Spondylolisthesis – Causes, Symptoms, Diagnosis, Treatment

Spondylolisthesis
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Spondylolisthesis is a condition in which one vertebra slips forward over the one below it. It is a slipping of vertebra that occurs, in most cases, at the base of the spine. Spondylolysis, which is a defect or fracture of one or both wing-shaped parts of a vertebra, can result in vertebrae slipping backward, forward, or over a bone below

Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the cervical spine and rarely, except for trauma, in the thoracic spine. Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese.  Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males. Dysplastic spondylolisthesis is more common in the pediatric population with females more commonly affected than males. Current estimates for prevalence are 6-7% for isthmic spondylolisthesis by the age of 18 years and up to 18% of adult patients undergoing MRI of the lumbar spine. Grade I spondylolisthesis accounts for 75% of all cases.  Spondylolisthesis most commonly occurs at the L5-S1 level with the anterior translation of the L5 vertebral body on the S1 vertebral body.  The L4-5 level is the second most common location for spondylolisthesis.

Spondylolisthesis is where a bone in the spine (vertebra) slips out of position, either forwards or backward.

spondylolisthesis

It’s most common in the lower back (lumbar spine), but it can also occur in the mid to upper back (thoracic spine) or the neck (cervical spine). Spondylolisthesis isn’t the same as a slipped disc, which is where one of the spinal discs between the vertebrae ruptures.

The word spondylolisthesis comes from the Greek words spondylosis, which means “spine” or “vertebra,” and listhesis, which means “to slip or slide

Classification / Types of Spondylolisthesis

Spondylolisthesis can be categorized by cause, location, and severity.

1.  By causes

  • Degenerative  – spondylolisthesis (a.k.a. type 3) is a disease of the older adult that develops as a result of facet arthritis and joint remodeling. Joint arthritis, and ligamentum flavum weakness, may result in slippage of a vertebra. Degenerative forms are more likely to occur in women, persons older than fifty, and African Americans.
  • Traumatic – spondylolisthesis is rare and results from acute fractures in the neural arch, other than the pars.
  • Dysplastic – spondylolisthesis (a.k.a. type 1) results from congenital abnormalities of the upper sacral facets or inferior facets of the fifth lumbar vertebra, and accounts for 14% to 21% of all spondylolisthesis.
  • Isthmic – spondylolisthesis (a.k.a. type 2) is caused by a defect in the pars interarticularis but it can also be seen with an elongated par.
  • Pathologic – spondylolisthesis (a.k.a. type 5) is caused by either infection or a malignancy.
  • Post-surgical/iatrogenic – spondylolisthesis (a.k.a. type 6) is caused by complications after surgery.

2.  By location

spondylolisthesis

Spondylolisthesis location includes which vertebrae are involved, and may also specify which parts of the vertebrae are affected.

Isthmic spondylolisthesis is where there is a defect in the pars interarticularis. It is the most common form of spondylolisthesis; also called spondylolysis spondylolisthesis, it occurs with a reported prevalence of 5–7 percent in the US population. A slip or fracture of the intravertebral joint is usually acquired between the ages of 6 and 16 years but remains unnoticed until adulthood. Roughly 90 percent of these isthmic slips are low-grade (less than 50 percent slip) and 10 percent are high-grade (greater than 50 percent slip). It is divided into three subtypes

  • A: pars fatigue fracture
  • B: pars elongation due to multiple healed stress fx
  • C: pars acute fracture

By Over all Types 0f spondylolisthesis

There are different types of spondylolisthesis. The more common types include.

  • Congenital spondylolisthesis — Congenital means “present at birth.” Congenital spondylolisthesis is the result of abnormal bone formation. In this case, the abnormal arrangement of the vertebrae puts them at greater risk for slipping.
  • Isthmic spondylolisthesis — This type occurs as the result of spondylolysis, a condition that leads to small stress fractures (breaks) in the vertebrae. In some cases, the fractures weaken the bone so much that it slips out of place.
  • Degenerative spondylolisthesis — This is the most common form of the disorder. With aging, the discs — the cushions between the vertebral bones — lose water, becoming less spongy and less able to resist movement by the vertebrae.

Less common forms of spondylolisthesis include

  • Traumatic spondylolisthesis, in which an injury leads to a spinal fracture or slippage
  • Pathological spondylolisthesis, which results when the spine is weakened by disease — such as osteoporosis — an infection, or tumor
  • Post-surgical spondylolisthesis, which refers to slippage that occurs or becomes worse after spinal surgery
  • Isthmic – spondylolisthesis refers to a defect within the pars interarticularis usually from repetitive microtrauma and accounts for the vast majority of cases in children and adolescents.
  • Degenerative – spondylolisthesis is the most common form of spondylolisthesis seen in adults. It is due to chronic degenerative changes at the posterior elements resulting in the incompetence of the surrounding ligamentous structures, leading to elongation and slippage.
  • Traumatic – spondylolisthesis can occur following a high-energy injury flexion/extension that causes a fracture-dislocation at the posterior elements.
  • Dysplastic – spondylolisthesis is a result of an abnormal formation of the posterior elements resulting in this subsequent instability.

Further classification by Grading

  • Type I – This is also called dysplastic or congenital spondylolisthesis. Congenital means that you’re born with it. Type I spondylolisthesis, then, is a defect in the articular processes of the vertebra (the part that’s supposed to control the movement of the vertebra; your facet joints are made of the articular processes). It usually happens in the area where the lumbar spine and the sacrum come together, the L5-S1 area. The defect allows the L5 vertebra (your last vertebra in your lumbar spine) to slip forward over the sacrum.
  • Type II – Also called isthmic, this is the most common kind of spondylolisthesis. With type II spondylolisthesis, there’s a problem with the pars interarticularis, a particular region of your vertebra. (You can see an illustration of this in Anatomy of Spondylolisthesis). Isthmic spondylolisthesis is divided further:
  • Type II A – Gymnasts, weight lifters, and football linemen are especially prone to this kind of spondylolisthesis. It’s caused by multiple micro-fractures on the pars interarticularis—micro-fractures that occur because of hyperextension (overarching) and overuse. The pars fractures completely in type II A.
  • Type II B – This type is also caused by micro-fractures. The difference, though, is that the pars don’t fracture completely. Instead, new bones grow as the pars heal, causing it to stretch. A longer par can then cause the vertebra to slide forward.
  • Type II C – Like type II A, this type has a complete fracture. However, it’s caused by trauma. The impact in a car accident could fracture your pars, for example.

A pars fracture can lead to a mobile piece of bone – the detached inferior articular process can actually move around. This bone fragment, also called a Gill fragment, can pinch the exiting nerve root, so the bone may need to be removed.Problems with the pars interarticularis can also be called spondylolysis. The word looks like spondylolisthesis, and they are somewhat related. Micro-fractures in the pars interarticularis—the kind that gymnasts, football linemen, and weightlifters are prone to—are a form of spondylolysis. The fractures are called spondylolysis; if the vertebra slips forward because it’s not being held in place properly, it’s called spondylolisthesis.

  • Type III – Aging can also cause spondylolisthesis. As you grow older, the parts of your spine can degenerate; they can wear out. Usually, your intervertebral discs change first. The older you get, the less water and proteoglycan content the discs have—and less fluid makes them less able to handle movement and shock. Less fluid can also cause the disc to thin, and a thinner disc brings the facet joints closer together. Without the disc acting as the cushion, the facets can’t control the spine’s movement as well, and they become hypermobile.
  • Type IV – Similar to type II C, type IV involves a fracture. However, it’s a fracture of any other part of the vertebra other than the pars interarticularis. Your facet joints, for example, can fracture, separating the front part of your vertebra from the back part.
  • Type V –  Tumors on the vertebra can also cause spondylolisthesis because they weaken the bones and can cause fractures that split your vertebra, leading to instability and a potential slip.
  • Type VI – You have this type of spondylolisthesis if the surgery caused your vertebra to slip forward. It’s also known as iatrogenic spondylolisthesis, and it’s caused by a weakening of the pars, often as a result of a laminectomy (a typical back surgery, but type VI spondylolisthesis isn’t a typical result of the surgery).

According to FDA and WHO

Spondylolisthesis, a related condition to spondylolysis, is defined by the forward displacement of the upper vertebra relative to the caudal vertebra. In 1976 Wiltse et al. classified spondylolisthesis into five types:

  • Type I or dysplastic: This is attributed to congenital dysplasia of the superior articular process of the sacrum.
  • Type II or isthmic: is due to a lesion in the pars interarticularis; these subclassify as:
    • (a) Lytic, when a fatigue pars fracture is present
    • (b) Pars elongation due to multiple healed stress fractures
    • (c) Acute pars fracture
  • Type III or degenerative: originates from facet instability without a pars fracture.
  • Type IV or traumatic: the displacement is due to an acute posterior arch fracture other than pars.
  • Type V or pathological: is due to posterior vertebral arch bone disease.
  • Type VI or iatrogenic: it is a potential sequel to spinal surgery.

For this activity, the focus will be on type II or isthmic spondylolisthesis.

Spondylolisthesis was classified by Meyerding et al.  in five subtypes according to the magnitude of slippage on plain lateral lumbar radiograph measured in accordance to the inferior vertebra.

  • Grade I,  less than 25% of displacement,
  • Grade II, between 25 and 50%,
  • Grade III, between 50 and 75%,
  • Grade IV, between 75 and 100% and
  • Grade V or spondylosis, when there is no contact between the vertebrae endplates. The commonly used Grade V, representing more than a 100% slip or spondylosis, is not part of the original grading system.

The majority of pars lesions or spondylolysis occur at L5 (85 to 95%), with L4 being the second most commonly affected vertebra (5 to 15%). The other lumbar levels are less often affected. The defect is unilateral in 22% of the cases.

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Retrolisthesis

Retrolistheses are found most prominently in the cervical spine and lumbar region but can also be seen in the thoracic area.

Causes of Spondylolisthesis

spondylolisthesis

There are five main types of spondylolisthesis, each with a different cause. Spondylolisthesis can be caused by

  • a birth defect in a part of the vertebra – this can cause it to slip forward (dysplastic spondylolisthesis)
  • repetitive trauma to the spine – this results in a defect developing in the vertebra, which can cause it to slip; this is known as isthmic spondylolisthesis and is more common in athletes such as gymnasts and weightlifters
  • the joints of the vertebrae becoming worn and arthritic – this is known as degenerative spondylolisthesis and is more common in older people
  • a sudden injury or trauma to the spine – such as a fracture, which can result in the vertebra slipping forward (traumatic spondylolisthesis)
  • a bone abnormality – this could be caused by a tumor, for example (pathologic spondylolisthesis)

Causes Of Post Operative Spondylolisthesis

  • Postoperative causes – It is the basic cause of an unsuccessful operation. It may be caused by the unconsciousness of the surgeon or vertebral malformation and abnormal nerve root compression with a spondylolisthesis.
  • Intraoperative causes  – it is the sense or mistake of failed back surgery syndrome to include the operation in the wrong way or furthers unconsciousness of the patient not maintain the proper guideline in that are given after discharge from hospital. 
  • The wrong vertebral  – It another cause of post-operative spondylolisthesis. The vertebral column may have suberization or sacralization means the stiffness formation in associate joints.
  • Lumbar decompression surgery – It is one of the most causes of post-operative spondylolisthesis. In such a condition nerve damage, spinal canal stenosis, disc herniation, and, inadequate decompression of a nerve root, preoperative nerve damage or postoperative that does not heal after decompressive surgery, or nerve damage that occurs during the surgery.
  • Scar tissue considerations – It causes after surgery in such as forming epidural fibrosis scar tissue formation, which around the nerve root and spinal column
  • Lake of Postoperative rehabilitation – Postoperative rehabilitation is an important factor for postoperative PLID. Due to adequate consciousness of continued pain from a secondary pain generator.
  • Spasms & Joint Lockage – It is one of the bad symptoms of the possibility of another issue is joint lockage and muscle spasms. Muscle spasms and cramps are not too uncommon immediately after surgery, but they shouldn’t occur after recovery. If you struggle to bend your leg or get sudden spasms and cramps preventing you from walking, then you must immediately consult a professional.
  • Sudden forceful thrust – It is the major or vital cause of postoperative spondylolisthesis. It caused by the conditions of the unconscious lifestyle, not maintain proper posture and spine positions.
  • Over Bending – Over bending also causes post-operative spondylolisthesis and back pain. In the maximum daytime and office work frequently we have to bend our spine forwardly that are causes the post-operative spondylolisthesis.
  • Lake of Adequate exercise –  It is another cause of post-operative, to maintain a healthy life minimum of two our exercise is essential for everyone. But lake of proper time it is not possible to perform the exercise and our body, cell, muscle, ligament, tendon don’t work properly or without exercise back muscle and whole body are not flexible and it causes the post-operative spondylolisthesis.

Long term back pain

Possible causes of spondylolisthesis are

  • Degenerative (arthritis)
  • Congenital (birth defect)
  • Isthmic, (having a spondylotic defect)
  • Traumatic (stress fractures etc often caused by repetitive hyper-extension of the back eg: gymnasts)
  • Pathologic (bone disease)

Many people may not realize they have spondylolisthesis because it doesn’t always cause symptoms.

Symptoms of  Spondylolisthesis

spondylolisthesis

Symptoms depend on the amount of contact with the nerves. They may include:

The severity of these symptoms can vary considerably from person to person.

Spondylolisthesis Grading

Spondylolisthesis

A radiologist determines the degree of slippage upon reviewing spinal X-rays. Slippage is graded I through IV:

  • Grade I — 1 percent to 25 percent slip
  • Grade II — 26 percent to 50 percent slip
  • Grade III — 51 percent to 75 percent slip
  • Grade IV — 76 percent to 100 percent slip

Generally, Grade, I and Grade II slips do not require surgical treatment and are treated medically. Grade III and Grade IV slips might require surgery if persistent, painful, slips are present.

spondylolisthesis

Spondylolisthesis Diagnosis

Early diagnosis of AS is important if the fusion of the joints and permanent stiffening of the spine is to be avoided. It can be difficult to diagnose in the early stages as symptoms may be attributed to more common causes of back pain.   A doctor will evaluate the following when diagnosing the condition:

  • A full medical history, including any family history of AS
  • Discussion of current symptoms including a history of back pain
  • The age of the patient when the pain started

History

  • Allow extra time to evaluate initially or properly
  • Essential to have prior records of medical record
  • Preoperative vs. Postoperative complaints and associate test
  • Was there a new problem immediately after surgery or not?
  • Current medication usage and issues of dependency.
  • Careful assessment of the psychological status
  • Vocational status and workers’ compensation
  • Postoperative systemic complaints(often subtle)
  • Back vs Leg pain that radiates or not
  • Unusual pain pattern (reflex sympathetic dystrophy, complex regional pain, )
  • Postoperative rehabilitation (aerobic, flexibility, strengthening, body mechanics, physical therapy).
  • Relieving and exacerbating positions and activities.

Physical Examination

  • Observe closely for pain behavior as a warning of associated problems.
  • Careful neurologic exam for focal localizing findings.
  • Evaluate for the potential major joint problem as referral source (hip, knee)
  • Palpation at surgery site for hematoma, local fluid, abscess, and pseudo meningocele.
  • Examination of extremity for sympathetic or RSD -type changes.
  • Screening for neural tension signs (SLR, Adson’s test)
  • Long tract signs (Babinski’s sign, clonus, Hoffman’s sign)
  • Vascular assessment (diabetics, elderly patients)
  • Local soft tissues (psoas muscle, iliotibial band, gluteal muscles)

Manual Examination

  • Straight Leg Raising Test – A manual test for pain from a disc herniation or nucleus proposal may present with a positive sign on straight leg raise.  Focal neurological deficits in post-operative back pain and spondylolisthesis that patients warrant further testing. Deficits in strength or sensation in the lower extremities may help nerve roots are affected and cause pain.
  • Waddell signs –It is are one of the vital manual tests that can be used to evaluate for psychogenic cause of lower back pain; while the interpretation of these tests is controversial, they may be useful especially if there is a suspicion of secondary gain.
  • One leg hyperextension test/stork test – It a simple and manual or home test the patient can do it own have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. If pain with hyperextension is the resulting increase positive for a pars interarticularis defect or associate abnormalities with post-operative spondylolisthesis.
  • Adam test – Patient has to bend over with feet together and arms extended with palms together. The practitioner should observe from the front side of you. If a thoracic lump is present on one left side or the other right side lower back pain, it is an indication of spine scoliosis with spondylolisthesis.There are numerous other examination techniques; however, they have mixed and anonymous evidence for inter-practitioner reliability and poor sensitivities or specificities lower back pain.

Lab test

  • Blood tests – CBC, Hb, RBS, CRP, Serum Creatinine, Serum Electrolyte. Blood tests may show the presence of the HLA-B27gene, a raised ESR (erythrocyte sedimentation rate), and a reactive protein that indicates inflammation.
  • Erythrocyte sedimentation rate and C-reactive protein – It may be used to evaluate for possible infection, especially in patients with constitutional symptoms or a predisposition towards infection.  Adherence to strict standards of accurate needle placement, contrast injection, as well as a limited active agent is essential in improving the sensitivity and specificity of these blocks.
  • Bone scan – It is a bone scan test that may be used for detecting bone tumors or compression of nerve root fractures caused by brittle bones and osteoporosis. The patient may receive an injection of a tracer (a radioactive substance) into a vein at the same time. The tracer collects or examines the bones and helps the doctor detect bone problems with the aid of a special camera.
  • Electromyography (EMG) – It one kind of test that helps assess the electrical activity in a muscle and nerve impulse velocity or nerve root compression and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body that is causing pain.
  • Evoked potential studies – It may involve two sets of electrodes are placed one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal that is transmitted to the brain.
  • Nerve conduction studies (NCS) – It also uses two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage for lower right and left side back pain.

Imaging

  • X-rays – It is a fundamental, simple and inexpensive first imaging system to evaluate to detect the bone and vertebrae related problem for suspected failed back surgery syndrome. X-rays are more specific use for detecting vertebral and sacroiliac defects and/or misalignment and are superior to MRIs for the detection of spondylolisthesis. Adjacent segment degeneration and loss of lordosis are common abnormalities found on radiography. However, X-rays are unable to detect spinal stenosis, the most common pathological finding in post-operative PLID, and are also unable to evaluate soft tissue, such as intervertebral discs, epidural scarring, or fibrosis.
  • MRI – It is the confirmation test with and without gadolinium contrast with one of the latest tests that continues to be the gold standard imaging modality for post-operative spondylolisthesis due to its excellent ability to detect soft tissue abnormalities such as epidural fibrosis and disc herniation. Contrast is especially indicated in patients with a history of disc herniation surgery. In patients with ferromagnetic implants, a CT myelogram is used to avoid implant artifacts created on MRI. It is the preferred and most sensitive study to visualize herniated disc, bulging disc, or sequestered disc. MRI findings will help to find the soft tissues, ligament, tendon, cartilage even spinal cord clearly to surgeons and other providers plan procedural for lower right and left side back pain care if it is indicated.
  • CT myelography -It is a special kind when the patient has either a contraindication to having an MRI such as heart problem, open-heart surgery, or having a pacemaker device or defibrillator or be used when a standard CT or MRI is negative or equivocal. Myelography is a CT scan or an MRI with intrathecal administration of contrast for post-operative spondylolisthesis. CT myelography visualizes a patient’s spinal nerve roots in their passage through the neuroforamina area. CT myelography can be used to assess the underlying root sleeve and nerve root compression. A CT is a poor test for the visualization of nerve roots, making it challenging to diagnose radicular disease.
  • Electromyography (EMG) – It is complete after three weeks of symptoms, not before the lower right and left back pain and post-operative spondylolisthesis. Diagnostic tests such as EMG or nerve conduction studies are accurate only after three weeks of persistent symptoms of right or left lower back pain with post-operative spondylolisthesis. The primary reason or why using an EMG or nerve conduction study is to identify the delayed three weeks or more time following the development of pain is because of fibrillation potentials after an acute injury in the brain and spinal cord lead to an axonal motor loss. These do not develop until two to three weeks following injury for the lower right and left back pain.
  • Cerebrospinal fluid analysis – It is a useful test for investigating the right and left lower back pain if there is an involvement of neoplasm or infectious cause or radiculopathy symptoms and radiating pain syndrome or post-operative spondylolisthesis. The recommendation for lower right and left back pain with post-operative spondylolisthesis in lumbar puncture is in the case of a patient with negative or nondiagnostic neuroimaging, without knowing primary cancer and its related condition, who has progressive neurological symptoms and has failed back syndrome and spondylolisthesis to improve it properly.
  • Bone scintigraphy – It is a special type of test that is done when some or above mention test failed to identify the causes of right and left lower back pain, spondylolisthesis with single-photon emission computed tomography (SPECT) is more sensitive in detecting facet joint lesions and bony lesion, none spurs and allows more accurate anatomical localization of lower back pain and spondylolisthesis. A recent study suggested that SPECT could help to identify patients with lower back pain who would benefit from facet joint intraarticular injections []. Facet joint block (FJB)injection is an indispensable diagnostic instrument in order to identify painful or painless back pain from painless facet joints and to plan the intervention strategy.
  • Foraminal nerve root entrapment test – It is best visualized on T1-weighted MRI where are used to identify the high contrast fat tissue and the nerve root sheath that is of great help for lower and right or left ba. In here usually, a combination of hypertrophic degenerative facets with osteophytes spurs posteriorly, and vertebral osteophytes and/or disc herniation anteriorly diminishes the anteroposterior diameter of the foramen and its associate condition. Foraminal height is erased by degenerative disc disease and subsequent disc height loss or not. In this case, the normal rounded (oval) appearance of the nerve root sheath is lost in combination with loss of the surrounding fat tissue, nerve root compression should be considered to identifying the lower right and left side back pain.
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Spondylolisthesis

In order for a diagnosis of AS to be made, a referral to a rheumatologist – who specializes in treating arthritis – may be recommended.

Spondylolisthesis

Treatment of Spondylolisthesis

Non-surgical

  • Rest – Initially, spondylolisthesis treatment includes resting as much as possible. Lying on your back on a firm mattress is typically the most comfortable position. Try to avoid extended periods of sitting. Your doctor may order a brace as a spondylolisthesis treatment to limit movement in your spine.
  • Avoid strenuous activity – This includes avoiding bending and lifting and avoiding prolonged standing.
  • Apply ice and/or heat – At first, ice can be helpful to relieve the initial inflammation as a treatment for spondylolisthesis. Apply an ice pack wrapped in a thin T-shirt or towel to your back for about 20 minutes several times daily. If you don’t have an ice pack, use a bag of frozen vegetables. Heat relaxes muscle spasms and increases blood flow to injured tissues. Use the low or medium setting on a heating pad, or try a steamy shower. Sometimes alternating heat and cold applications is an effective spondylolisthesis treatment to help relieve pain.
  • Alternative spondylolisthesis treatments – Acupuncture or acupressure helps relieve spondylolisthesis pain for some patients. Some people also find chiropractic care to be an effective alternative spondylolisthesis treatment. If you try an alternative therapy, be sure to find practitioners who are skilled in the treatment of spondylolisthesis.    
  • Bracing – Some patients may need to wear a back brace for a period of time to limit movement in the spine and provide an opportunity for a recent pars fracture to heal. We did not find any studies that specifically evaluated brace treatment for symptoms associated with DS. However, Prateepavanich et al. [] evaluated the effectiveness of a lumbosacral corset in a self-controlled comparative study on 21 patients (mean age 62.5) with symptomatic degenerative lumbar spinal stenosis (neurogenic claudication). Patients treated with the corset showed a statistically significant improvement in walking distance and decrement of pain score in daily activities in comparison with patients who did not wear the corset. Because most patients with symptomatic DS suffer from neurogenic claudication, the use of bracing needs to be examined for the treatment of patients with DS.
  • Physiotherapy – Stabilization exercises are the mainstay of treatment. These exercises strengthen the abdominal and/or back muscles, minimizing bony movement of the spine. Generally, eight to 12 weeks of aggressive daily treatment with stabilization exercises are needed to achieve clinical improvement. is the most common method used to apply a non-operative treatment of symptoms associated with DS? Therapeutic protocols may include the use of modalities for pain relief, bracing, exercise, ultrasound, electrical stimulation, and activity modification [ ]. Unfortunately, some of the evidence for the effectiveness of physical rehabilitation methods is coming from case reports [ ] and cannot be generalized to the rest of the population. Physiotherapy treatment is recommended to reduce pain [], restore range of motion and function, and strengthen and stabilize the spine [] and restore mobility of the neural tissue [].
  • Flexion/extension Physiotherapy –  is the most common method used to apply the non-operative treatment of symptoms associated with DS. Therapeutic protocols may include the use of modalities for pain relief, bracing, exercise, ultrasound, electrical stimulation, and activity modification []. Unfortunately, some of the evidence for the effectiveness of physical rehabilitation methods is coming from case reports [] and cannot be generalized to the rest of the population. Physiotherapy treatment is recommended to reduce pain [], restore range of motion and function, and strengthen and stabilize the spine [ ] and restore mobility of the neural tissue []. Flexion strengthening exercises those doing flexion and those doing extension back strengthening exercises. All patients received instructions on posture, lifting techniques, and the use of heat for the relief of symptoms. After 3 months, only 27% of patients who were instructed in flexion exercises had moderate or severe pain and only 32% were unable to work or had limited their work.
  • Stabilization exercises – O’Sullivan et al. [] found that individuals with chronic LBP and a radiological diagnosis of spondylolysis or spondylolisthesis who underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at 30-month follow-up. The control group that received treatment as directed by their treating practitioner showed no significant change in these parameters after intervention or at follow-up. Lindgren et al. [] found that exercise therapy in patients with chronic low back pain and segmental instability symptoms can improve strength and electromyographic parameters of paraspinal muscles, but not change the radiographic signs of instability.
  • Combined treatment – As we mentioned before, symptoms associated with spinal stenosis are the main complaint of patients with DS. Simotas et al. [] report on a case series of 49 patients treated non-operatively for spinal stenosis. In addition to pharmacologic intervention that may have included oral analgesics and ESI, the intervention consisted of therapeutic exercise (postural instruction, lumbopelvic mobilization exercises, and a flexion-based exercise program). After 3 years, nine of 49 patients (18%) had surgical intervention. Five patients (10%) reported their condition to be worse, and the remaining 35 patients (71%) either reported no deterioration in their condition or reported improvement (slight or sustained). The authors conclude that aggressive nonoperative treatment for spinal stenosis remains a reasonable option.
  • Spinal manipulation – Spinal manipulation is an alternative treatment often pursued by patients. No randomized clinical trials of patients with spondylolisthesis or spinal stenosis have been done. We found only one study [] that evaluated the effectiveness of spinal manipulative therapy for LBP by comparing two groups of patients: a small group (25) of patients with lumbar spondylolisthesis and a larger group (260) of patients without spondylolisthesis. This study showed that the results of manipulative treatment are not significantly different in patients with or without lumbar spondylolisthesis. Patients may have some short-term pain relief from chiropractic manipulation, but no long-term benefit has been proven.
  • Conservative treatment — The person should take a break from sports and other activities until the pain subsides. An over-the-counter non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen might be recommended to help reduce pain and inflammation (irritation and swelling). Stronger medications might be prescribed if the NSAIDs do not provide relief. Epidural steroid injections — in which medication is placed directly in the space surrounding the spine — might also help reduce inflammation and ease the pain.
  • A brace or back support – might be used to help stabilize the lower back and reduce pain. A program of exercise and/or physical therapy will help increase pain-free movement, and improve flexibility and muscle strength. Periodic X-rays are done to determine if the bone slippage is continuing.
  • Holistic therapy – Some patients want to try holistic therapies such as acupuncture, acupressure, nutritional supplements, and biofeedback. The effectiveness of these treatments for spondylolysis and spondylolisthesis may aid you in learning coping mechanisms for managing pain as well as improving your overall health.

Medications of Spondylolisthesis

Your first step to treat AS will be taking drugs called nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs help relieve inflammation, pain, stiffness, and swelling. Still, NSAIDs do not treat the problems with your immune system when you have AS. These problems cause damage to your joints and bones.

  • Analgesic medications  – are those specifically designed to relieve pain. They include OTC acetaminophen and aspirin, as well as prescription opioids such as codeine, oxycodone, hydrocodone, and morphine. Opioids should be used only for a short period of time and under a physician’s supervision. People can develop a tolerance to opioids and require increasingly higher dosages to achieve the same effect. Opioids can also be addictive. Their side effects can include drowsiness, constipation, decreased reaction time, and impaired judgment. Some specialists are concerned that chronic use of opioids is detrimental to people with back pain because they can aggravate depression, leading to a worsening of the pain.
  • Nonsteroidal anti-inflammatory drugs (NSAIDS) – relieve pain and inflammation and include OTC formulations (ibuprofen, ketoprofen, and naproxen sodium). Several others, including a type of NSAID called COX-2 inhibitors, are available only by prescription. Long-term use of NSAIDs has been associated with stomach irritation, ulcers, heartburn, diarrhea, fluid retention, and in rare cases, kidney dysfunction and cardiovascular disease. The longer a person uses NSAIDs the more likely they are to develop side effects. Many other drugs cannot be taken at the same time a person is treated with NSAIDs because they alter the way the body processes or eliminates other medications.
  • Anticonvulsants—drugs primarily used to treat seizures—may be useful in treating people with radiculopathy and radicular pain.
  • Antidepressants – such as tricyclics and serotonin and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain, but their benefit for nonspecific low back pain is unproven, according to a review of studies assessing their benefit.
  • Muscle Relaxants – If the muscles around the slipped disc experience painful spasms, a muscle relaxant such as Valium may be useful. The drawback to drugs like these is that they do not limit their power to the affected nerve. Instead, they have a generally relaxing effect and will interfere with daily activities. Cyclobenzaprine (Flexeril), might be prescribed to relieve the discomfort associated with muscle spasms. However, these medicines might cause confusion in older people. Depending on the level of pain, prescription pain medicines might be used in the initial period of treatment.
  • Steroids – If inflammation is severe, a doctor may also prescribe a steroid. Steroids, such as cortisone, reduce swelling quickly. A cortisone shot directly in the affected area will have an immediate effect on the displaced disc.
  • Counter-irritants – such as creams or sprays applied topically stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Topical analgesics reduce inflammation and stimulate blood flow.
  • Nerve Relaxant — Pregabalin or gabapentin and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve).
  • Calcium & vitamin D3 – to improve bone health and healing fractures.
  • Glucosamine & Diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.
  • Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
  • Dietary supplement -to remove the general weakness & improved the health.
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Treatment for spondylolisthesis depends on several factors, including the age and overall health of the person, the extent of the slip, and the severity of the symptoms. Treatment most often is conservative, involving rest, medication, and exercise. More severe spondylolisthesis might require surgery.

Surgery of Spondylolisthesis

  • Surgery might be necessary if the vertebra continues to slip or if the pain is not relieved by conservative treatment and begins to interfere with daily activities. The main goals of surgery for spondylolisthesis are to relieve the pain associated with an irritated nerve, to stabilize the spine where the vertebra has slipped out of place, and to increase the person’s ability to function.
  • Usually, two surgical procedures are used to treat spondylolisthesis. The first procedure is a decompressive laminectomy, which involves removing the part of the bone that is pressing on the nerves. Although this procedure can reduce pain, removing a piece of bone can leave the spine unstable.
  • The second procedure, called spinal fusion, is performed to provide stability. In a fusion, a piece of bone is transplanted to the back of the spine. As the bone heals, it fuses with the spine — creating a solid mass of bone — keeping the spine from moving and stabilizing it. In some cases, instruments such as rods or screws are used to hold the vertebra firm as the fusion heals.

Spondylolisthesis  Exercises

In spondylolisthesis, one of the vertebra in your spine slips forward out of its normal position onto the vertebra below it. This can cause pain and other symptoms. One treatment for this condition is surgical spinal fusion, but non-surgical spondylolisthesis treatments and exercises are also often recommended.

Exercises 

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced, and other exercises. As a general rule, the addition of exercises or progression to more advanced exercises should only take place provided there is no increase in symptoms.

Initial Exercises

Transversus Abdominus Retraining

Slowly pull your belly button in “away from your belt line” and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 3). Practice holding this muscle at one-third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain-free. Repeat 3 times daily.

spondylolisthesis-exercise

Rotation in Lying

Begin this exercise lying on your back as demonstrated (figure 4). Slowly take your knees from side to side as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms

.spondylolisthesis-exercise

 Rotation in Lying,Hip Flexion

Slowly take your knee towards your chest as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 5). Use your hands to gently bring your knee closer to your chest. Repeat 5 – 10 times on each leg provided there is no increase in symptoms.

spondylolisthesis-exercise-3

Hip Flexion

Intermediate Exercises

Knees to Chest

Begin lying on your back with your knees bent. Slowly take both knees towards your chest using your hands to assist as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 6). Repeat 5 – 10 times provided there is no increase in symptoms.

Knees to Chest

Knees to Chest

Cat Stretch

Begin this exercise on your hands and knees, with your hands in front of you above the level of the head. Gently take your weight back towards your heels, bringing your bottom towards your ankles as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 7). Hold for 2 – 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain-free.

spondylolisthesis-cat pose

 Cat Stretch

Bridging

Begin this exercise lying on your back in the position demonstrated (figure 8). Slowly lift your bottom pushing through your feet, until your knees, hips, and shoulders are in a relatively straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Repeat 10 – 20 times provided the exercise is pain-free.

Swiss Ball Squats

Begin this exercise in standing with your feet shoulder-width apart, your feet facing forwards and a Swiss Ball placed between a wall and your back, as demonstrated. Alternatively, you can perform these exercises with your back against a wall (ideally with a low friction surface). Slowly perform a squat, keeping your back straight. Your knees should be in line with your middle toes and should not move forward past your toes. Perform 10 – 20 repetitions provided the exercise is pain-free. Maintain activation of your transversus abdominis muscle throughout the exercise.

spondylolisthesis-swallwall

 Swiss Ball Squats

Sciatic Nerve Glide

Begin this exercise lying on your back, with your knee supported above your hip (by your hands) and your toes held up towards your shin. Slowly straighten your knee as far as you can go without pain and provided you feel no more than a mild to moderate stretch, then return to the sta

Chiropractic Care

spondylolisthesis
The main goals of chiropractic care in the treatment of spondylolisthesis include:

  • Optimize good spinal mechanics
  • Improve posture
  • Improve spinal function

Chiropractors do not reduce the slippage of spondylolisthesis. Instead, they address the spinal joints above and below the slipped vertebra—helping to address the mechanical and neurological causes of the pain, not the spondylolisthesis. This can help relieve low back pain and improve motion in the region.

Chiropractic Treatments for Spondylolisthesis

Your treatment plan depends on your symptoms. Your chiropractor may use one of the different types of spinal manipulation (also referred to as a “spinal adjustment”)—active, hands-on techniques that help restore spinal motion—to improve joint motion. Spinal manipulation techniques your chiropractor may use include:

  • Specific spinal manipulation identifies the joints that are restricted or those that show abnormal motion. A gentle thrusting technique that helps to return motion to the joint by stretching the soft tissues and stimulating the nervous system.
  • The Flexion-distraction technique is a gentle, non-thrusting type of manipulation usually used for degenerative disc conditions and facet strain that may be related to spondylolisthesis. This treatment is hands-on and uses a specialized table to assist the chiropractor—but instead of direct force, it’s a slow pumping action.
  • Instrument-assisted manipulation is another non-trusting technique. With this technique, the chiropractor applies force using a hand-held instrument without thrusting into the spine.

Your chiropractor may also use manual therapies in addition to spinal manipulation to treat injured soft tissues, such as muscles.

  • Trigger point therapy helps the chiropractor identify specific hypertonic (tight), painful points on a muscle. He or she puts pressure (using his or her fingers) on these points to reduce the tension.
  • Manual joint stretching and resistance techniques, such as muscle energy therapy, can be used.
  • Instrument-assisted soft tissue therapy can help treat injured soft tissue of the spine.

Spondylolisthesis

References

Spondylolisthesis

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