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Spondylolisthesis

Definition

Spondylolisthesis is a condition in which a bone (vertebra) in the lower part of the spine slips out of the proper position onto the bone below it.

Causes, incidence, and risk factors

In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma).

In adults, the most common cause is degenerative disease (such as arthritis). The slip usually occurs between the fourth and fifth lumbar vertebrae.

Other causes of spondylolisthesis include bone diseases, traumatic fractures, and stress fractures (commonly seen in gymnasts). Certain sport activities, such as gymnastics, weight lifting, and football, put a great deal of stress on the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.

Symptoms

Spondylolisthesis may vary from mild to severe. A person with spondylolisthesis may have no symptoms.

The condition can produce increased lordosis (also called swayback), but in later stages may result in kyphosis (roundback) as the upper spine falls off the lower spine.

Symptoms may include:

• Lower back pain
• Muscle tightness (tight hamstring muscle)
• Pain in the thighs and buttocks
• Stiffness
• Tenderness in the area of the slipped disc

Nerve damage (leg weakness or changes in sensation) may result from pressure on nerve roots and may cause pain radiating down the legs.

Signs and tests

The doctor will perform a physical exam. A straight leg raise may be uncomfortable or painful.

X-ray of the spine can show if a vertebra is out of place, and whether there are any fractures.

Treatment

Treatment varies depending on the severity of the condition. Most patients get better with strengthening and stretching exercises combined with activity modification, which involves avoiding hyperextension of the back and contact sports.

Nonsurgical treatments are tried first. This may include:

• Anti-inflammatory medicines to reduce back pain
• A stiff back brace
• Physicial therapy

You should take a break from activities until your symptoms go away. In most cases, you can resume activities slowly.

Surgery to fuse the slipped disc may be needed if you have severe pain that does not get better with treatment, a severe slip of the vertebra, or any neurological changes. Such surgery has a higher rate of nerve injury than most other spinal fusion surgeries. A brace or body cast may be used after surgery.

Periodic x-rays can show whether the vertebra is changing position over time.

Support Groups

Expectations (prognosis)

Conservative therapy for mild spondylolisthesis is successful in about 80% of cases.

When necessary, surgery leads to satisfactory results in 85 - 90% of people with severe, painful spondylolisthesis.

Complications

If too much slippage occurs, the bones may begin to press on nerves. Surgery may be necessary to correct the condition.

Other complications may include:

• Chronic back pain
• Infection
• Temporary or permanent damage of spinal nerve roots, which may cause sensation changes, weakness, or paralysis of the legs

Calling your health care provider

Call your health care provider if:

• The back appears to curve excessively
• There is persistent back pain or stiffness
• There is persistent pain in the thighs and buttocks

Prevention

People with marked lordosis should avoid back hyperextension (leaning way back), weight lifting, and contact sports.

Lower back pain, although common in preadolescent and adolescent children, should be evaluated, especially in the presence of marked lordosis.

References

Spiegel DA, Hosalkar HS, Dormans JP. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 678.

Rosenbaum RB, Ciaverella DP. Disorders of bones, joints, ligaments, and meninges. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J, eds. Neurology in Clinical Practice. 5th ed. Philadelphia, Pa: Butterworth-Heinemann; 2008:chap 77.