Spondylolisthesis

What is the anatomy of the lumbar spine?

The lumbar spine consists mainly of the vertebrae or bone of the spine with a disc in between each bone…

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What is a spondylolisthesis?

Spondylolisthesis is a condition where one vertebral body moves forward in relation to the next. This forward ‘slip’ can occur for a variety of reasons. The most common varieties of spondylolisthesis are:

Degenerative spondylolisthesis

Degenerative spolndylolisthesis occurs mainly in women and occurs most commonly at the L4/5 level. Degenerative spondylolisthesis is due to degenerative changes in the facet joints at the posterior aspect of the spine. The loss of integrity in these joints allows the superior vertebra to move forward. This results in narrowing of the spinal canal or spinal stenosis, as well as narrowing of the exit foramina for the individual nerve roots.

spondylolisthesis

Isthmic spondylolisthesis

Isthmic spondylolisthesis is a condition that is more common in males and occurs mostly at the L5/S1 level. It occurs when there are pars defects. The pars (or pars interarticularlis) are small areas of bone; one each side at the posterior aspect of the spine. It joins one facet joint to another. When the pars are fractured, or have a defect, the main part of the superior vertebra is allowed to ‘slip’ forward. In most cases this is a small slip, but it can be quite severe and rarely, the superior bone can have completely ‘slipped’ off the one below. This is called spondyloptosis and is fortunately very rare.

Isthmic spondylolisthesis is common but rarely requires surgery. The problems and their symptoms that occur due to isthmic spondylolisthesis are very similar to those described for degenerative spondylolisthesis. Surgery for this condition is performed only in patients who have significant symptoms that have not responded to more conservative treatment. Therefore, only a minority of people with this condition will require surgery during their lifetime.

Other forms of spondylolisthesis

Other forms of spondylolisthesis include trauma, congenital spinal dysplasia, tumour and infection.

What are the symptoms of spondylolisthesis?

The most common clinical symptoms of spondylolisthesis are:

Radiculopathy is a clinical condition usually due to compression of a nerve root. It is commonly referred to as a pinched nerve or sciatica.

The nerve root is the start of a nerve as it exits from the spinal cord and spinal canal. It usually will join with other nerve roots outside of the spinal canal to form various peripheral nerves. Nerve roots normally supply sensation to an area of the body as well as supply various muscles to make them move.

Radiculopathy is most commonly painful and the area in which the patient experiences pain will often indicate the nerve involved. In addition, there is often numbness and paraesthesia. Paraesthesia is commonly referred to as pins and needles. Again, these may indicate the nerve root that is affected. Finally, there may be weakness of a particular muscle or of a particular movement.

Nerve root compression causing radiculopathy is most commonly due to a disc protrusion or bony spurs (osteophytes). In the case of a spondylolisthesis, the exit foramen, that is the space between the bones where the nerve exits the spine, becomes too narrow. In addition, the space for the nerves within the spinal canal also becomes smaller and the nerve root may be compressed there as well.

Neurogenic claudication refers to pain, numbness and/or paraesthesia (pins and needles) that occurs during standing or walking. Typically, the symptoms begin when the patient walks long distances only and is relieved by a few minutes of rest after which they can walk again for a similar distance. Over time, as the condition progresses, the distance for which the patient can walk, or time that they can stand for, is reduced.

Eventually the symptoms become so severe that they occur at rest and may significantly limit mobility. The most common reason for this condition is a spinal canal stenosis which is a consequence of spondylolisthesis. This means that the space inside the spinal canal has become too small for the nerves. Essentially, they become crowded together and compressed.

The low back pain that people experience in this condition can take several forms. Typically, patients find that small degrees of flexion (bending forward) can cause significant pain. An example of this is experiencing pain while leaning over a sink to brush their teeth. However, they often also report that the pain is relieved by supporting their upper body on their elbows. For example, they find that leaning forward on the handle of the shopping trolley is more comfortable than when they walk straight upright.

What are the treatment options for spondylolisthesis?

When spondylolisthesis symptoms are mild, then conservative management such as physiotherapy may be appropriate. Cortisone injections may be useful to treat spondylolisthesis if the pain is mainly located in the back itself, particular if the origin is the facet joints. Cortisone injections are often used for the treatment of leg symptoms as well, but their effectiveness in the setting of spinal stenosis may be limited as the main issue is usually mechanical compression of the nerves rather than inflammation.

Cortisone will not relieve the mechanical compression of the nerve roots.

Surgery for spondylolisthesis is indicated for patients with significant symptoms including neurogenic claudication or radiculopathy that have not responded to conservative management.

spondylolisthesis treatments

What type of surgery is used to treat spondylolisthesis?

Surgery for spondylolisthesis usually involves a technique that will both decompress the affected nerve, but also restore stability and alignment to the lumbar spine. A number of factors are taken into account including the degree of the spondylolisthesis, the level, and number of levels involved, the overall alignment of the spine, and patient preferences.

For most patients, a decompression and fusion procedure will be performed. This may be in the form of a posterior lumbar interbody fusion (PLIF) which may be performed using an open or minimally invasive technique. Some patients may be better suited to minimally invasive approaches such as an extreme lateral interbody fusion (XLIF). Prof Owler will be able to discuss this with you at your consultation.

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