Spondylolisthesis
Article by J.Miller, S.Armfield
Spondylolisthesis
What is Spondylolisthesis?
Spondylolisthesis refers to a slippage of a vertebral body relative to an adjacent vertebra. Spondylolisthesis (or anterolisthesis) is the forward displacement of a vertebral body in relation to the vertebrae beneath it. The slippage may occur following structural changes (eg fracture or spondylolysis) or degenerative changes in the spine (eg spondylosis or degenerative disc disease). Approximately 5% of the population has a spondylolisthesis.
Retrolisthesis is the opposite. The upper vertebral body is displaced backwards relative to the vertebrae below. Laterolisthesis is a side ways shift that is rare. It can occur in advanced degenerative spines or after asymmetrical fractures or severe scoliosis.
Spondyloptosis refers to dislocated vertebrae. In these instances, your spondylolisthesis is so extensive that the upper vertebrae translates entirely forward and off the vertebrae below. See Grade V below.
What are the Symptoms of Spondylolisthesis?
Spondylolisthesis may not cause any symptoms for years (if ever) after the slippage has occurred. If you do have symptoms, they may include:
- insidious onset low back pain, buttock or leg pain
- pain arching your back
- increased sway back
- tight hamstrings – 80% of cases
- a limp (walking)
More severe cases are those that reproduce neurological signs eg
- numbness, tingling, (sciatica) pain, muscle tightness, muscle weakness in the leg and/or diminished reflexes.
A step deformity may also be observed or palpated in the lower back.
What Causes a Spondylolisthesis?
Isthmic vs Degenerative Spondylolisthesis
The two major causes of spondylolisthesis are isthmic spondylolisthesis associated with spondylolysis and degenerative spondylolisthesis associated with degeneration of the posterior facet joints (spondylosis) and/or intervertebral disc (degenerative disc disease).
Degenerative spondylolisthesis occurs mostly (88.5%) at the L4-5 level as opposed to isthmic spondylolisthesis, which occurs most often at the lumbosacral level (L5-S1) (84.6%). Approximately 75% of spondylolisthesis occur at L5 on S1 and 20% at L4 on L5. One study showed that 26% had suffered a fall.
Dysplastic & Other Spondylolisthesis
Dysplastic or congenital spondylolisthesis is caused by poorly formed facet joint structure at birth leading to the vertebral slippage. Other causes related to traumatic or pathological fractures and post-surgical failure are rare.
Spondylolisthesis and Your Age?
Congenital or dysplastic spondylolisthesis has an early childhood onset as mentioned above.
Isthmic spondylolisthesis is more prevalent in the pre-teen and adolescent years in the athletic youth populations. Sports that involve hyperextension and rotation. eg gymnastics, fast bowling (cricket), hurdling, tennis, wrestling and other throwing or overhead racquet sports are higher risks. Spondylolysis (back stress fracture) initially occurs and about 50% of cases slip to develop into a spondylolisthesis.
Most isthmic spondylolisthesis stabilise at skeletal maturity. The fractures themselves may not heal but it is thought that the muscles controlling the spondylolisthesis provide sufficient functional control to avoid painful symptoms.
Degenerative spondylolisthesis is more common with advancing age. The vertebrae slip forwards without a fracture present. The slippage is related to chronic spinal segment instability due co-existing pathologies such as degenerative disc disease or facet joint arthritis (spondylosis). They are also more likely to cause recurrent symptoms.
Due to the whole vertebrae and arch slipping forwards degenerative spondylolisthesis can cause spinal stenosis and compromise spinal nerve roots. Compromise of the spinal nerve roots may result in a radicular pain syndrome such as sciatica or significant develop motor power deficits (radiculopathy). In extreme cases, the stenosis and slippage could compromise the cauda equina and develop cauda equina syndrome, which is a medical emergency and will require immediate surgical intervention.
Spondylolisthesis Risk Factors
Known risk factors include:
- Sports involving hyperextension and rotation
- Genetic predisposition. You have a 26% chance if a parent has one.
- Spondylolisthesis: Females 2-3 times
- Spondylolysis (no slip): Males 2-3 times
- Generalised hypermobility.
- Spina bifida occulta
- Facet joint morphology
- Inuit population
- Degenerative spondylolisthesis is more prevalent in pregnant women and black individuals.
How is Spondylolisthesis Diagnosed?
Your physiotherapist will begin by taking a history and performing a physical examination. A palpable step or depression may be present to indicate the likelihood of a spondylolisthesis. Your physiotherapist may order X-rays of your back.
A CT scan or MRI scan can show a fracture or pars defect more clearly, plus exclude other potential pathologies such as malignancy, infections or spinal stenosis. They will also show whether any of the nearby facet joints or discs have suffered any degeneration.
If spondylolisthesis is present, it is graded as I (mild), II, III, IV or V based on how far forward the vertebra has slipped.
Classification by degree of the slippage, as measured as a percentage of the width of the vertebral body:
- Grade I: 0-25%
- Grade II: 25- 50%
- Grade III: 50-75%
- Grade IV: 75-100%
- Grade V: greater than 100% (Spondyloptosis)
Please consult your doctor or physiotherapist for your specific diagnosis, grading and recommended treatment plan.
Spondylolisthesis Treatment
If your physiotherapist or doctor determines that a spondylolisthesis is causing your pain, non-surgical treatment is the primary choice. Treatment will include activity modification plus some specific exercises. Please consult your physiotherapist for a thorough assessment and prescription of the best exercises for your spondylolisthesis. The prognosis is very good for low-grade spondylolisthesis. (Hardwick et al., 2012)
However, the type of exercise that you perform can significantly alter your outcome. One study showed a 73% improvement at 3-months with one exercise group versus only 33% improvement in the alternative exercise group. For advice specific to your spondylolisthesis, please consult with your physiotherapist.
Physiotherapy Treatment
As you begin a physiotherapy treatment regimen your physiotherapist may prescribe manual therapies or other pain relieving techniques to reduce your pain and muscle spasms.
Because your muscles are the only effective way of controlling your slipping vertebrae, exercises will be aimed at the recruitment of your deep spinal stabilising muscles. You may also be prescribed gentle stretches to improve your posture and help to reduce your back pain or leg symptoms.
Flexion based and localised stabilisation/motor control exercises have been shown to improve both pain and disability. (Hardwick et al., 2012, Nava-Bringas et al., 2014)
When you have less pain and improving neurological signs, your exercises will be progressed to improve your flexibility, strength, endurance, and the ability to return to a more normal lifestyle. A comprehensive program may require several weeks or a few months of supervised treatment. For specific advice relative to your spondylolisthesis, please consult your physiotherapist for an individualised assessment.
Spondylolisthesis Prognosis
The presence of a spondylolisthesis by itself usually does not represent a dangerous condition in the adult. Outcomes are excellent for low-level spondylolisthesis with the vast majority of cases having favourable short-term and long-term outcomes.
Most spondylolisthesis Grade I-II patients respond favourably within a few weeks of commencing treatment. A Swedish study showed no significant difference in a long-term randomised study that compared 111 patients who underwent an exercise program versus fusion surgery in adult isthmic spondylolisthesis patients. Patients improved in the short and long-term. Follow-up mean was 9 years. (Ekman et al., 2005)
Grade III+ patients have less favourable outcomes and may require surgery if they do not respond positively to conservative treatment.
Secondary Spondylolisthesis Treatment Options
In recalcitrant cases, Pulsed Radio Frequency (PRF) is a pain management technique that can be administered to your facet joint nerves. Researchers have found it is more effective than epidural steroid injections, which is another short-term pain relieving option. (Hashemi et al., 2014)
Spondylolisthesis Surgery?
Surgery is occasionally warranted if you have failed your exercise-based conservative treatment. 10-15% of patients with degenerative spondylolisthesis have surgery. Surgery is considered when there is a failure to improve a radiculopathy eg muscle weakness, poor function or another neurological deficit such as loss of bowel or bladder function. Persistent severe pain is also a consideration for surgery.
Surgery for isthmic spondylolisthesis is considered for athletes with Grade III+ slips if they have failed 6-months of conservative exercise rehabilitation. (Radcliff et al., 2009)
Your surgery options are best discussed with your Spinal Surgeon, but they would normally involve a spinal decompression +/- spinal fusion.
Fortunately, conservative exercise options are successful in the vast majority of Grade I-II cases. Please consult with your physiotherapist for their professional assessment and specific treatment guidance for your spondylolisthesis.
FAQs about Spondylolisthesis
Common Lower Back Pain Causes
The following conditions may cause lower back pain.
General Information
Muscle-related Injuries
- Back Cramps
- Back Muscle Pain
- Core Stability Deficiency
- DOMS - Delayed Onset Muscle Soreness
- Fibromyalgia
- Side Strain
Bone-related Injuries
- Back Stress Fracture
- Osteoporosis
- Scheuermann's Disease
- Scoliosis
- Spinal Stenosis
- Spondylosis
- Spondylolysis
- Spondylolisthesis
- Stress Fracture Spine (Cricket Bowlers)
Disc-related Injuries
Back Joint Injuries
Nerve-related Injuries
Pelvis-related Injuries
Pregnancy-related Pain
Systemic Diseases
Nerve Pain
Nerve pain is pain that is caused by damage or disease that affects the nervous system of the body. It is also known as neuropathic pain or neuralgia. Nerve pain is a pain that comes from problems with signals from the nerves. It is different to the common type of pain that is due to an injury. This is known as nociceptive pain.What Causes Nerve Pain?
Neuropathic pain is caused by a problem with your nerves themselves, which sends pain messages to the brain.
What is Nerve Pain Symptoms?
Nerve pain is often described as burning, stabbing, shooting, aching, or like an electric shock.What Causes Nerve Pain?
Various conditions can affect your nerves and cause nerve pain. Common sources of nerve pain include:- Shingles (post-herpetic neuralgia).
- Trigeminal neuralgia.
- Diabetic neuropathy.
- Phantom limb pain following an amputation.
- Cancer.
- Multiple sclerosis.
- Chemotherapy.
- HIV infection.
- Alcoholism.
- Other nerve disorders.
Nerve Pain & Nociceptive Pain
You can suffer both nerve pain and nociceptive pain simultaneously. Both pain types can be caused by the same condition.Nerve Pain Treatment
Nerve pain is less likely than nociceptive pain to be helped by traditional painkillers such as paracetamol, anti-inflammatories and codeine. However, other types of medicines often work well to ease the pain. Nerve pain is often eased by anti-depressant or anti-epileptic medicines. Please ask your doctor for more advice.Pain Links
Pain & InjuryTens Machine
What is a TENS Machine?Pins and Needles - Paraesthesia
What Causes Pins & Needles?
A moderately pinched nerve is the most common cause of "pins and needles". Pins and needles are referred to as "paraesthesia" in the medical community. Did you know that feeling "pins and needles" can be a worse sign than having pain in your arm or leg? The reason is that you can't even feel pain anymore when you significantly squash the nerve.
Even worse than "pins and needles" is "numbness" or "anaesthesia", which is a total lack of sensation. You will experience anaesthesia when there is severe nerve compression. Anaesthesia or numbness that persists for more than a few hours can be a sign of permanent nerve compression. Please seek prompt medical attention to prevent the nerve from permanent damage and the muscles it innervates to weaken drastically.
The majority of pinched nerves and nerve compressions are only transient and quickly reversed with early treatment. However, neglect can lead to permanent nerve compression injuries, which may never recover.
Common Causes of Pinched Nerves
The most common forms of nerve compression are in the spinal joints where either a disc bulge or a bony arthritic spur can irritate and compress the nerve. Compressions can also occur as the nerve passes through or around muscles. Your physiotherapist will know where to look.
How Can You Fix "Pins and Needles"?
If you know of someone who is experiencing chronic or permanent "pins and needles", "numbness" or "muscle weakness", please encourage them to seek urgent professional advice. The secret to quick success is the correct diagnosis. A highly trained health practitioner such as your physiotherapist or doctor is your best port of call.
More info
Youth Spinal Pain
Teenager Neck & Back Pain
Teenagers can be particularly vulnerable to back pain, mainly due to a combination of high flexibility and low muscle strength and posture control.
The competitive athlete and most individuals who exercise regularly or maintain a level of fitness and core stability control are less prone to spine injury and problems due to the strength and flexibility of supporting structures. Your physiotherapist can assist the resolution of any deficits in this area. Luckily, issues involving the lower lumbar spine are rare in athletes and account for less than 10% of sports-related injuries. Injuries do occur in contact sports and with repetitive strain sports.
Sports such as gymnastics, cricket fast bowlers, and tennis have a higher incidence of associated lumbar spine problems related to repetitive twisting and hyper-bending motions.
Spondylolisthesis is a significant concern and needs to be appropriately treated by a physiotherapist with a particular interest in these type of injuries. Luckily, most injuries are minor, self-limited, and respond quickly to physiotherapy treatment.
Common Adolescent Spinal Injuries
Lower Back (Lumbar Spine)
Midback (Thoracic Spine)
Neck (Cervical Spine)
Pelvis
For specific advice regarding youth neck or back pain, please seek the professional advice of your trusted spinal physiotherapist or doctor. Common Youth & Teenager Sports Injuries Common Youth Leg Injuries Common Youth Arm Injuries
Back Muscle Strains
Back muscle injuries are the most common form of back injury. Muscle fatigue, excessive loads or poor lifting postures are the most common problems. Inefficient back muscles can lead to poor joint stabilisation and subsequent injury. More info: Back Muscle PainLigament Sprains
Ligaments are the strong fibrous bands that limit the amount of movement available at each spinal level. Stretching ligaments too far or too quickly will tear them with subsequent bleeding into the surrounding tissues, causing swelling and pain. Awkward lifting, sports injuries, and motor vehicle accidents are very common causes. Just as in other regions of the body, physiotherapy hastens ligament healing and relieves pain so that you can enjoy life again as soon as possible. More info: Back Ligament SprainsBulging Discs
A bulging disc injury is a common spine injury sustained to your spine's intervertebral disc. Spinal discs are the shock-absorbing rings of fibrocartilage and glycoprotein that separate your bony vertebral bodies while allowing movement at each spinal level, and enough room for the major spinal nerves to exit from the spinal canal and travel to your limbs. The annulus is the outer section of the spinal disc, consisting of several layers of multi-directional fibrocartilaginous fibres all densely packed to create a wall around the glycoprotein filled jelly-like disc nucleus. A disc bulge (commonly referred to as a slipped disc), can potentially press against or irritate the nerve where it exits from the spine. This nerve pinch can cause back pain, spasms, cramping, numbness, pins and needles, or pain in your legs. More info: Bulging DiscsBone Injuries
You can also fracture your spine if the force involved is highly traumatic or you have a low bone density (e.g. osteoporosis). More info: OsteoporosisPoor Posture
Poor posture when sitting, standing or lifting at work can place unnecessary stress on your spine. Muscles fatigue, ligaments overstretch, discs stretch and this places spinal joints and nerves under pain-causing pressure. More info: Poor PostureWhat Can Cause Severe Low Back Pain?
A sudden injury most often causes acute low back pain. The most common injury sources are the muscles and ligaments supporting the back. The pain may be caused by muscle spasms or a strain or tear in the muscles and ligaments. But occasionally, it can have a more sinister cause.Warning Signs of a More Serious Back Injury?
In these instances of neurological deficit, please urgently consult your nearest hospital, doctor or physiotherapist. The following neurological signs warrant prompt assessment:- pins and needles (paraesthesia),
- numbness (anaesthesia),
- leg muscle weakness,
- altered reflexes,
- difficulty walking,
- loss of control of bladder or bowels.
Non-Musculoskeletal Causes of Low Back Pain
Although most low back pain is musculoskeletal in origin, other health conditions can cause low back pain.- Abdominal aortic aneurysm
- Infection of the spine (osteomyelitis, discitis)
- Kidney infection or kidney stones
- Spondyloarthropathies: e.g. rheumatoid arthritis, psoriatic arthritis.
- Female reproductive organs: e.g. pregnancy complications, ovarian cysts or cancer, endometriosis
What Causes Lower Back Pain?
Researchers and spinal health care practitioners categorise lower back bain into the following categories: 1. Specific Spinal Pathologies (<1%) 2. Radicular Syndromes (5-10%)- Radicular pain, e.g. sciatica
- Radiculopathy
- Spinal Stenosis
Specific Spinal Pathologies
Some conditions that cause back pain do require an urgent and specific referral and treatment. These conditions include:- spinal infections
- cancer (malignancy)
- spinal arthropathies (e.g. rheumatoid arthritis or ankylosing spondylitis)
- cauda equina syndrome
- spinal fractures.
Radicular Syndromes
Lower back pain can result from structural damage that can irritate or pinch a nerve. Researchers believe that radicular syndrome causes 5-10% of back pain presentations to general practitioners.Radicular pain (e.g. sciatica)
The most common pinched nerve in the lower back is your sciatic nerve. You may be diagnosed with sciatica if you are suffering radicular pain down your leg due to a back injury. While the sciatic nerve is the most common nerve that can be affected by a spinal injury, you can modify any spinal nerve function (e.g. femoral nerve). The following back injuries may cause radicular pain:- Herniated disc (slipped disc)
- Facet joint sprain
- Spondylolisthesis
- Spondylolysis
- Degenerative disc disease
- Spondylosis
- Back ligament sprain.
Radiculopathy
Lumbar radiculopathy can result in functionally disabling conditions such as foot drop, foot slap or eversion muscle weakness that can affect your ability to walk.Spinal Stenosis
Spinal stenosis is a slightly different condition and relates to the narrowing of the spinal canal. Spinal stenosis is usually more prevalent as you age.Non-Specific Lower Back Pain (NSLBP)
Non-Specific Lower Back Pain (NSLBP) is the diagnostic term used to classify lower back pain sufferers with no specific structure injured. It is a diagnosis of exclusion. In other words, your spinal health care practitioner has excluded specific spinal pathologies and any of the radicular syndromes mentioned above as the cause of your back pain or symptoms. Fortunately, these conditions account for approximately 90-95% of lower back pain and can nearly always successfully rehabilitate without the need for surgery. Most improve within two to six weeks. They can be fast-tracked with pain relief and physiotherapy techniques such as manual therapy and back exercises.NSLBP Causes
The causes of NSLBP are numerous but roughly fall into either a sudden (traumatic) or sustained overstress injuries. Most people can relate to traumatic injury such as bending awkwardly to lift a heavy load that tears or damages structures. However, sustained overstress injuries (e.g. poor posture) are probably more common and more straightforward to prevent. In these cases, positional stress or postural fatigue creates an accumulated microtrauma that overloads your lower back structures over an extended period to cause injury and back pain. Most commonly, NSLBP causes include back muscle strain or back ligament sprain. Other chronic back conditions such as degenerative disc disease may underly your acute disc health and predispose you to the severe pain. The good news is that you can take measures to prevent or lessen most back pain episodes. Early diagnosis and specific individualised treatment are the easiest way to recover quickly from lower back pain and prevent a recurrence.What is Back Muscle Pain?
Back muscle pain or its aliases: pulled back muscle, back muscle spasm, torn back muscle or back muscle strain, is very common. Back muscle pain is the most common source of back pain. The good news is that it is also one of the quickest to heal and rehabilitate.
What Causes Back Muscle Pain?
Most causes of low back pain are muscle, ligament or joint-related. Commonly, these muscular strains, ligament sprains and joint dysfunction arises suddenly during or following physical loading of your spine. Muscle fatigue, excessive loads, high speeds or poor lifting postures are the most common causes. The causes of pure back pain are numerous but roughly fall into the following categories.Back Muscle Strains
Muscle pain is the most common source of back pain. Muscle fatigue, excessive loads or poor lifting or sitting postures are the most common problems. Inefficient, weak, or back muscles that lack endurance or normal contraction timing can lead to reduced joint stabilisation and subsequent injury to your back muscles, ligaments, joints or even spinal discs.Poor Posture
Poor posture, when sitting, standing and lifting at work, can place unnecessary stress upon your spine. With muscle fatigue or overstretching, your ligaments and discs can stretch, and this puts spinal joint muscles and nerves under pain-causing pressure or strain, that results in back pain.Ligament Sprains
Ligaments are the durable, fibrous bands that limit the amount of movement available at each spinal level. Stretching ligaments too far or too quickly will tear them with subsequent bleeding into the surrounding tissues, causing swelling, muscular spasm and pain. Awkward lifting, sports injuries and motor vehicle accidents are prevalent causes. Just as in other regions of the body, physiotherapy hastens ligament healing and relieves pain so that you can enjoy life again as soon as possible.What are the Symptoms of Back Muscle Pain?
Back muscle pain symptoms may range from a mild ache to sudden debilitating back pain. Typical back muscle pain symptoms include:- Localised back pain, with no radiation into your buttock or leg.
- Back muscle tenderness and spasm.
- Protective back stiffness.
- Sudden back pain onset.
How is Back Muscle Pain Diagnosed?
Differentiating a back muscle strain from a ligament sprain can be difficult, as both injuries will show similar symptoms. In general, it doesn't significantly matter what you call the problem because the treatment and prognosis for both back muscular strains and ligament sprains are similar. Most spinal practitioners refer to both injuries as a category called a "Back Strain" or "Musculoligamentous Strain". X-rays and CT scans do not identify muscle or ligament injury. MRI scan is probably the best diagnostic test to determine the muscle or ligament structures injured.What is Back Muscle Pain Treatment?
Seek a Professional Diagnosis!
A spinal healthcare practitioner, such as your physiotherapist, should thoroughly; examine you to exclude more severe sources of back pain. Numerous injuries can cause back pain, and the treatment does vary significantly depending on your diagnosis. Physiotherapy treatment aims to protect your damaged tissue while hastening your muscle and ligament healing and then look at strategies to prevent a recurrence. Your physiotherapist has some nifty tricks for quickly relieving your back pain so that you can enjoy life again as soon as possible.Back Strain Causes
We do know that some people are vulnerable to repeated lower back sprains and strains. While it is easier to understand that lifting a heavy load in an awkward position can cause back pain, it's harder to comprehend how a simple movement can hurt your back. Yes, it can happen by merely leaning forwards to pick up your teacup or when bending to brush your teeth! The reason is poor local joint control. The main reason for this is inadequate or non-existent muscle activation of the deep core stability muscles. These muscles are small but are right next to the joint to control excessive slides and glides. When they don't work correctly, the joint can slide too far and strain its supporting ligaments. Ouch! That hurts. The good news is poor core stability can be easily corrected to prevent back pain. Please contact your physio for more information or to have your core activation accurately assessed. High-risk factors of back pain include:- sudden forceful movement
- lifting a heavy object
- twisting the back
- coughing or sneezing
- prolonged sitting with poor posture