From the Guidelines
Lithesis of the spine, or spondylolisthesis, should be initially managed with conservative approaches, including physical therapy and pain management, with imaging reserved for patients who have failed 6 weeks of conservative therapy or have signs of nerve root irritation, as recommended by the American College of Radiology in their 2021 update 1.
Initial Management
Treatment typically begins with conservative approaches, including:
- Physical therapy focusing on core strengthening exercises
- Pain management with NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily)
- Activity modification to avoid movements that worsen symptoms A physical therapy regimen should include specific exercises to strengthen abdominal and back muscles, typically performed 3-5 times weekly for at least 6-8 weeks.
Imaging and Further Management
Imaging, such as MRI of the lumbar spine, is recommended for patients who have failed 6 weeks of conservative therapy or have signs of nerve root irritation, as it can accurately depict lumbar pathology, including disc degeneration, and identify potential actionable pain generators that could be targeted for intervention or surgery 1. For moderate pain, muscle relaxants such as cyclobenzaprine (5-10mg three times daily) may be prescribed short-term. Weight loss is recommended for overweight patients to reduce stress on the spine. If conservative treatments fail after 3-6 months, epidural steroid injections might provide temporary relief. Surgery (spinal fusion or decompression) is generally reserved for cases with severe symptoms, neurological deficits, or progressive slippage.
Key Considerations
- The goal of imaging is to identify potential actionable pain generators that could be targeted for intervention or surgery.
- MRI has excellent soft-tissue contrast and accurately depicts lumbar pathology, including disc degeneration, as well as the thecal sac and neural structures 1.
- CT myelography of the lumbar spine can be useful in assessing the patency of the spinal canal/thecal sac and of the subarticular recesses and neural foramen, especially in patients with significant artifact from metallic surgical hardware on MRI 1.
From the Research
Definition and Causes of Spondylolisthesis
- Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, often separated into categories based on the causative etiology 2.
- Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population 3.
- It is defined as displacement of one vertebra over subjacent vertebra, associated with degenerative changes, without an associated disruption or defect in the vertebral ring 4.
Symptoms and Diagnosis
- Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity 2.
- A detailed history and physical exam, along with appropriate imaging tests are useful in making the diagnosis 2.
- A comprehensive physical exam and subsequent imaging including radiographs, CT and MRI play a role in the diagnosis of this disease process 5.
Treatment Options
- Conservative therapy is first-line and includes pain management with physical therapy 2.
- Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy 3.
- For well-selected patients who fail conservative management strategies, surgical management is appropriate 3.
- Surgical options may include decompression alone or decompression and fusion 4.
- Management of high-grade spondylolisthesis usually entails surgical decompression and fusion with instrumentation 6.