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Spondylolisthesis

Definition:

Slippage of a vertebra on another vertebra usually from a degenerative condition although it may be the result of a traumatic event or a congenital failure of fusion of the posterior elements of the vertebra

  • Pathophysiology As the intervertebral disc ages with time, there is degeneration of the disc. The disc loses height and there can be some laxity in the posterior joints (facet joints). This can lead to abnormal motion, or slippage of one vertebra in relation to another. The vertebra can slip forward (anterolisthesis), backward (retrolisthesis), or to a side (lateral listhesis).  The slippage can decrease the space allowed for nerve roots in the central canal, lateral recess and foraminal stenosis and cause spinal stenosis. The most important aspect of spondylolisthesis treatment is to determine if the slippage (listhesis) is stable (moves within normal limits) or unstable (abnormal motion).
  • Common terms: subluxation, instability, anterolisthesis, retrolisthesis, listhesis

Symptoms: (similar to lumbar stenosis or cervical stenosis)

  • Cramping, tight pain in muscles in lower back
  • Feeling of instablilty or movement in back with bending
  • Catching sensation in back

Diagnosis:  Spondylolisthesis

  • X-rays: Multiple views of the spine including bending over and leaning back (flexion/extension views) will help to determine if the slippage is stable.
  • MRI examination of the affected part of the spine is necessary to visualize compression of the nerves or spinal cord. CT myelogram will suffice for those unable to undergo an MRI.

Treatments:

  • Non-operative: Medications (preferably anti-inflammatory medications) can help control pain,. Physical therapy can help strengthen musculature surrounding spine and improve stability.  Epidural steroid injections can help decrease inflammatory response and pain.
  • Operative:  Surgical treatment of spondylolisthesis is made after evaluating for instablility.
  • Stable spondylolisthesis: The goal is decompression of the nerve(s) or root(s) affected. This can be done via a laminotomy/ foraminotomy.. Laminotomy/ foraminotomy is a minimally invasive technique removing the minimal amount of bone for visualization to ensure safe decompression of the nerve. Rarely, a laminectomy (complete removal of the back of the spine) is needed. However, a laminectomy has a higher rate of causing instability.
  • Unstable spondylolisthesis: This will require a decompression (similar to stable spondylolisthesis) and fusion procedure with instrumentation.  The nerve roots will need to be decompressed but also the spine will need to be stabilized so that the abnormal motion can be stopped. This is usually performed with the addition of pedicle screw instrumentation.

Evidence

  • SPORT Trial: Surgical treatment of lumbar degenerative spondylolisthesis led to substantially greater improvement in pain than those that were treated non-operatively.
  • Weintsein JN et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis: Four-year results from the SPORT trial. Spine 2004; 29(7)726-734.
  • Fusion with instrumentation will increase the chance of fusion and decrease the chance of pseudoarthrosis (bone not fusing or healing). A solid fusion increases the chance of a good outcome after surgery.

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