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    Spondylolisthesis

    What is spondylolisthesis?

    • Spondylolisthesis is a medical term to describe a slight change in position (usually further forward) of one vertebra relative to the vertebrae below (1).

    How common is spondylolisthesis?

    • It is a rare cause of back pain.
    • Research evidence suggests between 3.6%-18% of people may have a spondylolisthesis, but only a small percentage may cause back pain (2).

    Should I worry?

    • No.
    • Most cases have only mild symptoms or none at all.
    • 75% of cases are classified as “Grade 1” with only a mild change in the vertebrae’s position and are therefore less likely to get worse over time (3,4).
    • Less than 10% of people seeking treatment for this condition would ultimately be considered for surgery (4).

    Who is most likely to suffer from spondylolisthesis?

    • A degenerative spondylolisthesis (due to the normal ageing process of the spinal column) is more common in women than men (4).
    • Degenerative spondylolisthesis is also more common in those aged over 50 (3).
    • However, it may also be seen secondary to a stress fracture (a small fracture in an otherwise normal bone) inactive adolescents participating in sport (5).
    • It may be seen in adults who are either overweight or classed as obese.
    • It may also be seen in those with a family history of similar/same condition (4).

    What are the common symptoms?

    • Back pain, most often felt in the low back but occasionally in the neck.
    • In more severe cases, low back or neck pain may be accompanied by pain felt in the arms or legs or altered sensation (pins and needles or numbness in the arms or legs).
    • Low back or neck pain is often worse with standing or leaning backwards.
    • Low back pain is eased by sitting or lying down (3,6).

    What can I do?

    • Aim to reduce or ensure a healthy weight and body mass index (BMI).
    • Participate or engage in exercises to strengthen the back and surrounding muscles.
    • Inactive adolescents, ensure there are sufficient rest days or modify training to avoid activities that are painful.
    • Take any medication as prescribed to help manage your spinal pain and enable you to participate in rehabilitative exercise (7).

    How long will it take to recover?

    • Degenerative spondylolisthesis cannot be cured so treatment is aimed at managing or reducing symptoms and the impact on the person’s life.
    • With the right combination of therapies (including staying active, managing weight, strengthening exercises) the condition will have little or no impact on your daily life.
    • In the adolescent population, outcomes are generally good if caught early and activities are modified appropriately (7,8).
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    1. Introduction

    Spondylolisthesis is a medical term that describes a change in position of one vertebra (the bones that make up the spine) relative to the vertebrae directly below (1). The most common change in position is an “anterior slip” which simply means that one vertebra appears slightly further forward compared to the one below. This most commonly occurs in the low back (lumbar spine) and over 90% of cases occur at the L5-S1 level (where the 5th lumbar vertebrae connect to the sacrum or tail bone) (2,3).

    Spondylolisthesis may occur due to normal, age-associated changes to the spinal joints or due to a stress fracture (a small fracture in an otherwise normal bone due to repeated stress or load). This presentation is seen most often in young, active adolescents who participate in sports that involve jumping and landing, such as basketball and athletics (4).

    Spondylolisthesis is graded from 1-4. Grade 1 represents over 75% of cases and is the mildest form of the condition, often with very minimal symptoms. Grade 4 is the most severe form of the disorder that may present with more significant symptoms (6).

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    2. Signs & Symptoms

    Spondylolisthesis does not always cause symptoms so people may have it without knowing; this is therefore not of concern and does not require action (6). The severity of symptoms also varies from person to person.

    Symptoms, when this condition is associated with the low back, may include:

    In those cases where a spondylolisthesis is associated with the neck, symptoms may include:

    3. Causes

    There are five categories of spondylolisthesis that refer to the different reasons why this condition may occur (1,9). These are outlined below:

    1. Degenerative – spondylolisthesis can occur due to normal, age-related changes in the spine. It is usually related to instability and forward movement of one vertebral body relative to the adjacent vertebral body.
    2. Isthmic – spondylolisthesis is because of defects in the pars interarticularis (a small part of the vertebrae). A possible reason for this includes a stress response in adolescence related to sports such as football, cricket, and gymnastics, where repeated lumbar extension occurs (5).
    3. Traumatic – spondylolisthesis occurs after major trauma.
    4. Dysplastic – spondylolisthesis occurs due to natural variation in the way(s) that your bones are formed or aligned.
    5. Pathologic – spondylolisthesis can be from systemic causes such as bone or connective tissue disorders, cancer or infection (3, 5, 7).
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    4. Risk Factors

    This is not an exhaustive list. These factors could increase the likelihood of someone developing spondylolisthesis. It does not mean everyone with these risk factors will develop symptoms.

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    5. Prevalence

    Evidence suggests between 3.6%-18% of the general population may have a spondylolisthesis on imaging. However, as mentioned above, the vast majority of these will not cause pain. 75% of cases are considered “Grade 1” which is the mildest/least severe grade seen (1, 2).

    6. Assessment & Diagnosis

    Your physiotherapist will take a detailed history of your low back pain to better understand how the pain is affecting you. They may ask you questions about how the pain is at certain times of the day, which activities make it better or worse, and whether you have any symptoms in your leg. The physiotherapist will perform a physical examination, looking at how well you move and how your pain responds to different movements. They may also check the strength and sensation in your legs if this is required.

    In cases where symptoms are not responding to usual care, X-rays may be used to look at the alignment of the vertebrae. An MRI (magnetic resonance imaging) scan can also confirm the diagnosis and is more likely to be used if nerve involvement is suspected.

    7. Self-Management

    Self-management may consist of a period of rest, oral pain relief or non-steroidal anti-inflammatory drugs, heat, light exercise, weight loss and pacing of activities.

    As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help you manage your spondylolisthesis. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently, over weeks and months then they will, in most cases, make a significant difference.

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    8. Rehabilitation

    Your physiotherapist can work with you to devise a programme that suits your needs/goals and help you manage your symptoms.

    For this condition, you may be given exercises that will aim to:

    9. Spondylolisthesis Rehabilitation Plans

    Early Plan

    This basic rehabilitation programme includes simple exercises to mobilise the spine and begin to strengthen some of the key muscle groups that support your low back. It can be performed little and often during the day within the limits of your pain. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.

    Early Plan - Rating

    Intermediate Plan

    This more intermediate programme includes some more challenging exercises that will aim to strengthen the muscles that support your low back, as well as helping to strengthen the buttocks, hamstrings and quadriceps. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.

    Intermediate Plan - Rating

    Advance Plan

    This is an advanced programme of exercises to continue to build strength and muscle endurance around your lower limbs and low back. It may be completed 3-4 times per week, like a gym programme, and includes more functional or multi-joint exercises. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.

    Advance Plan - Rating
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    10. Return to Sport/Normal life

    This is very much symptom dependent. In those wishing to return to sport or more demanding levels of activity, we suggest a consultation with a musculoskeletal physiotherapist. The physiotherapist can guide you on the appropriate progression of rehabilitation relevant to your goals and construct a phased return to your sport to minimise the chances of recurrent pain.

    11. Other Treatment Options

    In some cases, particularly advanced cases or where physiotherapy and medications have not helped your pain, you may be recommended surgery (10). This is largely when there are more severe changes shown on scans and where there may be nerve involvement. However, it is worth noting that less than 10% of people seeking treatment for this condition would ultimately be considered for surgery (1, 11).

    12. Links for Further Reading

    www.nhs.uk/conditions/spondylolisthesis/

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    Book an Appointment

    Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

    We have Pure Physiotherapy clinics across the country including Norwich, Great Yarmouth, Manchester, Stockport, Sheffield and Rotherham. Please view our clinics to find the closest physiotherapy clinic for you.

    References

    1. Spondylolisthesis .(2020). Tenney & Gillis https://www.ncbi.nlm.nih.gov/books/NBK430767/.
    2. Wang et al .(2017). Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866399/.
    3. NHS – Spondylolisthesis https://www.nhs.uk/conditions/spondylolisthesis/ Accessed 12/04/21.
    4.  Kalichman et al. (2009). Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population.
    5.  Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg. 2006 Jul;14(7):417-24.
    6.  Syrmou E, Tsitsopoulos PP, Marinopoulos D, Tsonidis C, Anagnostopoulos I, Tsitsopoulos PD. (2010 Jan). Spondylolysis: a review and reappraisal. Hippokratia.;14(1):17-2
    7.  Evans N, McCarthy M. (2018 Dec). Management of symptomatic degenerative low-grade lumbar spondylolisthesis. EFORT Open Rev. 3(12):620-63.
    8.  Klein G, Mehlman CT, McCarty M. (2009). Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop.
    9. Ilyas H, Udo-Inyang I, Savage J. (2019 Aug). Lumbar Spinal Stenosis and Degenerative Spondylolisthesis: A Review of the SPORT Literature. Clin Spine Surg. 32(7):272-278.
    10. Austevoll IM, Gjestad R, Solberg T, Storheim K, Brox JI, Hermansen E, Rekeland F, Indrekvam K, Hellum C. (2020 Sep). Comparative Effectiveness of Microdecompression Alone vs Decompression Plus Instrumented Fusion in Lumbar Degenerative Spondylolisthesis. JAMA Netw Open.01;3(9):e201501.
    11.  Shenoy K, Stekas N, Donnally CJ, Zhao W, Kim YH, Lurie JD, Razi AE. (2019 Jun). Retrolisthesis and lumbar disc herniation: a postoperative assessment of outcomes at 8-year follow-up. Spine J.19(6):995-1000.
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    Lower back pain caused by structures in the back, such as joints, bones and soft tissues.

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    Low Back Pain and Sciatica

    Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.

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    Lumbar Disc Injury

    Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.

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    Spondylolysis

    An injury due to a stress fracture through part of a vertebra known as the pars interarticularis of the lumbar vertebrae (lower back).

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