Back doctor explains treatment for spondylolisthesis, a common cause of back pain

Spondylolisthesis: one more cause of neck and lower back pain

What is spondylolisthesis?

Spondylolisthesis (spon + dee + lo + lis + thee + sis) can be defined in either of two ways; one is more technically correct than the other.

First the technical definition:  Spondylolisthesis is a structural problem of the spine in which one of the spinal bones (vertebra) slips either forward or backward from its normal position in relation to the spinal bone that is below it.  When the spondylolisthesis slippage goes forward, which is by far the most common direction for this kind of misalignment, it is called anterolisthesis. When the slippage goes backward it is called retrolisthesis.

The more broadly used and commonly accepted definition:  Spondylolisthesis is a structural problem of the spine in which one of the spinal bones (vertebra) slips forward in relation to the spinal bone that is below it.  When a doctor only describes the slippage as a spondylolisthesis it is assumed the term is being used in this general way, and that the direction of displacement is forward.

The great problem of spondylolisthesis is that the exaggerated misalignment in either direction is likely to cause a deformity of the contour of the spine, leading to narrowing of the spinal canal, structural stress is applied to the spinal discs that eventually allow significant arthritis to develop at the level of the slippage and significant compression (pinching) of the nerves as they exit from the openings between the spinal bones.

While the vertebral slippage of spondylolisthesis can theoretically occur at most any level of the spine, it is far more common in the low back (lumbar spine), especially the three lowest lumbar spinal bones.  Only occasionally will spondylolisthesis occur in the neck (cervical spine), and rarely in the upper back (thoracic spine). Since lower back spondylolisthesis represents the most common location for this particular spinal instability, the rest of this discussion will address the problem from the standpoint of it occurring in the low back.

Lifting Do’s and Don’ts to avoid aggravating spondylolisthesis

What are symptoms of spondylolisthesis?

It is possible to have a mild or early case of spondylolisthesis and have no symptoms like pain or stiffness, and be unaware that the condition exists. When spondylolisthesis symptoms do appear it is most commonly low back pain that develops across the lower back at and slightly above the belt line, and it is easily aggravated by any exaggerated forward or backward bending of the lower back (as when brushing the teeth in the AM when the back is still stiff).

The most common complaint of someone with spondylolisthesis is chronic and intense lower back pain, often radiating into the buttocks, especially after prolonged standing on a hard surface, doing work that requires backward bending of the low back and wearing high heels.  Reduced range of movement of the low back can make walking difficult and painful. Tightness or spasm of the hamstring muscles also occur, along with an exaggerated and deep forward curvature of the lumbar spine (swayback) are other common findings associated with spondylolisthesis. Tight hamstrings related to spondylolisthesis can alter the gait so that the person will walk with a shorter than average stride, less on the heel and more on the forefoot and with the knees slightly bent.

It is not uncommon for spondylolisthesis to cause nerve compression that result in variable pain immediately around the location of the forward slippage, as well as numbness, tingling or muscle weakness in any part of the legs. When severe the spondylolisthesis can also cause compression of the nerves as they exit the spine to result in loss of control of bowel or bladder function; when this occurs it is known as a cauda equina syndrome.

Anyone with a spondylolisthesis who also has a large and pendulous abdomen would be well advised to reduce the amount of  abdominal fat since the forward pulling of the enlarged abdomen also aggravates the forward slippage of the lower lumbar segments.

What causes spondylolisthesis?

The forward or backward slipping of spondylolisthesis can occur as the result of five different problems that make a lumbar spinal bone so unstable that it can significantly slide from its normal position in relation to the spinal bone that it rests upon:

  1. Dysplastic fault: Dysplastic spondylolisthesis is caused by a congenital or birth defect that results in an abnormally formed spinal bone in the area called the facet of one or more vertebrae. This is a very common form of spondylolisthesis, and it frequently appears during the teen years after an aggressive period of growth. The facet is a bony projection that serves two purposes:  It acts as a hinge or gliding surface to guide or control the direction of movement of a vertebra, and it acts as a brake or stopper to prevent movement in a particular direction.  When the facet is absent or smaller or weaker than it should be, there is nothing to limit, guide or stop vertebral movement and excessive forward or backward slippage can occur.
  2. Isthmic fault: Isthmic spondylolisthesis is caused by a congenital or birth defect that results in an abnormally formed or weak area of one or more spinal bones called the isthmus or pars interarticularis.  This is a common form of spondylolisthesis. This area of the spinal bone connects the front section to the back section; if this area is weak or malformed the vertebra can essentially separate in half, with the back  staying where it belongs and the front section slipping forward.  The actual separation tendency can be started by repetitive trauma in the form of heavy lifting, falling, overweight, high heels, etc. .
  3. Degenerative or arthritic changes: Degenerative spondylolisthesis is caused by the structural changes that are part of arthritis occurring in the spine, primarily affecting the facet joints of the spinal bone due to erosion and weakening of the disc cartilage.  This is a common form of spondylolisthesis, usually occurring in the late 40s. While more common in the elderly, it can also occur in younger people who are prone to early arthritis for a variety of reasons.
  4. Trauma: Traumatic spondylolisthesis is caused by either a single massive trauma or injury to the spinal bones (auto accident, fall from great height, crushing injury) or small repetitive injury (repetitious heavy lifting, sports, overweight, wearing high heels, etc).  This trauma can break off  or fracture the facet or isthmus (pars interarticularis) of a spinal bone, allowing unrestrained movement forward or backward.
  5. Pathology: Pathologic spondylolisthesis is caused by a weakening or erosion of the bone tissue by disease or a tumor of the bone that makes up the facet or isthmus (pars interarticularis) of a spinal bone, allowing unrestrained movement forward or backward. This is an uncommon form of spondylolisthesis.

What is the best treatment for spondylolisthesis?

Initially, the best treatment for spondylolisthesis is conservative in nature and is based on the specifics of the case and the symptoms presented. The basic format for treating a case of spondylolisthesis and getting low back pain relief  is much like other painful structural spinal problems:

  • Rest. Lying in a comfortable position on a firm surface, usually lying face up, while staying off work and avoiding all stressful activities that increase pain, such as , prolonged sitting or standing, lifting, bending, wearing high heels, etc.
  • Cold/hot packs to the area of greatest discomfort.
    How to use a cold pack for spondylolisthesis 
  • Wear a hyperextension brace to limit movement in the early stages when pain and inflammation is greatest.
  • Stretch and exercise, to increase range of motion of the lumbar spine and hamstrings as well as strengthen the core muscles of the abdomen.
  • Acupuncture or acupressure treatment for spondylolisthesis can be extremely effective.
  • Chiropractic manipulation.  There are very specific gentle manual techniques that are very effective for this problem.  Please be sure to determine that you are using the  services of a skilled and dedicated chiropractor who is well versed in spondylolisthesis management.
  • Anti-inflammatory medications.  A brief course to reduce pain by decreasing the inflammation of the soft tissue of the low back.

For those whose pain and inflammation do not sufficiently improve after following a reasonable course of conservative treatment might consult with an orthopedic or spinal surgery for evaluation.

The complications of a non-resolved lumbar spondylolisthesis include easy and frequent aggravation of chronic lower back pain.  In addition, depending on many variable factors, weakness, numbness and tingling of the legs can also occur.  When severe a spondylolisthesis can result in direct compression of the nerves of the cauda equina, resulting in loss of bowel or bladder control.