From the Guidelines
For patients with spondylolisthesis, initial management should focus on conservative therapy, including physical therapy and pharmacologic treatment, with imaging such as MRI reserved for those who have failed 6 weeks of conservative therapy or have signs of spinal stenosis or radiculopathy 1.
Overview of Spondylolisthesis
Spondylolisthesis is a condition characterized by the forward displacement of a vertebra, typically in the lumbar region, over the vertebra below it. This condition can result from various factors, including degenerative changes, congenital abnormalities, or structural weaknesses such as stress fractures (spondylolysis) 1.
Conservative Management
Conservative management is the first line of treatment for spondylolisthesis, especially in mild cases. This approach includes:
- Physical therapy: Focusing on core strengthening exercises, such as pelvic tilts and bridges, to enhance spinal stability and reduce pain.
- Pain management: Utilizing NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for pain relief.
- Activity modification: Avoiding movements that exacerbate symptoms and promoting a healthy weight to reduce strain on the spine.
Imaging and Further Intervention
Imaging, particularly MRI, is recommended for patients who have not responded to 6 weeks of conservative therapy, or those presenting with signs of spinal stenosis or radiculopathy 1. MRI provides excellent soft-tissue contrast and can accurately depict lumbar pathology, including disc degeneration and nerve root compression. CT myelography and radiographs may also be useful in specific scenarios, such as assessing spinal canal patency or planning surgical interventions.
Surgical Intervention
Surgical intervention, typically involving spinal fusion, may be necessary for severe cases of spondylolisthesis with significant neurological symptoms or those that have failed conservative management. The goal of surgery is to stabilize the affected vertebrae and prevent further slippage, thereby alleviating pain and neurological symptoms.
Prevention and Long-term Management
Preventing progression and managing symptoms long-term involves maintaining proper posture, enhancing core strength through regular exercise, and achieving a healthy weight. These lifestyle modifications can help reduce the strain on the spine and mitigate the risk of further slippage or complications.
From the Research
Definition and Classification of Spondylolisthesis
- Spondylolisthesis is defined as the forward displacement of one vertebrae upon another, usually at the L5-S1 level, but also occurring at L4-5 2.
- The degree of vertebral body anterior displacement is rated from 1-4 depending upon the severity of the slip 2.
- Five major categories have been proposed for the classification of spondylolisthesis 2.
- The two most common types of spondylolisthesis are isthmic and degenerative 2, 3.
Causes and Risk Factors
- Isthmic spondylolisthesis is usually asymptomatic and discovered as an incidental radiographic finding, but it can be symptomatic due to its biomechanical effects on the adjacent neural structures 4.
- Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population 5.
- Degenerative spondylolisthesis most commonly occurs at the L4-5 level in women over the age of 40 2.
Diagnosis and Imaging
- Plain x-rays of the lumbar spine can reveal structural changes such as disc space narrowing, scoliosis, lumbarization or sacralization, spondylolysis, and spondylolisthesis 2.
- Standing plain radiographs can be obtained to confirm the presence or assess the degree of isthmic spondylolisthesis 4.
- Computed tomography (CT) clearly shows the pars defect and provides a better assessment of the pathology 4.
- Magnetic resonance imaging (MRI) is indicated in patients with neurologic manifestations and can be used to assess the degree of foraminal or central stenosis 4.
Treatment and Management
- Conservative management including oral anti-inflammatory medication, physical therapy, and/or transforaminal epidural corticosteroid injections can be utilized initially 4.
- Surgical intervention for treatment of spondylolisthesis is well documented, but literature regarding conservative management is scarce 2.
- Surgery can be considered in the setting of persistent symptoms unrelieved with conservative management or significant neurologic compromise 4, 6.
- Decompression alone or decompression and fusion are surgical options for degenerative lumbar spondylolisthesis 3.