Exploring the Pathophysiology and Treatment Options for Spondylolisthesis
Spondylolisthesis
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Spondylolisthesis is a spinal condition where one vertebra slips forward over the one beneath it. The term originates from the Greek words spondylos (vertebra) and olisthesis (slipping). It typically develops when there's a defect in the vertebra, leading to this misalignment. The condition appears in about 4% to 6% of children, most often in the form known as isthmic spondylolisthesis, usually affecting the L5–S1 segment. In adults, the prevalence rises to 5% to 10%, with degenerative spondylolisthesis being more common. This adult form most frequently affects women and tends to occur at the L4–L5 level, followed by L5–S1. In some cases, a vertebral stress fracture (spondylolysis) may develop into spondylolisthesis, potentially leading to clinical symptoms.
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Although it's generally agreed that spondylolisthesis doesn't occur at birth, genetics seem to play a role in 15% to 69% of cases. Several factors may contribute to its development, including advancing age, a more sagittally aligned facet joint orientation, a flattened lower back (lumbar hypolordosis), higher body mass index in women, and history of pregnancy.
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Thoracic spondylolisthesis, particularly of a degenerative nature, is extremely rare. This is due to the stabilizing effects of the rib cage and thoracic facet joints, which limit forward slippage in the thoracic spine.
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In children, spondylolisthesis most commonly presents as pain in the lower back or buttocks, which tends to worsen with physical activity. Discomfort is often aggravated by back extension, and tightness in the hamstrings is frequently observed.
In adults, particularly those with degenerative forms of the condition, symptoms may include lower back pain, nerve root irritation (radiculopathy), or neurogenic claudication—pain or weakness in the legs triggered by walking or standing, which may improve when sitting down.
As the condition progresses, more serious neurological symptoms can develop. These may involve radiating leg pain, issues with bowel or bladder control, and other neurological impairments. In the most severe cases, it can lead to cauda equina syndrome, a serious condition requiring urgent medical attention.
Symptoms:
Differential Diagnosis:
Conditions that should be considered when diagnosing degenerative spondylolisthesis include lumbar compression fractures, spinal canal stenosis, herniated lumbar discs, spondylolysis, and facet joint arthropathy. These disorders often share symptoms like lower back pain and radiculopathy. However, a distinguishing feature of spondylolisthesis is that symptoms typically worsen with spinal extension, and in some cases, the condition may present without any symptoms at all.
Examination:
On physical examination, spondylolisthesis may present with a flattened lumbar curve, pain during both flexion and extension movements, and muscle spasms. Specific findings can help identify the type of spondylolisthesis. In degenerative cases, a palpable "step-off" is often felt just above the level of the vertebral slip, while in isthmic types, it is usually below the slipped segment.
Children with isthmic spondylolisthesis may show a positive result on the stork test (one-legged hyperextension), which causes pain on the same side of the back and may also present with a scoliotic posture. In older adults, especially those with more advanced slippage, signs of nerve compression or spinal stenosis—such as motor weakness, altered reflexes, or sensory loss—are more frequently observed.
Diagnostic Imaging:
A lateral X-ray taken in an upright, weight-bearing position is the most reliable imaging test to detect spondylolisthesis. To assess spinal stability, flexion and extension views can be helpful. For more detailed evaluation—particularly of spinal stenosis or fluid in the facet joints—MRI is the preferred imaging method, as it provides superior visualization of soft tissue and nerve structures.
Treatment Considerations:
Although there have been favorable outcomes with non-surgical approaches like reduction and immobilization using a plaster cast, this method is rarely used today. The practical limitations and potential risk of neurological complications make closed reduction less favorable. Treatment is now more carefully selected based on individual assessment and may involve either surgical or non-surgical management depending on the severity of symptoms and degree of vertebral displacement.
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Conservative Treatment:
Non-surgical management options for degenerative spondylolisthesis include a variety of physical and manual therapy approaches. These may involve active physiotherapy, exercise education or counseling, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation. Other conservative methods include homeopathic treatments, soft tissue massage, trigger point therapy, spinal mobilization for restricted segments, cryotherapy, and chiropractic care.
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Mirror Image® Exercises:
These corrective exercises aim to realign and stabilize the spine by addressing muscular imbalances caused by poor posture or spinal misalignment. The exercises focus on strengthening underactive muscles and stretching overly tight ones. They typically involve controlled contraction and relaxation cycles designed to retrain posture and enhance spinal stability.
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Mirror Image® Traction:
This technique applies targeted mechanical force to move the spine into an exaggerated, corrected posture, promoting long-term realignment. It works by producing plastic deformation of spinal structures—such as ligaments and muscles—through sustained pressure, encouraging tissue adaptation and postural correction. The process involves cervical extension, thoracic flexion with posterior translation, and lumbar extension to restore proper spinal curvature and alignment over time.
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Surgical Treatment:
Surgical intervention for spondylolisthesis primarily focuses on restoring spinal stability and relieving nerve compression. To achieve these goals, a variety of spinal fusion techniques are commonly employed, including anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF).
In recent years, minimally invasive TLIF (MIS-TLIF) has gained popularity due to its benefits, which include reduced blood loss, minimal soft tissue damage, and faster postoperative recovery.
These surgical procedures follow the fundamental orthopedic principle of re-establishing the normal anatomical alignment of spinal structures disrupted by trauma or degeneration.
Surgical reduction specifically enables:
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Careful monitoring and alignment of the bony and nerve structures
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Effective nerve decompression by removing disc fragments or peridural hematomas
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Accurate and controlled application of corrective forces
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Strong initial stabilization
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Successful spinal fusion—either posterolateral or interbody—tailored to the mechanical needs of the affected spinal segment
References
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Griffiths, J. W., 1999. The Management of Spondylolisthesis. Current Orthopaedics, [online] 13(4), pp.277–283. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC3611181/pdf/586_1999_Article_90080290.586.pdf.
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Mobbs, R. J., Phan, K., Malham, G., Seex, K., Rao, P. J., Maharaj, M. and Redmond, M., 2020. Lumbar Interbody Fusion: Techniques, Indications and Comparison of Interbody Fusion Options Including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. Journal of Spine Surgery, [online] 6(2), pp.358–367. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7170696/.
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Wiltse, L. L., Widell, E. H. and Jackson, D. W., 1975. Fatigue Fracture: The Basic Lesion in Isthmic Spondylolisthesis. The Journal of Bone and Joint Surgery. American Volume, [online] 57(1), pp.17–22. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC1543196/?page=2.
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Manchikanti, L., Hirsch, J. A. and Falco, F. J. E., 2020. Spondylolisthesis: Diagnostic and Therapeutic Strategies. Pain Physician, [online] 23(4S), pp.S232–S254. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7315725/.
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Cho, S. K., Patel, A. A. and Emery, S. E., 2022. Surgical Treatment of Lumbar Degenerative Spondylolisthesis: Current Concepts and Recent Advances. Journal of Clinical Medicine, [online] 11(9), p.2480. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9063820/.
