What is Lumbar Spondylolysis and Spondylolisthesis?
Spondylolysis is a condition that refers to a specific kind of defect or damage in the back part of the vertebra, specifically at a region termed the ‘pars interarticularis’. This defect typically comes about as a result of injury or repeated stress and over stretching on this part of the spine. In some cases, if this weakness or instability causes movement (or translation) of the vertebral body, it leads to another condition known as spondylolisthesis.
This damage or movement usually happens because of a break or distortion in the back section of the spinal components, which results in elongation or stretching of the pars interarticularis. This issue can potentially occur at any age, and the root cause may differ depending on the patient’s age.
If the slip or movement of the vertebra reaches a point where it affects nerve function, then surgery might be required to relieve pressure (decompress) and provide stability to the affected areas of the spine. However, if there are no motor (movement-related) problems, initial treatment should involve a non-surgical approach, which includes pain relief (analgesia), changes in activity to reduce strain on the spine, and injections for several months.
What Causes Lumbar Spondylolysis and Spondylolisthesis?
Isthmic spondylolisthesis is a condition that often affects children and teenagers. It occurs when there’s a defect in a part of the spine known as the pars interarticularis, usually from repeated minor injuries. This is the most common reason for this condition in young people.
When it comes to adults, the most typical type of this condition is known as degenerative spondylolisthesis. It happens due to ongoing wear and tear changes in the back of the spine, which weakens the ligaments (bands of tissue that connect bones) around it. As these ligaments lose strength, they stretch, and this leads to slippage in the spine.
In some cases, a severe injury can lead to a type of this condition known as traumatic spondylolisthesis. This typically occurs after a high-energy accident that causes the back part of the spine to break and dislocate.
Another form is known as dysplastic spondylolisthesis, which happens when the back parts of the spine don’t form properly. This abnormal formation leads to instability in the spine.
Risk Factors and Frequency for Lumbar Spondylolysis and Spondylolisthesis
Spondylosis and spondylolisthesis are conditions that affect your spine and their rates vary with age groups. Among kids, about 5% have spondylosis, mostly (90%) between the fifth lumbar vertebrae and the first segment of the sacrum (named L5 to S1), even though problems at L4 tend to cause more symptoms. Research shows that 15% of those kids with spondylosis are likely to develop spondylolisthesis, which is a condition where a bone in your spine moves out of place.
As for adults, lumbar spondylolisthesis, which is when a lower vertebrae slips forward, is found in 5% of men, and twice as much in women, at 10%, even though it might not always cause symptoms. This condition mostly happens between the fourth and fifth vertebrae in the lower back (L4 to L5), rather than between the last lumbar vertebrae and the first segment of the sacrum. This type of spondylolisthesis is called degenerative, as it often occurs and progresses in adults.
Moreover, patients with this degenerative type rarely develop a severe form of spondylolisthesis. Over time, this disease might stabilize as the spine changes due to aging, and this might lead to improvement in symptoms.
Signs and Symptoms of Lumbar Spondylolysis and Spondylolisthesis
When a doctor is trying to figure out what’s causing someone’s lower back pain, they start by asking the patient about their pain. They will want to know when the pain started, if it moves around, and if anything particular seemed to start it (like lifting a heavy object or falling). The doctor will also want to know if there were any injuries in the past and what makes the pain feel better. Some people find that leaning forward or sitting down helps because it can reduce pressure on the spine. The doctor might also ask about specific actions or behaviors, like if pushing a grocery cart or walking upstairs eases the pain.
Patients often describe their pain as spreading out from their lower back and down their legs. The doctor will also want to watch a patient walk to see how the pain is affecting their daily life. As part of the overall check, the doctor will also examine how well the patient’s arms, legs, and parts of the body (like the bladder and bowels) are functioning. The examination will be thorough, checking not only the strength of muscles but also feeling (sensation) and reflexes. The skin on the patient’s back may also be checked for any signs of sensitivity or any unusual bumps or dips.
The doctor might also perform a “straight leg test” where the patient lies down and the doctor lifts their leg. This can help discover if the spinal canal is unusually narrow. It can also reveal if the muscles in the back of the patient’s thigh (the hamstrings) are tight, which can be a sign of a condition known as spondylolisthesis. As part of this comprehensive examination, the doctor may notice that the patient has weakness in certain movements, like lifting the foot or extending the big toe, which might indicate that a nerve in the spine (the L5 or L4 nerve) is pinched. The doctor will make detailed notes about these initial findings, as this forms a starting point for any future check-ups.
Testing for Lumbar Spondylolysis and Spondylolisthesis
If you are experiencing lower-back pain, your doctor will likely want to get a clear picture of what’s going on inside your body. To do this, they might take X-ray images of the affected area in your spine, or perhaps of your entire spine. Some important images they’ll want to capture show your spine as you bend forwards or backwards – these can give the doctor an idea of how stable your spinal bones, or vertebrae, are. They might take a series of standing X-rays over time to see if the situation changes.
A key thing your doctor will look at is how much the vertebral bodies (the main parts of your spinal bones) are slipping out of alignment with each other. This is called spondylolisthesis, and it’s categorised into four grades based on the amount of the slip – 1 being mild (0-25% out of place) and 4 severe (76-99%). The condition becomes much more serious, known as spondyloptosis, when there’s full displacement, or 100% of the vertebra is out of alignment. Grades 1 and 2 are considered low-grade slips, whereas grades 3 and 4 are considered high-grade.
In addition to the X-rays, another imaging test called a Magnetic Resonance Imaging (MRI) scan might be very helpful in assessing your case. If you’ve tried six weeks of physical therapy and are still in pain, your doctor might order an MRI. This type of imaging can show more detail than an X-ray, including any pressure on your nerves. The images to pay particular attention to are the ones captured from the side (sagittal) and from above (axial) – these will highlight any compression of the areas where your nerve branches are.
Treatment Options for Lumbar Spondylolysis and Spondylolisthesis
Non-surgery treatments include changing behaviors that might be causing the pain, taking non-steroidal anti-inflammatory drugs (NSAIDs), going through physical therapy, doing stretching exercises, and sometimes using a lumbosacral orthosis, which is a back brace. A 2009 study found that around 84% of young patients treated without surgery were much better after a year. This study also found that braces didn’t really make a difference to the outcomes. It’s likely that changing behaviors, not wearing a brace, resulted in the improvement. Also, a six-week course of physical therapy focusing on strengthening and stretching core muscles is worth trying. Sometimes, to help with temporary pain relief, epidural injections can be given, but while they aren’t common, there is a risk of infection.
Most patients get better with these non-surgery treatments. But for those who don’t, there are three options: living with ongoing pain, completely avoiding activities that cause pain, or having surgery. Importantly, surgery for this kind of back issue should generally be saved for those whose condition worsens rapidly, whose slip gets worse, or whose pain is so bad it affects their daily life
The optimal surgical procedure and approach are still under debate. Some controversy exists as to whether a certain type of surgery called posterior decompression is necessary for patients whose pain is localized to a specific path (radicular) but not for those whose pain is more generalized (non-radiating lower back pain). However, when a patient has a loss of motor function or muscle strength, everyone agrees that decompression surgery is necessary.
Moreover, patients who have a particular kind of spinal misalignment called retrolisthesis and a ruptured disc at the bottom of the spinal column have been found to have similar long-term outcomes whether they have surgery or not. Patients should take into account that while surgeries are likely to help with pain that is localized to a specific path, the results aren’t as predictable for pain that radiates throughout the lower back.
What else can Lumbar Spondylolysis and Spondylolisthesis be?
Lower back issues can come in many forms. Some conditions related to this part of the body that your doctor may consider in a diagnosis include:
- Disc injuries in the lower back
- Chronic pain caused by the discs in the lower back
- Issues with the joints that connect the spine in the lower back
- Injuries to the bones in the lower back
- Injury caused by overstretching or tearing the ligaments and tendons in the lower back region
- A condition where a vertebra in the lower back slips out of place
- Degradation of the spine in the lower back
- Muscle tension and pain in athletes
- Injury to the joint that connects the spine to the pelvis
What to expect with Lumbar Spondylolysis and Spondylolisthesis
The outlook for patients with spondylolisthesis, a condition where one of the bones in your spine slips forward onto the bone below it, is generally positive. Most patients find relief from their symptoms with non-surgical treatments. However, if someone continues to experience severe symptoms which aren’t helped by these non-surgical treatments, surgery could potentially offer relief.
Surgery could help especially with radicular leg symptoms, which are pinching or irritation of the nerve roots in the spine, resulting in pain that travels down the leg. In severe cases, when the pain is localized in the lower back and not relieved by other treatments, a procedure called lumbar fusion might be needed. In this procedure, two or more vertebrae (the small bones that make up the spine) are joined or “fused” together.
Possible Complications When Diagnosed with Lumbar Spondylolysis and Spondylolisthesis
The complications associated with spondylolisthesis primarily affect the nervous system. Symptoms you might experience include ongoing pain in the lower back or legs and feeling a numb, tingling sensation, or weakness in your lower body parts. In severe cases, if the nerve is squeezed too much, it can cause issues with controlling bowel or bladder movements. However, this is not a common occurrence.
Here are the potential complications:
- Chronic lower back or leg pain
- Numbness, tingling, or weakness in lower extremities
- Problems with bowel or bladder control (rare)
Preventing Lumbar Spondylolysis and Spondylolisthesis
It’s important for patients to understand their health condition and how it may limit them in daily life. This understanding might be different for each person, depending on the seriousness of their specific situation. The doctor will discuss the parts of the body that are affected, and might even use a model of the spine to help explain things. Additionally, the doctor will review the physical activities regularly performed by the patient like heavy lifting or long periods of sitting.
These details are crucial in helping the doctor to assess how the condition affects the patient’s day-to-day life. Depending on how severe the condition is, the doctor might suggest that the patient limit certain physical activities. Their aim is to help manage the condition effectively and prevent it from getting worse.