l5 spondylolisthesis symptoms

An Overview of Spondylolisthesis

What Is Spondylolisthesis?

Spondylolisthesis (pronounced spahn-duh-low-liss-thee-sus) is a condition in which one of the bones in your spine (the vertebrae) slips out of place and moves on top of the vertebra next to it.

It usually happens at the base of your spine (lumbar spondylolisthesis). When the slipped vertebra puts pressure on a nerve, it can cause pain in your lower back or legs.

Spondylolisthesis Symptoms

Sometimes, people with this condition don't notice anything is wrong. But you can have symptoms that include:

• Lower back pain
• Muscle tightness and stiffness
• Pain in your buttocks
• Pain that spreads down your legs (due to pressure on nerve roots)
• Pain that gets worse when you move around
• Tight hamstrings (muscles in the back of your thighs)
• Trouble standing or walking

Spondylolisthesis vs. Spondylolysis

Spondylolysis (pronounced spahn-duh-loll-iss-us) and spondylolisthesis are different conditions of the spine, though they're sometimes related. Both conditions cause pain in your lower back .

Spondylolysis is a weakness or small fracture (crack) in one of your vertebrae. This usually affects your lower back, but it can also happen in the middle of your back or your neck. It's most often found in kids and teens, especially those involved in sports that repeatedly overstretch the lower spine, like football or gymnastics.

It's not uncommon for people with spondylolysis to also have spondylolisthesis. That's because the weakness or fracture in your vertebra may cause it to move out of place.

Types of Spondylolisthesis

Doctors divide this condition into six main types, determined by cause.

Degenerative spondylolisthesis: This is the most common type. As people age, the disks that cushion vertebrae can become worn, dry out, and get thinner. This makes it easier for the vertebra to slip out of place.

Isthmic spondylolisthesis: This type is caused by spondylosis. A crack in the vertebra can lead it to slip backward, forward, or over a bone below. It may affect kids and teens who do gymnastics, do weightlifting, or play football because they repeatedly overextend their lower backs. But it also sometimes happens when you're born with vertebrae whose bone is thinner than usual.

Congenital spondylolisthesis: Also known as dysplastic spondylolisthesis, this happens when your vertebrae are aligned incorrectly due to a birth defect.

Traumatic spondylolisthesis: In this type, an injury (trauma) to the spine causes the vertebra to move out of place.

Pathological spondylolisthesis: This type is caused by another spine condition, such as osteoporosis or a spinal tumor.

Postsurgical spondylolisthesis: Also called iatrogenic spondylolisthesis, this happens when a vertebra slips out of place after spinal surgery.

Grades of Spondylolisthesis

Your doctor may give your spondylolisthesis a grade based on how serious it is. The most common grading system is called Meyerding's classification and includes:

• Grade I : The most common grade, this is defined as 1%-25% slippage of the vertebra
• Grade II : Up to 50% slippage of the vertebra
• Grade III : Up to 75% slippage
• Grade IV : 76%-100% slippage
• Grade V : More than 100% slippage, also known as spondyloptosis

Grades I and II are considered low grade. Grades III and up are considered high grade.

Spondylolisthesis Causes and Risk Factors

Causes of spondylolisthesis include:

• Wear and tear with age
• Birth defects
• Spondylolysis
• Injury to the spine
• Another condition such as a spinal tumor or osteoporosis
• Spinal surgery

You're more likely to get this condition if you:

• Take part in sports that put stress on your spine
• Were born with thinner areas of vertebrae that are prone to breaking and slipping
• Are 50 or older
• Have a degenerative spinal condition

Spondylolisthesis Diagnosis

If your doctor thinks you might have this condition, they'll ask about your symptoms and run imaging tests to see if a vertebra is out of place. These tests may include:

These tests can also help your doctor determine a grade for your spondylolisthesis.

Spondylolisthesis Treatments

The treatment you'll need depends on what grade of spondylolisthesis you have, as well as your age, symptoms, and your medical history. Low grade can usually be treated with physical therapy or medications. With high grade, you may need surgery, especially if you're in a lot of pain.

Nonsurgical treatment options include:

• Rest : You may need to take some time off from sports and other vigorous activities.
• Medications : Your doctor may recommend over-the-counter anti-inflammatory medicines to relieve your pain, such as ibuprofen or naproxen.
• Injections : Steroid shots in the area where you have pain can bring relief.
• Physical therapy : Daily exercises that stretch and strengthen your supportive abdominal and lower back muscles can lower your pain.
• Braces : For children with fractures in the vertebrae (spondylolysis), a back brace can restrict movement so the fractures can heal.

Spondylolisthesis Surgery

If you have high-grade spondylolisthesis or if you still have serious pain and disability after nonsurgical treatments, you may need surgery. This usually means spinal decompression, often along with spinal fusion.

Spinal surgery is always done under general anesthesia , which means you're asleep during the operation.

Spinal decompression: Decompression lessens the pressure on the nerves in your spine to relieve pain. There are several techniques your surgeon can use to give your nerves more room. They may remove bone from your spine, take out part or all of a disk, or make the opening in your spinal canal larger. Your surgeon might need to use all these methods during your surgery.

Spinal fusion: In spinal fusion, the doctor joins, or fuses, the affected vertebrae together to prevent them from slipping again. After this surgery, you may have a bit less flexibility in your spine.

Pars repair: This surgery repairs fractures in the vertebrae using small wires or screws. Sometimes, a bone graft is used to reinforce the fracture so it can heal better.

After spinal surgery, you'll likely need to stay in the hospital for at least a day. Most people can go home within a week. You may be able to stand or even walk the day after the operation. You may go home with pain medication to ensure that your recovery is as easy as possible.

You'll need to limit physical activity for 8-10 weeks after your surgery so your spine can heal. But you should still move around and even walk every day. This can make your recovery go faster and help keep complications at bay.

Around 10-12 weeks after your surgery, you'll start physical therapy to stretch and strengthen your muscles and help you move more easily. Ideally, you should have physical therapy for a year.

For the first year after your surgery, you'll need to see your surgeon about every 3 months. You'll likely have X-rays taken at these follow-ups to make sure your spine is healing well.

Spondylolisthesis Complications

Serious spondylolisthesis sometimes leads to another condition called cauda equina syndrome . This is a serious condition in which nerve roots in part of your lower back called the cauda equina get compressed. It can cause you to lose feeling in your legs. It also can affect your bladder.

This is a medical emergency. If left untreated, cauda equina syndrome can lead to a loss of bladder control and paralysis.

See your doctor if you:

• Have trouble controlling your bladder or bowels
• Notice numbness or a strange sensation between your legs or on your buttocks, inner thighs, backs of your legs, feet, or heels
• Have pain or weakness in a leg or both legs that may cause stumbling

The symptoms may come on slowly and vary in how serious they are.

Spondylolisthesis Outlook

For most people, rest and nonsurgical treatments bring long-term relief within several weeks. But sometimes, spondylolisthesis comes back again after treatment. This happens more often when it was a higher grade.

If you've had surgery, you'll most likely do well afterward. Most people get back to normal activities within a few months. But your spine may not be as flexible as it was before.

Spondylolisthesis is when one of your vertebrae moves out of place. This sometimes leads to back pain and other symptoms. It can be usually treated with rest, medication, and/or physical therapy. But serious cases may require surgery.

Spondylolisthesis FAQs

What is the main cause of spondylolisthesis?

In adults, it most often happens when cartilage and bones in the spine become worn from conditions such as arthritis. It's more common in people age 50 and older. In kids and teens, the most common causes are either a spinal birth defect or injury to the spine.

Is spondylolisthesis a serious condition?

For most people, it's not serious. Many people have few symptoms or no symptoms at all. It's only a problem when it causes pain or limits your ability to move. If that happens, you'll need to see a doctor for treatment.

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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: 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

Spondylolisthesis is a displacement of a vertebra in which the bone slides out of its proper position onto the bone below it. Most often, this displacement occurs following a break or fracture.

Surgery may be necessary to correct the condition if too much movement occurs and the bones begin to press on nerves.

Other complications may include:

• Chronic back pain
• Sensation changes
• Weakness of the legs
• Temporary or permanent damage of spinal nerve roots
• Loss of bladder control

When a vertebra slips out of proper alignment, discs can be damaged. To surgically correct this condition, a spinal surgeon removes the damaged disc. The slipped vertebra is then brought back into line, relieving pressure on the spinal nerve.

Types of spondylolisthesis include:

• Dysplastic spondylolisthesis , caused by a defect in part of the vertebra
• Isthmic spondylolisthesis , may be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions
• Degenerative spondylolisthesis , occurs with cartilage degeneration because of arthritic changes in the joints
• Traumatic spondylolisthesis , caused by a fracture of the pedicle, lamina or facet joints as a result of direct trauma or injury to the vertebrae
• Pathologic spondylolisthesis , caused by a bone defect or abnormality, such as a tumor

Symptoms may vary from mild to severe. In some cases, there may be no symptoms at all.

Spondylolisthesis can lead to increased lordosis (also called swayback), and in later stages may result in kyphosis, or round back, as the upper spine falls off the lower.

Symptoms may include:

• Lower back pain
• Muscle tightness (tight hamstring muscle)
• Pain, numbness or tingling in the thighs and buttocks
• Tenderness in the area of the vertebra that is out of place
• Weakness in the legs
• Stiffness, causing changes in posture and gait
• A semi-kyphotic posture (leaning forward)
• A waddling gate in advanced cases
• Lower-back pain along the sciatic nerve
• Changes in bladder function

Spondylolisthesis may also produce a slipping sensation when moving into an upright position and pain when sitting and trying to stand.

Spondylolisthesis may appear in children as the result of a birth defect or sudden injury, typically occurring between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis).

In adults, spondylolisthesis is the result of abnormal wear on the cartilage and bones from conditions such as arthritis , trauma from an accident or injury, or the result of a fracture, tumor or bone abnormality.

Sports that place a great deal of stress on bones may cause additional deterioration, fractures and bone disease, which may cause the bones of the spine to become weak and shift out of place.

A simple X-ray of the back will show any cracks, fractures or vertebrae slippage that are the signs of spondylolisthesis.

A CT scan or an MRI may be used to further diagnose the extent of the damage and possible treatments.

Treatment for spondylolisthesis will depend on the severity of the vertebra shift. Stretching and exercise may improve some cases as back muscles strengthen.

Non-invasive treatments include:

• Heat/Ice application
• Pain medicine (Tylenol and/or NSAIDS)
• Physical therapy
• Epidural injections

Surgery may be needed to fuse the shifted vertebrae if the patient has:

• Severe pain that does not get better with treatment
• A severe shift of a spine bone
• Weakness of muscles in a leg or both legs

Surgical process realigns the vertebrae, fixing them in place with a small rod that is attached with a pedicle screw, adding stability to the spine with or without the addition to an interbody (bone graft or cage) placed between the vertebra from the side or front.

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Lumbosacral spondylolisthesis.

Katarzyna Studnicka ; George Ampat .

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Last Update: July 22, 2023 .

• Continuing Education Activity

Lumbosacral spondylolisthesis is a forward translation of the fifth lumbar vertebrae over the first sacral vertebrae. Untreated, it may be associated with chronic lower back pain and lead to neurological complications. This activity evaluates the etiology, classification, diagnosis, and treatment options, as well as the role of interprofessional teams in the management of patients with this condition.

• Identify the etiology of lumbar spondylolisthesis.
• Review the evaluation of lumbar spondylolisthesis.
• Outline the management options available for lumbosacral spondylolisthesis.
• Describe some interprofessional team strategies for improving care coordination and communication to advance lumbosacral spondylolisthesis treatment and improve outcomes.
• Introduction

Lumbosacral spondylolisthesis is the forward translation of the fifth lumbar vertebra (L5) over the first sacral vertebra (S1). Bilateral L5 pars defect (spondylolysis) or repetitive stress injury is the primary etiology behind lumbosacral spondylolisthesis. The degree of a slip often correlates with the degree of symptoms.  

The prevalence of spondylolysis (pars defect), in the general population, is 6%, and a third of those will subsequently develop a degree of spondylolisthesis. [1]  The majority of cases are mild or asymptomatic, and only a relatively small percentage of symptomatic patients require surgical intervention. 

The most commonly affected populations are children and adolescents participating in sports that require repetitive lower back hyperextension (divers, pace cricket bowlers, baseball, softball, rugby, weightlifting, sailing, table tennis, wrestlers, gymnasts, dancers, and footballers). They usually present with lower back pain exacerbated by activity. [2]  Occasionally pain can radiate to both buttocks and legs, and in advanced cases, the gait pattern and walking distance may be affected. Presentation in adults is more insidious and commonly associated with long-standing degenerative changes secondary to the slip, often leading to spinal canal stenosis and radicular pain.

Management of the majority of the cases is non-operative, but patients who fail non-operative treatment and continue having disabling symptoms may require surgical treatment. [2] [3]

 A Wiltse-Newman classification describes different etiology of pars interarticularis failure  [4] :

• Type I  Dysplastic – congenital defect in pars 
• II A pars fatigue fracture
• II B pars elongation due to multiple healed stress fractures
• II C pars acute fracture
• Type III degenerative spondylolisthesis from degenerative facet instability without pars fracture
• Type IV Traumatic – due to acute posterior arch fracture other than pars
• Type V  Neoplastic – pathologic destruction of the pars

Depending on the degree of the forward slip, the severity of this process is graded as mild, severe, or complete slip (spondyloptosis) - described later in Myerding classification. 

In the most common isthmic spondylolisthesis, which leads to an L5/S1 slip, the following stages have been identified.

• Pars stress reaction (sclerosis with incomplete bone disruption/fracture)
• Spondylolysis (anatomic defect in the pars, radiolucent gap with adjacent bone sclerosis, without any translation of the vertebra)
• Spondylolisthesis (due to bilateral pars defect, forward translation of the superior vertebra over the inferior one)

The second most common types of spondylolisthesis are type I (dysplastic) and III (degenerative). Degenerative spondylolisthesis is most prevalent in the adult population, and levels affected most frequently are L4/L5 followed by L3/L4. Due to the chronicity of the instability, often associated degenerative changes in the intervertebral disc and facet joints occur. They often lead to secondary hypertrophy of the ligamentum flavum and subsequent spinal canal stenosis. This condition usually presents with bilateral buttock pain and neurogenic claudication (back pain eased by sitting down/leaning forward). 

• Epidemiology

Estimates are that 4 to 6% of the population has a degree of lumbosacral spondylolisthesis. The majority of cases are asymptomatic. [5]

Most of the symptomatic high-grade slips occur in the pediatric/adolescent population participating in sports involving repetitive hyperextension, while adults tend to present with milder and more chronic onset of symptoms. [6]  

The most commonly affected adolescent groups are female dancers or gymnasts with hyperlordosis and hyper flexibility, male football players, or weight lifters with limited motion at lumbar spine undergoing a growth spurt, or novice athletes vigorously training while having poor core strength. [7]

There are reports of familial association and congenital abnormalities, including spina bifida occulta, thoracic hyperkyphosis (Shauerman disease) as predisposing factors as well as general ligamentous laxity. 

Several anatomical factors described below predispose to spondylolisthesis. 

• Pathophysiology

Two mechanisms may cause the lytic defect. The first is the pincer effect due to repeated hyperextension. [8]  The inferior facet of L4 and the superior facet of S1 creates a pincer effect on the pars interarticularis, causing a failure of the L5 pars. This condition is more likely to occur in a situation where the sacral slope has a low value with a more horizontally orientated superior sacral endplate. The second mechanism is when there is an increased sacral slope and hence increased traction on the pars interarticularis. [9]  The repeated traction on the pars from a downsloping lumbosacral junction results in failure and fracture of the pars interarticularis. In high-grade slips, the anterosuperior part of the sacrum becomes dome-shaped, which may be due to repeated trauma to the anterosuperior apophyseal ring of the S1 vertebrae. [10]

The spinopelvic balance and the global spinal alignment are essential in understanding the etiology, grading, and planning the treatment protocol. [11]  These parameters are measured on a standing lateral radiograph. The main parameters and their definitions are as follows.

• Pelvic Tilt (PT) is the angle measured between a line drawn from the center of the superior endplate of S1 to the center of rotation of the femoral head and the vertical reference line. [11]
• Sacral Slope (SS) is the angle between the line drawn along the superior end of the S1 endplate and the horizontal reference line. [11] The pelvic tilt (PT) and the sacral slope are referenced to the vertical and horizontal planes and hence can vary based on the position of the pelvis. Though the standard measurements are on a standing radiograph, the values of PT and SS alter between sitting and standing.  
• The Pelvic Incidence (PI) is the angle between a line starting at the midline between centers of rotation of each femoral head drawn towards the midpoint of S1 superior endplate and a line perpendicular to the line drawn along the superior endplate of S1.[10]  The normal value is 50 degrees. An increased Pelvic Incidence (PI) is associated with higher severity of slips. [12]  In comparison to the PT and SS, the Pelvic Incidence is a fixed value and does not change with the position of the pelvis or in adult life. A value of 70 to 80 degrees presents in patients with significant spondylolisthesis.  Pelvic Incidence = Pelvic Tilt + Sacral Slope 
• Boxall’s Slip Angle and Dubosset’s lumbosacral angle  measures the relationship between L5 and S1. [13] [14] The Boxalls slip angle is measured between the perpendicular to the posterior aspect of the S1 vertebrae and the lower border of L5. If slip angle measures >45 degrees, it is associated with a greater risk of slip progression, instability, and post-op pseudo-arthrosis. It predicts intervention and affects cosmesis as well as prognosis. [11]  The Dubosset’s lumbosacral angle is measured between the posterior aspect of the S1 and the upper endplate of the L5. Unlike the slip angle, the lumbosacral angle does not involve surfaces that alter with dysplasia.

Forward translation of the vertebrae may cause a narrowing of the spinal canal at the level of the slip. This situation is rare as most of the slips are only grade I or II, but the secondary canal and foraminal stenosis can occur due to subsequent degenerative changes in facet joints, hypertrophy of ligamentum flavum, hypertrophic fibrous repair tissue of the pars defect, or bulging of L5/S1 disc. In severe L5/S1 slips, the L5 nerve root is most commonly affected by being pulled forward by the superior vertebra.

• History and Physical

Most cases of spondylolisthesis are asymptomatic.

Severe slips are uncommon, and deformity rarely progresses beyond Meyerding grade II (see Evaluation chapter).

Typical history and examination findings in symptomatic cases involve:

• Child participating in back hyperextension activities (gymnastics, football, weight lifting), most common age at presentation is 4 to 6 yrs old. 
• In adults insidious onset of axial back pain exacerbated by physical activity, periodic exacerbations that vary in intensity and duration
• L5 radicular symptoms (in severe slips), including weakness of the extensor hallucis longus
• Bladder and bowel dysfunction (including cauda equina syndrome in extreme cases)
• Neurologic claudication secondary to spinal canal stenosis (buttock and leg pain worse with walking but improving with leaning forward or sitting)

Examination Findings

• Pain with back hyperextension. Hyperextending the lower back while standing on one leg is termed the "stork test."
• Limitation of lumbar spine flexion and extension
• Increased popliteal angle
• Gait alteration with abductors weakness (L5) (pelvic waddle)
• Flattened lumbar lordosis or kyphosis of the lumbosacral junction 
• Palpable step-off of the spinous process
• Hamstring tightness (in extreme cases walking with hips and knees flexed- due to vertical orientation of the sacrum causing pelvic retroversion and compensatory lumbar hyperlordosis + shortened stride and lurched posture) 
• "Heart-shaped" buttocks in severe cases of significant lumbosacral kyphosis and sacral retroversion (sacrum becoming more vertical in orientation and moving away from the head of the femurs).
• Straight leg raise test may be positive. 
• Scoliosis may be present - this may be secondary to pain. 

Listhetic crisis (rapid progression of symptoms). Common during a growth spurt or increased physical activities with bilateral pars failure.

• Severe back pain aggravated by extension and relieved by rest.
• Neurologic deficit
• Hamstring spasm - walk with a crouched gait

Following the history and examination, the best screening tool is an AP and lateral weight-bearing X-ray of the lumbar spine. [15]   Lumbosacral spondylolisthesis can be best assessed mainly on the lateral view, but occasional coronal deformity should not be missed. In cases where clinical examination indicates an abnormal sagittal balance of the spinal column, a whole spine lateral standing X-ray is indicated. In the majority of cases, an isthmic defect will be detected on radiographs but in doubtful cases. An MRI scan is recommended. Oblique X-rays of the lumbosacral junction, Computerised Tomography (CT) scan, SPECT scans may also identify the defect but involve ionic radiation.

MRI scans are more sensitive in identifying pars lesions.MRI can also identify stress reactions that occur even before a fracture line develops. [16]  In dysplastic cases, dome-shaped or significantly inclined sacrum can present as well as trapezoid-shaped L5 and dysplastic facets of S1. Neoplasms and infections are an extremely rare primary cause of spondylolisthesis but should merit consideration as a differential diagnosis in patients with constitutional symptoms. To assess dynamic instability, flexion and extension views should be obtained. Either 4 mm of translation or 10 degrees of angulation of motion compared to the adjacent motion segment are diagnostic for spondylolisthesis. 

Grading of the forward slip is classified by Meyerding classification:

• Grade I <25% of the width of the vertebra on the lateral view
• Grade II 25 to 50%
• Grade III 50 to 75%
• Grade IV 75 to 100%
• Grade V >100% (spondyloptosis)

Pelvic incidence (PI) has a direct correlation to Meyerding's grade. [12]

The Spinal Deformity Study Group has created a new classification that guides treatment. This scale takes into account the spinopelvic parameters and the overall spinal alignment. [17]

• I < 50% slip, PI <45 degrees, Surgery only if symptoms not controlled by non-operative methods.
• II < 50% slip, PI 45 to 60, Surgery only if symptoms not controlled by non-operative methods.
• III < 50% slip, PI >60 degrees, posterolateral fusion can be considered
• IV >50% slip, balanced pelvis high SS / low PT, decompression + / - Posterolateral fusion may be adequate
• V >50% slip, Unbalanced pelvis (retroverted) Low SS / High PT, reduction of slip, and circumferential fusion may be a consideration.
• VI >50% slip, Unbalanced spine (retroverted pelvis) Low SS / High PT + C7 plumbline anterior to femoral heads reduction of slip and circumferential fusion may be considered.

MRI (T-2 weighted sequence is best to assess spinal canal stenosis, foraminal stenosis, and nerve root impingement, as well as the morphology of lumbar and sacral vertebrae which presence correlated with history and examination findings, will dictate the surgical management). The most commonly affected nerve root is L5. 

• Treatment / Management

The majority of the cases can be treated non-operatively by:

• Thoracolumbosacral / lumbosacral brace. [18]  In acute cases in the adolescent sportsperson bracing to prevent extension is shown to be superior to just activity modification.
• Activity modification (avoidance of hyperextension) [19]
• Core muscles strengthening focusing on the deep abdominal muscles and the multifidus muscle [20]
• Lumbar flexion-based exercises. [21]
• In cases of adult degenerative spondylolisthesis with canal stenosis, an epidural steroid injection can provide short-term relief. [22]

Non-operative management of acute cases among sportspersons was successful in 95% of patients, and only 5% required surgical intervention. Among that treated non-operatively, 82% returned to their previous level of play. [19]  Approximately one-third of patients with spondylolisthesis experience a disease progression over time. Operative treatment is reserved for those with intractable pain or neurological symptoms, including claudication or radiculopathy. [23]

Surgical intervention has shown >80% success in appropriately selected patients, with a low incidence of complications. Surgical techniques include the following:

• In the pediatric population with pars fracture or non-union, surgical repair of the pars may be an option with lag screw or tension band wire technique or pedicle screw hook fixation. [24] [25]
• Uninstrumented fusion in situ, A randomized control trial by Moller  [26] showed that there was no advantage in adding instrumentation. Pain, functional disability, and fusion rates were similar in both groups.
• Decompression, Though there was some skepticism in just performing decompression of the nerve roots without fusion, i.e Gills procedure, results show 70 % good results with regards to patient satisfaction. Only grade I and II patients met the inclusion criteria for the study. [27]
• Instrumented posterolateral fusion with decompression is the standard procedure. [26]
• Anterior / posterior / transforaminal and direct lateral lumbosacral interbody fusion, reduction, and fusion. [28]  The anterior, posterior, transforaminal, and direct lateral indicate the path through which the interbody device or cage is inserted. Posterior lumbar interbody fusion (PLIF) involves the insertion of the cage between the vertebral bodies medial to facets. Transforaminal lumbar interbody fusion (TLIF) requires facetectomy and a more lateralized and transforaminal approach to the disc space. Anterior Lumbar Interbody Fusion (ALIF) is via a trans or retroperitoneal approach and offers better access to disc space and endplate. They can also be associated with retrograde ejaculation and sexual dysfunction. Direct lateral or the transpsoas approach can only access the disc spaces above the L5 vertebrae. The iliac crest is in the path of reaching the L5/S1 disc on the direct lateral approach. [29]
• Reduction with spondylolectomy (vertebrectomy) of L5 and fusion of L4 on S1. [30]  In severe slips removing the L5 vertebrae allows reduction and better spinal alignment
• Sacral dome resection and fusion. [31]

Operative options should be considered only if non-operative options fail or symptoms are significant. The reduction of the slip is controversial as in approximately 20% of cases, it causes L5 nerve root injury. Nevertheless, some evidence suggests better functional and cosmetic outcomes for patients who underwent reduction and instrumented fusion. [32]  Foraminal decompression may also be necessary. Interbody fusion with the maintenance of intervertebral space improves the foraminal height, helps restore lumbar lordosis, and avoids fusion to L4 in high-grade slips. Each case requires an individual approach, and factors like the degree of spondylolisthesis, predominant neurological symptoms, and patients comorbidities should be taken into consideration. [33]  Minimally invasive surgical techniques are gaining in popularity. [34]

• Differential Diagnosis
• Mechanical or muscular back pain
• Disc degeneration, facet joint osteoarthritis (OA), and/or cyst
• Lumbar canal stenosis secondary to degenerative changes
• Neoplastic process/metastases
• Infection (discitis, TB, paraspinal abscess) 
• Vascular claudication (improves at rest in a standing position while neurological claudication improves with lumbar spine flexion - leaning forward or sitting) 

Despite the estimate of up to 6% of the population suffering from spondylolisthesis, the majority of them are asymptomatic. Only a small percentage of symptomatic cases will require surgical treatment. 

Worst prognosis in cases of:

• Very young age at presentation
• Female 
• Slip angle >45 degrees 
• High-grade slip
• Degenerative slip (most commonly in adults)
• Complications
• The most common reported neurological complication after lumbosacral spondylolisthesis surgery is L5 nerve root dysfunction. It is most frequently associated with high-grade slips and attempts of slip reduction as well as foraminal stenosis decompression. L5 nerve root dysfunction is usually transient and resolves within a few months in the postoperative period. In their cadaveric study, Petraco et al. found out that 71% of total nerve strain occurs during the second half of the reduction. [35]
• Pseudoarthrosis
• Adjacent segment disease (2 to 3%)
• Surgical site infection (0.1 to 2%)
• Positioning neuropathy: Lateral femoral cutaneous nerve - from a prone position with iliac bolster, ulnar nerve, or brachial plexopathy with inappropriate arm position) [36]

Complication rate increases with age, increased intraoperative blood loss, longer operative time, the number of levels fused.

• Deterrence and Patient Education

Sports coaches and personal trainers working with children and adolescents especially those practicing gymnastics, football, or weight lifting, should be aware of the symptoms of spondylosis and spondylolisthesis. They should be able to identify cases when pain does not improve after rest and basic stretching and strengthening exercises. These sportspersons need to be referred for specialist evaluation to diagnose and treat. This is particularly important as braces that prevent extension and activity reduction have shown excellent results.  

Affected patients should be educated about the importance of activity modifications and physiotherapy and engage with core muscle strengthening and flexion exercises for symptomatic treatment. 

They should receive reassurance that most of the symptoms are transient. But at the same time, especially those with a high risk of slip progression should be followed up by a specialist Orthopedic surgeon and educated about symptoms and signs of slip progression and potentially serious complications like cauda equina syndrome.

• Pearls and Other Issues

Pars interarticularis defects were common in sportsperson involved in increased activity. Hyperextension of the spine during the sport was a risk factor. In cricket fast bowlers extended and laterally flexed their spine, before throwing the ball to increase the speed of delivery. This repetitive movement increased the likelihood of developing a pars defect. In a recent review pars interarticularis defects were more common in the following sports, diving (35.38%), cricket (31.97%), baseball/softball (26.91%), rugby (22.22%), weightlifting (19.49%), sailing (17.18%), table tennis (15.63%), and wrestling (14.74%). [19] The suspicion that young adolescent sportspersons could develop spondylolysis is crucial in early diagnosis and prevention of progression. Bracing and activity restriction has shown excellent results with a good return to the same level of play. 

• Enhancing Healthcare Team Outcomes

A high level of suspicion within sports coaches, general practitioners, and parents is needed to recognize patients with symptoms of spondylolisthesis. 

Groups at risk like adolescent gymnasts, football players, and weight lifters should undergo health screening checks at regular intervals, and those with a history of lower back pain associated with activities undergo further evaluation and examination with those with suggestive signs and symptoms undergoing radiological investigations. 

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Spino pelvic parameters showing Pelvic tilt (PT), Sacral slope (SS) and Pelvic incidence (PI). Pelvic incidence (PI) = Pelvic tilt (PT) + Sacral slope (SS) Contributed by George Ampat FRCS

Spondylolysis with Spondylolisthesis, showing spino pelvic parameters, slip, dysplasia of upper endplate of S1, Slip angle (SA = angle between inferior endplate of L5 and line perpendicular to the S1 posterior wall) and lumbo sacral angle (LSA = angle (more...)

Lateral X-ray of the pelvis and lower lumbar spine showing spondylolysis and spondylolisthesis. Contributed by George Ampat FRCS

A - Degree of slip - Meyerding's grading. B - Spinopelvic parameters Slip angle (SA) and Lumbosacral angle (LSA). C Spinopelvic parameters showing Sacral slope (SS), Pelvic tilt (PT) and Pelvic incidence (PI). Contributed by George Ampat FRCS

Whole spine X-ray showing C7 plumbline. A vertical line dropped from the C7 vertebra. Should fall just behind the heads of the femurs. This allows economic weight bearing. Contributed by George Ampat FRCS

Disclosure: Katarzyna Studnicka declares no relevant financial relationships with ineligible companies.

Disclosure: George Ampat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Studnicka K, Ampat G. Lumbosacral Spondylolisthesis. [Updated 2023 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Spondylolysis and spondylolisthesis in children. [Instr Course Lect. 1983] Spondylolysis and spondylolisthesis in children. Hensinger RN. Instr Course Lect. 1983; 32:132-51.
• [Adjacent segment degeneration after lumbosacral fusion in spondylolisthesis: a retrospective radiological and clinical analysis]. [Acta Chir Orthop Traumatol Cec...] [Adjacent segment degeneration after lumbosacral fusion in spondylolisthesis: a retrospective radiological and clinical analysis]. Zencica P, Chaloupka R, Hladíková J, Krbec M. Acta Chir Orthop Traumatol Cech. 2010 Apr; 77(2):124-30.
• Review Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. [J Am Acad Orthop Surg. 2006] Review Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. J Am Acad Orthop Surg. 2006 Aug; 14(8):488-98.
• Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis. [Am J Sports Med. 2020] Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis. Gould HP, Winkelman RD, Tanenbaum JE, Hu E, Haines CM, Hsu WK, Kalfas IH, Savage JW, Schickendantz MS, Mroz TE. Am J Sports Med. 2020 Sep; 48(11):2765-2773. Epub 2020 Aug 14.
• Review Acute progression of spondylolysis to isthmic spondylolisthesis in an adult. [Spine (Phila Pa 1976). 2002] Review Acute progression of spondylolysis to isthmic spondylolisthesis in an adult. Stone AT, Tribus CB. Spine (Phila Pa 1976). 2002 Aug 15; 27(16):E370-2.

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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

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.

Type III (degenerative) can occur in patients who are > 60 and have  osteoarthritis ; this form is six times more common in women than men.

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

ZEPHYR/SCIENCE PHOTO LIBRARY

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.

Mild to moderate spondylolisthesis (anterolisthesis of ≤ 50%), particularly in the young, may cause little or no pain. Spondylolisthesis can predispose to later development of foraminal stenosis . Spondylolisthesis is generally stable over time (ie, permanent and limited in degree).

Treatment of spondylolisthesis is usually symptomatic. Physical therapy with lumbar stabilization exercises may be helpful.

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Spondylolisthesis L5-S1: Symptoms, Causes & Treatment

Qi spine clinic, 4 years ago, what do you mean by spondylolisthesis l5-s1, difference between spondylolysis & spondylolisthesis, overview of l5-s1, spondylolisthesis – types & grades, signs & symptoms of spondylolisthesis l5-s1, other common symptoms are: –.

• Lower back pain is the most common one.
• Weakness in one or both thighs/legs
• Pain might radiate to buttocks or thighs
• Decreased ability to control bowel/bladder movements (in type IV and above)
• The muscles in the back of thigh i.e. hamstrings feel tight
• Difficulty in standing, walking.

Causes of Spondylolisthesis L5-S1

• Birth defect
• Followed by trauma

Other common problems at L5-S1 are as follows: –

• Spondylolysis
• Disc herniation
• Facet joint arthropathy
• Nerve compression

Diagnosing L5-S1 Spondylolisthesis

Treatment for spondylolisthesis l5-s1, the non-surgical treatment methods include:-, pain management.

• Rest – Take relative rest. Taking a break from all the strenuous activities can help in relieving the pain but it won’t reverse the condition.
• Medication – You can ease your pain with the help of OTC medicines.
• Injections – You might be suggested to get steroid medications/injections directly into the affected area.
• Physical Therapy – Specific exercises can help you in strengthening your abdomen and back. Frequency specific microcurrent and certain exercises can relieve pain.

To stabilize the spine for a long term effect

• Spine rehab & accurate treatment by targeting specific muscle – This can be achieved by exercise plan focusing on the weaker muscles around abdomen and back. Regular exercise can relieve pain.
• Brace – A brace can help in stabilizing your spine. It limits movement so that fractures can heal.

Spondylolisthesis L5-S1 Exercises

Below are the exercises that may help in decreasing the pain..

• Pelvic tilt – It strengthens your lower abdominal muscles and also stretches your lower back.
• Lower trunk rotation – It increases the mobility and flexibility of your spine.
• Partial curl
• Pelvic bridging

Frequently Asked Questions about L5-S1 Spondylolisthesis

What do you mean by l5-s1, what is the best exercise for l5-s1 spondylolisthesis, what does spondylolisthesis mean, what are the common symptoms of l5-s1 spondylolisthesis.

• Pain in the lower back and/or associated leg pain
• Pain, numbness, weakness or tingling in legs or feet
• Pain that gets worse with activity
• Change in posture and gait caused by hamstring tightness
• Intermittent shooting pain that passes from buttocks down to legs

What are the different grades of spondylolisthesis?

What is the objective of l5-s1 spondylolisthesis treatment, what are the necessary diagnostic tests to be done for l5-s1 spondylolisthesis, what are the main causes of l5-s1 spondylolisthesis, what are the other problems that may occur at l5-s1.

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Spondylolisthesis

Spondylolisthesis is a condition where one of the bones in your spine, called a vertebra, slips forward over the bone below it. This can cause back pain and affect your ability to move.  The degree of slippage can worsen over time and lead to other spinal conditions such as neural compression.  This condition can affect spinal stability.

Common Causes

• Degenerative changes: Wear and tear on the spine from aging.
• Birth defects: Some people are born with a defective bone in their spine.
• Injuries: Trauma or stress fractures from sports or accidents.
• Previous surgery: Sometimes spinal surgery can lead to spondylolisthesis.
• Lower back pain.
• Pain that radiates to the buttocks or legs.
• Stiffness in the back.
• Muscle tightness or spasms.
• Numbness or tingling in the legs.
• Weakness in the legs.
• Difficulty walking or standing for long periods.

Diagnostic Tests

• Physical exam: The doctor checks for pain, range of motion, and muscle strength.
• X-rays: Pictures of the spine to see if a vertebra has slipped.
• MRI or CT scan: Detailed images of the spine to see any damage to the discs or nerves.
• Bone scan: A test to detect fractures and other bone changes.

Treatment Options

Non-surgical:.

• Medications: Over-the-counter pain relievers or prescription medications to reduce pain and inflammation.
• Physical therapy: Exercises to strengthen the core muscles and improve flexibility.
• Injections: Steroid injections to reduce inflammation and pain.
• Chiropractic care: Manual adjustments to improve spine alignment.
• Spinal fusion: Joining two or more vertebrae to stabilize the spine, which may include decompression of the nerves if needed.

Common Conditions That Can Cause Similar Symptoms

• Herniated disc: When the inner part of a spinal disc pushes out and presses on a nerve.
• Spinal stenosis: Narrowing of the spaces in the spine, putting pressure on the nerves.
• Sciatica: Pain that travels along the sciatic nerve from the lower back down the leg.
• Degenerative disc disease: When discs break down due to aging or injury.

When to See the Doctor

• If you have persistent back pain.
• If you experience numbness, tingling, or weakness in your legs.
• If the pain interferes with your daily activities or sleep.
• If you have difficulty walking or standing for long periods.

What to Ask the Doctor

• What is causing my symptoms?
• What treatment options are available?
• How long will it take to recover?
• What are the risks and benefits of surgery if needed?
• Are there specific exercises I should do or avoid?

Home Remedies for Mild Symptoms

• Exercise: Gentle exercises can help strengthen back muscles and reduce pain.
• Stretching: Regular stretching can relieve muscle tension and improve flexibility.
• Pain relief: Over-the-counter pain relievers like ibuprofen or acetaminophen can help with pain.
• Proper posture: Maintain good posture to reduce pressure on the spine.
• Heat or ice therapy: Applying heat or ice can reduce pain and swelling.

Understanding spondylolisthesis can help you know when to seek medical advice and what questions to ask your doctor. Early detection and treatment can help manage the condition, prevent worsening, and improve your quality of life.

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Lumbar Spondylolisthesis

What is lumbar spondylolisthesis.

Lumbar spondylolisthesis occurs when a vertebra in the lower spine shifts out of place and onto the bone below it, often because of weakness or a stress fracture. It is more common in young athletes and older adults who suffer from arthritis. It can cause pain, stiffness, and muscle spasms.

Non-surgical options are often successful in relieving the symptoms, but sometimes surgery is needed. Spinal fusion is one of the more common options to relieve lumbar spondylolisthesis.

What You Can Expect at UTHealth Neurosciences

The UTHealth Neurosciences Spine Center brings together a multidisciplinary team of board-certified, fellowship-trained neurosurgeons, neurologists, researchers, and pain management specialists who work together to help provide relief for even the most complex problems. Your team will share insights, leading to better treatment decisions and outcomes.

We first investigate nonsurgical treatment options, including medical management, pain management, physical therapy, rehabilitation, and watchful waiting. When surgery is needed, our neurosurgeons routinely employ innovative minimally invasive techniques. Throughout the treatment process, we will work closely with the doctor who referred you to ensure a smooth transition back to your regular care. While you are with us, you will receive expert care, excellent communication, and genuine compassion.

Causes of Lumbar Spondylolisthesis

Usually lumbar spondylolisthesis results from spondylolysis, a crack or stress fracture in the pars interarticularis, the thin portion of the vertebra that connects the upper and lower facet joints.

In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. The injury is most commonly seen in children and adolescents who participate in sports that involve repeated stress on the lower back, including football, weightlifting, and gymnastics. Repetitive stress can cause a fracture on one or both sides of the vertebra. It also may be caused by a birth defect in the lumbar spine or an acute injury.

In adults, the most common cause is abnormal wear on the cartilage and bones, such as through arthritis. The condition affects people over the age of 50 and is more common in women than in men. Bone disease and fractures also can cause lumbar spondylolisthesis. Genetics may play a role, as some people are born with thinner-than-normal vertebral bone.

Early Signs of Lumbar Spondylolisthesis and Diagnosis

Symptoms of spondylolisthesis may vary from none to mild to severe. The most common symptom is low back pain.

The condition can cause lordosis (swayback). In later stages it may result in kyphosis (roundback) as the upper spine falls off the lower spine. General symptoms are lower back pain; muscle tightness in the hamstrings; pain, numbness, or tingling in the thighs and buttocks; tenderness in the area of the vertebra that is out of place; weakness in the legs; and difficulty standing and walking.

Our spine specialists diagnose spondylolisthesis by taking a thorough medical history, conducting a physical exam, and asking you to undergo imaging studies that may include X-ray, CT scan, or MRI scan.

Treatments for Lumbar Spondylolisthesis

Your doctor may use X-rays, CT scans, or an MRI, as well as a physical exam, to determine the severity of your condition. Initial treatment may include rest, physical therapy, nonsteroidal anti-inflammatory drugs, oral corticosteroids, and/or bracing that limits movement of the spine and allows the fracture to heal.

Surgery may be recommended for patients who have severe or high-grade slippage of the vertebra, such as when more than 50% of the fractured vertebra slips forward on the vertebra below it. The procedures most often recommended for people with lumbar spondylolisthesis are spinal fusion or a laminectomy to decompress the nerves.

Anatomy of the neck and spine

The spine is divided into the following regions:

• The cervical region (vertebrae C1-C7) encompasses the first seven vertebrae under the skull. Their main function is to support the weight of the head, which averages 10 pounds. The cervical vertebrae are more mobile than other areas, with the atlas and axis vertebra facilitating a wide range of motion in the neck. Openings in these vertebrae allow arteries to carry blood to the brain and permit the spinal cord to pass through. They are the thinnest and most delicate vertebrae.
• The thoracic region (vertebrae T1-T12) is composed of 12 small bones in the upper chest. Thoracic vertebrae are the only ones that support the ribs. Muscle tension from poor posture, arthritis, and osteoporosis are common sources of pain in this region.
• The lumbar region (vertebrae L1-L5) features vertebrae that are much larger to absorb the stress of lifting and carrying heavy objects. Injuries to the lumbar region can result in some loss of function in the hips, legs, and bladder control.
• The sacral region (vertebrae S1-S5) includes a large bone at the bottom of the spine. The sacrum is triangular-shaped and consists of five fused bones that protect the pelvic organs.

Spine Disease and Back Pain

Arthrodesis Artificial Disc Replacement Cauda Equina Syndrome  Cervical corpectomy Cervical disc disease Cervical discectomy and fusion Cervical herniated disc Cervical laminectomy Cervical laminoforaminotomy Cervical radiculopathy Cervical spondylosis (degeneration) Cervical stenosis Cervical spinal cord injury Degenerative Disc Disease Foraminectomy Foraminotomy Herniated discs Injections for Pain Kyphoplasty Laminoplasty Lumbar herniated disc Lumbar laminectomy Lumbar laminotomy Lumbar radiculopathy Lumbar spondylolisthesis Lumbar spondylosis (degeneration) Lumbar stenosis

Neck Pain Peripheral Nerve Disorders Radiofrequency Ablation Scoliosis Spinal cord syrinxes Spinal deformities Spinal injuries Spinal fractures and instability Spinal Cord Stimulator Trial and Implantation Spinal Fusion Spinal Radiosurgery Spine and spinal cord tumors Spondylolisthesis Stenosis Tethered spinal cord Thoracic herniated disc Thoracic spinal cord injury Transforaminal Lumbar Interbody Fusion Vertebroplasty

At UTHealth Neurosciences, we offer patients access to specialized neurological care at clinics across the greater Houston area. To ask us a question, schedule an appointment, or learn more about us, please call (713) 486-8100, or click below to send us a message. In the event of an emergency, call 911 or go to the nearest Emergency Room.

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• Degenerative Spondylolisthesis

By: Marco Funiciello, DO, Physiatrist

Spondylolisthesis is Latin for "slipped vertebral body," and is diagnosed when one vertebra slips forward over the one below. 

Degenerative spondylolisthesis may occur as part of the normal aging process of the spine. It may alter normal spinal alignment. 1 Akkawi I, Zmerly H. Degenerative Spondylolisthesis: A Narrative Review. Acta Biomed. 2022 Jan 19;92(6):e2021313. doi: 10.23750/abm.v92i6.10526. PMID: 35075090; PMCID: PMC8823594. , 2 Cushnie D, Johnstone R, Urquhart JC, Gurr KR, Bailey SI, Bailey CS. Quality of Life and Slip Progression in Degenerative Spondylolisthesis Treated Nonoperatively. Spine (Phila Pa 1976). 2018;43(10):E574-E579. doi:10.1097/BRS.0000000000002429

Degenerative spondylolisthesis typically occurs in the lumbar spine (low back). In most cases, the L4-L5 spinal segment is affected, followed by the L3-L4 and L5-S1 spinal segments. 1 Akkawi I, Zmerly H. Degenerative Spondylolisthesis: A Narrative Review. Acta Biomed. 2022 Jan 19;92(6):e2021313. doi: 10.23750/abm.v92i6.10526. PMID: 35075090; PMCID: PMC8823594.

Show Transcript

In This Article:

• Degenerative Spondylolisthesis Symptoms
• Degenerative Spondylolisthesis Treatment
• Surgery for Degenerative Spondylolisthesis

Degenerative Spondylolisthesis Video

4 Most Common Causes of Degenerative Spondylolisthesis

Age-related changes, like facet joint arthritis, may lead to degenerative spondylolisthesis.

Degenerative spondylolisthesis is attributed to age-related changes that can disrupt spinal alignment. 

The specific changes include 1 Akkawi I, Zmerly H. Degenerative Spondylolisthesis: A Narrative Review. Acta Biomed. 2022 Jan 19;92(6):e2021313. doi: 10.23750/abm.v92i6.10526. PMID: 35075090; PMCID: PMC8823594. , 3 García-Ramos CL, Valenzuela-González J, Baeza-Álvarez VB, Rosales-Olivarez LM, Alpizar-Aguirre A, Reyes-Sánchez A. Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 2020;34(5):324-328. doi:10.35366/97997 :

• Degeneration of the spinal discs
• Loss of resilience and strength in the ligaments responsible for spinal stability
• Osteoarthritis of the facet joints that connect the vertebrae, resulting in less support for the spinal segment
• Inadequate muscle stabilization

Less commonly, pregnancy and participating in sports may accelerate degenerative changes in the spine, leading to spondylolisthesis. 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001

How Degenerative Spondylolisthesis Develops: The Role of the 3-Joint Complex

Spondylolisthesis occurs as a result of spinal motion segment degeneration.

Spondylolisthesis develops due to degeneration at a spinal motion segment, which comprises a 3-joint complex. 5 Bernard F, Mazerand E, Gallet C, Troude L, Fuentes S. History of degenerative spondylolisthesis: From anatomical description to surgical management. Neurochirurgie. 2019;65(2-3):75-82. doi:10.1016/j.neuchi.2019.03.006 This 3-joint complex includes:

• A disc in the front, which acts as a shock absorber between adjacent vertebrae (bones that make up the spinal column)
• A pair of facet joints in the back, which allow limited motion. The facet joints may bear weight and limit spinal forward bending (flexion), backward bending (extension), rotation, and side-to-side motion.

Aging-related degeneration of the facets and discs may make them less able to bear loads, resulting in vertebral slippage in load-bearing segments of the lower spine. 3 García-Ramos CL, Valenzuela-González J, Baeza-Álvarez VB, Rosales-Olivarez LM, Alpizar-Aguirre A, Reyes-Sánchez A. Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 2020;34(5):324-328. doi:10.35366/97997

2 Types of Vertebral Slippage in Degenerative Spondylolisthesis

Vertebral slippage can occur symmetrically when both facets are equally affected.

Vertebral slippage in degenerative spondylolisthesis can happen in two ways 3 García-Ramos CL, Valenzuela-González J, Baeza-Álvarez VB, Rosales-Olivarez LM, Alpizar-Aguirre A, Reyes-Sánchez A. Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 2020;34(5):324-328. doi:10.35366/97997 :

• Symmetrically, if both facets are equally affected and degenerated. In this case, the vertebra slips forward horizontally in a symmetrical manner.
• Asymmetrically, where one facet is more degenerated than the other, causing the slippage to occur asymmetrically, which usually results in rotation. 

In either case, the spinal disc also slips forward along with the vertebra. 3 García-Ramos CL, Valenzuela-González J, Baeza-Álvarez VB, Rosales-Olivarez LM, Alpizar-Aguirre A, Reyes-Sánchez A. Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 2020;34(5):324-328. doi:10.35366/97997

Degenerative spondylolisthesis commonly occurs in the low back and is relatively rare in other parts of the spine. The condition may occur in the neck (cervical spondylolisthesis) due to degenerative changes in the cervical facet joints.

How Degenerative Spondylolisthesis Causes Pain

In degenerative spondylolisthesis, pain occurs due to neural compression from spinal stenosis.

Degenerative spondylolisthesis causes pain through one or more of the following processes 3 García-Ramos CL, Valenzuela-González J, Baeza-Álvarez VB, Rosales-Olivarez LM, Alpizar-Aguirre A, Reyes-Sánchez A. Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 2020;34(5):324-328. doi:10.35366/97997 :

• Joint pain: Degeneration of facet joints causes inflammation of the cartilaginous facet joint lining
• Soft tissue pain: Tension within the capsule and ligaments that surround the facet joints as the vertebra slips
• Muscle pain: Spasm of the muscles that support the affected spinal segment
• Stenosis pain: Narrowing of the central canal ( spinal stenosis ) and/or intervertebral foramen (foraminal stenosis) causing compression of the neural elements

These processes can result in some combination of localized back pain, sciatica , lumbar radiculopathy , and/or neurogenic claudication. 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001

Hallmark Symptoms and Signs of Degenerative Spondylolisthesis

Back pain radiating to the buttocks is a common symptom of degenerative spondylolisthesis.

There’s a wide variation of spondylolisthesis symptoms. In general, the typical symptoms include some combination of 6 Matz PG, Meagher RJ, Lamer T, et al. North American Spine Society. Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2nd ed; 2016. :

• Occasional back pain that comes and goes with increased activity
• Chronic low back pain 
• Back pain with or without buttock, thigh, and/or leg pain (sciatica) 
• Neurogenic claudication (leg pain while walking or standing for variable periods of time)
• Pain while bending backward (extension)

Less commonly, muscle spasm, tightness and a burning sensation, or sense of weakness may be felt in the lower back and/or thigh. 6 Matz PG, Meagher RJ, Lamer T, et al. North American Spine Society. Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2nd ed; 2016.

The Grades of Degenerative Spondylolisthesis

A grading system, also called Meyerding’s classification, is used to measure the degree of slippage in spondylolisthesis. The grading relates to the amount the upper vertebral body slips forward on the lower vertebral body.

The amount of vertebral slip is measured via a side-view x-ray and then graded on a scale of 1 to 4. 7 Tenny S, Gillis CC. Spondylolisthesis. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430767/ In addition, flexion and extension x-rays (x-rays taken in the neutral, forward- and backward-bent positions) are performed to determine if there is any motion of one vertebra upon the other called translation or rotation.

In most cases, the degree of slippage is low and rarely exceeds grade 2. 1 Akkawi I, Zmerly H. Degenerative Spondylolisthesis: A Narrative Review. Acta Biomed. 2022 Jan 19;92(6):e2021313. doi: 10.23750/abm.v92i6.10526. PMID: 35075090; PMCID: PMC8823594. , 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001

The Course of Degenerative Spondylolisthesis

The degree of degenerative spondylolisthesis may increase over time.

The body naturally employs several mechanisms to protect against further slippage, including:

• Formation of bone spurs (a normal response to changes in the amount of stress placed on bone) 
• Hardening of bone (sclerosis)
• Deposition of calcium in the ligaments (ossification)

Because these mechanisms are relatively effective, the degree of degenerative spondylolisthesis is typically small. 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001

For most people, degenerative spondylolisthesis is generally asymptomatic or causes mild symptoms that can be managed with nonsurgical treatments. 2 Cushnie D, Johnstone R, Urquhart JC, Gurr KR, Bailey SI, Bailey CS. Quality of Life and Slip Progression in Degenerative Spondylolisthesis Treated Nonoperatively. Spine (Phila Pa 1976). 2018;43(10):E574-E579. doi:10.1097/BRS.0000000000002429

How long degenerative spondylolisthesis takes to heal

The most common case is a low-grade spondylolisthesis without neurological symptoms (symptoms that radiate to the leg, or sciatica), and these typically get better within 1 year of using targeted nonsurgical treatment. 8 Samuel AM, Moore HG, Cunningham ME. Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence. Curr Rev Musculoskelet Med. 2017 Dec;10(4):521-529. doi: 10.1007/s12178-017-9442-3. PMID: 28994028; PMCID: PMC5685964.

Higher grades of vertebral slippage are rare and may sometimes need surgical treatment.

What makes degenerative spondylolisthesis worse

Occupations or activities that require repetitive forward bending (such as a nanny, a parent who carries small children, or someone who is involved in manual labor) may accelerate the progression of the slip over time. 6 Matz PG, Meagher RJ, Lamer T, et al. North American Spine Society. Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2nd ed; 2016.

Who may need surgery for degenerative spondylolisthesis

Surgery for degenerative spondylolisthesis is rare. In general, patients with neurological symptoms, such as sensory changes or muscle weakness, who find little or no relief from nonsurgical treatments are more likely to benefit from surgery. 6 Matz PG, Meagher RJ, Lamer T, et al. North American Spine Society. Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2nd ed; 2016.

Research indicates that 10% to 15% of individuals seeking treatment for degenerative spondylolisthesis eventually opt for surgical treatment. 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001

Degenerative Spondylolisthesis vs Isthmic Spondylolisthesis

Isthmic and degenerative spondylolisthesis are distinct conditions with similar symptoms.

It is important to note that a similar type of vertebral slip can also occur due to a structural defect in the small piece of bone, the pars interarticularis, which connects the two vertebrae on the back of the spine. This condition is called isthmic spondylolisthesis .

See Isthmic Spondylolisthesis Symptoms

Spondylolisthesis may also occur due to congenital, traumatic, or pathologic (related to bone disease) causes, but isthmic and degenerative causes are more common. 9 Jhaveri MD, Salzman KL, Ross JS, Moore KR, Osborn AG, Chang Yueh Ho. ExpertDDx : Brain and Spine. Philadelphia Elsevier; 2018.

While the symptoms of both these conditions may overlap, the underlying causes and risk factors are distinct. 

When Degenerative Spondylolisthesis Is Serious

Degenerative spondylolisthesis is typically not a serious condition. The condition can become a medical emergency or require urgent care if it progresses to an extent that crucial spinal nerves are involved, or the stability of the affected segment is compromised. 

In such cases, it is important to be able to identify the warning signs and symptoms of degenerative spondylolisthesis to ensure prompt medical attention and appropriate treatment. 

Serious symptoms and signs are described below. 

Progressive pain and weakness

It is important to seek immediate medical attention if there is persistent or worsening pain in the lower back that interferes with daily activities. The pain may radiate into the buttocks, thighs, or legs and may be accompanied by numbness, tingling, or muscle weakness. Additionally, any concerning progression of neurological symptoms, such as muscle weakness or loss of sensation should be evaluated by a physician urgently. 

Changes in bowel or bladder function

Any changes in bowel or bladder function, such as difficulty controlling or emptying the bladder, bowel incontinence, or numbness in the genital area, is a medical emergency. These symptoms may indicate severe progression of spondylolisthesis leading to a serious condition known as cauda equina syndrome , which requires urgent surgical intervention. 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001 , 7 Tenny S, Gillis CC. Spondylolisthesis. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430767/

See Cauda Equina Syndrome Symptoms

Significant loss of function or mobility

Functional disabilities, such as difficulty walking, maintaining balance, or performing basic movements, may indicate a more advanced stage of the condition that requires prompt medical intervention.

Any of these issues are potentially serious and warrant immediate medical attention.

See When Back Pain May Be a Medical Emergency

A specialist with advanced training in spine care can help evaluate and diagnose degenerative spondylolisthesis. Receiving personalized treatment at an early stage of the condition can help manage pain, prevent further complications, and enhance the overall quality of life for individuals with degenerative spondylolisthesis.

• 1 Akkawi I, Zmerly H. Degenerative Spondylolisthesis: A Narrative Review. Acta Biomed. 2022 Jan 19;92(6):e2021313. doi: 10.23750/abm.v92i6.10526. PMID: 35075090; PMCID: PMC8823594.
• 2 Cushnie D, Johnstone R, Urquhart JC, Gurr KR, Bailey SI, Bailey CS. Quality of Life and Slip Progression in Degenerative Spondylolisthesis Treated Nonoperatively. Spine (Phila Pa 1976). 2018;43(10):E574-E579. doi:10.1097/BRS.0000000000002429
• 3 García-Ramos CL, Valenzuela-González J, Baeza-Álvarez VB, Rosales-Olivarez LM, Alpizar-Aguirre A, Reyes-Sánchez A. Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 2020;34(5):324-328. doi:10.35366/97997
• 4 Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat. 2016;11:39-52. Published 2016 Dec 1. doi:10.1016/j.jot.2016.11.001
• 5 Bernard F, Mazerand E, Gallet C, Troude L, Fuentes S. History of degenerative spondylolisthesis: From anatomical description to surgical management. Neurochirurgie. 2019;65(2-3):75-82. doi:10.1016/j.neuchi.2019.03.006
• 6 Matz PG, Meagher RJ, Lamer T, et al. North American Spine Society. Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2nd ed; 2016.
• 7 Tenny S, Gillis CC. Spondylolisthesis. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430767/
• 8 Samuel AM, Moore HG, Cunningham ME. Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence. Curr Rev Musculoskelet Med. 2017 Dec;10(4):521-529. doi: 10.1007/s12178-017-9442-3. PMID: 28994028; PMCID: PMC5685964.
• 9 Jhaveri MD, Salzman KL, Ross JS, Moore KR, Osborn AG, Chang Yueh Ho. ExpertDDx : Brain and Spine. Philadelphia Elsevier; 2018.

Dr. Marco Funiciello is a physiatrist with Princeton Spine and Joint Center. He has a decade of clinical experience caring for spine and muscle conditions with non-surgical treatments.

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Spondylolisthesis and spondylolysis

Peer reviewed by Dr Laurence Knott Last updated by Dr Colin Tidy, MRCGP Last updated 20 Nov 2021

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Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the  Cervical spondylosis  article more useful, or one of our other  health articles .

In this article :

What is spondylolisthesis, spondylolisthesis vs spondylolysis.

• Who gets spondylolisthesis and spondylolysis? (Epidemiology)

Spondylolisthesis causes (aetiology)

• Types of spondylolisthesis
• Presentation

Differential diagnosis

Investigations.

• Spondylolisthesis treatment and management

Complications of surgical repair

Spondylolisthesis prognosis.

Continue reading below

Spondylolisthesis is the movement of one vertebra relative to the others in either the anterior or posterior direction due to instability. Degenerative spondylolisthesis is a common pathology, often causing lumbar canal stenosis 1 .

Anatomy of the vertebrae

The vertebrae can be divided into three portions:

Centrum - involved in weight bearing. This is the body of the vertebra and is formed of cancellous bone.

Dorsal arch - surrounds and protects the spinal cord. It carries the upper and lower facet joints of each vertebra which articulate with the facet joints of the vertebra above and below, respectively. The part of the vertebral arch between them is the thinnest part and is called the pars interarticularis, or the isthmus.

Posterior aspect - protrudes and can be palpated on the lower back.

Lumbar vertebra 1 inferior surface

Lumbar vertebra 1 anterior surface

Images by Anatomography, via Wikimedia Commons . Click here to see a lumbar vertebra 1 close-up superior surface animation.

Spondylolysis and spondylolisthesis are separate conditions, although spondylolysis often precedes spondylolisthesis.

Spondylolysis is a bony defect (commonly due to a stress fracture but it may be a congenital defect) in the pars interarticularis of the vertebral arch, separating the dorsum of the vertebra from the centrum. It may occur unilaterally or bilaterally. It most commonly affects the fifth lumbar vertebra and may cause back pain.

Spondylolisthesis refers to the anterior slippage of one vertebra over another (or the fifth vertebra over the sacrum). There are five forms:

Isthmic : the most common form, usually acquired in adolescence as a consequence of spondylolysis but often unnoticed until adulthood.

Degenerative : developing in older adults as a result of facet joint osteoarthritis and bone remodelling.

Traumatic (rare): resulting from fractures of the neural arch.

Pathologic : from metastases or metabolic bone disease.

Dysplastic : (rare): congenital, resulting from malformation of the pars.

Spondylosis is a general term for degenerative osteoarthritic changes in the spine. It involves dehydration of the intervertebral discs with consequent narrowing of the intervertebral spaces. There may be changes in the facet joints with osteophyte formation and this may put pressure on the nerve roots, causing motor and sensory disturbance.

Who gets spondylolisthesis and spondylolysis? (Epidemiology) 2

Spondylolysis is a common diagnosis with a high prevalence in children and adolescents complaining of low back pain.

There is an increased risk of spondylolysis in young athletes like gymnasts, presumably due to impact-related stress fractures . However most cases are low-grade. At-risk activities include gymnastics, diving, tennis, cricket, weightlifting, football and rugby.

Isthmic spondylolisthesis affects around 5% of the population but is more common in young athletes. 60-80% of people with spondylolysis have associated spondylolisthesis 3 4 .

The majority of cases of spondylolysis and spondylolisthesis affect L5 and most of the remainder affect L4.

Degenerative spondylolisthesis is more common in older people, particularly women.

Traumatic, metastatic and dysplastic spondylolistheses are relatively rare.

Many cases of spondylolisthesis are asymptomatic.

Spondylolisthesis commonly occurs due to a fracture or defect in the pars interarticularis, the narrowest part of the posterior vertebral arch between the upper and lower facet joints. When this is breached, the upper facet joint may no longer be able to hold the vertebra in place against the downward force of body weight and forward/downward slippage occurs.

Risk factors that increase the risk of spondylolysis developing into spondylolisthesis include 5 :

Female gender.

Presence of spina bifida or spina bifida occulta .

Vertebral wedging.

Hyperlordosis.

Positive family history.

Certain high-impact sports, as evidenced by increased rates in athletes and gymnasts 3 .

Types of spondylolisthesis 2

Stable or unstable.

Asymptomatic or symptomatic.

Graded according to degree of slippage; the Meyerding classification is based on the ratio of the overhanging part of the superior vertical body to the anterio-posterior length of the inferior vertebral body:

Grade I: 0-25%.

Grade II: 26-50%.

Grade III: 51-75%.

Grade IV: 76-100%.

Grade V (spondyloptosis): >100%.

Graded according to type; the Wiltse classification (1976):

Type I: dysplastic (congenital).

Type II: isthmic: secondary to a lesion involving the pars interarticularis:

Subtype A: secondary to stress fracture.

Subtype B: result of multiple healed stress fractures resulting in an elongated pars.

Subtype C: acute pars fracture (rare).

Type III: degenerative.

Type IV: post-traumatic: fracture in a region other than the pars.

Type V: pathological: diffuse or local disease.

Type VI: iatrogenic.

Presentation 4

Spondylolysis symptoms.

Most cases of spondylolysis are asymptomatic and identified incidentally.

It may present with low back pain provoked by lumbar extension, paraspinal spasm and tight hamstrings.

It frequently does not show on X-ray. It is important to consider it in the differential diagnosis of back pain, as its identification can prevent progression and avoid the potential need for aggressive intervention.

Spondylolisthesis symptoms

Presentation varies slightly by type although common spondylolisthesis symptoms include exercise-related back pain, radiating to the lower thighs, which tends to be eased by rest, particularly in positions of spinal flexion.

Isthmic spondylolisthesis

Most patients are asymptomatic, even with progressing slippage.

Symptoms often begin around the adolescent growth spurt.

Back pain - worse with activity (particularly back extension) - this may come on acutely or insidiously.

Pain may flare with sudden or trivial activities and is relieved by resting.

Pain is worse with higher grades of disease.

Pain may radiate to buttocks or thighs

There are usually no neurological features with lower grades of slippage but radicular pain becomes common with larger slips. Pain below the knee due to nerve root compression or disc herniation would suggest more severe slippage. High degrees of spondylolisthesis may present with neurogenic claudication or even cauda equina impingement.

Tightened hamstrings are very common

There may be enhanced lordosis and a waddling gait with shortened step length.

There may be gluteal muscular wasting.

Degenerative spondylolisthesis

Pain is aching in nature and insidious in onset.

Pain is in the low back and posterior thighs.

Neurogenic claudication may be present with lower-extremity symptoms worsening with exercise.

Symptoms are often chronic and progressive, sometimes with periods of remission.

If lumbar stenosis is also present, reflexes may be diminished.

Dysplastic spondylolisthesis

Presentation and physical findings are similar to isthmic spondylolisthesis but with a greater likelihood of neurological compromise.

Traumatic spondylolisthesis

Patients will have experienced acute trauma and are likely to have significant pain.

Severe slips may cause cauda equina compression with bladder and bowel dysfunction, radicular symptoms or neurogenic claudication.

Physical findings are as for the other types.

Pathological spondylolisthesis

Symptoms may be insidious in onset and associated with radicular pain.

Other causes of back pain need to be ruled out - eg:

Osteoarthritis .

Ankylosing spondylitis .

Mechanical lower back pain .

Spinal cord lesion.

Multiple myeloma .

Vertebral compression fracture .

Lumbar disc prolapse.

Discitis/other spinal disc problems .

Blood tests - looking for infection, myeloma, hypercalcaemia/hypocalcaemia.

Lateral spinal X-rays - will show spondylolisthesis. These are best performed in the position of maximal pain.

Oblique spinal X-rays - may (but will often not) detect spondylolysis.

Radionuclide scintigraphy and CT may help in cases of spondylolysis in distinguishing progressing lesions of the pars from stable lesions.

MRI is often performed perioperatively to look at relationships between the bony and neurological structures in the compromised area.

Spondylolisthesis treatment and management 1 2 4

The goal of treatment is to relieve pain, stabilise the spinal segment and stop or reverse the slippage. Patients need to be evaluated for the presence of instability, as if there is an unstable segment early surgery will be needed.

Depending on the severity of the spondylolysis and symptoms associated it may be treated either conservatively or surgically, both of which have shown significant success.

Conservative treatments such as bracing and decreased activity have been shown to be most effective with patients who have early diagnosis and treatment. Low-intensity pulsed ultrasound in addition to conservative treatment appears to achieve a higher rate of bony union. Surgery may be required if conservative treatment, for at least six months, failed to give sustained pain relief for the activities of daily living.

For degenerative spondylolisthesis, surgery is indicated mainly for perceived functional impairment. Improvement in neurological symptoms is one of the main treatment objectives. For this, it is useful to perform radicular decompression. The most frequent technique is direct posterior decompression.

Conservative treatment

Complete bed rest for 2-3 days can be helpful in relieving pain, particularly in spondylolysis, although longer periods are likely to be counterproductive. Patients should try to sleep on their side as much as possible, with a pillow between the knees.

Activity modification to prevent further injury. This may mean avoidance of activities if there is >25% slippage.

Analgesia - eg, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), codeine phosphate.

Steroid and local anaesthetic injections are sometimes used around compressed nerve roots or even into the fracture area of the pars for diagnostic purposes.

Bracing: a brace or corset may be recommended for a pars interarticularis fracture which is likely to heal. Bracing with exercise may be beneficial for patients with mild or even more severe degrees of slippage.

Physiotherapy: this includes massage, ultrasound, bracing, mobilisation, biomechanical correction, hydrotherapy, exercises for flexibility, strength and core stability and a gradual return to activity programme.

More than 80% of children treated non-surgically will have full resolution of symptoms.

A meta-analysis of observation studies suggested that around 80% of all patients treated non-operatively would have a successful clinical outcome after one year. Lesions diagnosed at the acute stage and unilateral lesions were the best subgroups 6 .

Surgical treatment

If there is evidence of progression or if conservative measures are ineffective then surgical therapy may be offered. This depends also on degree and aetiology.

Surgical intervention involves a prolonged rehabilitation period so it is generally not considered until conservative treatments have failed. An exception would be in the case of significant instability or neurological compromise and in high-grade slips.

Surgical therapy involves fusing the affected vertebra with a neighbouring normally aligned vertebra (both anteriorly and posteriorly). The intervertebral disc is usually also removed, as it is inevitably damaged. The slipped vertebra may be realigned.

Whilst most surgeons agree that decompression of the nerves is of benefit to patients, the benefit of realigning slipped vertebrae is uncertain. For example, when the spondylolisthesis is very gradual in onset, or in cases of congenital spondylolisthesis, compensatory changes in the spine and musculature occur so that realignment may increase the possibility of further injury.

There is good evidence that surgical treatment of symptomatic spondylolisthesis is significantly superior to non-surgical management in the presence of 7 :

Significant neurological deficit.

Failed response to conservative therapy.

Instability with neurological symptoms.

Degree of subluxation of III or more.

Unremitting pain affecting quality of life.

A large systematic review concluded that reduction of displacement carried benefits over fusion alone, although a large retrospective review showed high complication rates, particularly for older patients with more severe disease 8 9 10 11 .

Fusion techniques can be associated with neurological complications in older patients with degenerative spondylolisthesis, but in adolescent patients outcomes are good 9 .

Surgery is commonly complicated by pseudoarthrosis (non-union) which may result in chronic pain years down the line.

In the case of spondylolysis, if surgery is offered it would involve pinning the defect. However, most cases are managed conservatively.

Implant failure.

Pseudoarthrosis (failure of bone healing leading to a 'false joint').

Poor alignment of the fusion.

Neurological damage: foot drop, spinal cord compression . Chronic nerve injury/inflammation: neuropathic pain can persist in the face of apparent surgical success, possibly due to permanent changes in the nerves or a deregulation of pain control mechanisms.

Spondylolisthesis is generally a benign condition; however, it runs a chronic course and is therefore a cause of much morbidity and disability. In degenerative spondylolisthesis this will relate in part to the progress and prognosis of the underlying changes.

Dr Mary Lowth is an author or the original author of this leaflet.

Further reading and references

• Guigui P, Ferrero E ; Surgical treatment of degenerative spondylolisthesis. Orthop Traumatol Surg Res. 2017 Feb;103(1S):S11-S20. doi: 10.1016/j.otsr.2016.06.022. Epub 2016 Dec 30.
• Gagnet P, Kern K, Andrews K, et al ; Spondylolysis and spondylolisthesis: A review of the literature. J Orthop. 2018 Mar 17;15(2):404-407. doi: 10.1016/j.jor.2018.03.008. eCollection 2018 Jun.
• Toueg CW, Mac-Thiong JM, Grimard G, et al ; Prevalence of spondylolisthesis in a population of gymnasts. Stud Health Technol Inform. 2010;158:132-7.
• Syrmou E, Tsitsopoulos PP, Marinopoulos D, et al ; Spondylolysis: a review and reappraisal. Hippokratia. 2010 Jan;14(1):17-21.
• Sadiq S, Meir A, Hughes SP ; Surgical management of spondylolisthesis overview of literature. Neurol India. 2005 Dec;53(4):506-11.
• Klein G, Mehlman CT, McCarty M ; Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop. 2009 Mar;29(2):146-56. doi: 10.1097/BPO.0b013e3181977fc5.
• Alfieri A, Gazzeri R, Prell J, et al ; The current management of lumbar spondylolisthesis. J Neurosurg Sci. 2013 Jun;57(2):103-13.
• Weinstein JN, Lurie JD, Tosteson TD, et al ; Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. doi: 10.2106/JBJS.H.00913.
• Sansur CA, Reames DL, Smith JS, et al ; Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis. J Neurosurg Spine. 2010 Nov;13(5):589-93. doi: 10.3171/2010.5.SPINE09529.
• Kasliwal MK, Smith JS, Kanter A, et al ; Management of high-grade spondylolisthesis. Neurosurg Clin N Am. 2013 Apr;24(2):275-91. doi: 10.1016/j.nec.2012.12.002. Epub 2013 Feb 21.
• Longo UG, Loppini M, Romeo G, et al ; Evidence-based surgical management of spondylolisthesis: reduction or arthrodesis in situ. J Bone Joint Surg Am. 2014 Jan 1;96(1):53-8. doi: 10.2106/JBJS.L.01012.

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Spondylolisthesis

• Medical Author: William C. Shiel Jr., MD, FACP, FACR
• Medical Editor: Catherine Burt Driver, MD

Spondylolisthesis Facts

What is spondylolisthesis, what are the types of spondylolisthesis, what causes spondylolisthesis, what are spondylolisthesis symptoms and signs, how do doctors diagnose and grade spondylolisthesis, what are treatments and home remedies for spondylolisthesis, what is the prognosis for spondylolisthesis, is it possible to prevent spondylolisthesis.

• Doctor's Notes on Spondylolisthesis Symptoms

• Slippage of one spinal vertebra over another is spondylolisthesis .
• Spondylolisthesis occurs in different grades and can be either congenital or acquired.
• Spondylolisthesis can cause symptoms by irritation of nervous tissue, either within the nearby spinal cord or of the adjacent spinal nerves.
• Radiology imaging is used to confirm the diagnosis of spondylolisthesis.
• Treatments of spondylolisthesis depend on the severity and persistence of symptoms.

Spondylolisthesis is slippage of one spinal vertebra over another. This most commonly occurs in the lower back in the lumbar spine.

Spondylolisthesis occurs in different degrees based on the amount of slippage of one vertebra on another. These degrees of slippage are medically termed grades . Accordingly, grade I is 0%-25%, grade II is 25%-50%, grade III is 50%-75%, grade IV is 75%-100%, and grade V is >100%.  See the below table.

Spondylolisthesis can also be classified as congenital (present at birth) as a result of inherited factors or acquired as a result of injury or degeneration.

In children, spondylolisthesis is often related to a defect in, or injury to, a portion of the lumbar vertebra that connects to the spinous process (called the pars interarticularis). Medical professionals refer to the "disconnection" of this bone (pars defect) as spondylolysis and leads to slippage of the entire body of the vertebra, or spondylolisthesis.

In adults, spondylolysis can be degenerative and lead to spondylolisthesis. Degeneration of the cervical or lumbar disc can cause spondylolisthesis in adults. This, too, can lead to spondylolisthesis of the vertebrae above and below the worn out disc.

Spondylolisthesis commonly causes no symptoms or signs. When spondylolisthesis causes symptoms, they are typically a result of irritation of nervous tissue, either within the nearby spinal cord or of the adjacent spinal nerves. Such symptoms include low back pain , as well as pain, numbness, tingling, and weakness of one or both lower extremities. This can lead to leg pain , difficulty walking , incontinence , insomnia , and inability to function. Spondylolisthesis can lead to spinal stenosis with pain in the extremities with movement.

Spondylolisthesis is diagnosed by the history of chronic pain , numbness, tingling, and weakness of the extremities. Physicians confirm and visualize it with X-ray imaging. Health care professionals can also visualize it with CAT scan or MRI scan imaging.

Treatments of spondylolisthesis depend on the severity and persistence of symptoms. These include heat, analgesics, physical therapy exercises, braces , cortisone (steroid) injections, and orthopedic surgery procedures.

Home remedies include heat and/or ice applications, rest, avoiding reinjury, lumbar exercises, and acetaminophen (Tylenol), ibuprofen (Motrin, Advil), or naproxen (Aleve).

The prognosis for spondylolisthesis depends on the cause, severity, and overall condition of the patient involved. Most spondylolisthesis can respond to conservative treatments. Patients with persisting symptoms, or with severe traumatic spondylolisthesis, may require surgery.

The only prevention for spondylolisthesis is to prevent spinal injury.

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Causes of Middle Back Pain on the Left Side, Plus Treatment Options

• Pain Location
• Relieving Pain
• When to See a Provider
• Preventing Pain

Middle back pain on your left side can take many diverse forms. It can occur as a sudden sharp stitch or as a throbbing, burning, or stabbing pain that worsens with each day.

This type of pain can occur as a result of many causes, including common injuries such as muscle sprains and strains . It can also happen when you become injured from a traumatic event. While less likely, left-sided middle back pain can also be caused by severe health problems such as a heart attack or cancer.

Iuliia Burmistrova / Getty Images

Left-Sided Middle Back Pain Causes

Common causes.

• Herniated disc : A herniated disc , also known as a slipped or ruptured disc, is a disc that bulges out from between the vertebrae (the 26 bones that make up your spine). In this position, the disc may exert pressure on your spinal nerves, causing middle back pain.
• Myofascial pain : Myofascial pain affects the fascia , the connective tissue in and between the muscles in your back. It is characterized by knotty "trigger points" that hurt when pressed. This type of middle back pain is typically a deep, aching, or throbbing muscle pain that lasts a long time and may worsen.
• Osteoarthritis : Osteoarthritis is caused by the breakdown of cartilage , the flexible tissue that cushions the small facet joints in your spine so they glide over each other.
• Poor posture : Poor posture puts uneven pressure on the tendons , muscles , and ligaments that support your spine. This is a common risk factor among people who sit for long periods and hunch over a keyboard. Sitting with proper posture helps to evenly distribute your weight without placing abnormal pressure on one area of your back and spine.
• Spinal deformity : A severe curve or abnormal development of the thoracic spine can strain the muscles and spinal discs in your middle back, resulting in pain. Examples include scoliosis (curvature of the spine) and kyphosis (curvature of the spine that leads to a round or hunched back).
• Tissue injuries : Tissue injuries, such as sprains or strains, to your spinal muscles, discs, or joints are the most common causes of left-sided middle back pain. They typically occur from impact that occurs during a fall, car accident, or sports injury.
• Vertebral fractures : The bones in your middle spine can become fractured as a result of an injury, fall, or automobile accident. Having osteoporosis (loss of bone mass and bone mineral density) leads to a decrease in bone strength, which increases your risk for vertebral fractures.

Rarer Causes

• Aortic aneurysm : Your aorta is your largest artery. It carries nutrients and oxygenated blood from your heart to other parts of your body. An aneurysm is a bubble that forms in the wall of a weakened, diseased artery. It causes the wall to expand and weaken. An abdominal aortic aneurysm can cause sudden, severe abdominal pain and referred back pain.
• Cauda equina syndrome : Cauda equina syndrome compresses or squeezes the nerves in your lower spine so they become paralyzed. It interferes with the normal motor and sensory functions of your bladder and lower extremities.
• Heart attack : Middle back pain can occur as a symptom of a heart attack, especially in women. This type of left-sided middle back pain may be accompanied by other signs of a heart attack such as tightness or pressure in your chest that radiates to your shoulders and arms, vomiting, dizziness, and/or shortness of breath .
• Pleurisy : Pleurisy is inflammation of the pleura , the lining that surrounds your lungs and chest cavity. The condition causes a sharp chest pain that can radiate to trigger middle back pain.
• Tumor : A benign (noncancerous) or malignant (cancerous) spinal tumor that grows in the middle back can exert pressure on the area. It can impact normal alignment and interfere with areas such as muscles and nerves.

Referred Pain

It's possible to have back pain caused by a disease or injury in another part of your body. This is called referred pain . When back pain occurs as a result of referred pain, the pain often originates in your chest or abdominal organs. Kidney stones and pancreatitis are two conditions that can cause referred pain in your middle back.

Basic Back Anatomy to Understand Pain Location

Your middle back, or thoracic spine, is the area between your upper back (cervical spine) and lower back (lumbar spine). Your middle back consists of 12 vertebrae labeled T1 through T12. These discs separate the bones from each other and absorb shock, and muscles and ligaments that hold your spine together. Your middle back starts under your shoulder blades and extends to the bottom of your rib cage, down to your last rib.

Muscles, nerves, tendons, and ligaments surround your thoracic spine to help with movement and flexibility. When these sites are damaged or diseased, they can cause middle back pain. Middle back pain on your left side can also be linked to your kidneys . These organs are located on each side of your spine behind your rib cage, so they can be the source of pain in this area when problems such as kidney stones or a pyelonephritis (kidney infection) occur.

Middle back pain can also occur from conditions that affect your pancreas . Chronic pancreatitis can cause pain that starts in the middle or left side of your abdomen and radiates to your back. Pancreatic cancer or colon cancer can also affect your middle back if the disease causes a tumor that presses on your spine.

Female-Related Left-Sided Middle Back Pain

Some causes of left-sided middle back pan affect only people assigned female at birth. They include:

• Adenomyosis : A condition in which cells from your uterine lining grow into the outer muscular walls of the uterus
• Endometriosis : A condition in which uterine tissue grows in areas outside the uterus, including the lower back
• Pelvic inflammatory disease (PID) : An inflammatory infection of the reproductive organs usually caused by an untreated sexually transmitted infection (STI)
• Pregnancy : Commonly linked with back pain due to changes in hormones, your center of gravity, weight gain, and posture
• Uterine fibroid : A benign growth that occurs inside or on your uterus that can press on the muscles and nerves in your lower back

How to Relieve Minor Middle Back Pain on Your Left Side

Most cases of minor middle back pain on your left side can be managed with conservative home care when symptoms are mild to moderate. These treatments can include:

Medications:

• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as Advil, Motrin ( ibuprofen ) Aleve ( naproxen ), or Bayer ( aspirin )
• Topical pain medicines applied directly to your skin at the site of pain, including topical NSAID creams like Voltarin (diclofenac) and capsaicin cream, which uses a substance found in cayenne peppers
• Tylenol ( acetaminophen )

Home Therapies:

• Avoid the tendency to seek bed rest. Instead, limit activities that cause pain and gradually increase physical activity as much as possible.
• Exercise to stretch and strengthen the muscles of your back.
• Maintain a healthy lifestyle with a well-balanced diet, relaxation, and a regular sleep schedule.
• Practice moving your body properly to avoid increasing pain.
• Use cold packs to relieve back pain.
• Use hot packs to increase blood flow and promote healing in damaged back muscles and tissues.

When Left-Sided Middle Back Pain Warrants a Provider Visit

While you may be able to achieve relief from some types of minor middle back pain, certain types of pain warrant a consultation with a healthcare provider. Though a telehealth visit may be appropriate for following up on chronic middle back pain, the assessment of new pain often requires an in-person visit.

To ensure you receive the right care as quickly as possible, ask your healthcare provider what type of visit is appropriate. Start with your primary healthcare provider to rule out causes of left-sided middle back pain that may involve other aspects of your health.

Contact your healthcare provider if your left-sided middle back pain involves any of the following characteristics:

• Accompanied by other abnormal sensations : When middle back pain is accompanied by sensations such as tingling, numbness, or weakness and the pain remains constant despite taking over-the-counter pain relievers, it may be a sign of a pinched nerve or other nerve damage.
• Accompanied by urinary or fecal incontinence : Middle back pain that occurs with the inability to control your bowels or urination, especially if it also involves leg numbness, may indicate a rare condition called cauda equina syndrome. This condition, in which the nerves in your lower spine become paralyzed, requires emergency treatment.
• After a traumatic injury : Middle back pain that occurs after any type of trauma, including a car accident, fall, or other type of injury may be a sign of a fracture or other more serious problem.
• Extends to other body parts : Middle back pain that irradiates to other body parts, such as down the back of the leg, may be a sign of sciatica or a herniated disc.
• Lasts longer than a week : Since back pain caused by minor issues usually subsides within a week, pain that lasts longer may be a sign of a more serious issue.
• With a fever : Middle back pain that occurs with a fever that does not improve with over-the-counter fever-reducing medication may be a sign of an infection.
• With weight loss due to unknown causes : Middle back pain that occurs with sudden and unexplained weight loss may indicate a more severe condition such as a tumor or an infection.
• Worsens at certain times or when you're in certain positions : Middle back pain that intensifies at night or when you assume certain positions, such as standing or lying down, may be a sign of a more severe problem such as a fracture, infection, nerve compression, or cancer.

When to Call 911 for Left-Sided Middle Back Pain

Left-sided middle back pain can occur as a symptom of a life-threatening condition, such as a heart attack, that requires immediate care. Call 911 if you have back pain with any of the following symptoms:

• Heartbeat that feels fast or uneven
• Light-headedness or dizziness
• Pain, pressure, or other abnormal feelings in your chest, neck, jaw, upper abdomen, or one or both arms or shoulders
• Nausea or vomiting
• Shortness of breath

An accurate diagnosis of left-sided middle back pain requires an in-person visit with a healthcare provider. Depending on your symptoms, your healthcare provider may use one or more of the following techniques to determine the cause of your pain:

• Blood tests : These tests may be used to identify infections, inflammation, or other medical disorders that may be causing your pain.
• Bone scan : A bone scan (bone scintigraphy) checks for abnormal areas of damage in your bones. This nuclear imaging technique involves the injection of a tracer (a small amount of radioactive material) into your vein to highlight areas of bone damage or disease.
• Computed tomography (CT) scan : A CT scan uses X-rays to create a three-dimensional image when an X-ray does not provide adequate detail.
• Electromyography (EMG) or nerve conduction velocity testing : An EMG test measures electrical activity within your muscles. A nerve conduction test measures how electrical signals travel down your nerves. These two tests are often performed together.
• Imaging tests : The following imaging tests are used to rule out or determine the cause of your back pain.
• Magnetic resonance imaging (MRI) : An MRI uses a strong magnetic field and radio waves to produce two-dimensional (2D) or three-dimensional (3D) images of your spine and other internal structures such as muscles, joints, ligaments, and discs.
• Physical examination : This involves a discussion of your symptoms, medical history, and current health conditions. Your healthcare provider will closely look at your spine, head, neck, and pelvis for signs of misalignment or inflammation that may indicate the cause of your pain. Your reflexes, muscle strength, and sensation will also be tested.
• X-ray : X-rays, or radiography, use a small amount of electromagnetic radiation to create images of your back that can show fractures, misalignment, and changes due to aging.

The type of treatment your healthcare provider advises for your left-sided middle back pain depends on the cause of your symptoms. When home remedies do not relieve your pain, one or more of the following prescribed treatments may be used:

• Epidural steroid injections or numbing injections for certain types of back pain, such as middle back pain that travels down your leg due to nerve irritation or compression
• Prescribed drugs called neuromodulatory drugs that change the way your nerves communicate with other nerves to reduce the influence of pain signals
• Prescription pain relievers for severe acute back pain
• Physical therapy  to strengthen the muscles that support your back and decrease pain
• Posture training to learn proper movement and standing
• Transcutaneous electrical nerve stimulation (TENS) to send mild electrical pulses to the nerves through a device and electrodes or pads that are placed on your skin
• Therapeutic ultrasound to provide deep heating to soft tissues such as muscles, tendons, joints, and ligaments.

Evidence suggests that complementary and alternative medicine (CAM), such as the following, may also be successful in relieving some types of left-sided middle back pain:

• Acupuncture
• Chiropractic care

While surgery is not routinely used to treat middle back pain, surgical treatments may be advised if conservative treatments do not provide relief from left-sided middle back pain. These procedures include:

• Vertebroplasty and kyphoplasty : Procedures that treat compression fractures of the spine by using a special cement to stabilize the fractured vertebrae
• Laminectomy : A procedure used to treat spinal stenosis (narrowing of the spinal canal that compresses the spinal cord and/or nerve roots) by removing the bone spurs (bony growths) on the bone walls of the vertebrae to open the spinal column and remove pressure on the nerves
• Discectomy : A procedure that removes a herniated disc and bone spurs compressing the spinal cord and/or surrounding nerve roots that branch off from it
• Spinal fusion : A procedure that corrects deformities caused by degenerative disc disease and spondylolisthesis by fusing two or more vertebrae to increase stability and decrease the motion that may be the source of your pain
• Disc replacement : A procedure that removes a damaged disc and replaces it with an artificial disc that mimics a healthy disc and preserves your spine's natural ability to move
• Foraminotomy : A procedure to widen the foramina, the openings in the vertebrae where the spinal nerve roots exit from the spinal cord
• Laser surgery : A procedure that uses bursts of laser energy to relieve nerve pressure by reducing the size of a damaged disc
• Radiofrequency lesioning : A procedure that blocks inputs of the pain signals outside the spinal cord from entering the spinal cord
• Spinal cord stimulation : A procedure that uses imperceptible levels of electricity to stimulate your spinal cord to block pain signals from the spinal cord to the brain

How to Stay Ahead of Back Pain Flares

While you may not be able to prevent all types of back pain flares, following these strategies can help reduce your risk of preventable causes and the damage that occurs:

• Establish and maintain a healthy weight. Avoiding excess weight reduces the amount of strain on your back.
• Maintain posture when sitting. This requires sitting up straight, with your back against the back of your chair. Keep your feet flat on the floor and your knees slightly higher than your hips.
• Use the correct lifting technique that concentrates on lifting with your legs, not your back. To do this, squat down at your knees, stand straight up without hunching over, and carry heavy objects close to your body without bending forward.
• Consume the recommended amounts of calcium and vitamin D through diet and supplements to keep your bones strong and prevent osteoporosis.
• Keep your back strong by performing exercises that strengthen and stretch your back muscles at least twice weekly.
• Remain active. Every week, aim for at least 150 minutes of moderate-intensity aerobic activity and at least two days that involve lifting weights or other activities that strengthen your muscles.
• Try a yoga class. This practice can help stretch and strengthen your back muscles and improve your posture.
• Quit smoking . Smoking increases your risk of atherosclerosis (hardening of the arteries), which can cause back pain and degenerative disc disorders.

Middle back pain on your left side describes pain that occurs below your neck and above the bottom of your rib cage. Also called the thoracic spine, your middle back can hurt as a result of problems that involve injuries, poor posture, or spinal conditions. Less common, pain in the area can also occur as a result of more severe problems such as a heart attack, cancer, or kidney stones.

While most causes of left-side middle back pain resolve with home treatment, more severe problems may need other types of care. Middle back pain on your left side that lasts more than a week should be diagnosed by your healthcare provider. Treatments that range from prescription drugs to surgery may be needed to provide relief. Health conditions must be addressed if they are the cause of the pain.

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By Anna Giorgi Giorgi is a freelance writer with more than 25 years of experience writing health and wellness-related content.

Patient-reported outcome of lumbar decompression with instrumented fusion for low-grade spondylolisthesis: influence of pathology and baseline symptoms

• Original Article
• Published: 28 August 2024

Cite this article

• Daniel Haschtmann   ORCID: orcid.org/0000-0003-0437-8521 1 , 2 ,
• Christian Brand 3 ,
• Tamas F. Fekete   ORCID: orcid.org/0000-0001-5231-5600 1 ,
• Dezsö Jeszenszky 1 ,
• Frank S. Kleinstück 1 ,
• Raluca Reitmeir 1 ,
• François Porchet 1 ,
• Laura Zimmermann 4 ,
• Markus Loibl 1 &
• Anne F. Mannion 4  

Introduction

Low-grade isthmic and degenerative spondylolisthesis (DS) of the lumbar spine are distinct pathologies but both can be treated with lumbar decompression with fusion. In a very large cohort, we compared patient-reported outcome in relation to the pathology and chief complaint at baseline.

This was a retrospective analysis using the EUROSPINE Spine Tango Registry. We included 582 patients (age 60 ± 15 years; 65% female), divided into four groups based on two variables: type of spondylolisthesis and chief pain complaint (leg pain (LP) versus back pain). Patients completed the COMI preoperatively and up to 5 years follow-up (FU), and rated global treatment outcome (GTO). Regression models were used to predict COMI-scores at FU. Pain scores and satisfaction ratings were analysed.

All patients experienced pronounced reductions in COMI scores. Relative to the other groups, the DS-LP group showed between 5% and 11% greater COMI score reduction ( p  < 0.01 up to 2 years’ FU). This group also performed best with respect to pain outcomes and satisfaction. Long-term GTO was 93% at the 5 year FU, compared with between 82% and 86% in the other groups.

Regardless of the type of spondylolisthesis, all groups experienced an improvement in COMI score after surgery. Patients with DS and LP as their chief complaint appear to benefit more than other patients. These results are the first to show that the type of the spondylolisthesis and its chief complaint have an impact on surgical outcome. They will be informative for the consent process prior to surgery and can be used to build predictive models for individual outcome.

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Daniel Haschtmann, Tamas F. Fekete, Dezsö Jeszenszky, Frank S. Kleinstück, Raluca Reitmeir, François Porchet & Markus Loibl

Department of Orthopaedic Surgery and Traumatology, Inselspital, University of Bern, Bern, Switzerland

Daniel Haschtmann

SwissRDL, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland

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Haschtmann, D., Brand, C., Fekete, T.F. et al. Patient-reported outcome of lumbar decompression with instrumented fusion for low-grade spondylolisthesis: influence of pathology and baseline symptoms. Eur Spine J (2024). https://doi.org/10.1007/s00586-024-08425-0

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Patient-reported outcome of lumbar decompression with instrumented fusion for low-grade spondylolisthesis: influence of pathology and baseline symptoms

Affiliations.

• 1 Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland. [email protected].
• 2 Department of Orthopaedic Surgery and Traumatology, Inselspital, University of Bern, Bern, Switzerland. [email protected].
• 3 SwissRDL, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
• 4 Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland.
• 5 Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Zurich, Switzerland.
• PMID: 39196407
• DOI: 10.1007/s00586-024-08425-0

Introduction: Low-grade isthmic and degenerative spondylolisthesis (DS) of the lumbar spine are distinct pathologies but both can be treated with lumbar decompression with fusion. In a very large cohort, we compared patient-reported outcome in relation to the pathology and chief complaint at baseline.

Methods: This was a retrospective analysis using the EUROSPINE Spine Tango Registry. We included 582 patients (age 60 ± 15 years; 65% female), divided into four groups based on two variables: type of spondylolisthesis and chief pain complaint (leg pain (LP) versus back pain). Patients completed the COMI preoperatively and up to 5 years follow-up (FU), and rated global treatment outcome (GTO). Regression models were used to predict COMI-scores at FU. Pain scores and satisfaction ratings were analysed.

Results: All patients experienced pronounced reductions in COMI scores. Relative to the other groups, the DS-LP group showed between 5% and 11% greater COMI score reduction (p < 0.01 up to 2 years' FU). This group also performed best with respect to pain outcomes and satisfaction. Long-term GTO was 93% at the 5 year FU, compared with between 82% and 86% in the other groups.

Conclusion: Regardless of the type of spondylolisthesis, all groups experienced an improvement in COMI score after surgery. Patients with DS and LP as their chief complaint appear to benefit more than other patients. These results are the first to show that the type of the spondylolisthesis and its chief complaint have an impact on surgical outcome. They will be informative for the consent process prior to surgery and can be used to build predictive models for individual outcome.

Keywords: Baseline Symptoms; Degenerative spondylolisthesis; Isthmic spondylolisthesis; Patient rated outcome; Spinal fusion.

© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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• Kriegova E, Kudelka M, Radvansky M, Gallo J (2021) A theoretical model of health management using data-driven decision-making: the future of precision medicine and health. J Transl Med 19:68. https://doi.org/10.1186/s12967-021-02714-8 - DOI - PubMed - PMC
• Staub LP, Aghayev E, Skrivankova V, Lord SJ, Haschtmann D, Mannion AF (2020) Development and temporal validation of a prognostic model for 1-year clinical outcome after decompression surgery for lumbar disc herniation. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sec Cerv Spine Res Soc 29:1742–1751. https://doi.org/10.1007/s00586-020-06351-5 - DOI
• Muller D, Haschtmann D, Fekete TF, Kleinstuck F, Reitmeir R, Loibl M, O’Riordan D, Porchet F, Jeszenszky D, Mannion AF (2022) Development of a machine-learning based model for predicting multidimensional outcome after surgery for degenerative disorders of the spine. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sec Cerv Spine Res Soc 31:2125–2136. https://doi.org/10.1007/s00586-022-07306-8 - DOI
• Marchetti PC, Bartolozzi P (1997) Classification of spondylolisthesis as a guideline for treatment. In: Bridwell KH, DeWald RL, Hammerberg KW (eds) The textbook of spinal surgery. Lippincott-Raven, Philadelphia
• Wiltse LL, Newman PH, Macnab I (1976) Classification of spondylolisis and spondylolisthesis. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-197606000-00003 - DOI - PubMed
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• Research article
• Open access
• Published: 29 August 2024

Can minimally invasive transforaminal lumbar interbody fusion achieve a better clinical and radiological outcome than traditional open technique in isthmic spondylolisthesis?

• Elsayed Mohamed Selim Ali   ORCID: orcid.org/0000-0002-1127-1127 1 ,
• Amr Mohamed Eladawy 1 &
• Tarek ElHewala   ORCID: orcid.org/0000-0001-5157-6673 1  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  523 ( 2024 ) Cite this article

Metrics details

Spondylolisthesis is a prevalent condition in the lumbar spine that can cause low back pain, leg pain, neurogenic claudication, and impact health-related quality of life in symptomatic individuals.

to assess the results of minimally invasive TLIF (MIS-TLIF) versus open-TLIF and the impact of correcting spino-pelvic parameters on the Health-Related Quality of Life (HRQoL) in patients with low-grade isthmic spondylolisthesis. The primary objective was to compare the effectiveness of both methods in correcting spinopelvic parameters. The secondary objectives involved comparing clinical improvement, operating time, blood loss, complications, and postoperative hospital stays between the two procedures.

Patients and methods

Seventy-two patients with low-grade isthmic spondylolisthesis were enrolled in this retrospective cohort-control study, with a minimum follow-up period of 18 months. Disability was assessed using the Oswestry Disability Index (ODI), while back and leg discomfort were rated using the Visual Analogue Scale (VAS) for each patient. The measurements comprised the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and Meyerding slip grades. We measured lumbar lordosis (LL), and segmental lordosis.

The seventy-two patients were 60 female and 12 males. There was no statistically significant difference in the duration of operation between the two groups. In the MIS group, there was a notable reduction in blood loss, higher radiation exposure, and a shorter hospital stay ( P  < 0.001). The back VAS showed more favorable outcomes in the MIS-TLIF, while the leg VAS showed better results in the Open-TLIF in the early outcome. Both procedures significantly reduced leg and back pain VAS scores and ODI, with no notable difference between the two groups at the final follow-up. Post-surgery, the pelvic incidence (PI) and lumbar lordosis (LL) matched properly in all patients, showing a rise in LL and sacral slope along with a decrease in pelvic tilt.

Both open-TLIF and MIS-TLIF are effective methods for correcting spino-pelvic parameters and improving HRQoL in patients with low-grade isthmic spondylolisthesis. The rapid improvement in back pain experienced by these patients favored the use of MIS-TLIF. However, the cost-effectiveness of this approach must be carefully evaluated.

Introduction

Spondylolisthesis is a ubiquitous lumbar spine disorder that often leads to symptoms such as neurogenic claudication, restricted function, and low back pain with or without leg discomfort. If conservative treatments fail to alleviate the symptoms, lumbar fusion surgery should be considered [ 1 ]. The goal of fusion surgery is to stabilize the spine and alleviate pain and neurological compression [ 2 ].

Transforaminal lumbar interbody fusion (TLIF) is the standard surgery for lumbar spondylolisthesis. It minimizes nerve root and thecal sac retraction while offering the benefits of overall fusion and maintaining or improving lumbar lordosis [ 1 ].

Minimally invasive spine (MIS) procedures yield equivalent or improved clinical and radiological outcomes compared to open treatments, along with decreasing soft tissue damage and its associated effects. MIS aims to decrease intraoperative blood loss, wound infections, postoperative hematomas, and maintain normal muscle function by preserving para-spinal muscular innervation. Additional advantages include accelerated wound healing, less analgesic requirement post-surgery, faster ambulation, and shorter hospitalization periods [ 3 ].

Drawbacks of MIS include extended operating times, heightened intraoperative radiation exposure due to prolonged and frequent fluoroscopy use, a challenging learning curve, and a potential rise in the risk of cage and pedicle screw misplacements and cage migrations [ 4 ].

Different research studied the relationship between pelvic incidence (PI), pelvic tilt (PT), and sacral slope with spinal deformities including spondylolisthesis, and their role in spinal sagittal alignment. Schwab F. et al. studied the relationships and variations of PI, PT, SS, LL, and thoracic kyphosis (TK) in a standard young adult group. They showed how these factors are interrelated and work together to support the overall balance of gravity over the femoral heads via muscle engagement. Recent findings suggest that a high Pelvic Incidence (PI) may be associated with adult individuals who have low-grade L5-S1 spondylolisthesis [ 5 ].

The Spinal Deformity Study Group (SDSG) introduced a classification system that relies on radiographic assessment of slip grade and spino-pelvic alignment, including pelvic incidence (PI), sacro-pelvic alignment, and spinal balance. Most guidelines and studies on spondylolisthesis focus on slip grade, however some research also highlights the significance of sacro-pelvic morphology and spino-pelvic alignment in assessing and treating spondylolisthesis [ 6 ].

In order to better understand how correcting spino-pelvic parameters impacts the health-related quality of life (HRQoL) of individuals with low-grade spondylolisthesis, we conducted this study to compare the results of open and minimally invasive TLIF surgeries. A comprehensive analysis of the effects of these treatment modalities for low-grade spondylolisthesis was our goal.

A retrospective cohort-control study was conducted to compare the effectiveness of Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) with Open Transforaminal Lumbar Interbody Fusion (Open-TLIF) in treating low-grade isthmic spondylolisthesis, which was carried out at the orthopedic department’s spine unit at our university hospital from December 2017 to December 2020 with a minimum 18-month follow-up duration, including 72 patients. We postulate that, in comparison to conventional open TLIF, MIS-TLIF will provide better radiological and clinical results. Our primary goal was to evaluate the corrective power of the two methods according to the spino-pelvic parameters. We aimed to assess clinical improvement, operating time, blood loss, complications, and postoperative hospital stays between the two procedures as our secondary objective.

The trial participants had low-grade isthmic spondylolisthesis, axial low back pain, and/or leg discomfort that persisted despite undergoing medical treatment including rest, non-steroidal anti-inflammatory drugs, muscle relaxants, physiotherapy, and lumbosacral support for at least six months. High-grade spondylolisthesis, severe osteoporosis, previous spinal surgery, spinal tumor, trauma, and infections were all excluded as contributing factors. Before the surgery, every patient provided their informed consent, and none of them were lost throughout the follow-up period.

Each patient had clinical evaluation before the surgery using the Oswestry Disability Index (ODI) to evaluate disability and the Visual Analogue Scale (VAS) to quantify leg and back pain. Demographic data, including age, sex, occupation, smoking status, and Body Mass Index (BMI), was collected from all patients.

Anteroposterior, lateral, and dynamic lumbar spine standing X-rays were used to evaluate each patient’s radiological status before surgery. An anterior–posterior and lateral X-ray from the base of the head to the tailbone was conducted. The radiographic analysis software Surgimap Spine (Nemaris Inc, New York, NY) was used to measure spino-pelvic parameters. Measurements were recorded for pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), and Meyerding slip grades. We assessed the segmental lordosis of the affected segment by measuring the angle between the upper endplate of the slid vertebra and the top endplate of the lower one, as well as lumbar lordosis (LL). All measures were taken by two experienced spine surgeons and then repeated by the same surgeons a month later. When they took the second round of measurements, the examiners were blind to their own previous measurements. The final analyses were performed using the average values of the measurements obtained at two separate time points. All patients got pre-operative MRI scans which consisted of sagittal, coronal, and axial views.

TLIF was used to treat the 72 participants with low grade lytic spondylolisthesis. They were divided into two groups: group A, comprising 40 patients who underwent open-TLIF, and group B, comprising 32 patients who underwent MIS-TLIF. Both groups used PEEK cages filled with autologous bone graft (taken from the laminectomy and the facets) and included posterior spinal fixation with pedicular screws using either an open or percutaneous approach. The open approach technique employed in this investigation was comparable to the methodology utilized in a previous study[ 7 ] (Fig.  1 ). Similarly, the MIS approach in this study was based on the methodology outlined in this other work [ 8 ], with same steps followed (Figs.  2 and 3 ). All patients in the study were operated by the same surgical team.

The open TLIF case, A and B anterior–posterior and lateral radiology of the slipped level, C and D MRI sagittal and axial cut, E intraoperative photo during insertion of the cage, F and G the final Anterior–posterior and lateral view of the operated level, and finally H : intra-operative photo of the operative field

The MIS-TLIF case, A and B anterior–posterior and lateral radiology of the slipped level, C CT scan of the fractured pars, D and E  showing MRI sagittal and axial cut of the slipped level

operative photos of the MIS-TLIF case: A showing the guide wires placed in the pedicles of the L4-5 with the tube system fixed over the facet joint before the osteotomy, B lateral radiology view during insertion of the cage, C intraoperative photo with the tube system in place with the percutaneous guide wires in place, D intraoperative microscopic picture of the dura (blue arrow) and the window for the insertion of the cage marked by the white arrow, E and F the final anterior–posterior and lateral view of the slipped level after insertion of the rods and G intraoperative photo of the operative microscope used

Patients were encouraged to ambulate as early as the first postoperative day. Plain x-ray was ordered for the patients on day two postoperative. The patients were advised to attend the out-patient clinic in the first two weeks then regularly every three months.

Statistical analysis

A sample size was calculated using openepi.com [ 9 ], with the assumption that the MIS-TLIF would make a 30% increase in the segmental lordosis in comparison to the open TLIF, depending on our previous study [ 8 ], with the assumption that the open TLIF group is the standard technique so it will be larger in size. The calculated sample size ranged from 70 to 85 patients. We approximated calculated numbers for groups to (40) patients in group A and (32) patients in group B, according to Kelsey and Fleiss methods ( supplementary figure ). Continuous variables were expressed as the Mean ± SD (Range). The categorical variables were expressed as a number (percentage). Data found to be normally distributed were analyzed using the independent sample t-test, while Repeated Measures ANOVA was used for analysis of repeated measured data within variables. Non-parametric data were analyzed using the Mann Whiteny U-test for rank sum of independent samples and Wilcoxon test measured if there was difference in dependent groups All statistical analyses were performed with SPSS version 24.0 for windows (SPSS Inc., Chicago, IL, USA), where P  < 0.05 was considered statistically significant.

Patients demographics

This study included 72 patients, 60 of whom were female and 12 of whom were male, with single-level low-grade isthmic spondylolisthesis. Table 1 shows that there were no significant differences between the two groups in terms of patient demographics. The TLIF procedure was performed openly in 40 patients (55.5%), and minimally invasively in 32 individuals (44.4%).

Operative data

The length of surgery differed statistically significantly between the two groups, with open procedures having a lower operative time. Furthermore, the open approach had a significantly lower radiation exposure than the MIS opens. In comparison to the MIS-TLIF group, the statistical analysis demonstrated a statistically significant decrease in both intraoperative and postoperative blood loss in the MIS group, with a considerably shorter hospital stay ( p  < 0.001) (Table  2 ).

Pain and functional outcomes

Modified oswestry disability index (fig.  4 ).

Modified Oswestry disability index

The Oswestry disability score was used to compare Open-TLIF with MIS-TLIF before, after surgery, and at final follow-up. No statistically significant difference was found between the two groups. Within each group, however, there was a discernible change from pre- to post-operative ODI values that persisted through the last follow-up, and this change was highly statistically significant.

Visual analogue scale back and leg pain (Figs. 5 , 6 )

VAS for back pain

VAS for leg pain

Each group’s back and leg pain were assessed using a VAS score. The results demonstrated a marked improvement in back pain scores across all groups from preoperative to postoperative data till the final follow-up. VAS score for Back pain improved from preoperative with the MIS-TLIF group outperforming the open group in the first month. When comparing the groups at pre- and post-operative follow-up, there was a statistically significant difference between the open and MIS-TLIF groups on the VAS for leg pain within the first month in favor the open group.

Radiological parameters including the spino-pelvic parameters (Table  3 )

Between the preoperative and final follow-ups, both groups had a significant reduction in slip % and disc height correction, as well as a significant improvement in lumbar and segmental lordosis in the affected level. In addition, the sacral slope and pelvic tilt revealed considerable degrees of correction, which correlated with the correction of the pelvic incidence lumbar lordosis mismatch. For data analysis between groups, there was a substantial difference in parameter correction, with the open technique having the most correction values when considering LL, SL, slip percentage, and disc height adjustment (Fig.  7 ).

Long standing radiographyof the whole spine pre and postoperative of the open-TLIF case in ( A and B ) and the MIS-TLIF case ( C and D ) with measurement of the spinopelvic parameters

The correlation between the sagittal parameters and the functional outcome at final follow up (Table  4 )

During the study of the results of the correlation (Pearson) between the sagittal parameters and the functional outcome (VAS and ODI) for both groups (open and MIS), there was no statistically significant correlation discovered except for the a negative correlation with lumbar lordosis and VAS_L (r (70) =  − 0.3, p  = 0.006.) and between the disc height and the ODI (r (70) =  − 0.2, p  = 0.01).

In the MIS group, the result of the Pearson correlation showed that there was a statistically significant negative correlation between ODI final and Disc height final (r(30) =  − 0.4, p  = 0.01) and a statistically significant negative correlation between VAS Back and Disc height r(30) =  − 0.35, p  = 0.05).

In the open group the result of the Pearson correlation showed that there was a statistically significant negative correlation between LL and VAS Leg (r (38) =  − 0.3, p  = 0.01) and a statistically significant negative correlation between LL and VAS Back (r (38) =  − 0.4, p  = 0.01).

Complications

One patient in the open group (2.5%) had a superficial wound infection five days following surgery. Once the first week had passed, the infection was under control thanks to intravenous antibiotics and frequent dressing changes. There were five cases (6.9%) of accidental durotomy: two in the open (5%) setting and three in the MIS-TLIF (9.4%) setting. Patients with MIS-TLIF had a muscle graft in surgicel with a tight fascia closure, whereas those with open lesions were treated by direct dural suture. Only one case from the MIS-TLIF group required revision with microscopic dural repair with durotomy suturing; all others did not require revision. Two patients in the MIS-TLIF (6.3%) groups had screws that were not in proper places, but no additional intervention was necessary in these circumstances. In neither group did any neurological complications occur.

There are several surgical procedures available for the treatment of lytic spondylolisthesis, such as open and minimally invasive transforaminal lumbar interbody fusion (TLIF). A study has indicated that a combination of unilateral TLIF and pedicle screw fixation can effectively treat low-grade spondylolisthesis. This approach offers the potential advantages of minimally invasive percutaneous long-arm pedicle screws in spondylolisthesis surgery. According to the study conducted by Nooraie et al., there was no statistically significant disparity observed in the outcomes of low-grade lytic spondylolisthesis when comparing spinal decompression, stabilization, and fusion, as well as stabilization and fusion without decompressive laminectomy[ 10 ].

The MIS-TLIF technique involves the utilization of a para-median skin incision, muscle dilation, or splitting to gain access to the posterior lumbar interbody space. To maintain an open access channel, various mechanisms such as sleeves, tubes, or cylindrical retractor blades are employed [ 11 ]. To mitigate the dependence on the indirect decompression technique with a unilateral approach, bilateral decompression was employed in the present investigation. Consequently, there were no instances of contralateral radiculopathy observed in any of our patients during the follow-up period.

The development of minimally invasive technologies for spinal surgery over the last few decades has undoubtedly resulted in the transition from Open-TLIF to MIS-TLIF. The MIS-TLIF technique has gained popularity for its advantages over open-TLIF, such as a smaller incision, less bleeding, and faster recovery. Minimally invasive spine surgery strives to achieve the same results as open procedures but in a less stressful manner [ 7 ].The purpose of this study was to evaluate and compare the safety and efficacy of Open-TLIF and MIS-TLIF in the treatment of low-grade, single-level isthmic spondylolisthesis.

The primary concern expressed by our patients encountered pain in the lower back together with radiating pain in the lower limbs. This was reported by 72.5% of patients who underwent open-TLIF and 75% of patients who underwent MIS-TLIF. The most frequently operated level was L5-S1. In our study group, it was evident that female patients had a greater prevalence of lytic spondylolysis compared to male patients. This was observed in both the open-TLIF group (85%) and the MIS-TLIF group (78.1%). However, there was no significant difference between the two groups in terms of demographic data.

Regarding the surgical data, it came to light that the open TLIF procedure had favorable outcomes in terms of operative time and radiation exposure. Fluoroscopy-based minimally invasive surgical (MIS) techniques expose patients and surgical workers to significant doses of radiation, as it is necessary for determining the anatomical location. Multiple studies have shown that the use of fluoroscopy is more extensive in the treatment of lumbar issues with MIS-TLIF compared to Open-TLIF [ 8 , 12 , 13 ]. The current analysis found that the radiation exposure (measured in seconds) was much lower in the open TLIF compared to the MIS-TLIF (20.1 ± 6.3 vs 60.3 ± 7, respectively), indicating a preference for the open TLIF procedure. Furthermore, we found that the duration needed to insert the percutaneous screw and guide wire was the primary factor contributing to the fluoroscopy time.

In the current study, the operating time in the MIS group was longer. This could be likely additional time was spent assembling the tubular retractors and accurately setting the screws using fluoroscopy. Specifically, the operating time for Open-TLIF was 114.4 ± 8 min, whereas for MIS-TLIF it was 120.9 ± 6.9 min. The visual field during minimally invasive surgery is narrower compared to standard surgery. The surgeon must possess significant practical expertise and a comprehensive comprehension of anatomy [ 14 ]. Multiple studies have demonstrated that the MIS-TLIF technique outperformed Open-TLIF in terms of intraoperative bleeding, postoperative drainage, and duration of hospitalization [ 3 ]. Our study’s results were in line with their conclusions on the smaller incisions, reduced tissue injury, and the utilization of a tubular retractor.

Because many of the possible advantages of MIS-TLIF may manifest themselves in the early post-operative recovery phase, favoring MIS-TLIF, early results in open-TLIF versus MIS-TLIF comparisons are significant [ 14 ]. When comparing MIS-TLIF to open-TLIF for VAS back pain, the results were clear. The open approach may result in more severe muscle injury and more muscle strapping compared to MIS-TLIF, which may explain why the former causes more discomfort in the first month after surgery (2.2 ± 0.7 vs 1.2 ± 0.7, respectively). The VAS back pain has a short-term effect, but there was no significant difference between the two groups at the final follow-up in the long-term follow-up (Open TLIF 2.1 ± 0.5 vs MIS-TLIF 2.4 ± 0.7). In terms of early VAS back pain, Xie et al. [ 15 ] discovered significant differences between the MI-TLIF and Open-TLIF groups (MD =  − 1; 95%CI =  − 1.98, − 0.2; p  = 0.02). Moreover, research was limited to the early groups experiencing VAS back discomfort (I2 = 90%, P  < 0.001) [ 16 ]. There is no discernible change in VAS scores for back pain in late follow-up trials [ 1 , 6 , 8 ].

Opposite to MIS-TLIF, Open TLIF showed a notable reduction in VAS leg pain in the initial one month following surgery (1.5 ± 0.6 vs 2.1 ± 0.7, respectively). This could be because surgeons are more comfortable with the open standard method, there is less manipulation of neural tissues and retraction, disc height restoration is successful, and nerve root and dura release are well-executed. In the last follow-up, however, there was no significant difference between the two methods with respect to radiculopathy (Open TLIF 1.2 ± 0.6 vs MIS-TLIF 0.9 ± 0.7).

Consistent with the increase in patient functional outcome indicated by ODI, both groups saw an improvement in back and leg discomfort. Both groups’ ODIs were significantly adjusted between the preoperative and final follow-up periods, with the Open group showing a difference of 56.9 ± 5.1 vs 19.9 ± 5 and the MIS-TLIF group showing a difference of 56.8 ± 3.8 vs 19.8 ± 3.8. The results show that in cases of single level spondylolisthesis, the MIS-TLIF can improve life function just as much as the traditional open-TLIF. Despite the brief duration of this study’s follow-up, the ODI scores were comparable to those of other research that compared open-TLIF and MIS-TLIF in the treatment of single-level spondylolisthesis and found that both methods improved ODI scores [ 8 , 16 , 17 ].

Schwab et al. demonstrate that the sagittal plane is the main driver of disability in patients with ASD and indicate that among the sagittal radio-graphical parameters, SVA, PT, and PI-LL mismatch are the key factors that impact disability. They have proposed threshold values of sagittal spino-pelvic alignment that should be achieved with spinal reconstructive procedures to obtain satisfactory outcomes in terms of HRQOL. Using these parameters, it is possible to predict theoretical values of regional sagittal parameters [ 5 , 18 ]. More recently, Shimokawa et al. [ 19 ] have reported high correlations between pelvic retroversion (measured by the PT) and sagittal vertical axis (SVA) with HRQOL scores . Although pelvic retroversion may compensate for sagittal balance, it significantly lowers quality of life. In addition to SVA, PT should be taken into consideration to enhance the assessment of patients with lumbar problems [ 19 ].

Spondylolisthesis is characterized by three basic abnormalities: segmental kyphosis, disc height decrease, and vertebral slippage. When forward slippage happens, the lumbar lordosis diminishes due of the disc degeneration and the segmental kyphosis generated by the slippage. In order to compensate the pelvic retroversion-induced displacement, the upper spinal segments hyperextend [ 8 , 20 ]. Although this compensation improves SVA, patients who have a high PT and an ongoing PI-LL mismatch may be at risk for severe impairment. Additionally, it is believed that PT couldn’t go above 20–22°[ 21 ].

We evaluated the PI-LL mismatch in addition to the alterations and corrections to various lumbo-pelvic parameters, including the SS, PT, LL, and PI, in relation to the sagittal parameters that needed adjustment. Additionally, we investigated at how the spondylolisthesis’s slip percentage changed, as well as how the disc angle (segmental lordosis) and disc height changed. There was no change in PI values between preoperative and final follow-up for either the open TLIF group ( p  = 0.7) or the MIS-TLIF group ( p  = 0.5). This lends credence to the theory that the PI remains constant across all individuals.

When comparing the two groups’ pre- and post-operative follow-ups on the remaining parameters, we find that the open and MIS groups differ significantly, especially in the post-operative final follow-up. In comparison to the MIS group, the open group achieved greater corrections for LL, SS, PT, PI-LL mismatch, and segmental lordosis. Possible causes include the simplicity of using a lordotic rod, applying compression on the screws, and doing away with facet joints entirely. Both groups displayed a clear restoration of height on the disc, with no discernible difference between them. One possible explanation is that the transforaminal corridor allowed for the application of a big cage to both groups.

Reduction of the slip percentage can increase the area of intervertebral bone grafting and return the spine to its physiological position with restoration of the sagittal balance [ 22 ]. It is unclear if forceful reduction is necessary during surgery for low-grade Isthmic spondylolisthesis [ 23 , 24 ]. When comparing each group’s preoperative status with the results of the last follow-up, a substantial improvement in the vertebral slip percentage was seen in our study ( P  < 0.001). Furthermore, at final follow-up time point, there was statistically significant difference in the vertebral slip ratio between the MIS-TLIF group and the Open-TLIF group ( P  < 0.001). It demonstrated that both groups had produced positive reduction outcomes with significant improvement in the open group at the final follow-up.

The most frequent complication (6.9%) seen in this study was accidental durotomy, which typically occurred during the placement of the TLIF cage. A single instance within the MIS group necessitated microscopic repair revision. There were claims that the fluoroscopic guided placement of pedicle screws during MIS operations contributed to the screws being misplaced. The accuracy of fluoroscopy-guided percutaneous pedicle screw placement in minimally invasive TLIF was recently investigated by El-Desouky et al. [ 25 ]. The researchers found that the technique was safe, with a total incidence of 13.9% of pedicles’ wall violations and 0.48% of patients reporting complaints due to these screws that were placed incorrectly. Since two patients (6.2% of the total) in the MIS group did not experience any discomfort because of the screws that were implanted, no additional action was necessary.

Neither group experienced a serious infection throughout the current investigation. The Open-TLIF group had a single case of superficial incision infection (2.5%). This was less than the overall prevalence of surgical site infection which was calculated to be (4.2%) in the MENA region [ 26 ]. The patient’s full recovery was achieved using antibiotics and frequent dressing changes. Our patients did not have any neurological complications. At the final follow-up, all cases in both research groups showed full interbody fusion with no evidence of cage displacement or screw loosening.

Both open-TLIF and MIS-TLIF are effective methods for correcting spino-pelvic parameters and improving the health-related quality of life in patients with low-grade isthmic spondylolisthesis. The rapid improvement in back pain experienced by these patients favored the use of MIS-TLIF. However, the cost-effectiveness of this approach must be carefully evaluated.

Patients with low-grade isthmic spondylolisthesis can benefit from both open-TLIF and MIS-TLIF, two dependable procedures for correcting spino-pelvic parameters and improving their health-related quality of life. Although MIS-TLIF had the advantage because to the patients’ quick recovery from back pain, the cost-effectiveness of this must likely be considered.

Limitations

First short term of follow up together with being a retrospective study, Second, the sample sizes in each arm of the trial were small, which could have an impact on the findings; third, a correlation analysis between the clinical effect and radiological evaluation was not done; and fourth, no data was gathered regarding the height of the intervertebral foramen. We recommend long-term follow up to detect more changes in results with multicenter study with wide base of population and large number of cases.

Availability of data and materials

All data is available in the main text or the supplementary material.

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Elsayed Mohamed Selim Ali, Amr Mohamed Eladawy & Tarek ElHewala

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Study conception and design: EL. M.S.A., T.EL, A.EL. Material preparation, data collection and analysis: EL. M.S.A., T.EL, A.EL.; EL.M.S.A. prepared the initial draft of the manuscript; all authors revised and evaluated it before approving the final version.

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Ali, E.M.S., Eladawy, A.M. & ElHewala, T. Can minimally invasive transforaminal lumbar interbody fusion achieve a better clinical and radiological outcome than traditional open technique in isthmic spondylolisthesis?. J Orthop Surg Res 19 , 523 (2024). https://doi.org/10.1186/s13018-024-04994-4

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Received : 29 June 2024

Accepted : 11 August 2024

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DOI : https://doi.org/10.1186/s13018-024-04994-4

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