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Introduction

Spondylolisthesis refers to an anterior or posterior movement of a vertebrae in relation to its adjacent vertebrae.

Spondylolisthesis affects about between 5-12% of the population but most cases are asymptomatic. It is thought that in the cases where pain results, the pain is due to degeneration of the affected intervertebral disc.

Pain is typically exacerbated by prolonged standing, walking or exercise.

There are several causes, but many cases are thought to be secondary to laxity of the interspinous ligaments.

Generally spondylolisthesis is a relatively benign, although chronic disorder. Chronic pain can result in disability and reduced quality of life. Most cases respond well to conservative management, especially in teenagers. Surgery may be considered in resistant or more severe cases.

Spondylolisthesis

Spondylolisthesis of L4 / L5. Note how anterior of the L4 vertebral bodies sits in front of the the corresponding L5 vertebral body. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

 

Epidemiology

There are several types of spondylolisthesis:

  • Isthmic – the most common form. Acquired, usually in teenage years, and secondary to spondylosis (see below)
  • Degenerative – due to facet joint degeneration and osteoarthritis which can both cause bone remodelling
  • Traumatic
  • Pathological – from metastasis
  • Dysplastic – congenital and rare

Dysplastic, traumatic and pathological causes are rare.

  • Spondylosis(a common precursor to spondylolisthesis – see below) typically occurs between the ages of 6 and 16, and affected about 5% of the population. The incidence is as high as 15% in young athletes an gymnasts, thought to be the result of trauma-induced stress fractures. Particular at risk activities include:
    • Gymnastics
    • Rugby
    • Cricket
    • Footbal
    • Weight lifting
    • Diving
    • Tennis
  • F>M
  • 60-80% of people with spondylosis also have spondylolisthesis
  • 90% of cases affect L5, almost all other cases affect L4
  • Degenerative spondylolisthesis affects older patients

Aetiology

Risk factors include:

  • Female gender
  • Young age of onset
  • Wedge shaped vertebra
  • Hyperlordosis
  • Family history
  • High impact sports

 Pathology

  • Spondylosis is a separate disorder, but often precedes, and is associated with spondylolisthesis. It describes a Bony defect in the pars interarticularis, which results in the body of the vertebrae becoming partially separated from the vertebral arch and thus the normal support mechanisms in pace to prevent the body of the vertebrae from moving are reduced. It can be congenital, or the result of a stress fracture. It may be unilateral or bilateral.
Pars interarticularis

Pars interarticularis

Grading

Types of spondylolisthese are typically graded by the degree to which the vertebrae have slipped (there are 5 grades, from I-V, with grade V being the worst).

Other grading systems may differentiate types by the cause.

Presentation

  • Most cases are asymptomatic and may be discovered incidentally
  • Low back pain, particularly with extension of the lumbar spine
  • Spondylosis is typically NOT visible on x-ray – as the changes are subtle. Once it progresses to spondyolisthesis, then the degree of vertebral slippage may be visible on x-ray
  • Isthimic
    • Exercise related back pain
    • Pain received by rest
    • Tight hamstrings
    • Enhanced lordosis
    • Waddling gait”
    • Gluteal muscle wastage
    • Typical onset in adolescent years
    • Pain may radiate to buttocks or thighs, or have other features similar to that of vertebral disc prolapse
    • In severe cases, the slippage can cause cauda equina syndrome
  • Degenerative
  • Trauma. pathological and dysplastic
    • Features typically similar to other causes
    • Traumatic will obviously have a history of trauma, and if significant, , may have signs of cauda equina syndrome

Differential Diagnosis

Differentials are broad and I highly recommend reading the lower back pain article for an overview of assessing lower back pain.

Differentials include:

Investigations

Most presentations of lower back pain do not warrant investigation. However, be wary of cases presenting in people <20 and >50 years old – relevant to spondylolisthesis because in these patients, isthimic and degenerative spondylolistheses are relatively more common. In such patients, or in those with other back pain red flags or in other patients in whom back pain is not settling after 6-12 weeks, consider the following:

  • Bloods
    • CRP and FBC – for signs of infection (discitis)
    • FBC – myeloma
    • Calcium – hypo/herpcalcaemia
  • Lateral spine x-rays
    • Will show spondylolisthese and can help to give a grade
    • Perform x-rays at the position of maximum pain
  • CT +/- radionuclide scan – can better define the lesion than on x-ray, and is often used to assess if the lesion is stable of progressive
  • MRI may be performed pre-operatively

Management

The aims of treatment are to:

  • Reduce pain
  • Maintain or improve function
  • Prevent further slippage / stabilise the spine

>80% of symptomatic children will have complete resolution of symptoms with conservative management

Conservative management

  • Suitable or cases with <50% slippage, with no neurological signs
  • Sleep
    • Advise sleeping on the side with a pillow between the knees
  • Activity modification
    • If >25% slippage, patients should avoid high risk activities (typically weight lifting, contact sports, gymnastics)
  • Analgesia
    • Paracetamol 1g QID
    • NSAIDs – e.g. ibuprofen 400mg TDS
  • Steroid injection
    • May receive symptoms if there is nerve root compression
  • Brace
    • A brace may be advised if there is a part interarticularis fracture which has a good chance of healing
    • Some debate over whether or not this actually improve long-term outcomes
  • Physiotherapy
    • Biomechanical correction
    • Flexibility and strengthening exercises
    • Core stability exercises
    • Graduated return to activity levels

Surgical Intervention

Surgical intervention is indicated in:

  • Patients who fail to respond to conservative management
  • Evidence of progression (typically defined on x-rays several months apart)
  • Significant neurological deficit
  • Significant pain resulting in disability

Surgical procedures

  • There is often a long rehabilitation period following surgery
  • Surgery typically involves fusing the affected vertebrae with an adjacent vertebra. The damaged intervertebral disc is usually removed
    • The benefit or realignment surgery is controversial. Especially in slow or prolonged cases. Over time, there are associated changes in the surrounding musculature, and thus surgical realignment of the spine may not necessary provide benefit
    • In younger patients, or more acute episodes of spondylolisthesis, then realignment is likely to be of more benefit
    • Complication rates are high, especially in older patients
  • Decompression of nerves that have becomes squashed as a result of spoondylolisthesis is of more proven benefit
  • Neurological complications and chronic pain are potential complications

 

 

CT and X-ray of spondylolisthesis

52 year old male with a degenerative spondylolisthesis at L5 – S1.
(A) CT sagittal view of a low grade slip.
(B) Lateral radiograph pre-operative intervention. –
(C) Surgically treated with L5 – S1 decompression, instrumented fusion and placement of an interbody graft between L5 and S1. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

References

  • Spondylolisthesis - patient.info
  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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