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Spondylolisthesis; an on again off again back pain

Spondylolisthesis happens when one vertebrae ‘slips’ forward out of alignment. The name comes from the Greek root words spondylos (spine) and olisthesis (slippage).

Spine. Slippage.

Gross.

Our chief common symptom is pain. Often it's 'sometimes' pain. Many patients complain, they didn't do much different, there was no major event, but today their is debilitating!

Spondylolisthesis most commonly won’t come from one event. Instead, pain sort of pops up a day or so after some hard work or a lot of standing, increases rapidly, then stabilizes at a certain pain level. It can even disappear for a while. If something causes the slippage to get worse, or if the case starts off severe, pain won't go away and numbness tingling or shooting pain can start in the legs. There are a lot of things which can cause this, and each cause has it's own characteristics.

We name the types of Spondylolisthesis by the underlying condition causing it (1). Our most common causes usually involve either of two important structures; the ligamentum flavum (a special inner-spinal-canal ligament) or a small area of the back bone called the ‘pars interarticularis’ (medical talk for “the part between the moving stuff.”)


The underlying cause will determine our treatment and some of the symptoms we can expect. We clinically see 6 types of spondies.

Type I dysplastic congenital dysplasia (medical for abnormal development causing abnormalities. We need to work on our naming.) For this, the shape of the sacral bone and the bottom lumbar vertebrae push against each other. Over time, the ligaments get stretched and some bone changes let the bottom vertebrae get pushed forward. This will likely be noticed at a young age. It’s extra important for these patients to keep a strong core to keep it from getting worse.



Type II is isthmic, which means lack of blood flow (Our most commonly seen type, mentioned earlier.) Bad blood flow weakens the back bone at the pars. Slippage is caused in one of two ways. Type IIA, the weakened pars suffers a big enough stress fracture (spondylolysis) that the vertebrae slip forward. Type II B is similar, but no single big break occurs. The weakened area has repeated mini-fractures and healing over and over, lengthening the pars over time.

In Type III, “degenerative”, weakening of our earlier mentioned ligamentum flavum. It wears down the stability of the spine and lets a vertebrae slide forward. this happens a lot in older adults and is associate with arthritis in the back. One may cause the other in some cases, but both can happen independently

Type IV, is traumatic. But like, a trauma happens. It might not be as obvious as it sounds. A direct trauma to the pars, okay, you’ll probably know about that. Less obvious examples may be moving furniture, or heavy weightlifting. In fact, a lot of young weightlifters will get this injury, and think that it is a ‘bad pull’. Most of the time this isn't very progressive, once the damage is done, it's done and will heal as long as it isn't re-injured by accidents or bad habbits. Severe cases might get progressively worse and need immediate treatment to prevent that.

Now our obligatory mention of the pathological: Type V, caused by lytic bone tumors, osteopetrosis, or osteoporosis. We won’t get deep in to this one. Suffice to say, the root cause needs to be addressed by a Doctor. Because of imaging associated with suspected tumors, this one is unlikely to go unnoticed. Without treatment, this will likely progress. A Doctor will help weight the risks and benefits of different treatment option specific to the afflicted individual.

Type VI is iatrogenic, which means the illness was caused by medical intervention. This can happen a lot of ways, but will most likely be known about. (1,2)

Despite multiple causes, Spondylolisthesis has common patterns. All cases will usually show up with increased lordosis and a 'step' deformity. If it progresses or is a severe case, back ‘hinging’ can occur. The spine moves at one vertebrae instead of all the vertebrae moving as one unit. Divots may appear on either side of the spine when standing up-right.

If this process progresses further, lordosis increases. Which can cause pressure pushing the spine forward, increasing the slippage. Luckily there are a lot of ligaments and muscles stabilizing the spine, so there is a good chance the slippage will reach a point and stabilize. In some cases, people can live with this condition for years without it getting worse, although without treatment it is still quite painful.

As the process goes on, bending forward will start to hurt, similar to a disc hernia. Severe cases will start to cause muscle spasms in the hamstrings and difficulty walking or standing for short periods. Numbness, weakness, and/or tingling in their feet or legs may show up soon after. It happens first in standing, and later in sitting. Most of the time, lying face up will be relieving. This can be confused with disc herniations and cause AND be confused with sciatica.


In early stages, simple core training may resolve the condition. If there is a break the condition may need splinting, postural correction, partial immobilization, or surgery. This condition can be related to being overweight or obese, and is definitely made worse by excess weight (3,4). This condition will likely require patients to reach a healthy weight before many symptoms can resolve, and sometimes before surgery is performed. In which case, it is important to stay consistent with a health professional supervising a slowly progressive exercise plan that will keep you safe and not cause further injury (4).


Works Cited

  1. Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. Spondylolysis and spondylolisthesis: A review of the literature. J Orthop. 2018 Mar 17;15(2):404-407. doi: 10.1016/j.jor.2018.03.008. PMID: 29881164; PMCID: PMC5990218.

  2. Wiltse L.L., Newman P.H., Macnab I. Classification of spondylolisis and spondylolisthesis. Clin Orthop Relat Res. 1976;117:23–29.

  3. Samuel AM, Moore HG, Cunningham ME. Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence. Curr Rev Musculoskelet Med. 2017 Dec;10(4):521-529. doi: 10.1007/s12178-017-9442-3. PMID: 28994028; PMCID: PMC5685964.

  4. Vanti C, Ferrari S, Guccione AA, Pillastrini P. Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment. Arch Physiother. 2021 Aug 9;11(1):19. doi: 10.1186/s40945-021-00113-2. PMID: 34372944; PMCID: PMC8351422.

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