traumatic spondylolisthesis symptoms

Spondylolisthesis

What is Spondylolisthesis?

Patient education video.

Types of Spondylolisthesis

What Are the Signs and Symptoms of Spondylolisthesis?

How is it diagnosed.

• Grade I – Less than 25 percent slippage
• Grade II – Between 25 and 50 percent slippage
• Grade III – Between 50 and 75 percent slippage
• Grade IV – More than 75 percent slippage
• Grade V – The upper vertebral body has slipped all the way off the front of the lower vertebral body. This is a rare situation that is called a spondyloptosis.

How is it Treated?

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Spondylolisthesis: Definition, Causes, Symptoms, and Treatment

by Dave Harrison, MD • Last updated November 26, 2022

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What is Spondylolisthesis?

The spine is comprised of 33 bones, called vertebra , stacked on top of each other interspaced by discs . Spondylolisthesis is a condition where one vertebra slips forward or backwards relative to the vertebra below. More specifically, retrolisthesis is when the vertebra slips posteriorly or backwards, and anterolisthesis is when the vertebra slips anteriorly or forward.

Spondylosis vs Spondylolisthesis

Spondylosis and Spondylolisthesis are different conditions. They can be related but are not the same. Spondylosis refers to a fracture of a small bone, called the pars interarticularis, which connects the facet joint of the vertebra to the one below. This may lead to instability and ultimately slippage of the vertebra. Spondylolisthesis, on the other hand, refers to slippage of the vertebra in relation to the one below.

Types and Causes of Spondylolisthesis

There are several types of spondylolisthesis, often classified by their underlying cause:

Degenerative Spondylolisthesis

Degenerative spondylolisthesis is the most common cause, and is due to general wear and tear on the spine. Overtime, the bones and ligaments which hold the spine together may become weak and unstable.

Isthmic Spondylolisthesis

Isthmic spondylolisthesis is the result of another condition, called “ spondylosis “. Spondylosis refers to a fracture of a small bone, called the pars interarticularis, which connects the facet joint of the vertebra to the one below. If this interconnecting bone is broken, it can lead to slippage of the vertebra. This can sometimes occur during childhood or adolsence but go unnoticed until adulthood when degenerative changes cause worsening slippage.

Congenital Spondylolisthesis

Congenital spondylolisthesis occurs when the bones do not form correctly during fetal development

Traumatic Spondylolisthesis

Traumatic spondylolisthesis is the result of an injury such as a motor vehicle crash

Pathologic Spondyloslisthesis

Pathologic spondylolisthesis is when other disorders weaken the points of attachment in the spine. This includes osteoporosis, tumors, or infection that affect the bones and ligaments causing them to slip.

Iatrogenic Spondylolisthesis

Iatrogenic spondylolisthesis is the result of a prior surgery. Some operations of the spine, such as a laminectomy, may lead to instability. This can cause the vertebra to slip post operatively.

Spondylolisthesis Grades

Spondylolisthesis is classified based on the degree of slippage relative to the vertebra below

• Grade 1 : 1 – 25 % forward slip. This degree of slippage is usually asymptomatic.
• Grade 2: 26 – 50 % forward slip. May cause mild symptoms such as stiffness and pain in your lower back after physical activity, but it’s not severe enough to affect your everyday activities.
• Grade 3 : 51 – 75 % forward slip. May cause moderate symptoms such as pain after physical activity or sitting for long periods.
• Grade 4: 76 – 99% forward slip. May cause moderate to severe symptoms.
• Grade 5: Is when the vertebra has slipped completely of the spinal column. This is a severe condition known as “spondyloptysis”.

Symptoms of Spondylolisthesis

Spondylolisthesis can cause compression of spinal nerves and in severe cases, the spinal cord. The symptoms will depend on which vertebra is affected.

Cervical Spondylolisthesis (neck)

• Arm numbness or tingling
• Arm weakness

Lumbar Spondylolisthesis (low back)

• Buttock pain
• Leg numbness or tingling
• Leg weakness

Diagnosing Spondylolisthesis

Your doctor may order imaging tests to confirm the diagnosis and determine the severity of your spondylolisthesis. The most common imaging tests used include:

• X-rays : X-rays can show the alignment of the vertebrae and any signs of slippage.
• CT scan: A CT scan can provide detailed images of the bones and soft tissues in your back, allowing your doctor to see any damage or abnormalities.
• MRI: An MRI can show the spinal cord and nerves, as well as any herniated discs or other soft tissue abnormalities.

Treatments for Spondylolisthesis

Medications.

For those experiencing pain, oral medications are first line treatments. This includes non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, acetaminophen, or in severe cases opioids or muscle relaxants (with extreme caution). Topical medications such as lidocaine patches are also sometimes used.

Physical Therapy

Physical therapy can help improve mobility and strengthen muscles around your spine to stabilize your neck and lower back. You may also receive stretching exercises to improve flexibility and balance exercises to improve coordination.

Surgery is reserved for severe cases of spondylolisthesis in which there is a high degree of instability and symptoms of nerve compression.

In these cases a spinal fusion may be necessary. This surgery joins two or more vertebra together using rods and screws, in order to improve stability.

Reference s

• Alfieri A, Gazzeri R, Prell J, Röllinghoff M. The current management of lumbar spondylolisthesis. J Neurosurg Sci. 2013 Jun;57(2):103-13. PMID: 23676859.
• Stillerman CB, Schneider JH, Gruen JP. Evaluation and management of spondylolysis and spondylolisthesis. Clin Neurosurg. 1993;40:384-415. PMID: 8111991.

About the Author

Dave Harrison, MD

Dr. Harrison is a board certified Emergency Physician with a part time appointment at San Francisco General Medical Center and is an Assistant Clinical Professor-Volunteer at the UCSF School of Medicine. Dr. Harrison attended medical school at Tufts University and completed his Emergency Medicine residency at the University of Southern California. Dr. Harrison manages the editorial process for SpineInfo.com.

Spondylolisthesis

• Diagnosis |
• Treatment |

Spondylolisthesis is partial displacement of a bone in the lower back.

Injuries or a degenerative condition can cause this disorder.

Pain is felt in the low back and may travel down one or both legs.

The diagnosis is based on the results of imaging tests.

Treatment includes measures to relieve pain.

The spine (spinal column) consists of back bones (vertebrae) stacked one on top of another. In lumbar spondylolisthesis, a vertebrae in the lower back slips forward. This disorder usually occurs during adolescence or young adulthood (often in athletes). It is usually caused by a birth defect or an injury that causes fractures (breaks) in a part of the vertebra. If both sides of the vertebra are involved, the vertebra can then slip forward over the one below it. Spondylolisthesis can also occur in older adults, mainly as the result of degeneration of the discs between the vertebrae or osteoarthritis . People who develop spondylolisthesis as adults are at risk of developing lumbar spinal stenosis .

Symptoms of Spondylolisthesis

Mild to moderate spondylolisthesis may cause little or no pain, particularly in young people.

When pain occurs in adolescents, it is felt on only one side of the spine and may travel down a leg. The pain may accompany a fracture.

When pain occurs in adults, it is felt over a specific part of the spine and travels down both legs. In these cases, the pain results from a degenerative condition.

Pain is worsened by standing or leaning back. It can be accompanied by numbness, weakness, or both in the legs.

Diagnosis of Spondylolisthesis

Imaging tests

Doctors base the diagnosis of spondylolisthesis on imaging tests, usually x-rays taken of the lower spine.

Other imaging tests, such as magnetic resonance imaging (MRI) or sometimes computed tomography (CT), may be done.

Treatment of Spondylolisthesis

Measures to relieve pain and stabilize the spine

One to two days of bed rest may provide pain relief for people with spondylolisthesis. Longer bed rest weakens the core muscles and increases stiffness, thus worsening back pain and prolonging recovery. Sleeping in a comfortable position on a medium mattress is recommended. People who sleep on their back can place a pillow under their knees. People who sleep on their side should use a pillow to support their head in a neutral position (not tilted down toward the bed or up toward the ceiling). They should place another pillow between their knees with their hips and knees bent slightly if that relieves their back pain. People can continue to sleep on their stomach if they are comfortable doing so.

Applying cold (such as ice packs) or heat

Physical therapy and exercises to strengthen and stretch the muscles in the abdomen, buttocks, and back (the core muscles) may help. (See also Low Back Pain: Prevention .)

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Medical Information

Traumatic Lumbar Spondylolisthesis - Understanding Spinal Instability After Injury

Introduction:.

Traumatic lumbar spondylolisthesis is a condition where one vertebra slips forward or backward over an adjacent vertebra due to a traumatic injury to the spine. This condition can lead to spinal instability and compression of the spinal nerves, causing significant pain and neurological deficits. Understanding the causes, symptoms, diagnosis, and treatment options for traumatic lumbar spondylolisthesis is crucial for effective management and recovery.

Causes of Traumatic Lumbar Spondylolisthesis:

Motor Vehicle Accidents:

• High-impact car collisions can cause severe trauma to the spine, leading to vertebral displacement.

Falls from Height:

• Falls from significant heights can result in compression and displacement of lumbar vertebrae.

Sports Injuries:

• High-velocity sports or activities with sudden movements may cause traumatic spondylolisthesis.
• Persistent and severe lower back pain, worsened by movement and weight-bearing.

Leg Pain and Weakness:

• Radiating pain, tingling, or weakness in the legs due to nerve compression.

Difficulty Walking:

• Spinal instability can affect gait and balance, leading to difficulty in walking.

Physical Examination:

• A thorough physical examination, including neurological assessment, helps identify signs of nerve compression and spinal instability.

Imaging Studies:

• X-rays, CT scans, and MRI are essential to visualize the spinal alignment and assess the severity of the spondylolisthesis.

Dynamic Imaging:

• Dynamic X-rays or flexion-extension imaging evaluates the stability of the spine during movement.

Treatment Options:

Conservative Management:

• Rest, physical therapy, and pain management are recommended for mild cases or initial management.
• External braces may be used to stabilize the spine during healing.
• Surgical intervention is considered for severe cases or when conservative treatments fail to provide relief.

Surgical Procedures:

Spinal Fusion:

• Stabilization of the spine using bone grafts and implants to fuse the affected vertebrae together.

Laminectomy and Decompression:

• Removing part of the vertebra to relieve pressure on the compressed nerves.

Dynamic Stabilization:

• Implants that allow controlled movement while providing stability to the spine.

Rehabilitation:

Physical Therapy:

• Rehabilitation focuses on strengthening the core muscles and improving flexibility.

Gradual Return to Activities:

• Patients are advised to slowly resume physical activities after adequate healing and rehabilitation.

Conclusion:

Traumatic lumbar spondylolisthesis is a challenging condition that requires early diagnosis and appropriate management to prevent further spinal damage and alleviate symptoms. Conservative treatments and surgical interventions, when necessary, can help patients regain functionality and improve their quality of life.

Hashtags: #TraumaticLumbarSpondylolisthesis #SpinalInstability #TraumaticSpinalInjury #Causes #Symptoms #Diagnosis #TreatmentOptions #PhysicalExamination #ImagingStudies #DynamicImaging #ConservativeManagement #Bracing #Surgery #SpinalFusion #Laminectomy #Decompression #DynamicStabilization #Rehabilitation #PhysicalTherapy #GradualReturnToActivities #SpinalHealth #QualityOfLife

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

Sandhya Kumar

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Understanding Spondylolisthesis Surgery and Other Treatments

Spondylolisthesis surgery may be required to fuse bones back together or alleviate pressure from the spinal nerves. 

Spondylolisthesis occurs when a bone in your spine slips forward, causing symptoms such as pain, numbness, and tingling. Early diagnosis and appropriate treatment can help manage symptoms and prevent complications. In some cases, spondylolisthesis surgery is required to fuse bones back together or alleviate pressure from the spinal nerves. 

What is Spondylolisthesis?

Spondylolisthesis is a  condition  where one of the  bones in your spine (called a vertebra) slips out of place and shifts forward  over the bone below it. This displacement can occur in any part of the spine but is most common in the lower back, known as the lumbar spine. 

Spondylolisthesis can be caused by various factors such as:

• Congenital abnormalities
• Repetitive stress on the spine
• Degenerative changes due to aging 

In some cases, defects in the structure of the vertebrae, such as incomplete formation or abnormal alignment, are present at birth. Children born with spinal abnormalities may be at a higher risk of developing spondylolisthesis later in life, especially if there’s increased stress or pressure on the affected area. 

Consistent stress on the spine can also contribute to developing or worsening spondylolisthesis in pediatric patients. Factors that may cause such stress include high-impact sports activities that place excessive strain on the spine, poor posture, and traumatic injury. Weakness in the muscles supporting the spine can also contribute to spondylolisthesis.

Spondylolisthesis Symptoms

Spondylolisthesis symptoms can  vary in severity depending on the degree of spinal bone slippage  and its  effects  on your surrounding body structures.

Some common spondylolisthesis symptoms include:

• Persistent lower back pain that may worsen with certain movements or activities
• Leg pain that extends from the lower back down one or both legs
• Muscle tightness or stiffness in the muscles of the lower back or thighs
• Difficulty bending or twisting the spine
• Numbness, tingling or weakness in the legs, feet or buttocks
• Difficulty walking or standing for extended periods

If you’re experiencing symptoms of spondylolisthesis, contact your  doctor  to perform a physical exam. An X-ray of the spine can show broken or out-of-place bones. MRI scans or CT scans will show abnormalities of the vertebrae. 

Spondylolisthesis Treatment

Treatment for spondylolisthesis aims to alleviate symptoms, stabilize the spine, and improve overall function. Your doctor’s treatment  approach  will depend on the severity of your condition. 

Standard treatment options  used  to manage spondylolisthesis include:

• Physical Therapy:  Using targeted exercises and stretches to strengthen the muscles supporting the spine, improving flexibility and alleviating pain
• Activity and Posture Changes:  Avoiding activities that make symptoms worse and improving posture to reduce stress on the spine
• Bracing:  Supportive braces or orthotic devices to stabilize the spine and alleviate discomfort
• Epidural Steroid Injections:  Using corticosteroid injections to reduce inflammation and alleviate pain associated with nerve compression
• Surgery:  In some cases, surgery is required to reduce symptoms and prevent your condition from worsening. Your  orthopaedic surgeon  will discuss surgical options for your individual case. 

Types of Spondylolisthesis Surgery 

Spinal fusion.

Spinal fusion surgery stabilizes the spine by joining two or more vertebrae together using bone grafts or implants. Fusing vertebrae together helps reduce movement between the bones and alleviates nerve compression.

Spinal Decompression

Spinal decompression surgery relieves pressure on the spinal cord or nerves by removing the bone, or tissue causing compression. This type of surgery helps to reduce symptoms such as numbness, tingling, and pain in the legs or back. Several spinal decompression techniques can be used, depending on what part of the spine is affected. 

Pars Repair

Pars repair surgery involves the use of bone grafts or screws to stabilize the fractured bone in the spine so that it can heal properly. This procedure aims to alleviate pain and restore stability to the spine.

What to Expect After Spondylolisthesis Surgery

After spondylolisthesis surgery, you’ll need time to recover and regain strength. Your doctor will provide pain management medication to help with discomfort so that you can remain comfortable as you heal. 

Your ability to move around may be limited at first, but you should notice improvements within a week after surgery. Physical therapy will be essential to regain full movement and flexibility in your spine. Your physical therapist will generally focus on gentle, low-impact movements at first and then incorporate exercises that will help to strengthen your core muscles.

You will have follow-up appointments with your surgeon to track progress and address any concerns. While you’ll gradually return to normal activities, it’s important to follow your doctor’s advice and attend regular check-ups for long-term monitoring of your spine’s stability.

The  Spine and Scoliosis Center  of Stony Brook Orthopaedic Associates specializes in treating all  spinal disorders . It is comprised of board-certified, fellowship-trained Orthopaedic surgeons who surgically treat adult and pediatric spinal pathology. 

James Barsi, M.D. is a Clinical Associate Professor in the Department of Orthopaedic Surgery at Stony Brook University. Certified by the American Board of Orthopaedic Surgery, Dr. Barsi completed fellowship training in Pediatric Orthopaedic Surgery with an emphasis on scoliosis and pediatric trauma. He specializes in all care of the pediatric patient including: scoliosis and kyphosis, hip disorders, fractures and growth plate injuries of the extremities, and pediatric sports medicine.

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Traumatic Lumbar Spondylolisthesis: A Systematic Review and Case Series

Affiliation.

• 1 Norton Leatherman Spine Center, Louisville, KY, USA.
• PMID: 31552159
• PMCID: PMC6745646
• DOI: 10.1177/2192568218801882

Study design: Systematic review and case series.

Objectives: Any acute injury to the posterior elements of the lumbar spine resulting in listhesis is considered a traumatic spondylolisthesis. This rare injury caused by high-energy trauma is variably described in the literature as fracture-dislocation, where only case reports and series have been published. Our objectives were to propose evidence-based treatment recommendations and a new classification system for this injury.

Methods: A systematic review of literature from PubMed, EMBASE, and Cochrane without time frame limitations was performed, which included 77 level IV and V articles and 9 patients as case series in the analysis.

Results: A total of 125 cases were reviewed with mean age of 30.5 years. Half of the cases resulted from a vehicular accident. Back pain presented in 82%, while 50% had neurologic deficits. Operative treatment was performed in 93.6% (posterior decompression [PD] = 4%; posterior spinal fusion [PSF] = 43.2%; interbody fusion [IB] = 46.4%) with overall fusion rates of 74%. Binomial regression analysis for achieving solid fusion showed a 28.6× higher odds for IB compared to PSF ( P = .008, r 2 = 0.633). Subanalysis of cases with disc injuries revealed higher fusion outcomes for IB (87%) compared to PSF (46%; P = .006), while there were no significant differences for patients without disc injury. Pain and neurological symptoms improved significantly on final follow-up ( P < .001). Overall complication rate was 22%.

Conclusion: Operative management with reduction, decompression for neurologic deficits, instrumentation, and fusion is recommended for traumatic spondylolisthesis. Interbody fusion is recommended to achieve better fusion outcomes especially with preoperatively identified disc lesions.

Keywords: classification; dislocation; fracture; fracture-dislocation; lumbar spine; outcomes; surgical treatment; traumatic spondylolisthesis.

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• v.14(3); 2022

Spondylolisthesis

1 Medical College of Wisconsin

John Scofield

2 Louisiana State University Shreveport

Payton Mangham

Joshua cooper, william sherman.

3 Tulane University Department of Orthopaedic Surgery

Alan D. Kaye

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam, along with appropriate imaging tests are useful in making the diagnosis. Conservative therapy is first-line and includes pain management with physical therapy. Patients who fail conservative therapy may consider surgical decompression, stabilization, and fusion. This review aims to discuss the epidemiology, pathophysiology, presentation, and treatment options of spondylolisthesis.

Introduction

Spondylolisthesis is a broad term used to describe the anterior, lateral, or posterior slippage of one vertebral body over another. Isthmic spondylolisthesis occurs when anterior displacement of the vertebra is caused by a defect in the pars interarticularis, commonly due to previous spondylolysis at the L5-S1 joint. 1–4 While isthmic spondylolisthesis is the most common form of spondylolisthesis in children, degenerative spondylolisthesis predominates in adults, which can occur independent of pars interarticularis injury and has a tendency to present in female patients. 1,2,5 The presentation of spondylolisthesis can vary widely, including but not limited to compressive neurologic defects (i.e. spinal stenosis), mild-to-severe back pain, a cosmetic defect, and as an incidental finding. 1 The standard classification of spondylolisthesis is the Meyerding system (graded I through V), which correlates with the percentage of superior disc translocation over the inferior disc. The degree of Meyerding grading is generally associated with symptom severity. 1,3,6 Grade IV and V spondylolisthesis indicates severe disc translation and is usually due to isthmic spondylolisthesis since significant damage to the pars interarticularis is generally required for impressive degrees of translation. 3 While many patients respond to conservative management (NSAIDs, injections, bracing), many cases often require decompression, fusion, reduction, fixation, among other surgical interventions. 2,3 Surgical treatment for spondylolisthesis should be considered it patients with persisting, debilitating symptoms that have not responded to conservative management. 7

Epidemiology/Risk factors

Spondylolisthesis is typically categorized into isthmic and degerative spondylolisthesis. Isthmic (i.e. spondylolytic) spondylolisthesis is classically precipitated by progression of previous spondylolysis. Spondylolysis is exceedingly rare in individuals who do not bear weight (i.e. infants, children with disabilities), with incidence and risk of progression to spondylolisthesis continually increasing from birth until age 18, with relatively stable incidence rates thereafter. 4 The incidence of spondylolysis in adults has been estimated to be between 3-8% with a prevalence of 11.5%. 8–10 Spondylolisthesis is less prevalent than spondylolysis, with an estimated prevalence of 3.1%. 11,12 Interestingly, most patients with these conditions are asymptomatic, with only 23% of patients reporting clinical complaints prior to the age of 20. In fact, studies have estimated that between 2.5-3.5% of children undergoing CT scans or MRI for unrelated abdominal or pelvic pathologies discover spondylolysis and isthmic spondylolisthesis as incidental findings. 13 Additionally, the extent of disc slippage in spondylolisthesis has not been strongly correlated with symptomatic severity. Both progression from spondylolysis to isthmic spondylolisthesis, as well as symptomatic onset are often correlated with periods of rapid pubertal bone growth in adolescents between 10-15 years old. 8

Young athletes have been well-documented to have increased risk for developing spondylolysis and subsequently progressing to spondylolisthesis. These patients typically present with unilateral low back pain that is relieved by rest, and interestingly usually do not exhibit neurologic deficits. 14 Athletes participating in sports with high torsion in their lumbar spine are at particularly increased risk of developing spondylolysis due to either unilateral or bilateral damage to the lumbar pars interarticularis. 4,15 Harvey et al. reported a spondylolysis incidence rate of between 23-63% of young athletes participating in high risk sports, which include football, gymnastics, hockey, diving, wrestling, pole vaulting, racquet sports, and body building. 14,16 Medical conditions may also predispose to development of spondylolysis. Inherent spinal disease such as scoliosis, kyphosis, and spina bifida occulta have been correlated with increased risk of development of spondylolysis. 4,8,17 Additionally, studies suggest an element of heritability, with 15-70% of patients with spondylolysis also possessing first-degree relatives who have spondylolysis. 18 Additional genetic risk factors include Native Alaskan heritage. 9,14

In contrast to isthmic spondylolisthesis, degenerative spondylolisthesis is most commonly seen in adults, with increased risk associated with progression of age. Degenerative spondylolisthesis is almost six times more common in females than males. 5,19 In a prospective study of 142 women, Aono et al. reported that 12.7% of previously healthy women developed degenerative spondylolisthesis over a period of 8 years. Retrospective analysis of baseline radiographs suggested that the pelvic incidence, vertebral inclination angle, degree of lumbar lordosis, as well as baseline vertebral sizes were all additional risk factors for development of degenerative spondylolisthesis. 5,20

Pathophysiology

Spondylolisthesis is the anterior, lateral, or posterior translation of a superior vertebral segment over the adjacent inferior vertebra. 3 Spondylolisthesis may progress from spondylolysis, which is the degeneration of the pars interarticularis. In fact, up to 70% of patients with bilateral pars defects progress to isthmic spondylolisthesis. This slippage most commonly occurs during periods of rapid growth. 11 Disc slippage most often occurs at the L5-S1 joint. 1–4 Severity of disc slippage is often quantified with the Meyerding grading system and is graded from I through V. 1,3,6 High grade spondylolisthesis with greater than 50% disc slippage corresponds to Meyerding grade III or higher and presents with higher risk of neurological complications due to spinal cord and neural compression. High grade spondylolisthesis is most often due to isthmic rather than degenerative spondylolisthesis, as severe translation is enabled by pars interarticularis fracture. 3

Degenerative spondylolisthesis is considered a disease of aging with a predilection for females, hypothetically due to both the increased laxity in female ligaments as well as other hormonal factors. 5 Most cases of degenerative spondylolisthesis are low grade and classified as either Meyerding grade I or II. 5 Low back and lower extremity pain may be observed due to focal disc slippage and degeneration as well as nerve impingement and ensuing spinal stenosis.

There exist numerous other etiologies of spondylolisthesis in addition to the isthmic and degenerative subtypes. A rarer etiology of spondylolisthesis includes dysplastic (i.e. congenital) spondylolisthesis, and is due to a congenital anomaly of the pars interarticularis which subsequently results in early anterior disc translocation, most commonly at L5-S1. 21 Early disc slippage can also result in spondylolysis due to increased stress on the pars interarticularis. Congenital disease is often multifactorial and made worse by repetitive movements of the lower back. Traumatic spondylolisthesis is caused by trauma that fractures a part of the posterior column of the spine besides the pars, and usually coexists with other injuries. 8 Pathologic spondylolisthesis is similar to traumatic, but is however due to infection, neoplasm, autoimmunity, or another pathology unrelated to trauma. 8 Iatrogenic spondylolisthesis can cause all of the aforementioned variants of the disease, and usually occurs following a large spinal decompression (laminectomy). This procedure can cause destabilization of the vertebrae, with subsequent disc slippage. 8

Classification and Grading

The symptomatic severity of spondylolisthesis has been weakly correlated with the degree of vertebral slippage. 22–24 The most common grading scale to describe the degree of vertebral slippage in spondylolisthesis patients was proposed by Meyerding. 23,25–28 Specifically, this scale correlates the degree of anterior displacement of a vertebral body to a numerical score. 25 The grading scale of the Meyerding scale is as follows: Grade I is equivalent to a <25% slippage of the vertebral body, grade II is equivalent to a 25% to 50% slippage of the vertebral body, grade III is equivalent to a 50% to 75% slippage of the vertebral body, grade IV is equivalent to a 75% to 100% slippage of the vertebral body, and grade V equivalent to a complete slippage of the vertebral body. 23,25,26 The majority of cases usually fall into either grade I or grade II. 25 This grading system is invaluable for continual assessment of both the current degree of disc slippage as well as the progression of the displacement of the vertebrae, thus providing valuable prognostic information and assisting in determination of the most appropriate future management. 23,29 However, studies have suggested that additional factors including etiology, lumbopelvic measurements, sacral structure, and global spinal alignment are also important in determination and prediction of spondylolisthesis progression, and grading scales which take these variables into account ought to be developed in order to optimize future treatment. 1

Another useful grading scale was proposed by Wiltse et al and functions by separating the different etiologies of spondylolisthesis into five distinct categories. 30,31 Type I of the Wiltse system corresponds to dysplastic spondylolisthesis resulting from congenital dysplasia that causes anterior and superior rounding of the S1 vertebrae, which allows the L5 vertebrae to slip anteriorly. 31 Type II correlates with isthmic spondylolisthesis and is further divided into types IIA and IIB. Type IIA is the result of a stress fractures of the pars interarticularis and causes anterior slipping of the vertebrae. Type IIB is the result of repeated fractures and healing resulting in lengthening of the pars interarticularis. Both subtypes result in anterior slippage of the vertebrae. Type III correlates with degenerative spondylolisthesis and is most commonly due to arthritis, which leads to weakening of the ligamentum flavum which then allows anterior slipping of the vertebrae. 31,32 Type IV correlates with traumatic spondylolisthesis caused by high energy trauma. Type V correlates with pathologic spondylolisthesis and can be caused by various pathologies such as osteoporosis, lytic neoplasms of the bone, and osteopetrosis. Type VI is iatrogenic in origin and is usually caused by spinal surgery such as laminectomy. 31 The categorization proposed by Wiltse et al is helpful in many scenarios, it does not describe the severity of each subtype of spondylolisthesis, and also does not allow for monitoring for progression of disease.

Clinical Features

A vast majority of patients with spondylolisthesis are asymptomatic. 33 Symptoms typically derive from either mechanical etiology or spinal stenosis, and patients frequently complain of intermittent neurogenic claudication; a consequence of spinal stenosis which presents with low back pain with radiation to the proximal bilateral lower extremities, with associated paresthesia and weakness while ambulating or standing. 25,28 Isthmic spondylolisthesis patients most commonly experience symptoms including hamstring tightness and lower back or buttock pain that is worse with spinal extension. 23,29 This radiculopathy is due to compression of the nerve roots in the area of the anterior slippage of the vertebral body. 31 Similarly, clinical features of degenerative spondylolisthesis predominantly include lower back pain, radiculopathy, or neurogenic claudication. 23 This pain often worsens with activity and/or spinal extension, but the pain may be relieved by movements that cause spinal flexion such as sitting or leaning forward. 25,27,34,35 Progressively worsening spondylolisthesis may present with new or augmented neurogenic symptoms, such as radicular pain, bowel and bladder dysfunction, and even cauda equina syndrome. Patients may also report a preceding traumatic event prior to onset of symptoms; however, many cases are correlated with insidious onset. Nighttime pain may also occur and is usually concerning for malignancy. 26

Diagnostics

Although spondylolisthesis is most often asymptomatic, a detailed history taking and a thorough musculoskeletal and neurologic physical exam are helpful in accurately diagnosing spondylolisthesis. 26,29 Isthmic spondylolisthesis often presents with a palpable step-off which may be felt at the level below the affected segment, while degenerative spondylolisthesis presents with a step-off occurring at the level above the affect spinal cord segment. 23 Patients may also present with varying degrees of lumbar lordosis, with stooped posture, spinal muscle atrophy, tight hamstrings, and hip flexion contraction. 28,29 Children with advanced spondylolisthesis may present with shortened stride length with excessive hip and knee flexion, and thus work up within the pediatric population should include extensive gait analysis. 26,29 Additionally, children with isthmic spondylolisthesis with associated scoliosis may present with a positive stork test, which is a one-legged hyperextension maneuver and indicates impaired mobility of the sacroiliac joint. 24,36

When working up patients with clinical suspicion for spondylolisthesis, useful imaging includes supine oblique views of the lumbosacral spine as well as standing posteroanterior and lateral x-rays of the thoracolumbar spine. 25,26,37 These views allow for optimal evaluation of the affected level of spondylolisthesis by judging the degree of anterior vertebral slippage. 26 When possible, supine radiographs should be avoided, as they potentially allow for the pathologic vertebra to temporarily reduce into an anatomically correct position. 25

When there is a high clinical suspicion of spondylolysthesis in spite of normal imaging results, single-photon emission CT of the lumbosacral spine is useful for further workup. 26,38–40 Additionally, MRI is often used in patients who present with neurologic deficits, although MRI has been shown to possess a low positive predictive value and is therefore not preferable as a primary diagnostic tool. 26,41 Thin-section CT with reverse gantry angle may also be useful in determining the degree of spondylolisthesis. 26,42 Preoperative two-dimensional and three-dimensional CT reconstruction can be used in severe cases to further define the anatomy of the region of interest. 26

Treatment Options

Conservative management.

Although there have been no prospective randomized clinical trials which outline the optimal conservative management algorithm, conservative modalities are widely considered the first line treatment for most cases of low-grade spondylolisthesis. 28 In fact, between 70-90% of athletes with spondylolisthesis can expect to return to athletic activities within 3-6 months with only conservative management. 37 The mainstay for conservative treatment is activity restriction, bracing, physical therapy, and pain control. Pain control can be achieved with either NSAIDs, narcotics, or muscle relaxants. 29,31 If a patient elects to undergo conservative management, they are closely followed with full physical exams and repeat imaging to monitor treatment efficacy. 29 Vibert et al. has stated that most physicians initially start with a 1- to 2- day trial of rest followed by a short course of anti-inflammatory medication. If the patient’s symptoms have not resolved within two weeks, physical therapy is an appropriate next step in management. The benefits of activities such as cycling, swimming, and elliptical machines have been well documented to avoid further vertebral injury and are considered superior to other forms of high impact aerobic exercises such as running. 27,43 Additionally, Kalichman and Hunter have referenced numerous other studies that have examined the efficacy of various conservative treatment modalities such as physiotherapy, bracing, flexion/extension strengthening exercises, and stabilization exercises. 27 If the patient fails to see improvement in symptoms after completing a 4-6 week course of physical therapy or other treatment modalities, it is often appropriate to consider more aggressive treatment options such as epidural steroid injections or selective nerve blocks. 27,29,43 If the patient continues to fail conservative therapies and more invasive procedures such as epidural corticosteroid injections, further surgical management may be indicated. 34

Surgical Management

Although spondylolisthesis management has generally trended toward more conservative options in effort to minimize risk and maximize outcomes, surgical treatment should be considered in patients with persisting and debilitating symptoms with inadequate response to conservative management. 44–46 Historically, degenerative spondylolisthesis was treated aggressively with focus on neural decompression, reduction, fixation, and fusion. Treatment has evolved throughout the years with emergence and re-emergence of techniques arriving in conjunction with the development of new technologies. Initially, isolated neural decompression was a popular procedure but resulted in increased likelihood of slippage progression in younger patients with dynamic instability due to lack of fusion. 47,48 Posterior fusion using a posterior lumbar interbody fusion (PLIF) was described in the early-20 th century, but was discouraged at the time due to high risk of complications and procedural difficulty. It was not until the advent of transpedicular screwing and the development of spinal instrumentation that led to breakthrough of transforaminal lumbar interbody fusion (TLIF) and other interbody fusion techniques. More recent advances including minimally invasive surgery (MIS) and stereotactic spinal guidance. MIS procedures has been shown to decrease muscular injury and perioperative pain, leading to faster recovery and improved quality of life. Similarly, stereotactic spinal guidance provides invaluable guidance of intraoperative anatomical landmarks and have been correlated with decreased likelihood of complications related to screw misplacement. 48

Surgical treatment of spondylolisthesis usually involves a combination of decompression, stabilization, and fusion. Although decompression is discouraged in patients with dynamic instability, it remains a viable option in the elderly and patients without dynamic instability due to lower associated morbidity and mortality. 44 Stabilization with spinal instrumentation is often utilized to correct deformity and prevent deformity progression. 49 There currently remains a lack of consensus on the decision to reduce slippage versus in-situ fusion during surgical management. Those in favor of reduction prior to arthrodesis argue that while patients report improvement following in-situ fusion, there is a greater risk of decompensation and pseudoarthrosis due to uncorrected positive sagittal balance, especially in high grade slips. One study investigating this found that pseudoarthrosis was more frequent in the fusion in-situ group versus the reduction group (17.8% vs 5.5%). 50 Conversely, those in favor of in-situ fusion argue that patients demonstrate compensation for uncorrected positive sagittal balance through reduced thoracic kyphosis and pelvic retroversion. They also site literature emphasizing a greater likelihood of neurological impairment with reduction, though there is also evidence denying any additional risk. Despite ongoing debate, treatment has begun focused on correcting segmental lordosis and global sagittal balance. It is proposed that reduction with anterior and posterior fixation results in improved outcomes and allows for optimal correction of deformity, indirect neuroforaminal decompression, greater surface area for arthrodesis, and increased biomechanical stability. 51–55

With recent recognition of the importance of slip angle and spinopelvic alignment to global sagittal alignment, more evidence suggests that at least partial reduction of slip angle should be considered in the setting of a high-grade slip. Interbody fusion is also favored in these cases to provide greater stability and increase fusion rates. 54–56 There is a lack of randomized controlled trials confirming or negating the generally accepted techniques of reduction and anterior column support for treatment of high-grade spondylolisthesis, but smaller studies are frequently performed. 57 Nonetheless, the benefits of surgery are typically significant for patients with regard to health-related quality of life, especially in patients who can tolerate the procedures. 58

Newer techniques for surgical intervention and evaluation continue to arise for patients with high-grade slips. One example of innovative surgical techniques includes the extreme lateral interbody fusion, which has shown promising improvement in clinical outcomes with isthmic spondylolisthesis patients at each postoperative evaluation (1, 3, and 12 months), along with no signs of hardware loosening or failure. 59 Another novel technique to evaluate post-surgical outcomes includes a 3D finite element model (FEM) used to analyze the biomechanics of the spine after spinal fusion for spondylolisthesis at L5-S1. This model was described by Wang et al with an objective to determine the advantages of reduction versus no reduction in patients with “unbalanced” and “balanced” spines, which are defined by measurement of spinal parameters such as sacral slope and pelvic tilt. The “unbalanced” spine was correlated with high pelvic tilt and low sacral slope and showed significant improvements in pelvic alignment post-reduction, likely due to inherent inability to compensate through spinal extension. However, FEM showed a significantly increased incidence of lumbosacral deformation and adjacent disc stress in “unbalanced” spines following reduction. Similarly, although the “balanced” spine (correlated with low pelvic tilt and high sacral slope) also exhibited improvements in spinal alignment post-reduction, there was no increase in incidence of lumbosacral deformation or adjacent disc stress. Further research is necessary to determine if the efficacy of reduction in treatment of spondylolisthesis in patients with “unbalanced” spinal alignment. 60

Care must also be taken to factor other spinal pathologies into the surgical treatment of spondylolisthesis. The current literature has not fully investigated the combination of spondylolisthesis and spinal tumors. In patients with concomitant tumors and spondylolisthesis, the location of one relative to the other is important in guiding treatment. Oncological treatment takes priority, however if that treatment involves spinal fixation, an adjacent spondylolisthesis can be included in the fusion construct and potentially reduced depending on symptomology and instability. 61 Furthermore, congenital deformities of the spine, traumatic spondylolisthesis, and osteoporosis can pose unique challenges to surgical management of spondylolisthesis due to the complex presentations, peri-operative planning, and recovery. 62,63

There remains a significant degree of variability between providers regarding appropriate surgical recommendations. A survey of 445 U.S. spine surgeons sought to determine patterns in the treatment of spondylolisthesis and posed clinical/radiographic case scenarios on patients with spondylolisthesis, neurogenic claudication with and without mechanical back pain. Results showed that 64% and 71% of surgeons disagreed with regards to proper treatment of spondylolisthesis with and without mechanical back pain, respectively. Many factors influence operative decision making for a given condition, but awareness of this variability can guide research to develop better practice guidelines. 64 Data analysis from surgical registries may also prove invaluable in guiding future studies and improving outcomes of spondylolisthesis treatment. Examination of present management and outcomes can lead future studies in the right direction. There are several surgical options for treatment of spondylolisthesis which branch into a multitude of specific approaches and techniques. There is a need for a comprehensive surgical classification and treatment algorithm that would lead to a unified standard of care for patients with spondylolisthesis. 65,66 Current management appears to exhibit positive outcomes and subjective improvements in most surgical patients, regardless of the specific procedure. However, many of the studies lack the power to provide strong evidence as a foundation for universal recommendation guidelines. Thus, further randomized trials and large-scale registry analysis will guide future research to demonstrate optimal surgical treatments and improve outcomes for all patients with spondylolisthesis. 58,67

Finally, although surgical management has been shown to be efficacious in treatment of spondylolisthesis, an often-overlooked aspect of surgery is cost effectiveness with respect to the patient. Although research is scarce in this area, operative treatment has been shown to be significantly more expensive than non-operative management due to fusion, instrumentation, and labor adding to the cost. Patients who receive surgical interventions do report improvement in quality of life, although more data needs to be gathered and analyzed to determine the appropriate cost/benefit between various surgical treatment options in patients with limited finances. 68

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Isthmic spondylolisthesis occurs due to damage to the pars interarticularis, resulting in instability and slippage between the lamina, pedicle, facet joints, and transverse process. Incidence of isthmic spondylolisthesis plateaus after age 18 and occurs most commonly at the L5-S1 joint. In contrast, degenerative spondylolisthesis occurs due to chronic degenerative processes such as arthritis and is observed in adults, with incidence directly correlated with age. Spondylolisthesis is most commonly described with the Meyerding classification system, with each grade corresponding to a given degree of disc slippage. Other classification scales have been proposed, such as one by Wiltse et al which categorizes spondylolisthesis based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam is imperative in diagnosing spondylolisthesis, and evidence of disc slippage may be found on spinal xrays, single-photon emission CT, and MRI. Conservative therapy is first line and includes symptomatic management such as NSAIDs, narcotics, and muscle relaxants, as well as physical therapy, low impact exercises, and steroid injections. If a patient fails conservative therapy, surgical interventions such as decompression, stabilization, and fusion may be considered at that time.

Funding & Conflict of Interest

The authors did not receive any funding or financial support or potential sources of conflict of interest.

The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.

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