What is Spondylolisthesis?

Written by Bethany Elliott-Hutton

Spondylolisthesis occurs when one of the bones in the spine, known as a vertebrae, moves out of its normal position. It usually refers to the vertebral body slipping forward or backward over the bone beneath it. It is most common in the lower back at the junction between the lumbar spine and sacrum, known as the lumbosacral junction. This can also occur higher up the spine.

It is common for people to have a spondylolisthesis but not know about it as it doesn’t always cause symptoms. The most common place for a spondylolisthesis to occur is in the lower back.

This can cause symptoms such as:

• Low back pain: the pain is usually exacerbated when standing and when bending or arching the back backwards. Low back pain is normally relieved when lying down due to there being a reduced amount of pressure on the vertebrae when lying down.
• Stiffness or tenderness in the low back.
• Sciatic type symptoms: this usually occurs down both legs and can cause pain, pins and needles, numbness. This occurs in instances where the slipped bone is compressing onto the spinal cord or spinal nerve.
• Tight hamstring muscles.
• Muscle weakness in the legs.
• A visible step deformity – depending on the severity of the spondylolisthesis, sometimes it is possible to feel and/or see a obvious dip in the curve of the lower back

There are five types of spondylolisthesis which are classified by their cause.

Dysplastic Spondylolisthesis – also known as congenital spondylolisthesis can occur due to congenital abnormalities of the spine at birth which allow the spinal vertebrae to slip forward on the bone below. This in turn causes increased stress on a part of the vertebrae called the ‘pars articularis’ resulting in a spondylolisthesis. It is typically seen in children aged between 10-18 years of age.

Isthmic Spondylolisthesis – occurs when there is a development of a tiny stress fracture in the pars articularis. This is the bone that connects the joints on the back part of the spine. Isthmic spondylolisthesis normally develops in children between the ages of 5-7. However, the symptoms are not usually noticed until adulthood.

Degenerative Spondylolisthesis – refers to the degeneration of the joints, ligaments and bones of the spine. Sometimes spondylolisthesis can result as a consequence of bony changes and weakness within the spine. This type of spondylolisthesis is most common at L4/5.
Degenerative spondylolisthesis can sometimes lead to spinal stenosis. This is where there is a narrowing of the spinal cord which can then cause sciatic type symptoms down the legs.

Traumatic Spondylolisthesis – any trauma in which there is severe impact to the spine is at risk of causing spinal fractures at the pars articularis. This in turn may result in the vertebrae slipping forward or backwards.

Pathologic Spondylolisthesis – this is when a spondylolisthesis results from an underlying disease which in turn causes weakness in the vertebrae. This can result in sudden injury to the spine with little or no trauma. Conditions such as paget’s disease, spinal tumours or osteomyelitis are risk factors for pathologic spondylolisthesis.

During the consultation period of your appointment, a case history will be taken by your practitioner. They will take note of your symptoms perform a thorough physical examination. This examination and case history will assist the practitioner when diagnosing the pain and its original cause.

Throughout the case history the following questions may be asked by your practitioner;

• When did your first notice symptoms and/or pain?
• When the pain started, do you remember what you were doing?
• What is the nature of this pain
• How long is pain lasting?
• Do you have a history of back or hip injuries?
• Are there any medical conditions your practitioner should be aware of?

During your physical assessment, a series of tests may be completed by your practitioner. This includes an assessment of your posture. Palpitations may also be performed by your practitioner in order to assess step deformity. This can be done with you standing and with you lying on your side. This is to see if there is any visible or palpable slippage of the vertebrae.

The practitioner may also examine to see if there is any compression of the nerves in the low part of your back. This may include testing reflexes, strength of your muscles in your legs and carrying out nerve stretch tests.

If your osteopathic practitioner suspects a spondylolisthesis and depending on the severity of your symptoms further imaging such as an MRI or X-ray may be required. X-ray is the most common medical diagnostic tool used for spondylolisthesis as it is very good at showing any bony misalignment.The degree of slippage is measured as the percentage of distance the vertebrae has moved forward or backward, relative to the vertebral body below it. The degree of slippage is classified using the following grading system:

• Grade 1: 1-25 % slippage
• Grade 2: 26 -50% slippage
• Grade 3: 51-75% slippage
• Grade 4: 76-100% slippage

The treatment approach for spondylolisthesis depends on a few different factors; the age and overall health of the patient, the grade of slippage and the severity of the symptoms.

Generally, grade 1 and grade 2 spondylolisthesis can be treated using conservative treatment such as physical therapy. Depending on the severity of the symptoms, grade 3 & grade 4 spondylolisthesis may require surgery. If this is the case your orthopedic consultant will discuss the most appropriate type of surgery.

Conservative treatment includes:

Activity Modification – depending on the severity and grade of the spondylolisthesis, certain movements may need to be modified. It is advised that you avoid movements that put excessive strain on your back and also movements that put your back into an arched or extended position. It is also advised to restrict or be careful when playing sports that extend the low back. This includes: bowling in cricket, dancing, gymnastics and tennis.

It is also recommended to steer clear of high impact sports or sports that take the spine into extension, as this can increase injury risk. Low impact sports such as swimming, walking, cross training and Pilates are great alternatives, and are great ways to increase muscle strength and spinal stability.

Epidural Steroid Injections (ESI): A form of pain relief known as steroid injections can be used . ESI’s involve local anesthetic and corticosteroids being injected into the around around the spinal called. This space is referred to as the epidural space. The purpose of this is to provide temporary relief from your sciatic symptoms. Epidural Steroid Injections do this by reducing the inflammatory response.

For some individuals, surgical intervention may be necessary in order to restore stability within the spine. This will be dependent on the severity of the instability and intensity and severity of symptoms, including neurological symptoms.

There are a couple of different options for surgery which should be discussed in detail with your spinal surgeon. Below are a few of the spinal procedures that are used to help correct spondylolisthesis:

• Discectomy: this is a surgery in which part or all of the damaged disc that is compressing the sciatic nerve is removed.
• Laminectomy: this is a surgery in which the back part of one or more of your vertebraes in your lumbar spine (low back), known as the lamina is removed. This creates more space for the sciatic nerve and reduces the likelihood of the nerve being compressed.
• Spinal Fusion: this is a surgery in which the affected bone in the spine is joined together to the bone below to stabilise and strengthen the spine.

The outlook for somebody suffering with a spondylolisthesis is usually good. Most patients respond well to conservative treatment including exercise prescription. This again is dependent on the severity of instability. Those with Grade 3 and above instability are more likely to need surgery if they do not respond well to conservative treatment.

In some circumstances not all spondylolisthesis can be prevented. There are ways to lower your risk and support your lower back from further injury.

Exercise: Abdominal and spinal strength are key in providing stability to your spine. Exercise classes such as yoga and pilates are effective ways to improve strength in these areas.

Lifting techniques: good lifting technique is pivotal in lowering the risk of injuring your back. Important consideration when lifting are:

1. Bend from your hips and knees, not from your back, and that you squat down to the object you are picking up.
2. Keep the object close to your body and engage your abdominal muscles when straightening your legs to lift the object up.
3. Avoid twisting or turning your back when you are lifting the object.
4. Never lift a heavy object above the height of your shoulders.

Posture: Being proactive in ensuring good posture whilst sitting and standing allows for decreased pressure on your joints, ligaments and muscles.

Maintain a healthy weight – excess abdominal weight increases pressure on the spine, this may increase the likelihood of spondylolisthesis.

Pelvic tilt

Lie on your back with your knees bent and a pillow underneath your head, to support your neck. Take a deep breath in. As you exhale slowly push your lower back into the floor, you will find that your pelvis tilts as you do this. Inhale and slowly return to your neutral position. Then lift your back off the table, arching your back, tilting your pelvis in the opposite direction. Return to the neutral position and repeat. This exercise is a building block to more advanced exercises. Book in with one of our osteopaths to explore more advanced exercise programmes for sciatic pain.

Hamstring stretch

Lie on your back with your knees bent and a pillow underneath your head, to support your neck. Bend one knee up towards your chest and grasp behind the thigh. Lift your foot up to stretch the back of your leg. Hold the stretch for 20-25 seconds and then relax, repeat 5-6 times, making sure to also stretch the other side. A great modification of this exercise is to use a resistance band or rolled up towel behind the thigh or roped around the arch of your foot. Hold the band with straight arms. To assist the stretch, gently pull on the rope or towel to increase the stretch in the back of your leg.

Hip flexor stretch

Kneel on one knee creating a 90° angle with the opposite hip.Tilt your pelvis backwards to flatten your lower back and gently transfer your weight forward until you feel a stretch on the front of your thigh. Make sure that your lower back is straight and upright. Hold the stretch for 20-25 seconds and then relax. Repeat 5-6 times and make sure to do the other leg.

The NHS website suggests that you should go to your GP if you are experiencing any of the following symptoms.

• Have neurological symptoms in both of your legs.
• Have weakness or numbness in both legs that is severe or getting worse.
• Have numbness around or under your genitals, or around your anus.
• Find it hard to start peeing, cannot pee or cannot control when you pee – and this is not normal for you.
• Do not notice when you need to poo or cannot control when you poo – and this is not normal for you.

These could be symptoms of a more serious back problem. It is worthwhile going to visit your local GP or calling 101 to seek further medical advice on how to treat your symptoms.