Brief overview
- Prognosis: In some cases, stabilization on its own; therapy prevents progression; conservative therapy often relieves symptoms; in severe cases, symptom relief after surgery
- Symptoms: Initially often without symptoms; with increasing severity, back pain, possibly movement and sensory disturbances extending into the legs
- Causes and risk factors: Congenital or acquired cleft formation between vertebral joints; overuse often in high-risk sports such as gymnastics or javelin throwing; after surgery; spinal injuries
- Diagnosis: Medical history, physical examination, X-ray, magnetic resonance imaging, classification of spondylolisthesis into Meyerding grades
- Treatment: Mostly conservative treatment with physiotherapy, physical therapy, electrotherapy and administration of painkillers; surgery in severe cases usually with stiffening of the affected vertebrae.
- Prevention: No prevention in case of congenital form; avoid risky sports at first signs, back-friendly work and carrying techniques
What is spondylolisthesis?
The spine – structure and function
The spine carries the load of the body and transfers it to the legs. It consists of 33 vertebrae and 23 intervertebral discs. Some vertebrae are fused together. A strong muscular and ligamentous apparatus strengthens the spine.
Two vertebrae each, together with the intervertebral disc between them, form a so-called motion segment. They are connected by ligaments, muscles and joints. If these connections are weakened, it is possible for the vertebra to slip forward or even backward. Most often, the affected vertebrae are located in the lumbar region. Because the lowest lumbar vertebra is firmly connected to the pelvis, spondylolisthesis primarily affects the second to last lumbar vertebra (L4).
What is spondylolisthesis in lumbar spine?
By far the most frequently affected ethnic group worldwide is the Inuit. Around 40 percent of them have slipped vertebrae. Outside this ethnic group, competitive athletes whose spine is particularly stressed by overstretching suffer from spondylolisthesis. These include javelin throwers or wrestlers, for example. Athletic exercises such as trampolining, gymnastics or dolphin swimming also count as “risk sports” for spondylolisthesis.
Course of the disease and prognosis
Not all spondylolisthesis progresses. It is possible for spondylolisthesis to stabilize on its own.
Progression of a diagnosed spondylolisthesis can also be prevented with consistent therapy. If spondylolisthesis worsens, the discomfort, movement and nerve problems usually increase. If the problems quickly worsen, decisive therapeutic intervention is necessary.
Three months of intensive conservative therapy for spondylolisthesis significantly improves the symptoms in the vast majority of cases.
How long is a spondylolisthesis incapacitated for work?
Whether you are unable to work as a result of spondylolisthesis depends on the individual case. On the one hand, it depends on how pronounced the symptoms are, and on the other hand, it depends on the activity of the affected person.
If the symptoms can be alleviated with conservative therapy, the period of sick leave and incapacity for work may be shorter. After an operation, the patient is usually off sick for between two and twelve weeks, depending on the occupation.
Symptoms
Spondylolisthesis often progresses without complaint. Other affected persons, however, suffer from pain that occurs primarily under stress and during certain movements. The pain caused by spondylolisthesis then often spreads in a belt-like pattern from back to front. In addition, there is a feeling of instability in the spine.
However, there are no specific slipped vertebra symptoms, as the complaints are often similar to those of other back problems, such as herniated discs. Some sufferers report a “cracking” sensation.
In the congenital form of spondylolisthesis, sufferers usually have no symptoms or only mild symptoms because it is a slowly progressive process. This gives the nerves the opportunity to adapt to the changed conditions.
Causes and risk factors
In order for the affected vertebra to have the opportunity to slide forward, a gap must form in the so-called interarticular portion. This is the area between the articular processes of the vertebrae upward and downward, which form a flexible connection between the vertebrae. If these articular connections are damaged, the vertebra is more mobile, thus possibly slipping out of the spinal axis – spondylolisthesis develops.
A high load on the spine, combined with severe hyperextension to the back, may lead to isthmic spondylolisthesis. High-risk sports include javelin throwing, gymnastics and weight lifting. There is often a genetic predisposition in these.
Severe injuries (traumas) to the spine also significantly reduce stability and may thus lead to spondylolisthesis.
In connection with certain diseases of the bone, such as brittle bone disease, it is possible that a so-called pathological spondylolisthesis occurs. However, this is very rare.
Spondylolisthesis is also possible as a complication after spinal surgery (postoperative form).
Sometimes, however, spondylolisthesis has congenital causes. This is mainly the case with malformations (dysplasias, spondylolysis) of the vertebral arch. The triggers for this are almost always unclear. First-degree relatives of affected individuals also have an increased risk of congenital malformation. In boys, this damage occurs three to four times more often than in girls. In girls, however, spondylolisthesis is usually more pronounced.
Examinations and diagnosis
If you suffer from severe back pain, first consult your family doctor. He or she will refer you to an orthopedist if a disease of the spine, possibly spondylolisthesis, is suspected. However, if you experience severe pain, severe disturbances in motor function or sensitivity, or problems with bowel movements or urination, you should consult a clinic immediately.
However, spondylolisthesis is only rarely an emergency. In most cases, therefore, the orthopedist in private practice is the right specialist, who will ask the following questions, among others:
- Is the pain dependent on strain or movement?
- Do you have sensory or motor disturbances?
- Does your spine feel unstable?
- Do you engage in any sports?
- Have you injured your spine?
- Are there any similar complaints in your family?
- Have you seen other doctors for your complaints?
- Have you tried any treatments for your discomfort?
Physical examination
It is possible that a hump in the course of the spine is already visible when looking at the spine (entrenchment phenomenon). The physician also finds such steps by palpating the posterior processes of the vertebrae (spinous processes). In addition, he thus records the muscle status around the spine and defines the position of the pelvis. By tapping and pressing, he identifies painful regions.
Functional test of the spine
This is followed by physical tests to check the function of the spine. One of the tests used for this purpose is the Schober sign. The physician marks a distance of ten centimeters starting from the uppermost coccygeal vertebra. The patient is then asked to bend forward as far as possible. The previously defined distance should increase by five centimeters. If movement is restricted or the spine is hyperextended, the distance remains smaller.
Imaging examinations
For subsequent clarification, the physician produces an X-ray image from various directions (planes). In certain cases, it is necessary to supplement these images with more specialized procedures such as magnetic resonance imaging (MRI), primarily to evaluate the intervertebral discs, and computed tomography (CT) for a more detailed examination of the bones.
Further measures
In exceptional cases, a nuclear medicine examination (such as a skeletal scintigraphy) is necessary. Also in individual cases, neurological electrophysiological examinations are useful, for example if (possibly) a nerve root is irritated by the spondylolisthesis and the pain radiates.
If there are indications that the patient suffers from concomitant psychological disorders (such as depression) or that the pain is becoming chronic, a visit to a psychotherapist may be indicated.
Classification into degrees of severity
Spondylolisthesis is classified into different degrees of severity. This classification was made by the US physician Henry William Meyerding in 1932:
- Grade I: spondylolisthesis < 25 percent
- Grade II: 25 to 50 percent
- Grade III: 51 to 75 percent
When vertebral slippage exceeds 100 percent, the two adjacent vertebral bodies are no longer in contact with each other. Doctors then speak of spondyloptosis. It is sometimes referred to as grade V on the severity scale.
Treatment
The main goal of therapy is to improve the quality of life, especially a reduction in pain. This is achieved primarily by stabilizing the vertebrae. Spondylolisthesis therapy is based on two pillars, conservative and surgical treatment. While counseling and conservative therapy are usually sufficient in mild cases, inpatient treatment is sometimes required as a second step. Only in severe cases surgery is necessary.
Conservative therapy
Slipped vertebra therapy always begins with a comprehensive consultation. During this consultation, the patient learns how to relieve the strain on his or her spine in a targeted manner. If the patient reduces the physical strain at home and at work, the symptoms often improve significantly. In particular, certain types of sports that put strain on the spine due to frequent overstretching must be avoided in the case of spondylolisthesis.
Patients with increased body weight are advised to reduce their weight as part of spondylolisthesis therapy.
Various pain medications are available to manage the pain. In addition, anti-inflammatory and muscle relaxant medications often help. In some cases, these medications are injected locally into the painful regions in spondylolisthesis.
Physiotherapy in various forms and intensities should reduce the pain. Strong muscles guarantee a stable spine and counteract spondylolisthesis. This is best achieved through gymnastics.
In a back school, those affected learn strategies for training and dealing with the condition. Among other things, patients learn favorable postures and slipped vertebra exercises to relieve strain. Above all, the therapy is designed to help patients help themselves. Continuing exercises consistently after completing guided physical therapy is critical to therapeutic success.
Electrotherapy also often helps with spondylolisthesis. Here, current flows reduce pain and activate the muscles.
In children with spondylolisthesis, the initial focus is on good muscle training. Until bone growth is complete, they are closely monitored for disease progression. The children should avoid any particular strain on the spine.
In more severe cases, surgery to fuse the affected area of the spine is sometimes advisable.
Surgical therapy
Surgical procedures to treat spondylolisthesis are called spondylodesis. Through surgery, the surgeon stabilizes the vertebrae in their correct position, stiffening them and relieving pressure on the nerves. This stabilization is also of particular importance for the biomechanics of the entire spine and the correct distribution of loads.
Surgical intervention is not necessarily required. Factors in favor of surgery are:
- The load due to spondylolisthesis is high.
- Conservative therapy does not help sufficiently.
- The spondylolisthesis progresses or is very pronounced.
- Neurological symptoms appear such as reflex deficits, sensory or motor disturbances.
- The patients are not yet old.
Risks of surgery are mainly general complications such as wound healing disorders or vascular and nerve injuries. The mobility of the spine is reduced in some cases following the operation.
After spondylolisthesis surgery, physiotherapy follow-up is usually provided. In addition, it is sometimes necessary to wear a medical brace for some time for stabilization.
Prevention
Congenital forms cannot be prevented. However, the common cause of overload and wear and tear can be most easily prevented by back-friendly behavior. This includes, for example, “correct” sitting during sedentary activities (as upright as possible) or back-friendly carrying and lifting techniques (from the knees instead of the hips).
If symptoms occur, especially in children who are involved in sports, doctors advise them to stop playing high-risk sports in order to avoid aggravating spondylolisthesis.
