Spondylolisthesis – information, diagnosis, and treatment options
Spondylolisthesis refers to one of the vertebrae of the spine slipping out of place onto the vertebrae below. If the condition is painful, a conservative therapy is the treatment of choice. A stabilizing surgery is meaningful if the pain becomes unmanageable, the disease progresses or has already strongly progressed at initial presentation.
What is spondylolisthesis?
Spondylolisthesis refers to one of the vertebrae of the spine slipping out of place onto the vertebra below it. Most common is a sliding of the fifth lumbar vertebra over the first sacral vertebrae (L5/S1). It is rare that the segment between the fourth and fifth lumbar vertebrae is affected (L4 / 5).
What are the causes of spondylolisthesis?
The most common cause of spondylolisthesis is the wear-induced instability of a motion segment. This spondylolisthesis occurs only in old age. The classic spondylolisthesis, which can already be observed in young people, is caused by a congenital defect in the joint-supporting part of the vertebral arch, the so-called "spondylolysis". This disruption of the bony vertebral structure causes the sliding motion of the vortex to the front.
How is spondylolisthesis diagnosed?
As a result of spondylolisthesis a) the cross sectional area of the spinal canal and b) the cross-sectional area of the nerve exit holes are reduced. The nerves must join the sliding movement, which forces them into a pulling maneuver. The pulling stress and the narrowing of the exiting nerve cause pain, numbness, and often even paralysis in the legs. Back pain is then caused by the overloading of the small vertebral joints and muscles due to the misalignment of the vertebrae to each other.
A comprehensive physical examination may also show an increased lordosis. Radiographs of the lumbar spine are taken from the front and from the side. The radiographs help the physician to evaluate the shape of the spine. A possible displacement or a rotation of two vertebral bodies to each other can easily be recognized. Functional images, i.e. a lateral radiograph in forward and reverse tilt of the trunk, then show the instability accurately. Magnetic resonance imaging is used to assess the spinal canal, the intervertebral discs, and facet joints, and thereby also shows the condition of the back muscles.
What treatments are availaible for spondylolisthesis?
Persons affected with the disease are treated for about four to six months strictly conservative with anti-inflammatory and analgesic drugs, which are taken as tablets or injections into the corresponding facet joints and the affected nerve roots. Physical therapy strengthens the back and especially the abdominal muscles, physical therapy relaxes aching muscle strands. Under certain circumstances, the patient can wear a lightweight corset (brace).
Surgery is only necessary if
- conservative treatment does not relieve the pain
- spondylolisthesis progresses during the course of controlled examinations
- already at the first presentation, the spondylolisthesis is very pronounced (slippage of the vertebra by more than half of the vertebral body diameter)
- the posture has strongly degenerated (hollow round back) with correspondingly shortened muscles
- paralysis has started in the legs.
The "Anterior lumbar interbody fusion" ("ALIF") is carried out from the front and is the method of choice when surgery of the back (dorsal) cannot be performed. In the ALIF, a less invasive access is done through the abdominal wall musculature, in which no muscle should be severed. An intervertebral disc can now easily be removed and a placeholder made of plastic (= "cage") can be inserted.
After a lumbar fusion surgery, the patient can move on the first day after the operation. The patient learns techniques that allow him to move his back in the first few weeks after surgery. Sitting is immediately possible. Step by step, the patient regains his/her normal mobility. After about seven to ten days, the patient can be discharged from the hospital. Following the discharge from the clinic, the patient should continue with further stabilizing by means of physiotherapy to strengthen the core muscles.
Are there alternatives for a stabilizing surgery in spondylolisthesis?
In a classical spondylolisthesis, a direct screw fixation of the defect in the joint-supporting part of vertebral arch can only be performed in rare cases.