis age, the potential for spinal stenosis arises similarly to that of degenerative spondylolisthesis. This can lead to the formation of bone spurs, which constrict the spinal canal and cause nerve compression. Statistics indicate that around 4% to 6% of the U.S. population experiences spondylolysis and spondylolisthesis.
What are the symptoms of spondylolisthesis?
Spondylolysis and spondylolisthesis are present in approximately 4% to 6% of the United States population. A significant portion of these individuals have coexisted with the condition for numerous years, enduring it without experiencing any pain or other associated symptoms. It’s important to note that you might not encounter any symptoms attributed to spondylolisthesis.
Some individuals harbor the condition unknowingly, as its presence goes unnoticed. However, if symptoms do arise, lower back pain usually assumes a central role. This pain can radiate down to the buttocks and extend further into the thighs. Additionally, you might also undergo:
- Muscle spasms in the hamstrings (muscles located at the back of the thighs).
- Stiffness in the back.
- Challenges in walking or maintaining a standing position for prolonged periods.
- Discomfort when bending forward.
- Sensations of numbness, weakness, or tingling in the foot.
Degenerative Spondylolisthesis
Patients grappling with degenerative spondylolisthesis often encounter pain in the lower back and/or legs as the slippage of vertebrae exerts pressure on spinal nerves. Predominant symptoms in the legs encompass a sensation of generalized weakness, particularly after prolonged periods of standing or walking. These leg symptoms may coincide with feelings of numbness, tingling, and/or pain, frequently influenced by one’s posture. Leaning forward or sitting frequently alleviates symptoms due to the expansion of space within the spinal canal, whereas standing or walking often exacerbates them.
Isthmic Spondylolisthesis
A majority of patients affected by isthmic spondylolisthesis report experiencing low back pain that they attribute to physical activity. This back pain might also be accompanied by leg discomfort. In elderly individuals, isthmic spondylolisthesis can coexist with symptoms characteristic of spinal stenosis.
Diagnosis and Evaluation for Low Back Spondylolisthesis:
Medical professionals employ identical tools for diagnosing both degenerative spondylolisthesis and isthmic spondylolisthesis. Upon discussing your symptoms and medical background, your doctor will conduct an examination of your back. This evaluation entails observing your back and applying pressure to various regions to gauge any discomfort. Your doctor might also request you to perform forward, backward, and side-to-side bending motions to assess your range of movement and identify any pain.
Diagnostic Imaging for Low Back Spondylolisthesis in Adults
To bolster the accuracy of your diagnosis, your doctor may recommend imaging tests, encompassing:
- X-rays: These images spotlight bones and can reveal whether a lumbar vertebra has shifted forward. They also provide insights into age-related changes such as decreased disk height or the formation of bone spurs. Flexion-extension X-rays, captured as you lean forward and backward, can unveil potential instability or excessive movement within your spine.
- Magnetic Resonance Imaging (MRI): MRI scans offer superior visualization of soft tissues, including muscles, disks, nerves, and the spinal cord, compared to X-rays. These scans offer more intricate details about the slippage and whether any nerves are compressed.
- Computed Tomography (CT): CT scans generate cross-sectional images of your spine, excelling at capturing bone-related details. While CT is adept at imaging bone structure, MRI stands out in its ability to image nerves.
If undergoing an MRI scan proves challenging due to an associated medical condition, your doctor might recommend a CT myelogram. This procedure entails injecting a contrast dye into your spinal canal, followed by a CT scan. You might be positioned on a movable table during the scan to facilitate the dye’s dispersion within the spinal canal.
Treatment Options Low Back Spondylolisthesis:
The appropriate course of treatment hinges on factors including the degree of slippage, your symptoms, age, and overall health. Your healthcare provider will engage in discussions with you to explore treatment options, which might encompass medication,
physical therapy, or surgical intervention.
Non-Surgical Treatment for Low Back Spondylolisthesis in Adults
While nonsurgical methods won’t rectify the vertebral slippage itself, many patients report these strategies to be effective in alleviating symptoms.
- Physical therapy and exercise: Tailored exercises can enhance the strength and flexibility of your lower back and abdominal muscles.
- Medication: Pain relief can be achieved through analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen.
- Steroid injections: Cortisone, a potent anti-inflammatory, can be injected near nerves or into the outermost part of the spinal canal (epidural space) to reduce swelling and pain. These injections tend to mitigate pain and numbness, although not leg weakness. It’s advisable to limit cortisone injections to three times annually.
Surgical Treatment for Low Back Spondylolisthesis in Adults
- Degenerative Spondylolisthesis: Should you have degenerative spondylolisthesis and your symptoms show no improvement after 3 to 6 months of nonsurgical treatment, surgery might be recommended. This is particularly applicable if mobility is compromised, and pain and weakness significantly impact your quality of life. Your surgeon will also factor in the extent of arthritis in your spine and the degree of spinal movement.
- Surgical goals for degenerative spondylolisthesis are two-fold: 1) alleviating nerve compression and 2) preventing instability. Often, the priority is to relieve nerve compression, typically accomplished through a laminectomy. This procedure involves removing bone spurs and thickened ligaments contributing to compression. In certain cases, alternative surgical techniques can indirectly decompress the spine.
If your spine’s stability is deemed sufficient by your doctor, spinal fusion might not be necessary to achieve stabilization.
- Isthmic Spondylolisthesis: For individuals with isthmic spondylolisthesis and no symptom improvement after 6 to 12 months of non-surgical interventions, surgery may be considered. Surgical candidacy might also include cases of progressing neurological symptoms such as weakness, numbness, falling, or indications of damage to nerves below the spinal cord’s end (cauda equina syndrome).
The primary objective of surgery for isthmic spondylolisthesis is spinal stabilization. This involves spinal fusion, a process wherein screws and rods are employed to fuse two or more vertebrae into a unified, solid bone. In instances involving nerve compression, a laminectomy may be performed to decompress the spine.
Rehabilitation and Lifestyle Modifications:
Surgical intervention for back pain caused by spondylolisthesis usually revolves around spinal decompression, often accompanied by fusion. In cases of
isthmic spondylolisthesis, decompression alone is infrequent, as research indicates that fusion in conjunction with decompression tends to yield more favorable outcomes. In a decompression procedure, your surgeon removes sections of bone and disk from the spine, creating additional space within the spinal canal to alleviate pressure on the nerves and subsequently alleviate pain.
Fusion surgery involves your surgeon connecting the two affected vertebrae. Over time, as they heal, they meld into a single bone, eliminating movement between them. While this surgery may somewhat limit spinal flexibility, it often offers improved stability. Particularly for children, your
healthcare provider might suggest exercises aimed at bolstering the back and abdominal muscles. It’s advisable to maintain regular checkups to facilitate early detection of any potential issues.
The likelihood of spondylolisthesis recurrence is higher for individuals with more severe grades of the condition. For those with minor slippages, recurrence might be less likely or not occur at all. Recovery following a laminectomy without fusion might span only 1 to 2 months due to the absence of a fusion process. Conversely, fusion requires time for the bones to solidify. While it might take several months for complete bone fusion, you’ll often experience improved comfort relatively quickly.
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