Spondylolisthesis

Spondylolisthesis is a common cause of back and leg pain in both adolescents and adults. The term spondylolisthesis comes from the Greek words spondylos, meaning vertebrate, and oliothesis, meaning slipping. Spondylolisthesis describes the abnormal slipping or dislocation between two vertebrate. The causes, severity, and symptoms associated with spondylolisthesis are quite variable. Many people with spondylolisthesis have no symptoms while others may have chronic low back pain, leg pain, or neurogenic claudication from spinal stenosis.

Spondylolisthesis is divided into 5 main types, based on the cause of the vertebrate slippage. These types are:

Isthmic: This is the most common type of spondylolisthesis in adolescents and young adults. The slippage most commonly occurs in the lowest part of the spine, between the 5^th lumbar and 1^st sacral vertebrate, although it may occur at higher levels in the lumbar spine. It is caused by a stress fracture in the back portion of the spine, an area known as the pars articularis. Even though these fractures usually occur in adolescents and young adults, symptoms may not occur until many years or even decades later.

Degenerative:  This is the most common type of spondylolisthesis in adults.  As it’s name implies, vertebral slipping is caused by wear and tear degenerative changes in the disc and facet joints of the spine that weakens the attachments between two adjacent vertebrate to allow slippage.  Degenerative spondylolisthesis is a common cause of spinal stenosis and neurogenic claudication in adults.  The most common location of degenerative spondylolisthesis is between the 4^th and 5^th lumbar vertebrate.

Traumatic:  Fractures arising from acute trauma to the spine may result in slippage of vertebrate.

Dysplastic: This type of spondylolisthesis, also called congenital (present at birth) spondylolisthesis, is caused by abnormal development of the spine. It usually occurs in the lower lumbar and sacral spine.

Pathologic: Erosion or damage to the back portion of the spine from tumors, bone conditions, or even previous spinal surgery, including the lamina, facet joints and connecting ligaments may also weaken the attachments between adjacent vertebrate and result in spondylolisthesis.

Many people with spondylolisthesis have no symptoms.  However, symptoms may occur due to the weakness of the spine at the level of the spondylolisthesis. Abnormal movement or irritation at the level of the slippage may produce back pain. The pain is usually worse with activities such as standing and walking and is typically relieved with rest. This type of activity or posture related pain is referred to as mechanical pain. In other patients, symptoms may include leg pain (sciatica, radiculopathy) or even weakness and or numbness due to irritation of the nerve roots that can be stretched or compressed by the slipped vertebrate. In adult patients, the slippage may occur with other degenerative changes, so called arthritis or spondylosis of the spine, such as disc bulging, enlarging ligaments (hypertrophy), facet joint overgrowth and bone spurs. These changes may narrow the spinal canal, leading to spinal stenosis and neurogenic claudication.

• X-ray (also known as plain films) –test that uses invisible electromagnetic energy beams (X-rays) to produce images of bones. Soft tissue structures such as the spinal cord, spinal nerves, the disc and ligaments are usually not seen on X-rays, nor are most tumors, vascular malformations, or cysts. X-rays provide an overall assessment of the bone anatomy as well as the curvature and alignment of the vertebral column. Spinal dislocation or slippage (also known as spondylolisthesis), kyphosis, scoliosis, as well as local and overall spine balance can be assessed with X-rays. Specific bony abnormalities such as bone spurs, disc space narrowing, vertebral body fracture, collapse or erosion can also be identified on plain film X-rays. Dynamic, or flexion/extension X-rays (X-rays that show the spine in motion) may be obtained to see if there is any abnormal or excessive movement or instability in the spine at the affected levels.
• Magnetic resonance (MR) imaging – provides detailed images of soft tissues like the spinal cord and nerve roots. As a result, MRIs are very helpful in determining the location and severity of the stenosis and in identifying spinal cord or nerve root compression.
• Computed tomography scan (CT scan) – this scan uses X-rays and a computer to provide images that are more detailed than general X-rays.

Non-operative treatment is usually recommended for patients as the first line of treatment. Physical therapy to work on posture, balance and spinal mechanics is often combined with strengthening of the back, flank and abdominal muscles to provide dynamic support to the lower lumbar spine. The careful use of over the counter anti-inflammatory medications along with periodic pain management for flare-ups, possible including spinal injections, can often make spondylolisthesis symptoms more manageable. Some weight loss, reconditioning, and life style modifications and ergonomic efficiencies may also be useful.

Surgery

Surgery is considered for patients who have severe, progressive and intolerable back and/or leg pain that does not improve with conservative treatments such as physical therapy, medication, and activity modulation. For patients with numbness and/or weakness surgery may also be considered.  The objective of the surgery is to relieve the pressure that is on any of the nerve roots and to strengthen the attachment between the vertebrate. In adult patients with degenerative spondylolisthesis this usually consists of a laminectomy and spinal fusion. In younger patients with isthmic spondylolisthesis, laminectomy and spinal fusion may also be performed but in some patients a limited repair of the stress fracture may be considered.