Definition

Spondylolisthesis is the displacement of the lower spine that causes back pain. This displacement occurs forward, resulting in a change in the alignment of the spine. The term spondylolisthesis comes from the Greek words "spondylos" meaning "vertebra" and "listhesis" meaning "slippage or movement". As its name implies, spondylolisthesis is closely related to spinal stability. The abnormal movement of the spine exerts pressure on the nerves, causing lower back pain and leg pain.

A term often misinterpreted as spondylolisthesis is spondylolysis. Both can cause lower back pain, but they describe different conditions:

• Spondylolysis refers to a fracture or cracks in the vertebra.
• Spondylolisthesis refers to the forward displacement of a vertebra compared to the one below it.

Spondylolisthesis affects 4-6% of adults. A person can live with spondylolisthesis for years without realizing it. Degenerative spondylolisthesis (caused by aging) is more common in those over 50 years old and occurs more frequently in women than men. Spondylolisthesis in adolescents and young adults is called isthmic spondylolisthesis, which follows spondylolysis. Untreated spondylolysis can lead to spondylolisthesis, especially if the fracture is caused by a stress fracture.

Causes

There are three types of spondylolisthesis based on their causes:

• Congenital spondylolisthesis: Occurs during fetal development when the spine is not properly formed, increasing the risk of spondylolisthesis in old age.
• Isthmic spondylolisthesis: Occurs after spondylolysis. The fracture makes the spinal alignment more fragile and prone to movement.
• Degenerative spondylolisthesis: The most common type, associated with aging when the cushioning between the vertebrae and joints deteriorates.

Less common types include:

• Traumatic spondylolisthesis: Caused by trauma or accidents that displace the spinal alignment.
• Pathological spondylolisthesis: Caused by other medical conditions, such as osteoporosis or tumors.
• Post-surgical spondylolisthesis: Resulting from spinal surgery.

Risk factor

Several factors increase the risk of spondylolisthesis, including:

• Athletes: Young athletes involved in sports that strain the lumbar spine, like gymnastics and football, are at higher risk. Displacement often occurs during puberty or growth spurts and is a common cause of back pain in children and teenagers.
• Genetics: Some people have a genetic predisposition to isthmic spondylolisthesis, being born with thinner parts of the vertebrae that connect the spinal joints, making them more prone to fractures and leading to spondylolisthesis. Degenerative spondylolisthesis also has a strong genetic component.
• Age: With age, spinal degeneration weakens the vertebrae compared to when one is younger.

Symptoms

You can have spondylolisthesis without experiencing the symptoms listed below. If symptoms are present, the main one is lower back pain radiating to the back of the thighs. Other possible symptoms include:

• Hamstring muscle cramps (back of the thighs)
• Stiffness in the back
• Difficulty walking or standing for long periods
• Pain when bending forward
• Numbness or tingling in the legs

Diagnosis

The doctor will ask about your main complaint, the quality of the pain, its triggers, pain relievers, and the location of the pain. Spondylolisthesis is often accompanied by other complaints such as leg weakness, difficulty walking, and urinary issues like incontinence. The doctor will also inquire about medications you have taken for pain relief. A physical examination of your back will be conducted to check the spinal structure and locate the pain.

Additional tests are necessary to confirm a diagnosis of spondylolisthesis and rule out other possible causes. These tests include:

• X-ray: To view the structure and alignment of the spine.
• CT scan or MRI: May be needed if the doctor suspects involvement of soft tissues around the spine.

Management

Based on severity, spondylolisthesis can be categorized into:

• Low-grade spondylolisthesis (grade I and II): These cases are not severe and do not require surgery, commonly occurring in adolescents and degenerative spondylolisthesis.
• High-grade spondylolisthesis (grade III and IV): These cases require surgery due to the pain they cause.

For grade I and II spondylolisthesis, conservative therapy is recommended to prevent worsening, including:

• Rest: Avoid strenuous activities like sports for a few days.
• Pain relievers: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain. If these medications are ineffective, consult your doctor.
• Physical therapy: Can help with exercises to strengthen the abdomen and back. Light exercises may reduce pain after a few weeks.
• Bracing: A brace can help stabilize the spine. The brace aims to prevent excessive movement to allow proper healing. Bracing is generally not used for adults.

Approximately 10-15% of young patients with low-grade spondylolisthesis may require additional therapy, such as surgery. Indications for surgery include high-grade spondylolisthesis and pain that does not improve with conservative therapy. The goals of surgery are to relieve nerve pain, stabilize the spine, and restore function. Surgery involves decompression (reducing pressure on the nerves). During surgery, the surgeon will remove bone and disc material to create space for the spinal cord. The bones will fuse during healing. After surgery, pain will decrease, and you can gradually return to daily activities.

Complications

Untreated spondylolisthesis can lead to serious complications such as cauda equina syndrome, caused by compression of the lowest spinal nerves (cauda equina). If compression occurs, you may lose sensation and movement in your legs and experience urinary issues. This condition is a medical emergency requiring immediate treatment. Without proper care, cauda equina syndrome can cause permanent damage and paralysis.

Other complications include kyphosis (a hunched back), infections, and chronic pain interfering with daily activities.

Prevention

The following steps can help prevent spondylolisthesis:

• Engage in regular physical activity to strengthen the abdominal and back muscles.
• Maintain a healthy weight.
• Consume a nutritious and balanced diet to support bone health.
• If you have had spondylolisthesis, perform exercises to prevent recurrence. Consult your doctor about these exercises.

When to see a doctor?

Consult a doctor if you have persistent, worsening back pain that does not improve with pain relievers. Associated conditions such as urinary issues or sudden inability to move your legs are warning signs that require immediate medical attention.

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