Spondylolisthesis

The spine consists of a series of interconnected bones called vertebrae. In approximately 5% of adults, a developmental fracture may occur in the bone part connecting the upper and lower joints of the lowest vertebrae of the lower back. This fracture may occur on one or both sides of the vertebra. These are “stress fractures” caused by overload, most commonly in the lower vertebrae of the lumbar region, which is highly mobile. These fractures are called “spondylolysis.” Because this region is very mobile, these fractures often do not heal. However, while these fractures usually cause pain in adolescence, they may not cause serious problems in adulthood. In some patients, due to the fracture, the upper vertebrae may slip forward relative to the lower spine. This condition is called “lumbar slippage” or “spondylolisthesis.” Spondylolisthesis may cause more serious problems depending on the amount of slippage. “Lumbar slippages” caused by this type of fracture are called “isthmic spondylolisthesis” in medical terminology and are usually seen as the L5 vertebra slipping over the S1 vertebra. Lumbar slippage has been found in 5 to 10% of patients who consult a doctor for low back pain.

Another type of lumbar slippage is the “lumbar slippage” that usually occurs over the age of 40 due to wear and tear of the spine and surrounding connective tissues as a result of aging. In medical terminology, this condition is called “degenerative spondylolisthesis.” Lumbar slippage that occurs with aging and wear is usually the forward displacement of L4 over L5. Spinal canal stenosis often accompanies lumbar slippage.

What are the symptoms?

Stress fractures (spondylolysis) may not always cause clinical symptoms. Sometimes they may be discovered incidentally on lumbar X-rays taken for other reasons. If there are clinical findings, these may appear as low back pain, buttock pain, tension in the back muscles, and less frequently, numbness and pain in the legs (sciatica) and loss of strength in the feet. Pain usually increases with standing, walking and other activities, and decreases with rest.

How is it diagnosed?

After listening to your complaints and performing your examination, your doctor will request your X-ray films if they suspect spondylolysis or isthmic spondylolisthesis. However, stress fractures (spondylolysis) may not be visible on plain films. In this case, if your doctor still suspects a fracture, they may request scintigraphy and/or CT. If a fracture is detected with these tests, they may consider an MRI necessary for treatment planning. In addition, in patients with slippage and leg pain and/or numbness, an MRI may be necessary to evaluate the spinal cord and nerves. If you have isthmic spondylolisthesis, its severity will be determined on a scale from grade 1 to grade 4 according to the amount of slippage. For the diagnosis of degenerative spondylolisthesis, evaluation will be performed with plain radiographs and MRI. For this type of lumbar slippage, scintigraphy and CT generally may not be necessary.

What are the treatment options?

If your complaints are only low back pain, the slippage is not severe, and your doctor does not suspect serious nerve compression or involvement on examination and tests, the first-choice treatment is non-surgical treatment. These methods may include rest, painkillers and anti-inflammatory drugs, temporary use of a back brace, and one or more physical therapy methods. If your pain continues, another option that may be chosen is steroid and local painkiller injections into the fracture site and the joints connecting the vertebrae (facet joints). If low back pain is accompanied by leg pain and numbness due to nerve compression, epidural or foraminal injections may be added. Pain from stress fractures (spondylolysis) generally improves with these treatments. However, in these patients, the fracture may not always heal completely. Once the pain has resolved, a fracture that has not healed does not pose a danger. Generally, severe slippage is not expected in these patients at older ages. Nevertheless, these patients may occasionally need to be followed up with radiographic imaging.

When might surgical treatment be necessary?

Surgical treatment may be necessary for patients whose complaints do not resolve with non-surgical treatment methods. At the same time, if there is spinal cord compression due to slippage and this causes serious neurological deficits (foot drop, urinary incontinence), early surgical intervention may also be necessary. Two types of surgical treatment can be applied for spondylolysis. The first is repair of the fractured area. The other method is spinal fusion. For isthmic spondylolisthesis, the preferred surgical method is spinal fusion. Also, if there is spinal cord compression, the areas causing the compression are cleared to relieve it. The surgery may be performed from the front, from the back, or from both sides. Fixation materials may be used. Recovery is achieved with a good rehabilitation program after the operation.