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Oct 05, 2023

Spondylolisthesis Grading: How to Diagnose and Treat Grades 1, 2, 3, 4 and 5

What grade of spondylolisthesis do i have.

Like many other conditions, spondylolisthesis can be measured using a grading system, where your spondylolisthesis grade is based on the degree of displacement of your vertebrae. Grades of spondylolisthesis influence what symptoms you might experience as well as what treatment you will likely receive.

Wondering what might be the cause of your spondylolisthesis? Read more about the causes and symptoms .

The grade of your condition is based on the distance from the posterior edge of the superior body of the vertebrae to the same edge of the inferior vertebral body. The ratings range from spondylolisthesis grade 1 to spondylolisthesis grade 5: grade 1 spondylolisthesis being least severe and grade 5 most severe. To diagnose this condition, your doctor will take X-rays in order to see if any of the bones in your vertebrae have slipped or are misaligned. They may order a CT scan or MRI to figure out how severe your slippage may be.

Do I Have Grade 1 Spondylolisthesis?

Grade I, or grade 1 spondylolisthesis is the least severe case. The degree of slippage for spondylolisthesis grade 1 ranges from 0%-25%. Grade 1 anterior spondylolisthesis usually occurs in the l4 on the l5 segment of the spine, which is connected, to your facet joints. Fortunately, spondylolisthesis conditions are typically not very severe, leaving grade 1 and grade 2 being the most frequent gradings.

Spondylolisthesis grade 1 treatment is typically using conservative methods since the slippage isn’t very severe. For starters, bed rest can help relieve your pain and take the extra stress off of your spine and back. In addition, try avoiding activities that may further your injury and slippage such as high contact sports.

Do I Have Grade 2 Spondylolisthesis?

Similar to grade 1, grade 2 is a low-grade spondylolisthesis. Grade ii spondylolisthesis degree of slippage is between 26% to 50%.

Spondylolisthesis grade 2 treatment is similar to grade 1, it starts with conservative methods such as resting, anti-inflammatory medications, and reducing the number of daily activities that may harm your back. Exercises and stretches for spondylolisthesis help strengthen the muscles surrounding your spine and is another great conservative treatment option.

Physical therapy works similarly. It helps to improve the strength and flexibility of your back and other parts of the core, which can reduce the amount of pressure the spine, endures. This ultimately relieves discomfort associated with grade 1 spondylolysis or spondylolisthesis grade 2 and helps slow additional slippage.

For those whose grade 2 spondylolisthesis condition doesn’t respond to such methods above or if you feel as though your condition is worsening, try bracing to help immobilize your spine. Such braces are usually used for individuals with 50% slippage or less. 

Do I Have Grade 3 Spondylolisthesis?

Grade 3 spondylolisthesis tends to be on the more serious side of the spectrum. Grade iii spondylolisthesis slippage is between 51% to 75%.

Grade 3 spondylolisthesis treatment typically involves the same conservative methods mentioned above, but if your condition persists or get worse, surgery for spondylolisthesis is an option for this grade.

Before considering surgery for spondylolisthesis grade 3, it’s important to take in consideration:

• If your pain from spondylolisthesis has lasted for 6-12 months and has not improved
• If your slip is progressing
• If you are having trouble walking, sleeping, etc.
• If you are an obese individual, you may have a higher risk for surgery complications

Do I Have Grade 4 Spondylolisthesis?

Grade 4 spondylolisthesis goes along with grade 3 but is more severe. Spondylolisthesis grade 4 slippage is between 76% to 100%.

Treatment options for spondylolisthesis more commonly involve isthmic and degenerative surgery . Surgery for spondylolisthesis can help the instability in your spine as well as relieve compression that is being placed on your nerve roots.

Do I Have Grade 5 Spondylolisthesis or Spondyloptosis?

For grade 5 spondylolisthesis, your vertebra has completely fallen off the next vertebra. When the vertebra slides completely off the vertebra that is supposed to be beneath it, this is known as spondyloptosis.

For this rare condition, surgery is the only way to completely fix or heal spondylolisthesis of grade 5. Your surgeon may perform a vertebrectomy, which is an alternative procedure to help align your vertebra.

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Spondylolisthesis: Definition, Causes, Symptoms, and Treatment

by Dave Harrison, MD • Last updated November 26, 2022

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What is Spondylolisthesis?

The spine is comprised of 33 bones, called vertebra , stacked on top of each other interspaced by discs . Spondylolisthesis is a condition where one vertebra slips forward or backwards relative to the vertebra below. More specifically, retrolisthesis is when the vertebra slips posteriorly or backwards, and anterolisthesis is when the vertebra slips anteriorly or forward.

Spondylosis vs Spondylolisthesis

Spondylosis and Spondylolisthesis are different conditions. They can be related but are not the same. Spondylosis refers to a fracture of a small bone, called the pars interarticularis, which connects the facet joint of the vertebra to the one below. This may lead to instability and ultimately slippage of the vertebra. Spondylolisthesis, on the other hand, refers to slippage of the vertebra in relation to the one below.

Types and Causes of Spondylolisthesis

There are several types of spondylolisthesis, often classified by their underlying cause:

Degenerative Spondylolisthesis

Degenerative spondylolisthesis is the most common cause, and is due to general wear and tear on the spine. Overtime, the bones and ligaments which hold the spine together may become weak and unstable.

Isthmic Spondylolisthesis

Isthmic spondylolisthesis is the result of another condition, called “ spondylosis “. Spondylosis refers to a fracture of a small bone, called the pars interarticularis, which connects the facet joint of the vertebra to the one below. If this interconnecting bone is broken, it can lead to slippage of the vertebra. This can sometimes occur during childhood or adolsence but go unnoticed until adulthood when degenerative changes cause worsening slippage.

Congenital Spondylolisthesis

Congenital spondylolisthesis occurs when the bones do not form correctly during fetal development

Traumatic Spondylolisthesis

Traumatic spondylolisthesis is the result of an injury such as a motor vehicle crash

Pathologic Spondyloslisthesis

Pathologic spondylolisthesis is when other disorders weaken the points of attachment in the spine. This includes osteoporosis, tumors, or infection that affect the bones and ligaments causing them to slip.

Iatrogenic Spondylolisthesis

Iatrogenic spondylolisthesis is the result of a prior surgery. Some operations of the spine, such as a laminectomy, may lead to instability. This can cause the vertebra to slip post operatively.

Spondylolisthesis Grades

Spondylolisthesis is classified based on the degree of slippage relative to the vertebra below

• Grade 1 : 1 – 25 % forward slip. This degree of slippage is usually asymptomatic.
• Grade 2: 26 – 50 % forward slip. May cause mild symptoms such as stiffness and pain in your lower back after physical activity, but it’s not severe enough to affect your everyday activities.
• Grade 3 : 51 – 75 % forward slip. May cause moderate symptoms such as pain after physical activity or sitting for long periods.
• Grade 4: 76 – 99% forward slip. May cause moderate to severe symptoms.
• Grade 5: Is when the vertebra has slipped completely of the spinal column. This is a severe condition known as “spondyloptysis”.

Symptoms of Spondylolisthesis

Spondylolisthesis can cause compression of spinal nerves and in severe cases, the spinal cord. The symptoms will depend on which vertebra is affected.

Cervical Spondylolisthesis (neck)

• Arm numbness or tingling
• Arm weakness

Lumbar Spondylolisthesis (low back)

• Buttock pain
• Leg numbness or tingling
• Leg weakness

Diagnosing Spondylolisthesis

Your doctor may order imaging tests to confirm the diagnosis and determine the severity of your spondylolisthesis. The most common imaging tests used include:

• X-rays : X-rays can show the alignment of the vertebrae and any signs of slippage.
• CT scan: A CT scan can provide detailed images of the bones and soft tissues in your back, allowing your doctor to see any damage or abnormalities.
• MRI: An MRI can show the spinal cord and nerves, as well as any herniated discs or other soft tissue abnormalities.

Treatments for Spondylolisthesis

Medications.

For those experiencing pain, oral medications are first line treatments. This includes non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, acetaminophen, or in severe cases opioids or muscle relaxants (with extreme caution). Topical medications such as lidocaine patches are also sometimes used.

Physical Therapy

Physical therapy can help improve mobility and strengthen muscles around your spine to stabilize your neck and lower back. You may also receive stretching exercises to improve flexibility and balance exercises to improve coordination.

Surgery is reserved for severe cases of spondylolisthesis in which there is a high degree of instability and symptoms of nerve compression.

In these cases a spinal fusion may be necessary. This surgery joins two or more vertebra together using rods and screws, in order to improve stability.

Reference s

• Alfieri A, Gazzeri R, Prell J, Röllinghoff M. The current management of lumbar spondylolisthesis. J Neurosurg Sci. 2013 Jun;57(2):103-13. PMID: 23676859.
• Stillerman CB, Schneider JH, Gruen JP. Evaluation and management of spondylolysis and spondylolisthesis. Clin Neurosurg. 1993;40:384-415. PMID: 8111991.

About the Author

Dave Harrison, MD

Dr. Harrison is a board certified Emergency Physician with a part time appointment at San Francisco General Medical Center and is an Assistant Clinical Professor-Volunteer at the UCSF School of Medicine. Dr. Harrison attended medical school at Tufts University and completed his Emergency Medicine residency at the University of Southern California. Dr. Harrison manages the editorial process for SpineInfo.com.

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Spondylolisthesis: Understanding Causes, Symptoms & Treatment

Are you experiencing lower back pain that won't go away? Have you or a loved one recently been diagnosed with spondylolisthesis? If so, you're not alone. Spondylolisthesis is a common condition that affects the spine, and understanding its causes, symptoms, and treatment is crucial for managing and improving your quality of life. 

This blog post will explore everything you need about spondylolisthesis, including its various forms, underlying causes, and effective treatment options. So, whether you're dealing with this condition or simply looking to educate yourself on this joint spine issue, keep reading to understand better spondylolisthesis and how to address it effectively.

What is Spondylolisthesis? 

Spondylolisthesis is a common condition that affects the spine and can cause discomfort and pain for those with it. It occurs when one vertebra (bone in the spine) slips forward over another vertebra, causing the spinal column to become misaligned. This condition can affect people of all ages, but it is most commonly seen in adults over 50 .

What is the root cause of Spondylolisthesis?

The most common cause of spondylolisthesis is a fracture or defect in the pars interarticularis , a small bony section of the vertebra. This fracture can be caused by repetitive stress due to sports or activities that pressure the spine, such as weightlifting, gymnastics, or football. It can also happen due to congenital conditions or degenerative diseases like arthritis. Sometimes, spondylolisthesis can be caused by sudden trauma, such as a car accident or a fall.

What are the signs and symptoms of Spondylolisthesis?

The symptoms of spondylolisthesis vary depending on the severity of the condition. In mild cases, there may be no noticeable symptoms, but as the condition progresses, symptoms may include:

• Lower back pain
• Muscle spasms in the back
• Stiffness in the back
• Numbness or tingling in the legs
• Difficulty standing or walking
• Decreased range of motion in the back
• Weakness in the legs

How do you stop spondylolisthesis from progressing?

How exactly do you stop spondylolisthesis from worsening? There are practical strategies for managing and halting the progression of spondylolisthesis. Get ready to take control of your spinal health and stop spondylolisthesis in its tracks.

• Exercise regularly – Regular exercise helps to strengthen the muscles in your back and abdomen, providing better support for your spine. However, if you have spondylolisthesis, some exercises may be harmful. Consult a physical therapist to create a safe, individualized exercise plan for your condition.
• Avoid high-impact activities – Jumping and landing on the feet, such as running or basketball, can put additional stress on the spine. Instead, opt for low-impact exercises like swimming or cycling.
• Practice good posture – Poor posture can contribute to spondylolisthesis. Make a conscious effort to maintain good posture throughout the day, whether sitting, standing, or bending over. Consider using a lumbar support cushion if you spend much time sitting.
• Lose weigh t – Being overweight stresses the spine, which can worsen spondylolisthesis. Maintaining a healthy weight can help ease symptoms and stop the condition from progressing.
• Avoid lifting heavy objects – Putting strain on the lower back can worsen spondylolisthesis. If you need to lift heavy objects, use proper lifting techniques, such as bending your knees and keeping your back straight.
• Consider chiropractic care – Chiropractic manipulation and adjustments can help improve joint function and decrease pain in spondylolisthesis patients.
• Seek medical treatment – If you have persistent symptoms of spondylolisthesis, it's crucial to seek medical treatment. Your doctor may recommend physical therapy, pain medication, or in severe cases, surgery.

What are the 5 stages of spondylolisthesis?

Understanding the stages of spondylolisthesis is essential to identify its severity and manage it effectively. These are the five stages of spondylolisthesis and the accompanying symptoms.

Stage 1: Grade 1 Spondylolisthesis

The first stage of spondylolisthesis is also known as mild spondylolisthesis and is characterized by the slippage of less than 25% of one vertebra over another. In this stage, the symptoms may be minimal, and most people may not experience any. However, some common symptoms of grade 1 spondylolisthesis include mild back pain, stiffness, and muscle tightness in the lower back.

Stage 2: Grade 2 Spondylolisthesis

Grade 2 spondylolisthesis is characterized by the slippage of 26% to 50% of one vertebra over another. At this stage, the symptoms can become more noticeable, including increased back pain, numbness or tingling in the legs or feet, and difficulty standing or walking for extended periods. This stage may also lead to changes in posture and decreased flexibility in the lower back.

Stage 3: Grade 3 Spondylolisthesis

In this stage, the slippage increases to 51% to 75% of one vertebra over another. At this point, the spinal deformity may become apparent. Patients may experience severe back pain that radiates to the hips and legs, making it difficult to perform daily activities. Nerve compression is also standard in this stage, leading to symptoms like weakness, numbness, and tingling in the legs.

Stage 4: Grade 4 Spondylolisthesis

Grade 4 spondylolisthesis is characterized by the slippage of more than 75% of one vertebra over another. This stage can be severely debilitating, causing extreme back pain, nerve compression, and even difficulty in controlling bladder and bowel movements. Patients may also experience weakness and numbness in the legs, making it challenging to walk or stand for extended periods.

Stage 5: Grade 5 Spondylolisthesis

The final stage of spondylolisthesis, grade 5, is also known as spondyloptosis. In this stage, the slippage is more than 100% of one vertebra over another, meaning the vertebra has completely slipped off the one below it. At this point, the spinal deformity is severe and can lead to life-altering symptoms, including severe back pain, nerve damage, and loss of motor control in the legs.

Treatment options for Spondylolisthesis

Various treatment options for spondylolisthesis can help manage and relieve its symptoms. Let’s explore these treatment options and how they can help those with spondylolisthesis.

• Physical therapy: 

Physical therapy is often the first line of treatment for spondylolisthesis. A physical therapist will work with the patient to strengthen the muscles in the back and abdomen, which can help stabilize the spine and prevent further slippage. They will also teach the patient proper posture and body mechanics to reduce pressure on the affected area. Physical therapy can also include exercises to increase flexibility and range of motion, which can help alleviate pain and stiffness.

• Medications:  

Over-the-counter pain relievers such as ibuprofen and acetaminophen can help manage the pain caused by spondylolisthesis. Sometimes, a doctor may prescribe more vital pain medication or muscle relaxants if the pain is severe. However, these medications should only be used under the supervision of a doctor and are not a long-term solution for managing the condition.

• Bracing:  

In some cases, a back brace may be recommended to provide support and stability to the affected area. This can help alleviate pain and prevent further slippage. It is crucial to work with a physical therapist to ensure the proper fit and usage of the brace.

• Steroid injections:  

If other treatment options do not provide enough relief, a doctor may recommend steroid injections. These injections can help reduce inflammation and pain in the affected area. They are generally used as a short-term solution and may need to be repeated periodically.

• Surgery: 

In severe cases of spondylolisthesis, surgery may be required. The most common surgery for this condition is spinal fusion, where the affected vertebrae are fused together to prevent slippage. This surgery can help alleviate pain and prevent further damage to the spine and nerves.

Get lasting relief from Spondylolisthesis!

Ready to take control of your Spondylolisthesis and find lasting relief? Look no further than Neuro Spine & Pain Center - your top choice for comprehensive treatment and expert care for Miami pain management .

Our team of renowned spine specialists in Miami understands the complexity of Spondylolisthesis and is dedicated to creating personalized treatment plans to address its underlying causes. From advanced imaging techniques to cutting-edge therapies, we have the tools to help you overcome this condition and live your life to the fullest. 

Don't let Spondylolisthesis hold you back any longer, schedule a consultation with our experts today and let us guide you towards a pain-free and active lifestyle.

The material on this site is for informational purposes only and DOES NOT CONSTITUTE THE PROVIDING OF MEDICAL ADVICE, and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions or concerns you may have regarding your health.

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Spondylolisthesis

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Spondylolisthesis is slippage of a lumbar vertebra in relation to the vertebra below it. Anterior slippage (anterolisthesis) is more common than posterior slippage (retrolisthesis). Spondylolisthesis has multiple causes. It can occur anywhere in the spine and is most common in the lumbar and cervical regions. Lumbar spondylolisthesis may be asymptomatic or cause pain when walking or standing for a long time. Treatment is symptomatic and includes physical therapy with lumbar stabilization.

There are five types of spondylolisthesis, categorized based on the etiology:

Type I, congenital: caused by agenesis of superior articular facet

Type II, isthmic: caused by a defect in the pars interarticularis (spondylolysis)

Type III, degenerative: caused by articular degeneration as occurs in conjunction with osteoarthritis

Type IV, traumatic: caused by fracture, dislocation, or other injury

Type V, pathologic: caused by infection, cancer, or other bony abnormalities

Spondylolisthesis usually involves the L3-L4, L4-L5, or most commonly the L5-S1 vertebrae.

Types II (isthmic) and III (degenerative) are the most common.

Type II often occurs in adolescents or young adults who are athletes and who have had only minimal trauma; the cause is a weakening of lumbar posterior elements by a defect in the pars interarticularis (spondylolysis). In most younger patients, the defect results from an overuse injury or stress fracture with the L5 pars being the most common level.

Anterolisthesis requires bilateral defects for type II spondylolisthesis. For type III (degenerative) there is no defect in the bone.

Spondylolisthesis is graded according to the percentage of vertebral body length that one vertebra subluxes over the adjacent vertebra:

Grade I: 0 to 25%

Grade II: 25 to 50%

Grade III: 50 to 75%

Grade IV: 75 to 100%

Spondylolisthesis is evident on plain lumbar x-rays. The lateral view is usually used for grading. Flexion and extension views may be done to check for increased angulation or forward movement.

Treatment of spondylolisthesis is usually symptomatic. Physical therapy Physical Therapy (PT) Physical therapy aims to improve joint and muscle function (eg, range of motion, strength) and thus improve the patient’s ability to stand, balance, walk, and climb stairs. For example, physical... read more with lumbar stabilization exercises may be helpful.

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Spondylolisthesis

Learn all about the causes, symptoms, diagnosis and treatment of spondylolisthesis.

Grade 3 Spondylolisthesis

Grade 3 spondylolisthesis is the frontier where vertebral migration conditions tend to become much more problematic. Grade 3 listhesis is certainly considered significant and often requires treatment, particularly with conditions that fall on the upper end of the grade 3 rating scale. However, it should be known that the condition is not inherently pathological and some people do not suffer any symptoms even from their considerable degree of listhesis.

Grade 3 conditions should always be closely monitored by a qualified neurologist for best outcomes. This is because they can progress quickly and due to many different factors into serious health issues in rare cases.

This patient guide covers spondylolisthesis conditions that have earned a grade 3 classification. We will explain what grade 3 diagnosis means, how it can become symptomatic and what steps should be taken to ensure patient safety into the future.

Grade 3 Spondylolisthesis Defined

Classification of grade 3 listhesis depends on the vertebral slippage being rated at between 51% and 75% slippage when compared to a typical spinal anatomy. This means that conditions rated at the upper end of 75% are only 1.5x more substantial than those at which are rated at the bottom criteria of 51%. Grade 3 listhesis also can involve forward or rearward migration of one or more affected vertebral bones.

Grade 3 anterolisthesis describes forward movement of the affected spinal bone between 51% and 75% towards the anterior side of the body. Meanwhile grade 3 retrolisthesis describes rearward movement of the affected vertebral bone between 51% and 75% compared to a normal vertebral column alignment. Retrolisthesis of grade 3 is less common than anterolisthesis migration of the same grading.

Problems with Spondylolisthesis 3

When diagnostic grading approaches the level 3 classification, there is more of the vertebral body that is out of alignment with the rest of the spine than that which remains in alignment. This tends to really push the condition into the symptomatic zone, especially as the degree of slippage reaches the upper end of the spectrum for grade 3, nearing 75%.

Spinal canal narrowing and foraminal loss of patency are virtually universally experienced occurrences in grade 3 listhesis patients. Some might suffer symptomatic spinal stenosis or foraminal stenosis leading to a compressive neuropathy due to listhesis alone, but patients will also have to deal with the collateral additional consequences of spinal aging which may also contribute, including disc desiccation, osteoarthritis and other structural changes.

As listhesis reaches grade 3, the incidence of related herniated disc development also rises, as the migrating vertebral bones place tremendous pressure on the endplate attachments of the spinal discs, causing discs to bulge, herniate and rupture quite often.

Grade 3 Spondylolisthesis Prognosis

There are many patients with all ranges of grade 3 listhesis who do not suffer any pain. However, there are also many people who do have pain in the back, neck or appendages. In some instances, the listhesis may be incidental, with symptoms coming from some other causation. However, there are definitely pathological causes of grade 3 listhesis which are fully capable of creating pain and neurological dysfunction all by themselves.

Stable grade 3 listhesis patients tend to fare much better than patients demonstrating spinal instability . Stable listhesis can often be managed conservatively, even when pain does exist from spinal pathology. Additionally, stable listhesis can often also be corrected surgically with better outcomes and less dramatic interventions. Meanwhile, most unstable grade 3 vertebral slippage is grounds for emergency surgical intervention which typically involves the most invasive forms of spinal fusion , with larger scale reinforcing hardware.

Spondylolisthesis  >  Spondylolisthesis Diagnosis > Grade 3 Spondylolisthesis

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Spondylolisthesis

We design a unique treatment plan for your condition of spondylolisthesis and take into account your life goals., what is spondylolisthesis.

Low back pain, leg pain and weakness in the legs can happen if the bone that’s out of position significantly narrows the spinal column and begins to press on nerves.

Causes of spondylolisthesis

• Birth defect of the vertebral joint – This usually occurs in the lower spine where the lumbar spine and sacrum come together
• Stress “micro-fracture” in the bone due to overstretching and overuse – This can occur with sports activities such as gymnastics, weight lifting, ice skating and football
• Aging or overuse-related wear on the spinal joints

Rest and anti-inflammatory medication resolve most cases.

If it’s more severe, you may need physical therapy or surgery.

Spondylolisthesis grades

Doctors commonly describe spondylolisthesis as either high-grade or low-grade, depending on how severe your condition is. Grades are from 1 to 4.

• Low-grade (grade 1 and grade 2) usually occurs in adolescents and is considered less severe. Low-grade doesn’t typically require surgery.
• High-grade (grade 3 and grade 4) may require surgery if you’re experiencing severe pain.

The grade of your condition is based on how far away from proper alignment your spine has become.

Spondylolisthesis symptoms

In many cases, people who have spondylolisthesis don’t have any symptoms. You may not be aware you have the condition until an X-ray is taken for an unrelated reason. If you do have symptoms, the most common are:

• Lower back pain that feels like a muscle strain
• Muscle spasms or tightness in your hamstring
• Lower back pain that worsens with activity and improves with rest
• Difficulty walking or standing
• Pain when bending over
• Stiffness in your back
• Pain extending down from your lower back to your thighs

If you have high-grade spondylolisthesis, you may experience tingling, numbness or weakness in one or both legs.

Diagnosing spondylolisthesis

Following a thorough medical history, physical and neurological exams, our spine surgeons may recommend any of the following tests to confirm whether a bone in your spine is out of alignment. All tests are available at Ohio State Spine Care :

• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI) scan
• Electromyography (EMG) to test your muscles and nerves

Spondylolisthesis treatment

Ohio State’s Spine Care team has the benefit of extra expertise from treating many people with spondylolisthesis. Because of this, the Spine Care team, composed of orthopedic and neurological specialists, is uniquely qualified to determine whether you’re likely to benefit from nonsurgical treatment. We also recommend lifestyle changes to prevent future problems with your spine.

We offer treatments ranging from physical therapy to the most complex spine surgeries. Physicians, therapists and other care providers work together to provide you with options that increase mobility and reduce pain.

Most people who come to Ohio State Spine Care don’t require surgery.

Lifestyle changes

• Exercise, such as Pilates or yoga, to strengthen muscles in your back
• Quitting smoking
• Guidance on weight loss to reduce pressure on your spine

Nonsurgical treatments

• Physical therapy – We’ll work with you one-on-one to customize a treatment plan for your needs and goals
• Spine orthobiologics use substances in your body to activate the healing process naturally
• Wearing a back brace to limit spine movement
• Medication for pain management

Most people return slowly to full function, including athletic activity.

Spondylolisthesis surgery

You may need surgery if a spinal bone that has slipped is likely to cause damage to nerves and the surrounding spinal structure, or if it’s causing severe pain or muscle weakness in one or both legs.

Our surgeons can perform minimally invasive surgery to correct the symptoms of spondylolisthesis. The surgeon makes tiny incisions in the back and works through a tube to minimize skin and muscle damage, reduce blood loss and reduce postsurgical pain.

At Ohio State, we can use both minimally invasive surgery and conventional surgical techniques for these procedures:

• Decompression surgery (laminectomy) to remove part of the vertebra and relieve pressure on your spinal cord or nerves
• Spinal fusion surgery to fuse a severely slipped bone with the vertebra below it and restore stability to the spinal column

Most people who have decompression or fusion surgery can return to full function, including athletic activities.

Ohio State conducts innovative research in the laboratory, as well as through clinical trials.

Those who have a pinched nerve may be eligible to participate in one of the following areas of research at The Ohio State University Wexner Medical Center.

Biomechanical testing:  We’re doing biomechanical testing to assess the spine before and after surgery. A specialized vest helps us assess your spinal movement and measure the effectiveness of surgery. It ultimately may provide valuable information about which treatment methods will best increase mobility and function of the spine.

Back pain consortium:  We’re members of the International Consortium for Health Outcomes Measurement (ICHOM). Membership in this elite organization allows us to engage with other top U.S. medical centers in global research studies on back pain. As we measure our results against established international standards, we share best practices and elevate our standard of care.

Enroll in a clinical trial

• Learn more about spine care at Ohio State Download our guide

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Spondylolisthesis

Spondylolisthesis is where one of the bones in your spine, called a vertebra, slips forward. It can be painful, but there are treatments that can help.

It may happen anywhere along the spine, but is most common in the lower back.

Check if you have spondylolisthesis

The main symptoms of spondylolisthesis include:

• pain in your lower back, often worse when standing or walking and relieved when sitting or bending forward
• pain spreading to your bottom or thighs
• tight hamstrings (the muscles in the back of your thighs)
• pain, numbness or tingling spreading from your lower back down 1 leg ( sciatica )

Spondylolisthesis does not always cause symptoms.

Spondylolisthesis is not the same as a slipped disc . This is when the tissue between the bones in your spine pushes out.

Non-urgent advice: See a GP if:

• you have lower back pain that does not go away after 3 to 4 weeks
• you have pain in your thighs or bottom that does not go away after 3 to 4 weeks
• you're finding it difficult to walk or stand up straight
• you're worried about the pain or you're struggling to cope
• you have pain, numbness and tingling down 1 leg for more than 3 or 4 weeks

What happens at your GP appointment

If you have symptoms of spondylolisthesis, the GP may examine your back.

They may also ask you to lie down and raise 1 leg straight up in the air. This is painful if you have tight hamstrings or sciatica caused by spondylolisthesis.

The GP may arrange an X-ray to see if a bone in your spine has slipped forward.

You may have other scans, such as an MRI scan , if you have pain, numbness or weakness in your legs.

Treatments for spondylolisthesis

Treatments for spondylolisthesis depend on the symptoms you have and how severe they are.

Common treatments include:

• avoiding activities that make symptoms worse, such as bending, lifting, athletics and gymnastics
• taking anti-inflammatory painkillers such as ibuprofen or stronger painkillers on prescription
• steroid injections in your back to relieve pain, numbness and tingling in your leg
• physiotherapy to strengthen and stretch the muscles in your lower back, tummy and legs

The GP may refer you to a physiotherapist, or you can refer yourself in some areas.

Waiting times for physiotherapy on the NHS can be long. You can also get it privately.

Surgery for spondylolisthesis

The GP may refer you to a specialist for back surgery if other treatments do not work.

Types of surgery include:

• spinal fusion – the slipped bone (vertebra) is joined to the bone below with metal rods, screws and a bone graft
• lumbar decompression – a procedure to relieve pressure on the compressed spinal nerves

The operation is done under general anaesthetic , which means you will not be awake.

Recovery from surgery can take several weeks, but if often improves many of the symptoms of spondylolisthesis.

Talk to your surgeon about the risks and benefits of spinal surgery.

Causes of spondylolisthesis

Spondylolisthesis can:

• happen as you get older – the bones of the spine can weaken with age
• run in families
• be caused by a tiny crack in a bone (stress fracture) – this is more common in athletes and gymnasts

Page last reviewed: 01 June 2022 Next review due: 01 June 2025

Spondylolisthesis grading system

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Citation, DOI, disclosures and article data

At the time the article was created Frank Gaillard had no recorded disclosures.

At the time the article was last revised Patrick O'Shea had no financial relationships to ineligible companies to disclose.

• Grading of spondylolisthesis
• Meyerding classification

A commonly adopted method of grading the severity of spondylolisthesis is the Meyerding classification . It divides the superior endplate of the vertebra below into 4 quarters. The grade depends on the location of the posteroinferior corner of the vertebra above.

This classification was originally developed for anterolistheses but can be adapted for retrolistheses , and some publications have done so 3 .

• grade I : 0-25%
• grade II : 26-50% 
• grade III : 51-75% 
• grade IV : 76-100%  
• grade V ( spondyloptosis ): >100%

History and etymology

The grading system is named after its inventor Henry W Meyerding (1884 - 1969), who was an American orthopedic surgeon at the Mayo Clinic, Rochester, Minnesota. He proposed the classification in an article in 1932 2 .

Quiz questions

• 1. Lovell WW, Winter RB, Morrissy RT et-al. Lovell & Winter's Pediatric Orthopaedics. Lippincott Williams & Wilkins. (2006) ISBN:0781753589. Read it at Google Books - Find it at Amazon
• 2. Meyerding HW. Spondyloptosis. Surg Gynaecol Obstet. 1932;54:371–377.
• 3. He LC, Wang YX, Gong JS, Griffith JF, Zeng XJ, Kwok AW, Leung JC, Kwok T, Ahuja AT, Leung PC. Prevalence and risk factors of lumbar spondylolisthesis in elderly Chinese men and women. (2014) European radiology. 24 (2): 441-8. doi:10.1007/s00330-013-3041-5 - Pubmed

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• Isthmic Spondylolisthesis Symptoms

By: Arth Patel, MD, Sports Medicine Physician

Peer-Reviewed

The majority of people with isthmic spondylolisthesis are asymptomatic. Around 25% of people with the condition may experience pain around the affected spinal segment with a possibility of nerve involvement and radiating pain into the thigh and/or leg. 1 Bhalla A, Bono CM. Isthmic lumbar spondylolisthesis. Neurosurgery Clinics of North America. 2019;30(3):283-290. doi:10.1016/j.nec.2019.02.001

Isthmic spondylolisthesis typically occurs in childhood and affects the lower back, but the symptoms mostly start to manifest only by adolescence or in adulthood. 2 Ganju A. Isthmic spondylolisthesis. Neurosurgical Focus. 2002;13(1):1-6. doi:10.3171/foc.2002.13.1.2

In This Article:

• Isthmic Spondylolisthesis
• Understanding the Causes and Diagnosis of Isthmic Spondylolisthesis
• Nonsurgical Treatment for Isthmic Spondylolisthesis
• Spinal Fusion Surgery for Isthmic Spondylolisthesis

Isthmic Spondylolisthesis Video

Lumbar isthmic spondylolisthesis: common symptoms and signs.

The symptoms of isthmic spondylolisthesis vary depending on the severity of the condition. 

The common symptoms and signs of isthmic spondylolisthesis in the lower back are described below:

Low back pain

Isthmic spondylolisthesis may cause a dull ache or a sharp, stabbing pain in the low back.

Low back pain is the most common symptom of isthmic spondylolisthesis. The pain is usually located in the lower back and may be described as a dull ache or a sharp, stabbing pain. The pain may be worse with activity and may improve with rest. 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/

Show Transcript

Sciatica , or lumbar radiculopathy, may occur in case of nerve root irritation or compression at the affected spinal segment. Sciatica symptoms include pain that radiates down one or both legs, which is often described as a shooting or burning sensation and may be accompanied by numbness or tingling. 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/

Watch Sciatica Causes and Symptoms Video

Muscle weakness and areas of skin numbness

Spinal nerve compression can affect the areas of skin and groups of muscles supplied by the nerve

Isthmic spondylolisthesis can cause weakness in the muscles of the legs and buttocks. This can make it difficult to walk or stand for long periods of time. 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/

The skin over the thigh, leg, and/or foot may feel numb or have diminished sensations in the areas supplied by the affected spinal nerve. 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/

Leg pain while walking

Some people may experience neurogenic claudication, or pain in both legs while walking varying distances. 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/

See Leg Pain and Numbness: What Might These Symptoms Mean?

Back stiffness

Postural changes from isthmic spondylolisthesis can cause increased lordosis and hamstring tightness. 

Some people with isthmic spondylolisthesis may experience stiffness in the lower back. This can make it difficult to bend or twist the spine. 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/

Additionally, the posture and muscles in the back and legs may be affected, including:

• Hamstring tightness. A tightness may be felt in the hamstring muscles along with a feeling of weakness or pain. 4 Li N, Scofield J, Mangham P, Cooper J, Sherman W, Kaye A. Spondylolisthesis. Orthop Rev (Pavia). 2022;14(4):36917. Published 2022 Jul 27. doi:10.52965/001c.36917
• Change in the curvature of the lower spine. The “C” shaped curve of the lower back may get exaggerated, causing lordosis (increased inward curving) or swayback. 4 Li N, Scofield J, Mangham P, Cooper J, Sherman W, Kaye A. Spondylolisthesis. Orthop Rev (Pavia). 2022;14(4):36917. Published 2022 Jul 27. doi:10.52965/001c.36917  
• Stooped posture. Changes in the affected vertebral segment may cause balance and alignment issues, leading to a forward stooped posture. 4 Li N, Scofield J, Mangham P, Cooper J, Sherman W, Kaye A. Spondylolisthesis. Orthop Rev (Pavia). 2022;14(4):36917. Published 2022 Jul 27. doi:10.52965/001c.36917  

Pain that worsens with activity and subsides with rest

Activities that involve hyperextension (bending backward) or rotation of the torso usually exacerbate the pain, and the pain is typically relieved with rest. 5 Pereira Duarte M, Camino Willhuber GO. Pars Interarticularis Injury. [Updated 2023 Feb 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545191/

Symptoms and Progression of Isthmic Spondylolisthesis in Children

A low back pain may be a symptom of isthmic spondylolisthesis in kids.

Symptoms of isthmic spondylolisthesis in children and teens can vary. Some kids may be asymptomatic, and the condition may incidentally be discovered during a routine medical examination or imaging. Others may experience localized lower back pain (axial back pain). This pain tends to worsen as the level of activity intensifies. 6 Mansfield JT, Wroten M. Pars Interarticularis Defect. [Updated 2022 Aug 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538292/

Some teens may complain of hamstring tightness, and a gait change (shortened stride length) may be seen around the pubertal age. 7 Stanitski CL. Spondylolysis and spondylolisthesis in athletes. Operative Techniques in Sports Medicine. 2006;14(3):141-146. doi:10.1053/j.otsm.2006.04.008

How Isthmic Spondylolisthesis Symptoms Affect Athletic Performance

Isthmic spondylolisthesis can have a significant impact on an athlete's performance. Chronic lower back pain can limit range of motion, flexibility, and overall athletic capabilities. Pain and discomfort may affect training consistency, resulting in decreased performance levels and potential setbacks in achieving athletic goals. Additionally, the fear of aggravating symptoms may impact an athlete's mental and emotional well-being.

The Relationship Between Isthmic Spondylolisthesis and Scoliosis

Isthmic spondylolisthesis and scoliosis may occur together in some individuals.

Low grade isthmic spondylolisthesis, typically at the L5-S1 spinal level , and scoliosis may occur together in some teenagers. The two conditions occurring in tandem usually does not influence the course or outcome of either condition, and each condition may be treated independent of the other, as needed. 8 Schlenzka D, Ylikoski M, Poussa M, Yrjönen T, Ristolainen L. Concomitant low-grade isthmic L5-spondylolisthesis does not affect the course of adolescent idiopathic scoliosis. Eur Spine J. 2019;28(12):3053-3065. doi:10.1007/s00586-019-06089-9

• 1 Bhalla A, Bono CM. Isthmic lumbar spondylolisthesis. Neurosurgery Clinics of North America. 2019;30(3):283-290. doi:10.1016/j.nec.2019.02.001
• 2 Ganju A. Isthmic spondylolisthesis. Neurosurgical Focus. 2002;13(1):1-6. doi:10.3171/foc.2002.13.1.2
• 3 Burton MR, Dowling TJ, Mesfin FB. Isthmic Spondylolisthesis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441846/
• 4 Li N, Scofield J, Mangham P, Cooper J, Sherman W, Kaye A. Spondylolisthesis. Orthop Rev (Pavia). 2022;14(4):36917. Published 2022 Jul 27. doi:10.52965/001c.36917
• 5 Pereira Duarte M, Camino Willhuber GO. Pars Interarticularis Injury. [Updated 2023 Feb 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545191/
• 6 Mansfield JT, Wroten M. Pars Interarticularis Defect. [Updated 2022 Aug 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538292/
• 7 Stanitski CL. Spondylolysis and spondylolisthesis in athletes. Operative Techniques in Sports Medicine. 2006;14(3):141-146. doi:10.1053/j.otsm.2006.04.008
• 8 Schlenzka D, Ylikoski M, Poussa M, Yrjönen T, Ristolainen L. Concomitant low-grade isthmic L5-spondylolisthesis does not affect the course of adolescent idiopathic scoliosis. Eur Spine J. 2019;28(12):3053-3065. doi:10.1007/s00586-019-06089-9

Dr. Arth Patel is a board-certified, fellowship-trained sports medicine physician and serves as the Assistant Director of Sports Medicine at Princeton Spine and Joint Center, NJ. Dr. Patel specializes in the care of orthopedic and sports injuries as well as musculoskeletal and nerve pain.

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• Research article
• Open access
• Published: 01 April 2024

Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis

• Renfeng Liu 1 ,
• Wei Tan 1 ,
• Zuyun Yan 1 &
• Youwen Deng 1  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  209 ( 2024 ) Cite this article

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Metrics details

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis.

Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS).

Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment.

The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models.

Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Introduction

Lumbar degenerative spondylolisthesis (LDS) is a common disorder of the spine, frequently observed in the elderly, which manifests as the upper vertebrae slipping relative to the lower vertebrae on the basis of images [ 1 , 2 ]. The L3-4 and L4-5 segments are the most affected index segment [ 3 ]. In clinical scenarios, most of the patients suffer from lower back pain due to LDS; with the progress in slip, the condition is accompanied by pain and numbness in the lower limbs, leading to functional limitations [ 4 ]. Around 4.1% of individuals suffer from LDS globally [ 5 ], which lays a huge economic burden [ 6 ]. Surgical intervention is the traditional method used for patients who are not responding to conservative treatment options [ 6 , 7 ].

Decompression combined with fusion, whether through open approaches or minimally invasive surgeries, has achieved excellent clinical results in patients with spondylolisthesis [ 8 , 9 ]. Laminectomy combined with cage implantation assisted with screw-rod fixation can effectively release the pressure of the nerve root or dura well and also avoid the risk of iatrogenic instability [ 10 ]. However, concerns have been raised regarding the necessity of instrument fusion which can lead to additional costs, longer surgical time, more blood loss, and possible nerve root injury [ 11 , 12 ]. Several studies have compared decompression alone with decompression united fusion and have shown that decompression alone can yield excellent clinical outcomes [ 1 , 6 , 12 , 13 ]. However, some researchers believe certain patients with lower-grade LDS could benefit more from laminectomy combined with fusion, based on their studies [ 1 ]. The choice between the two procedures may depend on the patient’s symptoms and the segment stability, as decompression alone may not be suitable for mechanical back pain or unstable spondylolisthesis [ 3 , 10 ]. Currently, there is contradictory evidence regarding the indications and clinical outcomes of the two surgeries based on published reports [ 12 , 14 ]. In most cases, the choice between decompression alone or instrument fusion in treating LDS depends on the surgeon’s preference, as there is still insufficient evidence to evaluate which operative type is more effective [ 5 ]. While clinical studies comparing decompression alone with additional instrument fusion are common, there are very few studies comparing the biomechanics of the two surgeries.

The finite element method (FEM) is a powerful tool in the field of biomechanics and has been used to study spine biomechanics in the last decades [ 15 ]. FEM has several advantages when compared to in vitro experiments, including good repeatability and low cost. Additionally, it is easy for FEM to obtain the stress or pressure distribution of bone and soft tissue [ 15 ]. At present, the common biomechanical parameters include segmental ROM, IDP, AFS, FJCF, and IS. In this FE study, we evaluated the biomechanical characteristics of lower LDS after total laminectomy, hemi-laminectomy, and one-third facetectomy by analyzing the above parameters.

Intact L3-S1 finite element model

The L3-S1 finite element (FE) model was established based on high-resolution computed tomography images of a 27-year-old healthy male participant (height :175 cm, weight :70 kg). The L3-S1 geometric model was first constructed based on the lumbar CT data using the software Mimics 21.0 (Materialise Inc., Leuven, Belgium), Geomagic Wrap 2017 (Geomagic, Inc., Research Triangle Park, NC, United States), and SOLIDWORKS 2018 (Dassault Systèmes Inc., France). The intact FE model was then established by meshing the geometric model, checking the mesh quality, and FE preprocessing in the software of HyperMesh 2020 (Altair Engineering, Inc., Executive Park, CA, United States). The normally intact L3-S1 model is shown in Figs.  1 and 2 , and the lumbar spondylolisthesis model is shown in Fig.  1 .

The normally intact L3-S1 model and lumbar spondylolisthesis model

Details of the normally intact L3-S1 model

The intact L3-S1 FE model included cortical bone, cancellous bone, cartilage, endplate, annulus fibrosus, nucleus pulposus, and seven major ligaments, namely, the anterior longitudinal (ALL), posterior longitudinal (PLL), ligament flavum (LF), supraspinous (SSL), interspinous (ISL), capsular (CL), and intertransverse ligaments (IL). The thickness of the endplate and cortical bone was set to 0.6 mm, and the cartilage material is elastic, with a joint gap of 0.5 mm. The major ligaments were assumed to be tension-only truss elements. The volume of the nucleus pulposus accounted for 40% of intervertebral disc [ 16 ]. The posterior cartilage was modeled as surface-to-surface friction contact with a friction coefficient of 0.1 [ 17 ]. A detailed description of the mechanical properties, the element type, and numbers is listed in Table  1 .

Surgical FE models and spondylolisthesis model

Seven experiment models were constructed by modifying the intact FE model (model A). For the intact spondylolisthesis model (model B), L4 vertebrae slipped 5 mm to simulate grade I spondylolisthesis based on the Meyerding classification. The slipping part accounts for 1/7 of the length of the L5. To ensure the consistency of L4 vertebrae anteroposterior diameter, bilateral isthmuses were stretched in the spondylolisthesis models. In models A and B, a hemilaminectomy and total laminectomy were performed, respectively, at the L45 segment. In the hemilaminectomy models, the left side LF was removed; in the total laminectomy models, all the LF, SSL, and ISL were removed. The hemilaminectomy models were divided into models A1 and B1, and total laminectomy models were divided into models A2 and B2. For the 1/3 facetectomy, we only removed part of cartilage and CL, and didn’t remove any bony structure. The 1/3 facetectomy models were divided into models A3 and B3. All the modified models are shown in Fig.  3 .

A , the intact spondylolisthesis model (Model B); B , the model of hemi-laminectomy; C , the model of total laminectomy; D , one-third facetectomy

Boundary and loading conditions

To simulated different types of movement, the normal mode wasl subjected to a 10 Nm applied to the L3 cranial endplate for flexion (FLE), extension (EXT), left lateral bending (LLB), right lateral bending (RLB), left axial rotation (LAR), and right axial rotation (RAR) movement. A vertical compression load of 400 N was applied to the central area of the L3 cranial endplate and kept vertical at all times [ 21 ]. During lumbar movement, the sacrum was fixed in all directions. The displacement of the intact model at 10 Nm was calculated, and the calculated displacement load was applied to the surgical models instead of the moment. All surgical models were analyzed using Abaqus 2020(Abaqus, Inc., Providence, RI, United States).

The loading condition for validation was the same as in previous studies (10 Nm pure moment). The ROM of each segment is illustrated in Fig.  4 , and the predicted value of ROM was found to be consistent with previous results [ 22 , 23 , 24 , 25 , 26 ].

Comparison of ROM between the current models with previous studies. LLB, left lateral bending; RLB, right lateral bending; LAR, left axial rotation; RAR, right axial rotation

The A-C in Fig.  5 shows the different models of ROMs in the L4-L5 segments. The results indicated that hemilaminectomy and facetectomy had a relatively minor impact on segment stability, regardless of whether normal or spondylolisthesis models were used. In contrast, total laminectomy had a significant impact on stability. Additionally, for the same surgical condition, the movement level of spondylolisthesis models was slightly greater than that of normal lumbar models.

Comparison of ROM、IDP and AFS at the L4-L5 segment of different models. A-C indicates ROM, D-F indicates IDP, and G-L indicates AFS. The model A (intact normal model); the model A1 (hemi-laminectomy); the model A2 (total laminectomy); the model A3 (one-third laminectomy); The model B (intact spondylolisthesis model); the model B1 (hemi-laminectomy); the model B2 (total laminectomy); the model B3 (one-third laminectomy); FLE, flexion; EXT, extension

Compared to the intact normal model (model A), the ROM of the intact spondylolisthesis model (model B) increased by 21.69% (1.45°), 26.1% (1.67°), and 24.37% (0.53°) during flexion-extension, lateral bending, and rotation, respectively. In the lumbar normal models, the maximal motion of models A1 and A3 occurred during extension movement, with increasing rates of 3.71% and 4.17%, respectively. Compared to model A, the ROM of model A2 increased by 15.74%, 3.69%, 5.84%, 5.73%, 9.23%, and 9.37% during FLE, EXT, LLB, RLB, LAR, and RAR, respectively. Similarly, in the spondylolisthesis models, the maximal motion of models B1 and B3 occurred during extension movement, with the increase rates being 3.81% and 4.10%, respectively. Compared to model B, the ROM of model B2 increased by 19.2%, 3.68%,6.82%, 7.67%, 11.9%, and 10.58% during FLE, EXT, LLB, RLB, LAR, and RAR, respectively.

The IDP changes in L4-L5 segments of normal lumbar spine model and lumbar spondylolisthesis model are shown in D-F of Fig.  5 . According to the calculated results, no significant increase was observed in IDP after three decompression-alone procedures in all the models lateral bending and axial rotation. For models A1, model A3, model B1, and model B3, their maximal rate occurred in extension movement, the increase rates being 1.26%, 1.34%, 2.76%, and 2.79%, compared with models A and B, respectively. After total laminectomy, the IDP of model A2 increased by 11.44%, 1.49%, 1.11%, 1.23%, 2.53%, and 2.51% compared to model A during FLE, EXT, LLB, RLB, LAR, and RAR, respectively; while the IDP of model B2 increased by 20.98%, 3.83%, 4.56%, 3.41%, 8.09%, and 6.46% compared with model B during FLE, EXT, LLB, RLB, LAR, and RAR, respectively. However, there was a significant decrease in the tendency of the segmental IDP after the vertebrae slipped. The IDP of the model B decreased by 34.58%, 5.1%, 32.92%, 32.95%, 40.58%, and 32.35% during FLE, EXT, LLB, RLB, LAR, and RAR, respectively.

Annulus fibrosus stress

Compared with normal lumbar models, the annulus fibrosus stress (AFS) in the spondylolisthesis models presented a higher value for the same conditions. The AFS of model B increased by 25.02%, 31.54%, 14.64%, 8.11%, 13.60%, and 7.01% under FLE, EXT, LLB, RLB, LAR, and RAR, respectively, when compared to model A. In the normal lumbar models, the AFS of model A2 increased by 19.12% more than model A under flexion, with other motions having little influence on AFS. In the spondylolisthesis models, the AFS of model B2 increased by 17.14%, 5.5%, 2.75%, and 5.46% compared with model B under FLE, EXT, lateral bending, and axial rotation, respectively. The AFS comparison of different models at the L4-L5 segment is shown in G-L of Fig.  5 , while the stress distribution of the disc at the L4-L5 segment is shown in Fig.  6 .

The stress is primarily distributed in the posterior-lateral region of the caudal intervertebral disc during flexion movement, and the stress is primarily distributed in the right anterior or left anterior region of the caudal intervertebral disc during axial rotation movement, while the stress is primarily distributed in the right posterior or left posterior region of the cephalic intervertebral disc during lateral bending movement

Facet joints contact force

The comparison of facet joint contact forces of different models in segments L4-5 is shown in A-C of Fig.  7 . The greatest facet joint contact force was observed during the axial rotation in all movements, followed by extension, and the FJCF of axial movement was above 200 N. For both normal lumbar and spondylolisthesis models, FJCF decreased after each of the decompression-alone procedures, with a more significant decrease observed with resection ranges. Except for rotation movement, the contact force of bilateral facet joints in model B showed an increase compared to model A; the value of FJCF in spondylolisthesis models was larger than that in normal lumbar models for the same surgical operation. In the normal lumbar models, the greatest decrease in FJCF occurred in total laminectomy, followed by facetectomy and hemilaminectomy; the same tendency also occurred in spondylolisthesis models. In addition, the greatest decrease degree of the FJCF occurred during extension (more than 20%), followed by lateral bending and rotation after the three surgeries in all surgical models. The decrease in FJCF after the same surgery was not significant between normal and spondylolisthesis models.

Figure A-C shows the FJCF, the “-L” presents the left facet joint, and “-R” presents the right facet joint. Figure D-F shows the IS, the “-L” presents the left isthmus, and “-R” presents the right isthmus

Isthmus stress

The isthmus stress (IS) of different models at the L4-L5 segment is shown as D-F in Fig.  7 . The results showed that the maximal stress occurred in rotational movement in all models, followed by extension, lateral bending, and flexion movements. There was an apparent increase in stress on the ipsilateral isthmus during lateral bending, while contralateral isthmus stress had a larger change under axial rotation.

Compared to model A, the IS of model B increased at different levels, especially during flexion and extension movements, with average rates of 71.22% and 22.85%, respectively. For the hemilaminectomy, the stress of the resection side had an increase of more than 50% during extension and lateral bending in models A1 and B1, and the increasing rates were more than 110% during rotation. For the total laminectomy, the stress of the bilateral isthmus showed a huge increase in models A2 and B2 under all movements. Although the IS of spondylolisthesis models showed a larger value than normal lumbar models after hemilaminectomy and total laminectomy, there was no greater extent of increase to observe. The stress contour map of hemilaminectomy and total laminectomy under rotation is shown in Fig.  8 .

The stress distribution of isthmus during axial rotation. LAR, left axial rotation; RAR, right axial rotation

In recent years, studies have shown that laminectomy alone also yields satisfactory clinical outcomes for LDS [ 12 , 27 ], and some studies have reported that a higher rate of reoperation for laminectomy alone compared to laminectomy combined with instrument fusion in the postoperative [ 28 ]. However, there is a lack of biomechanical results of laminectomy alone for LDS. In this study, we developed a normal L3-S1 finite element model based on CT data and then constructed a lower-grade LDS model and several surgical models using simulation tools. The purpose of this study was to investigate the biomechanical characteristics of decompression alone for spondylolisthesis using parameters such as ROM, IDP, FJCF and IS calculated by FE software.

The range of motion

Laminectomy is a common surgical method for lumbar stenosis. According to the results of finite element analysis and cadaveric specimen experiments [ 29 , 30 ], unilateral laminectomy had a minimal impact on the segmental ROM. Zander et al. conducted finite element analysis by establishing a lumbar spine model to compare the biomechanical effects of graded facetectomy. They found that if facetectomy is performed in a graded manner, removing less than 50% of the bone, lumbar spine stability will not be significantly affected [ 21 ]. In the Burkhard et al. study, the segmental ROM after hemilaminectomy increased by 6% (5–10%), 3% (1–5%), and 12% (4–22%) during flexion-extension, lateral bending and rotation, respectively [ 31 ]. These studies collectively indicate that hemilaminectomy and facetectomy involving less than 50% of the facet joints have no apparent adverse effects on spinal stability, consistent with our findings. In our study, hemilaminectomy increased 3.18%, 1.15%, and 3.71% in flexion-extension, lateral bending, and axial rotation ROM, respectively. Hemilaminectomy and 1/3 facetectomy led to increases of 3.58%, 1.28%, and 4.17% in the mentioned ROM parameters. In addition, the ROM of the intact lower-grade spondylolisthesis model (model B) showed an obvious increase compared to model A, but hemilaminectomy or 1/3 facetectomy did not significantly change the ROM in the spondylolisthesis model. Considering that the anterior vertebral body bears a considerable portion of spinal stress, the buffering effect of intact intervertebral discs and the preservation of posterior midline structures such as facet joints and spinous processes compensate for removing partial bone structures and ligaments, we speculate that even with partial removal of bone structures and ligaments, spinal stability may not be significantly altered.

However, the index segment bears the risk of iatrogenic instability after total laminectomy if it lacks an additional fusion procedure. Postacchini et al. reported that 3 out of 32 patients suffered from significant segment disability after total laminectomy [ 32 ]. In Lener et al.‘s study [ 30 ], when complete laminectomy was performed with bilateral partial facetectomy, segmental ROM increased by 20% ± 15.9, 11% ± 9.9, and 19% ± 10.5% in flexion-extension, lateral bending, and axial rotation, respectively. In our study, due to the preservation of facet joints, the percentage increase in segmental ROM was smaller compared to cadaveric specimen experiments. After total laminectomy, segmental ROM increased by 9.71%, 5.79%, and 9.30% in flexion-extension, lateral bending, and axial rotation, respectively. These results suggest that in the lumbar spondylolisthesis model, the increase in ROM is greater compared to the normal lumbar spine model after total laminectomy, indicating that total laminectomy is not recommended in cases of lumbar spondylolisthesis. It is reported that the preservation of the dorsal midline structures could contribute to maintaining enough stability in the normal lumbar, bilateral laminotomy or unilateral laminectomy with “over the top” could be an alternative procedure when bilateral decompression is acquired [ 33 , 34 , 35 , 36 ]. In situations where total laminectomy is deemed necessary for decompression, it may be advisable to consider laminectomy with implantation techniques to reduce the risk of postoperative instability.

Intradiscal pressure and annulus fibrosus stress

The intradiscal pressure embodies a response from the nucleus in a state of compression [ 37 ]. As the carrying load of the nucleus increases, the IDP also increases [ 38 ], indicating a higher possibility of nucleus degeneration [ 39 ]. The IDP did not show an obvious increase tendency in both normal lumbar and spondylolisthesis models after hemilaminectomy and 1/3 facetectomy. In contrast, the IDP of total laminectomy shows an obvious increase during flexion movement. In the normal models, the IDP increased by 0.09 MPa, and in the spondylolisthesis models, the IDP increased by 0.11 MPa. The above data show that total laminectomy could easily induce the degeneration of the nucleus pulposus compared with other procedures. Compared to the normal intact lumbar model, the IDP decreased significantly in the intact spondylolisthesis model. Disc degeneration is regarded as the inducement of segment stability loss and LDS [ 4 ]. The degenerative disc loses the ability to bind water under compression, which leads to a decrease in intradiscal pressure [ 40 ]. Because of the loss of intradiscal pressure, the annulus and nucleus will bear more shear stress, which could induce the annulus tear [ 40 , 41 ].

Apart from carrying the load, the nucleus pulposus also induces tensile stress on the annulus fibrosus [ 37 ]. High stress may lead to a higher degeneration risk of annulus fibrosus; this study found that the AFS increased with the resection range. The stress of total laminectomy was higher level in both normal lumbar and spondylolisthesis models, which was consistent with previous studies [ 29 ]. The highest AFS occurred in model B2 during flexion, at 4.62 MPa, which is less than the failure strength of 8.5 MPa [ 15 ]. Although there was no significant increase in AFS compared to the intact spondylolisthesis model after facetectomy and hemilaminectomy in spondylolisthesis models, it is worth noting that the index segment AFS in intact spondylolisthesis model experienced an obvious rise compared to the intact normal lumbar model. Therefore, patients with spondylolisthesis may be at a higher risk of annulus degeneration.

Face joints contact force

As a part of a three-joint complex, facet joints play a crucial role in maintaining spine stability, especially during extension and rotation movements [ 39 , 42 , 43 ]. Previous studies have shown that the FJCF is greatest during rotation, followed by extension and lateral bending, consistent with our findings [ 44 , 45 ]. It is reported that the coronal angle of the facet joint gradually decreased and sagittal orientation increased with age, and the change of direction could lead to spondylolisthesis [ 46 ]. However, Leng et al. posit an interaction force between the lower vertebra’s superior articular process and the sliding vertebra’s inferior articular process, leading to the remodeling and morphological changes of the facet joints [ 47 ]. Morphological changes can weaken the resistance of the facet joints to anterior shear forces. When the forward shear force on the vertebra exceeds the resistance of the articular processes and posterior ligaments, it can result in lumbar spondylolisthesis. Changes in direction are a consequence of facet joint remodeling. In addition, the study of Liu et al. found The FJCF increased with the increase in the coronal angle of facet joints; they speculated that a bigger coronal angle of facet joints could contribute to bearing more mechanical load and maintaining spine stability [ 48 ].

In both normal lumbar and spondylolisthesis models, the greatest decrease in FJCF was observed with total laminectomy, followed by hemilaminectomy combined with 1/3 facetectomy and hemilaminectomy. The variation in FJCF was similar to the ROM. The capability of bearing load in facet joints is believed to be relevant to spine stability. However, high FJCF can induce facet joint arthrosis and painful articular facets [ 39 , 49 ], as the normal facet joints can bear approximately 4-25% of the total load [ 49 ]. Park et al. found that a severe degenerative spine can cause a greater FJCF [ 50 ]. Similarly, the FJCF in the intact spondylolisthesis model was larger than the intact normal model in our results. We do not observe a significantly greater decrease in the FJCF in spondylolisthesis models compared to normal lumbar models under the same surgical condition. Therefore, we believe that stability loss in lower-grade LDS is acceptable after hemi-laminectomy and facetectomy.

The isthmus was recognized as a weak area in the lumbar spine [ 37 ]. Spondylolysis is believed to result from repetitive mechanical stress on the lower lumbar vertebrae [ 51 ]. Excessive activity and stimulation of the fractured isthmus can lead to symptoms such as pain. While most individuals affected by these conditions are asymptomatic, a minority may experience chronic disabling lower back pain, sometimes radiating to the buttocks or thighs; this may be due to altered disc stress and increased disc degeneration following isthmic fracture, leading to chronic irritation [ 52 , 53 ]. Despite most surgical interventions targeting the involved motion segment, some patients may continue to experience or exacerbate symptoms even after successful bony fusion of the affected segment. Studies have shown that partial isthmic resection may increase pressure in the area [ 45 ], increasing the risk of isthmus fracture. In a study by Spina et al., it was found that more than 75% of the isthmus resection would cause the IS to approach the ultimate strength (120–140 MPa) of cortical bone; they suggested that surgeons should avoid resecting more than 50% of the isthmus [ 45 ]. We performed a pure laminectomy without destroying the isthmus, which is similar to the 0% isthmus resection in the Nicholas et al. study [ 45 ]. Our results showed that the maximal stress in the isthmus was 109.80 MPa during rotation, which is lower than the ultimate strength. However, excessive rotation moments should still be avoided. Overall, the isthmus exhibited higher stress in spondylolisthesis models and may have a higher risk of isthmus fracture during vigorous exercise.

Limitations

Some limitations in our study should be acknowledged. First, there is no suitable method of validation for developing a spondylolisthesis model, so we developed our spondylolisthesis model based on normal lumbar spine by extending the isthmus, without considering the issue of ligament pre-tension, which may not accurately reflect the morphological characteristics of lower-grader LDS. It is reported that the tropism and morphology of the facet joint could change in the LDS, which could influence the biomechanics of the motion segment [ 47 , 54 ]. Therefore, it may not fully simulate the true physiological status of spondylolisthesis. Second, due to the complexity in vivo, we simplified the model in the process. Therefore, the FE results should be considered to have a similar tendency to the actual situation and provide a possible consequence in clinical settings but not present the same mechanical behavior as in vivo. The FE results should be considered to have a similar tendency to the actual situation and provide a possible consequence in clinical settings but not present the same mechanical behavior as in vivo. Besides, there may be individual differences in each lumbar CT scan. Including differences in the height of disc space, the facet joint tropism, and bilateral asymmetry of the vertebral body, which could lead to diverse outcomes. Thus, developing multiple finite element models by adding CT data could increase the credibility of the results. Additional samples or in vitro experiments are needed to validate our findings in the future.

This study suggests that hemilaminectomy and one-third facetectomy may be viable surgical options for lower-grade LDS, with minimal impact on segment stability. However, patients with LDS undergoing hemilaminectomy and facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics of both normal lumbar and spondylolisthesis models.

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Renfeng Liu, Tao He, Xin Wu, Wei Tan, Zuyun Yan & Youwen Deng

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Ren-Feng Liu, Tao He, Wei Tan, Xin Wu carried out the model development and simulation, data analysis and drafted the manuscript.Ren-Feng Liu, Tao He, Zuyun Yan and You-Wen Deng participated in the study design. Ren-Feng Liu,Tao He, and You-Wen Deng participated in revising the manuscript. All authors read and approved the final manuscript.

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Liu, R., He, T., Wu, X. et al. Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis. J Orthop Surg Res 19 , 209 (2024). https://doi.org/10.1186/s13018-024-04681-4

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DOI : https://doi.org/10.1186/s13018-024-04681-4

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5 Best Spondylolisthesis Exercises to Ease Pain and Discomfort

S pondylolisthesis exercises are often the first treatment plan for spondylolisthesis, a condition in which the vertebrae lose their natural alignment.

Regular practice of spondylolisthesis physical exercises not only help strengthens the spine but also improves the range of motion of the abdomen, back, and legs. These muscles help reduce the pressure that is usually placed on the spine, which further eases back pain and other symptoms associated with this condition.

Additionally, these exercises aid in weight loss, which reduces strain on the hamstrings and ultimately reduces extra pressure on the back and spine.

Why Does Spondylolisthesis Occur?

The condition occurs when one of the spine's muscle, called vertebrae, slips slightly forward out of its natural alignment. This leads to pain and other symptoms, including:

• lower back pain that worsens when standing
• hamstring and back stiffness
• pain in the buttocks
• tingling or numbness in the legs

In severe cases, doctors might recommend surgery, although in mild cases, certain spondylolisthesis exercises can help ease pain, improve flexibility , and enhance the overall quality of your life.

Spondylolisthesis Exercises to Alleviate Pain

Here are some of the best exercises for spondylolisthesis that can help manage your condition:

1. Pelvic tilt

The pelvic tilt is one of the most effective spondylolisthesis exercises that not only work on the spine but activates some of the core muscles as well. This helps provide stability and strength to the lower spine.

• Lie on your back and keep your knees bent and feet on the floor.
• Contract your belly button using your abdominal muscles and press your lower back onto the floor.
• Hold the position for a few seconds while keeping your midsection engaged.

2. Bird dog

Also called the quadruped leg and arm raise, the bird dog is also one of the best spondylolisthesis exercises that targets the core muscles, helps build strength and stability in the glutes, spine, hip flexors and abdomen, and eases back pain as well.

• Take a position on your fours and raise one arm and your opposite leg straight.
• Engage your core muscles and hold the position.
• Lower your leg and arm and repeat with your opposite leg and arm.
• Repeat on both sides.

3. Knee-to-chest

One of the best stretches for spondylolisthesis, the knee-to-chest stretch helps stabilize the spine by targeting the core and alleviating pain and discomfort.

• Lie on your back with your feet on the floor and knees bent and keep your arms on the sides with your palms facing down.
• Tighten your core muscles by contracting your belly button in towards the spine and then pulling one knee up towards your chest. Hold the position.
• Now lower the knee down and bring your other knee up and repeat the move.
• Repeat a few times. You can also do this exercise by using both knees simultaneously.

4. Hamstring stretch

Spondylolisthesis can often lead to pain and tightness in the hamstrings . This, as a result, can cause strain on the lower back and lead to uncomfortable symptoms as well. Hamstring stretch can help keep the muscles strong and flexible and also prevent tightness.

• Sit on the floor with both your legs stretched out to the front. Keep your toes pointed up towards the ceiling.
• Now, lean slightly forward to reach your toes and hold the position.
• Don't worry if you are unable to touch your toes. Just stretch to the point that is comfortable for you.
• Hold the position for a few seconds.

5. Gluteal stretch

The gluteal stretch is among the imperative spondylolisthesis exercises that ease pressure and stiffness along the glutes and reduces lower back pain .

• Lie on your back with your knees bent and rest your right ankle over your left leg, above the knee.
• Hold the left thigh (bottom leg) and slowly pull it towards your chest. Continue to pull until you feel a stretch in your glutes or buttocks.
• Hold and then release. Repeat with your other leg.

Spondylolisthesis Exercises to Avoid

While the aforementioned exercises are beneficial and can help provide you with relief, some movements need to be avoided when you have spondylolisthesis pain. This is because your spine can be weak and vulnerable during the condition and certain exercises can lead to extra pressure on the back.

The following exercises should be avoided when you have spondylolisthesis:

• any bending or twisting exercises
• heavy weightlifting
• high-intense exercises and sports activities like basketball, running, football, etc.

It is recommended that you stay away from any exercise that may cause pressure or extra strain to the spine as it may worsen your condition and lead to serious problems.

Also, never perform exercises if you have severe pain in your back. If any exercise causes any kind of discomfort, stop immediately. If you have symptoms like numbness or tingling that is not subsiding, consult a doctor immediately.