degenerative 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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Degenerative Spondylolisthesis

• Degenerative Spondylolisthesis is a common degenerative condition characterized by subluxation of one vertebral body anterior to the adjacent inferior vertebral body with intact pars.
• The condition is most common in females over 40 years of age, at the L4-5 level.
• Diagnosis is made with lateral radiographs. Flexion and extension lateral lumbar radiographs can identify the degree of instability. MRI studies can be helpful for central or foraminal stenosis.
• Treatment is a trial of nonoperative management with NSAIDs and physical therapy.  Surgical management is indicated for progressive disabling pain that has failed nonoperative management, and/or progressive neurological deficits.
• ~9% in woman
• more common in African Americans, diabetics, and woman over 40 years of age
• increase in prevalence in women postulated to be due to increased ligamentous laxity related to hormonal changes
• this is different that isthmic spondylolisthesis which is most commonly seen at L5/S1
• sacralization of L5 (transitional L5 vertebrae)
• sagittally oriented facet joints
• facet joint degeneration
• facet joint sagittal orientation
• intervertebral disc degeneration
• ligamentous laxity (possibly from hormonal changes)
• disc degeneration leads to facet capsule degeneration and instability
• microinstability which leads to further degeneration and eventual macroinstability and anterolithesis
• instability is worsening with sagittally oriented facets (congenital) that allow forward subluxation
• caused by slippage, hypertrophy of ligamentum flavum, and encroachment into the spinal canal of osteophytes from facet arthrosis
• a degenerative slip at L4/5 will affect the L4 nerve root as it is compressed in the foramen
• loss of disk height
• osteophytes from posterolateral corner of vertebral body pushing the nerve root up against the inferior surface of the pedicle
• degenerative changes of the superior articular facet and posterior vertebral body

• most common presenting symptom
• usually relieved with rest and sitting
• second most common symptoms
• relieved by sitting
• not relieved by standing in one place (as is vascular claudication)
• may be unilateral or bilateral
• same symptoms found with spinal stenosis
• cauda equina syndrome (very rare)
• best seen with sit to stand exam maneuver
• best seen with heel-walk exam maneuver
• decreased patellar reflex
• weakness to EHL (great toe extension)
• weakness to gluteus medius (hip abduction)
• if pain resolves this is consistent with vascular claudication
• if pain resolves this is consistent with neurogenic claudication (DS)
• commonly found in this patients, and must differentiate this from neurogenic leg pain
• weight bearing lumbar AP, lateral neutral, lateral flexion, lateral extension
• slip is evident on lateral x-ray
• instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment
• persistent leg pain that has failed nonoperative modalities
• best study to evaluate impingement of neural elements
• T2 weighted sagittal and axial images best to look for compression of neurologic elements
• useful to identify bony pathology
• helpful in patients in which a MRI is contraindicated (pacemaker)
• most patients can be treated nonoperatively
• activity restriction
• second line of treatment if non-invasive methods fail
• most common is persistent and incapacitating pain that has failed 6 mos. of nonoperative management and epidural steroid injections
• progressive motor deficit
• cauda equina syndrome
• often combined with a posterior lumbar interbody fusion or transforaminal interbody fusion
• new data shows equivalent outcomes using cortical screw fixation verses pedicle screw fixation
• decompression often performed with a PLC perserving unilateral (undercutting) approach
• navigation and MIS techniques are widely used
• ~79% have satisfactory outcomes
• improved fusion rates shown with pedicle screws
• improved outcomes with successful arthrodesis
• smokers should undergo smoking cessation prior to surgery
• usually not indicated due to instability associated with spondylolithesis
• only indicated in medically frail patients who cannot tolerate the increased surgical time of performing a fusion
• ~69% treated with decompression alone are satisfied
• ~ 31% have progressive instability
• reserved for revision cases with pseudoarthrosis
• injury to superior hypogastric plexus can cause retrograde ejaculation
• posterior midline approach
• multiple parasagittal incisions for minimally invasive approaches
• usually done with laminectomy, wide decompression, and foraminotomy
• posterolateral fusion with instrumentation most common
• TLIF/PLIF growing in popularity and may increase fusion rates and decrease risk of postoperative slip progression
• limited role in adults
• in degenerative spondylolisthesis adding an interbody cage increases hospital costs without increasing fusion rates
• lower intraoperative blood loss, smaller skin incision, and decreased pain scores at 1-week post-op
• fusion rates and functional outcomes similar to conventional pedicle screw fixation
• other studies have demonstrated greater screw pullout strength given cortical contact of screw
• mostly described in combination with interbody fusion (PLIF or TLIF)
• trajectory is more cephalad and lateral than traditional screw
• cortical trajectory screws are generally smaller than traditional pedicle screws
• CT scan is more reliable than MRI for identifying failed arthrodesis
• risk of adjacent segment degeneration requiring surgery is about 20-29% at 10 years
• treat with irrigation and debridement (usually hardware can be retained)
• seen with prone positioning due to iliac bolster
• from prone positioning with inappropriate position
• increased intraoperative blood loss
• longer operative time
• number of levels fused

Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC.

• - Adult Isthmic Spondylolisthesis

• - Degenerative Spondylolisthesis

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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.

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In spondylolisthesis, one of the bones in your spine — called a vertebra — slips forward and out of place. This may occur anywhere along the spine, but is most common in the lower back (lumbar spine). In some people, this causes no symptoms at all. Others may have back and leg pain that ranges from mild to severe.

(Left) In spondylolysis, a fracture often occurs at the pars interarticularis. (Right) Because of the pars fracture, only the front part of the bone slips forward.

What are the different types of spondylolisthesis?

Many types of spondylolisthesis can affect adults. The two most common types are degenerative and spondylolytic. There are other less common types of spondylolisthesis, such as slippage caused by a recent, severe fracture or a tumor.

What is degenerative spondylolisthesis?

As we age, general wear and tear causes changes in the spine. Intervertebral discs begin to dry out and weaken. They lose height, become stiff, and begin to bulge. This disc degeneration is the start to both arthritis and degenerative spondylolisthesis (DS).

As arthritis develops, it weakens the joints and ligaments that hold your vertebrae in the proper position. The ligament along the back of your spine (ligamentum flavum) may begin to buckle. One of the vertebrae on either side of a worn, flattened disc can loosen and move forward over the vertebra below it. This can narrow the spinal canal and put pressure on the spinal cord. This narrowing of the spinal canal is called spinal stenosis and is a common problem in patients with DS.

Women are more likely than men to have DS, and it is more common in patients who are older than 50. A higher incidence has been noted in the African-American population.

What is spondylolytic spondylolisthesis?

One of the bones in your lower back can break and this can cause a vertebra to slip forward. The break most often occurs in the area of your lumbar spine called the pars interarticularis.

In most cases of spondylolytic spondylolisthesis, the pars fracture occurs during adolescence and goes unnoticed until adulthood. The normal disc degeneration that occurs in adulthood can then stress the pars fracture and cause the vertebra to slip forward. This type of spondylolisthesis is most often seen in middle-aged men.

Because a pars fracture causes the front (vertebra) and back (lamina) parts of the spinal bone to disconnect, only the front part slips forward. This means that narrowing of the spinal canal is less likely than in other kinds of spondylolisthesis, such as DS in which the entire spinal bone slips forward.

What are the symptoms of degenerative spondylolisthesis?

Patients with DS often visit the doctor's office once the slippage has begun to put pressure on the spinal nerves. Although the doctor may find arthritis in the spine, the symptoms of DS are typically the same as symptoms of spinal stenosis. For example, DS patients often develop leg and/or lower back pain. The most common symptoms in the legs include a feeling of vague weakness associated with prolonged standing or walking.

Leg symptoms may be accompanied by numbness, tingling, and/or pain that is often affected by posture. Forward bending or sitting often relieves the symptoms because it opens up space in the spinal canal. Standing or walking often increases symptoms.

What are the symptoms of spondylolytic spondylolisthesis?

Most patients with spondylolytic spondylolisthesis do not have pain and are often surprised to find they have the slippage when they see it in x-rays. They typically visit a doctor with low back pain related to activities. The back pain is sometimes accompanied by leg pain.

How is a spondylolisthesis diagnosed?

Doctors diagnose both DS and spondylolytic spondylolisthesis using the same examination tools.

After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side- to-side to look for limitations or pain.

Other tests which may help your doctor confirm your diagnosis include:

X-rays. These tests visualize bones and will show whether a lumbar vertebra has slipped forward. X-rays will show aging changes, like loss of disc height or bone spurs. X-rays taken while you lean forward and backward are called flexion-extension images. They can show instability or too much movement in your spine.

Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, discs, nerves, and the spinal cord. It can show more detail of the slippage and whether any of the nerves are pinched.

Computed tomography (CT). These scans are more detailed than x-rays and can create cross-section images of your spine.

How is spondylolisthesis treated without surgery?

Although nonsurgical treatments will not repair the slippage, many patients report that these methods do help relieve symptoms.

Physical therapy and exercise . Specific exercises can strengthen and stretch your lower back and abdominal muscles.

Medication . Pain killers and non-steroidal anti-inflammatory medicines may relieve pain.

Steroid injections . Cortisone is a powerful anti-inflammatory. Cortisone injections around the nerves or in the "epidural space" can decrease swelling, as well as pain. It is not recommended to receive these, however, more than three times per year. These injections are more likely to decrease pain and numbness, but will not relieve weakness of the legs.

When should someone with degenerative spondylolisthesis be treated with surgery?

Patients should consider surgery for degenerative spondylolisthesis if they have tried the nonsurgical treatments for 3 to 6 months with no improvement.

Before committing to surgery, your provider will take a close look at the extent of the arthritis in your spine and whether your spine has excessive movement.

DS patients who are candidates for surgery are usually not able to walk or stand, and have a poor quality of life due to the pain and weakness.

When should someone with spondylolytic spondylolisthesis be treated with surgery?

Patients should consider surgery for spondylolytic spondylolisthesis if they have tried the nonsurgical treatments for at least 6 to 12 months with no improvement.

If the slippage is getting worse or the patient has progressive neurologic symptoms, such as weakness, numbness, or falling, and/or symptoms of cauda equina syndrome, surgery may help.

How is spondylolisthesis treated with surgery?

Surgery for both DS and spondylolytic spondylolisthesis includes removing the pressure from the nerves and spinal fusion.

Removing the pressure involves opening up the spinal canal. This procedure is called a laminectomy. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

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What Is Spondylolisthesis?

Types of spondylolisthesis, frequently asked questions.

Spondylolisthesis is a condition in which a vertebra in the lumbar (lower) spine slips out of normal position, sliding forward (or sometimes backward) relative to the vertebra beneath it. It can be the result of an injury, lower back stress associated with sports, or age-related changes in the spine.

Depending on the extent of movement of the vertebra involved, symptoms can range from none at all to severe pain caused by pressure on a  spinal nerve .

Spondylolisthesis usually is diagnosed with an X-ray . Low-grade spondylolisthesis may be relieved with non-invasive measures, while more severe cases may require a surgical procedure.

Hero Images / Digital Vision / Getty Images

The vertebrae are the box-shaped bones stacked on top of each other that make up the spinal column. Each vertebra should be neatly stacked on the one above and below. The spinal column has a normal S-shaped curvature when viewed from the side, but each vertebra should be neatly positioned on top of the vertebra below.

In spondylolisthesis, the vertebrae shift from their normal position. As a result, the condition is often referred to as "slipped vertebrae." Forward slippage is called anterolisthesis and backward slippage is called retrolisthesis .

Most often, this is a very slowly progressive condition with different types that include:

• Isthmic spondylolisthesis:  This results from spondylolysis, a condition that leads to small stress fractures (breaks) in the vertebrae. In some cases, the fractures weaken the bone so much that it slips out of place.
• Degenerative spondylolisthesis:  Degenerative spondylolisthesis is related to spine changes that tend to occur with age. For example, the discs can start to dry up and become brittle; as this occurs, they shrink and may bulge. Spinal arthritis is another age-related condition. Degenerative spondylolisthesis can cause  spinal stenosis , in which the bones narrow and put pressure on the spinal cord.
• Congenital spondylolisthesis:  Congenital spondylolisthesis results from abnormal bone formation that is present from birth, leaving the vertebrae vulnerable to slipping.

Less common forms of the condition include:

• Traumatic spondylolisthesis:  With this, a spinal fracture or vertebral slipping occurs due to injury.
• Pathological spondylolisthesis:  In this case, spondylolisthesis occurs due to another disease, such as  osteoporosis , a tumor, or an infection.
• Post-surgical spondylolisthesis:  This occurs when spine surgery results in slippage of the vertebrae.

Many people with spondylolisthesis have no obvious symptoms. Sometimes the condition is not discovered until an X-ray is taken for an unrelated injury or condition.

The most common symptom is lower back pain that can radiate to the buttocks and down the backs of the thighs. The symptoms may get worse during activity and subside during rest. Specifically, you may find that symptoms disappear when you bend forward or sit and get worse when you stand or walk.

This is because sitting and bending open up the space where spinal nerves are located, relieving pressure. Other potential symptoms include:

• Muscle spasms
• Tight hamstrings (muscles in the back of the thigh)
• Difficulty walking or standing for a long period of time
• Changes in gait

Severe or high-grade slips may result in pressure on a nearby spinal nerve root, causing tingling, numbness, or weakness in one or both legs.

Children involved in sports such as gymnastics, football, and diving tend to be at an increased risk for isthmic spondylolisthesis. These sports require repeated spinal hyperextension , which can cause a stress fracture of the pars interarticularis in the L5 vertebra.

Unless the hyperextension exercises are stopped to give the bone time to heal, scar tissue can form and prevent the bones from ever healing properly. This can lead to spondylolysis or stress fractures in the pars interarticularis, a condition that commonly leads to spondylolisthesis.

It's possible to be born with spondylolysis or spondylolisthesis, but both conditions can also develop from an injury, a disease, or a tumor.

Genetics may play a role in the risk of spondylolisthesis. There have been higher reports of spondylolisthesis in certain ethnic groups, namely Inuit Eskimos and Black Americans assigned female at birth .

Degenerative spondylolisthesis, the most common type, tends to affect adults over the age of 40. Older age, female gender, being overweight or obese, and conditions that can affect the spine, such as degenerative disc disease (DDD) and osteoarthritis , are thought to be factors that elevate the risk for this condition.

A healthcare professional will first talk to you and/or your child about symptoms, medical history, general health, and any participation in sports or physical activities. Then, they will examine the spine, looking for areas of tenderness or muscle spasms, and assess whether there are problems with gait or posture.

Next, your practitioner may order imaging studies, including:

• X-rays: These help distinguish between spondylolysis and spondylolisthesis. An X-ray taken from the side is also used to assign a grade between I and V, based on the severity of the slippage.
• Computed tomography (CT) scans :  These provide greater detail than X-rays and help a healthcare professional prescribe the most appropriate treatment.
• Magnetic resonance imaging (MRI) scans :  An MRI focuses on the body's soft tissues and can reveal damage to the intervertebral disks between the vertebrae or compression of spinal nerve roots.

There are five spondylolisthesis grades, each representing an incremental 25% increase of slippage in the vertebra.

Spondylolisthesis is treated according to the grade. For grades I and II, conservative treatments are often sufficient, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, physical therapy, home exercises, stretching, and the use of a brace.  In physical therapy,  core strengthening and stabilization  exercises are emphasized.

Over the course of treatment, periodic X-rays may be taken to determine whether the vertebra is changing position.

For high grades or progressive worsening,  spinal fusion surgery  may be recommended. During this procedure, the affected vertebrae are fused together so that they heal into a single, solid bone.

During the procedure, the surgeon will realign the vertebrae in the lumbar spine. Small pieces of bone—called a bone graft—are then placed into the spaces between the vertebrae to be fused. Over time, the bones grow together, much like when a broken bone heals. Metal screws and rods may be installed to further stabilize the spine and improve the chances of successful fusion.

In some cases, patients with high-grade slippage also have compression of the spinal nerve roots. If this is the case, a procedure known as spinal decompression can help open up the spinal canal and relieve pressure on the nerves.

Spondylolisthesis is a spine condition in which a vertebra slips out of position. This may cause symptoms like low back pain and back stiffness. Young athletes are often at increased risk for spondylolisthesis as overextending the spine—which commonly happens in sports like football and gymnastics—is one of the most common causes of the condition.

To diagnose spondylolisthesis, a healthcare professional will review a person's symptoms and medical history, and they'll use imaging tests like X-rays and CT scans to analyze the spine and determine the severity, or grade, of the problem.

Lower-grade cases of spondylolisthesis typically respond well to conservative treatment like anti-inflammatory medication and physical therapy, while higher-grade cases may require surgery.

In most cases, it's possible to resume activities, including sports, once the condition has been treated. If symptoms reappear after treatment, tell a healthcare provider so that they can determine what strategies are needed to relieve them and restore your quality of life.

Spondylosis is a condition in which there is a stress fracture or weakness in a vertebra. Spondylolisthesis occurs when a vertebra slips out of position. Spondylosis may lead to spondylolisthesis, as a fracture in a vertebra may cause it to slip.

If you have spondylolisthesis, you may qualify for disability insurance if symptoms are severe and greatly impact your quality of life.

Those with spondylolisthesis should avoid movements that put great stress on the spine, such as lifting heavy objects. They should also avoid participating in sports that can lead to overtwisting or overextending the spine, like gymnastics and wrestling, until after treatment.

Cleveland Clinic. Spondylolisthesis .

Cedars Sinai. Spondylolisthesis .

American Academy of Orthopaedic Surgeons.  Spondylolysis and spondylolisthesis .

NYU Langone Health. Diagnosing spondylolisthesis in adults .

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. doi:10.1016/j.jot.2016.11.001

Tedyanto EH. Relationship between body mass index and radiological features of spondylolisthesis . International Journal of Science and Research. 2020;9(2):2319-7064. doi:10.21275/SR20215210921

Koslosky E, Gendelberg D. Classification in brief: The Meyerding classification system of spondylolisthesis . Clin Orthop Relat Res . 2020;478(5):1125-1130. doi:10.1097/CORR.0000000000001153

American Academy of Orthopaedic Surgeons. Spinal fusion .

Cleveland Clinic. Spondylolysis .

By Jonathan Cluett, MD Dr. Cluett is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the U.S. national soccer teams.

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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• Degenerative Spondylolisthesis Treatment

By: Marco Funiciello, DO, Physiatrist

Peer-Reviewed

As a general guideline, nonsurgical treatments are tried first for managing degenerative spondylolisthesis. 

If a medical emergency , such as bowel or bladder incontinence is present, surgical management is considered.  

Nonsurgical treatments are essentially divided into 6 categories, and depending on the grade of spondylolisthesis and the severity of signs and symptoms, a combination of treatments may be used.  

In This Article:

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

Degenerative Spondylolisthesis Video

Rest and pain-relieving medication.

Your user agent does not support the HTML5 Video element.

A short video showing calming effect of NSAIDs on lower back pain.

NSAIDs provide anti-inflammatory effects and help reduce radiating pain.

During the initial stages of the condition, physicians generally advise relative rest for 1-2 days and a short course of over-the-counter (OTC) and/or prescription medication to relieve symptoms. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

Common oral medications that may help manage degenerative spondylolisthesis signs and symptoms are 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383. , 2 Ko S, Kim S, Kim J, Oh T. The Effectiveness of Oral Corticosteroids for Management of Lumbar Radiating Pain: Randomized, Controlled Trial Study. Clin Orthop Surg. 2016 Sep;8(3):262-7. doi: 10.4055/cios.2016.8.3.262. Epub 2016 Aug 10. PMID: 27583108; PMCID: PMC4987309. :

• Acetaminophen  
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Aspirin 
• Opioids and muscle relaxants 
• Nerve pain medications such as gabapentin or pregabalin 
• Oral steroids

Since most individuals with degenerative spondylolisthesis belong to the older age group, medications such as NSAIDs are avoided due to the potential risk of gastrointestinal irritation. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

If it is necessary to take an NSAID, cyclooxygenase (COX)-2 selective agents, such as celecoxib, may be prescribed as they cause less gastrointestinal irritation. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

Before taking any medication checking liver and kidney function is advisable. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

Read more about Medications for Back Pain and Neck Pain

Physical Therapy for Degenerative Spondylolisthesis

Flexion-based exercises strengthen and stabilize the soft tissues of the spine.

Physical therapy for degenerative spondylolisthesis includes a focus on carefully and progressively strengthening and stabilizing the lower back through flexion-based and strengthening exercises. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

See Lumbar Spine Stabilization Exercises

The goals of physical therapy and exercise in treating degenerative spondylolisthesis are to 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383. :

• Reduce pain 
• Improve range of motion 
• Strengthen and stabilize the soft tissues of the spine 
• Improve function and endurance

Physical therapy typically starts under the guidance of a physical therapist followed by a longer-term home program.

See Physical Therapy for Low Back Pain Relief

Spinal Manipulation for Degenerative Spondylolisthesis

Studies have shown short-term improvement in degenerative spondylolisthesis pain through manual manipulation provided by appropriately trained health professionals. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

Read Understanding Spinal Manipulation

Lumbar Bracing for Degenerative Spondylolisthesis

A lumbar brace may help stabilize the spine and relieve lower back pain.

The use of a lumbosacral brace or corset has been shown to improve degenerative spondylolisthesis symptoms while walking and performing daily activities. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

A brace also limits spinal rotation, which may help people who have pain due to impingement of spinal nerves as they exit the spine (foraminal stenosis). 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

See Using a Back Brace for Lower Back Pain Relief

Epidural Steroid Injections for Degenerative Spondylolisthesis

Longitudinal section of vertebral spine showing epidural space.

Epidural injections relieve inflammation and improve function in the lower back and legs.

Epidural steroid injections deliver a corticosteroid medication, such as methylprednisolone, around the cauda equina nerves and spinal nerve roots in the lower spine. These injections aim to relieve severe pain, especially leg pain related to radiculopathy and neurogenic claudication, and improve function in the lower back and legs. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

Studies have shown that epidural steroid injections are effective in reducing pain and increasing lower back function in almost 50% of people with degenerative spondylolisthesis. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

The length of time that a lumbar epidural injection can be effective is variable. The treatment may provide no benefit, short- or long-term benefit. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

See Epidural Steroid Injections: Risks and Side Effects

Epidural steroid injections may provide a good alternative to surgery in older individuals with other medical conditions. 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.

Activity Modification

Modifying certain types of daily activities can help take pressure off the spinal nerve roots in the degenerated segment. If activity modification substantially reduces the pain and symptoms, it could serve as an acceptable way to manage degenerative spondylolisthesis in the long term. 

Activity modification for degenerative spondylolisthesis generally includes:

• Avoiding standing or walking for long periods
• Avoiding activities that require bending backward

Simple self-care can assist in this approach, such as the application of cold packs or heating pads and/or taking over-the-counter pain relievers before walking or doing any strenuous activity.

For individuals who prefer to be more active, stationary biking is a reasonable option, as exercise in the sitting position is typically more tolerable. Another option is  pool therapy  – exercising in a swimming pool. The buoyancy of the water supports the body’s weight and creates an environment to exercise with less stress on the joints and muscles.

• 1 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar;17(3):327-335. doi: 10.1007/s00586-007-0543-3. Epub 2007 Nov 17. PMID: 18026865; PMCID: PMC2270383.
• 2 Ko S, Kim S, Kim J, Oh T. The Effectiveness of Oral Corticosteroids for Management of Lumbar Radiating Pain: Randomized, Controlled Trial Study. Clin Orthop Surg. 2016 Sep;8(3):262-7. doi: 10.4055/cios.2016.8.3.262. Epub 2016 Aug 10. PMID: 27583108; PMCID: PMC4987309.

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

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.

Steven Tenny ; Andrew Hanna ; Christopher C. Gillis .

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Last Update: May 22, 2023 .

• Continuing Education Activity

Spondylolisthesis is a condition that occurs when one vertebral body slips with respect to the adjacent vertebral body causing radicular or mechanical symptoms or pain. It is graded based on the degree of slippage of one vertebral body on the adjacent vertebral body. Any pathological process that can weaken the supports keeping vertebral bodies aligned can allow spondylolisthesis to occur. This activity illustrates the evaluation and management of spondylolisthesis and reviews the role of the interprofessional team in improving care for patients with this condition.

• Describe the pathophysiology of spondylolisthesis.
• Review the workup of a patient with spondylolisthesis.
• Summarize the treatment options for spondylolisthesis.
• Describee the importance of collaboration and communication among the interprofessional team in encouraging weight loss in patients to reduce symptoms and increase the quality of life in those with spondylolisthesis.
• Introduction

Spondylolisthesis is the slippage of one vertebral body with respect to the adjacent vertebral body causing mechanical or radicular symptoms or pain. It can be due to congenital, acquired, or idiopathic causes. Spondylolisthesis is graded based on the degree of slippage of one vertebral body on the adjacent vertebral body. [1]

Spondylolisthesis commonly classifies as one of five major etiologies: degenerative, isthmic, traumatic, dysplastic, or pathologic. Degenerative spondylolisthesis occurs from degenerative changes in the spine without any defect in the pars interarticularis. It is usually related to the combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body relative to the adjacent vertebral body. Isthmic spondylolisthesis results from defects in the pars interarticularis. The cause of isthmic spondylolisthesis is undetermined, but a possible etiology includes microtrauma in adolescence related to sports such as wrestling, football, and gymnastics, where repeated lumbar extension occurs. Traumatic spondylolisthesis occurs after fractures of the pars interarticularis or the facet joint structure and is most common after trauma. Dysplastic spondylolisthesis is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment.  In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation. Pathologic spondylolisthesis can be from systemic causes such as bone or connective tissue disorders or a focal process, including infection, neoplasm, or iatrogenic origin. Additional risk factors for spondylolisthesis include a first-degree relative with spondylolisthesis, scoliosis, or occult spina bifida at the S1 level. [1]

• Epidemiology

Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the cervical spine and rarely, except for trauma, in the thoracic spine. Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese. Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males. Dysplastic spondylolisthesis is more common in the pediatric population, with females more commonly affected than males. Current estimates for prevalence are 6 to 7% for isthmic spondylolisthesis by the age of 18 years, and up to 18% of adult patients undergoing MRI of the lumbar spine. Grade I spondylolisthesis accounts for 75% of all cases. Spondylolisthesis most commonly occurs at the L5-S1 level with an anterior translation of the L5 vertebral body on the S1 vertebral body. The L4-5 level is the second most common location for spondylolisthesis. 

• Pathophysiology

Any process that can weaken the supports keeping vertebral bodies aligned can allow spondylolisthesis to occur. As one vertebra moves relative to the adjacent vertebrae, local pain can occur from mechanical motion or radicular or myelopathic pain can occur due to compression of the exiting nerve roots or spinal cord, respectively. Pediatric patients are more likely to increase spondylolisthesis grade when going through puberty. Older patients with lower grades I or II spondylolistheses are less likely to progress to higher grades over time.

• History and Physical

Patients typically have intermittent and localized low back pain for lumbar spondylolisthesis and localized neck pain for cervical spondylolisthesis. The pain is exacerbated by flexing and extending at the affected segment, as this can cause mechanic pain from motion. Pain may be exacerbated by direct palpation of the affected segment. Pain can also be radicular in nature as the exiting nerve roots become compressed due to the narrowing of nerve foramina as one vertebra slips on the adjacent vertebrae, the traversing nerve root (root to the level below) can also be impinged through associated lateral recess narrowing, disc protrusion, or central stenosis. Pain can sometimes improve in certain positions such as lying supine. This improvement is due to the instability of the spondylolisthesis that reduces with supine posture, thus relieving the pressure on the bony elements as well as opening the spinal canal or neural foramen. Other symptoms associated with lumbar spondylolisthesis include buttock pain, numbness, or weakness in the leg(s), difficulty walking, and rarely loss of bowel or bladder control.

Anteroposterior and lateral plain films, as well as lateral flexion-extension plain films, are the standard for the initial diagnosis of spondylolisthesis. One is looking for the abnormal alignment of one vertebral body to the next as well as possible motion with flexion and extension, which would indicate instability. In isthmic spondylolisthesis, there may be a pars defect, which is termed the "Scotty dog collar." The "Scotty dog collar" shows a hyperdensity where the collar would be on the cartoon dog, which represents the fracture of the pars interarticularis. Computed tomography (CT) of the spine provides the highest sensitivity and specificity for diagnosing spondylolisthesis. Spondylolisthesis can be better appreciated on sagittal reconstructions as compared to axial CT imaging. MRI of the spine can show associated soft tissue and disc abnormalities, but it is relatively more challenging to appreciate bony detail and a potential pars defect on MRI. [2] [3]

• Treatment / Management

For grade I and II spondylolisthesis, treatment typically begins with conservative therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), heat, light exercise, traction, bracing, and/or bed rest. Approximately 10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment and need surgical treatment. No definitive standards exist for surgical treatment. Surgical treatment includes a varying combination of decompression, fusion with or without instrumentation, or interbody fusion. Patients with instability are more likely to require operative intervention.  Some surgeons recommend a reduction of the spondylolisthesis if able as this not only decreases foraminal narrowing but also can improve spinopelvic sagittal alignment and decrease the risk for further degenerative spinal changes in the future. The reduction can be more difficult and riskier in higher grades and impacted spondylolisthesis. [4] [5] [6] [7] [8] [2] [9] [10]

• Differential Diagnosis
• Degenerative  Lumbar Disc Disease
• Lumbar Disc Problems
• Lumbosacral Disc Injuries
• Lumbosacral Discogenic Pain Syndrome
• Lumbosacral Facet Syndrome
• Lumbosacral Radiculopathy
• Lumbosacral Spine Acute Bony Injuries
• Lumbosacral Spondylosis
• Myofascial Pain in Athletes
• Pearls and Other Issues

Meyerding’s classification of spondylolisthesis is the most commonly used grading method. Its basis is on the percentage of anterior translation relative to the adjacent level. Grade I spondylolisthesis is 1 to 25% slippage, grade II is up to 50% slippage, grade III is up to 75% slippage, and grade IV is 76-100% slippage. If there is more than 100% slippage, it is known as spondyloptosis or grade V spondylolisthesis.  

Subclasses of isthmic spondylolisthesis are subtype A (stress fractures of the pars), subtype B (elongation of the pars without overt fracture), subtype C (acute fracture of the pars).

Subclasses of pathologic spondylolisthesis are subtype A (systemic causes) and subtype B (focal processes).

• Enhancing Healthcare Team Outcomes

An interprofessional team consisting of a specialty-trained orthopedic nurse, a physical therapist, and an orthopedic surgeon or neurosurgeon will provide the best outcome and long-term care of patients with degenerative spondylolisthesis. Chiropractors may also have involvement, as they may be the first to encounter the condition on X-rays. The treating clinician will decide on the management plan, and then have the other team members engaged - surgical cases with include the nursing staff in pre-, intra-, and post-operative care, and coordinating with PT for rehabilitation. In non-operative cases, the PT will keep the rest of the team informed of progress or lack thereof. The team should encourage weight loss as weight reduction may reduce symptoms and increase the quality of life. Interprofessional collaboration, as above, will drive patient outcomes to their best results. [Level 5]

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• Access free multiple choice questions on this topic.
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Grade II Spondylolisthesis, CT. Lumbar spine sagittal CT of L5-S1 revealing grade II spondylolisthesis. Contributed by C Gillis, MD, and S Tenny, MD

Disclosure: Steven Tenny declares no relevant financial relationships with ineligible companies.

Disclosure: Andrew Hanna declares no relevant financial relationships with ineligible companies.

Disclosure: Christopher Gillis 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 Tenny S, Hanna A, Gillis CC. Spondylolisthesis. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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chronic pain health center / chronic pain a-z list / spondylolisthesis article

Spondylolisthesis

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

What is spondylolisthesis?

What causes spondylolisthesis, what are the risk factors for spondylolisthesis, what are the symptoms of spondylolisthesis, diagnosis and grading of spondylolisthesis, what is treatment and surgery for spondylolisthesis, what are the complications of spondylolisthesis, what is the prognosis for spondylolisthesis, is it possible to prevent spondylolisthesis.

Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a condition of the spine whereby one of the vertebra slips forward or backward in relation to the next vertebra. Forward slippage of an upper vertebra on a lower vertebra is referred to as anterolisthesis, while backward slippage is referred to as retrolisthesis. Spondylolisthesis can lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis). Spondylolisthesis is most common in the low back (lumbar spine) but can also occur in the mid to upper back (thoracic spine) and neck (cervical spine).

There are five major types of lumbar spondylolisthesis.

• Dysplastic spondylolisthesis : Dysplastic spondylolisthesis is caused by a defect in the formation of part of the vertebra called the facet that allows it to slip forward. This is a condition that a patient is born with (congenital).
• Isthmic spondylolisthesis : In isthmic spondylolisthesis, there is a defect in a portion of the vertebra called the pars interarticularis. If there is a defect without a slip, the condition is called spondylolysis. Isthmic spondylolisthesis can be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions, including gymnasts and football linemen.
• Degenerative spondylolisthesis : Degenerative spondylolisthesis occurs due to arthritic changes in the joints of the vertebrae due to cartilage degeneration and is acquired later in life. Degenerative spondylolisthesis is more common in older patients.
• Traumatic spondylolisthesis : Traumatic spondylolisthesis is due to direct trauma or injury to the vertebrae. This can be caused by a fracture of the pedicle, lamina, or facet joints that allows the front portion of the vertebra to slip forward with respect to the back portion of the vertebra.
• Pathologic spondylolisthesis : Pathologic spondylolisthesis is caused by a defect in the bone caused by abnormal bone, such as from a tumor.

Risk factors for spondylolisthesis include a family history of back problems. People who are born with a defect in the pars interarticularis bone in the spine (a condition called spondylolysis) are at increased risk of isthmic spondylolisthesis. Other risk factors include a history of repetitive trauma or hyperextension of the lower back or lumbar spine. Athletes such as gymnasts, weight lifters, and football linemen who have large forces applied to the spine during extension are at greater risk for developing isthmic spondylolisthesis.

The most common symptom of spondylolisthesis is lower back pain . This is often worse after exercise especially with extension of the lumbar spine. Other symptoms include tightness of the hamstrings, and stiffness and decreased range of motion of the lower back. Pain in the legs, thighs, and buttocks may worsen with standing. Some patients can develop pain , numbness, tingling, or weakness in the legs due to nerve compression . Severe compression of the nerves can cause loss of control of bowel or bladder function, or cauda equina syndrome .

Radiologists diagnose spondylolisthesis using X-rays , CAT scans, or MRI scans. Orthopedic surgeons, neurosurgeons specializing in the spine, physical medicine and rehabilitation doctors, neurologists, internists, primary-care providers, and rheumatologists commonly treat spondylolisthesis. Chiropractors and physical therapists also frequently treat patients with spondylolisthesis.

Usually, it is not possible to see visible signs of spondylolisthesis by examining a patient. Patients typically have complaints of pain in the back with intermittent pain to the legs. Spondylolisthesis can often cause muscle spasms , or tightness in the hamstrings.

The diagnosis of spondylolisthesis is easily made using plain radiographs. A lateral X-ray (from the side) will show if one of the vertebra has slipped forward compared to the adjacent vertebrae. Spondylolisthesis is graded according the percentage of slip of the vertebra compared to the neighboring vertebra.

• Grade I is a slip of up to 25%.
• Grade II is between 26%-50%.
• Grade III is between 51%-75%.
• Grade IV is between 76%-100%.
• Grade V, or spondyloptosis, occurs when the vertebra has completely fallen off the next vertebra.

If the patient has complaints of pain, numbness, tingling, or weakness in the legs, additional studies may be ordered. These symptoms could be caused by stenosis, or narrowing of the space for the nerve roots to the legs. A CT scan or MRI scan can help identify compression of the nerves associated with spondylolisthesis. Occasionally, a PET scan can help determine if the bone at the site of the defect is active. This can play a role in treatment options for spondylolisthesis as described below.

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The initial treatment for spondylolisthesis is conservative and based on the symptoms.

• A short period of rest or avoiding activities such as lifting and bending and athletics may help reduce symptoms.
• Physical therapy can help to increase range of motion of the lumbar spine and hamstrings as well as strengthen the core abdominal muscles.
• Anti-inflammatory medications can help reduce pain by decreasing the inflammation of the muscles and nerves.
• Patients with pain, numbness, and tingling in the legs may benefit from an epidural steroid (cortisone) injection.
• Patients with isthmic spondylolisthesis may benefit from a hyperextension brace. This extends the lumbar spine, bringing the two portions of the bone at the defect closer together, and may allow for healing to occur.
• Home remedies for spondylolisthesis are similar to those for low back pain and include ice, heat, and over-the-counter analgesics such as acetaminophen ( Tylenol ) and anti-inflammatory medications.

For those whose symptoms fail to improve with conservative treatment, surgery may be an option. The type of surgery is based on the type of spondylolisthesis. Patients with isthmic spondylolisthesis may benefit from a repair of the defective portion of the vertebra, or a pars repair. If an MRI scan or PET scan shows that the bone is active at the site of the defect, it is more likely to heal with a pars repair. This involves removing any scar tissue from the defect and placing some bone graft in the area followed by placement of screws across the defect.

If there are symptoms in the legs, the surgery may include a decompression to create more room for the exiting nerve roots. This is often combined with a fusion that may be performed either with or without screws to hold the bone together. In some cases, the vertebrae are moved back to the normal position prior to performing the fusion, and in others the vertebrae are fused where they are after the slip. There is some increased risk of injury to the nerve with moving the vertebra back to the normal position. Outcomes and recovery after surgery are improved with physical therapy rehabilitation.

Complications of spondylolisthesis include chronic pain in the lower back or legs, as well as numbness, tingling or weakness in the legs. Severe compression of the nerve can cause problems with bowel or bladder control, but this is very uncommon.

The prognosis for patients with spondylolisthesis is good. Most patients respond well to a conservative treatment plan. For those with continued severe symptoms, surgery can help alleviate the leg symptoms by creating more space for the nerve roots. The back pain can be helped through a lumbar fusion.

Spondylolisthesis cannot be completely prevented. Certain activities, such as gymnastics, weight-lifting, and football, are known to increase the stress on the vertebrae and increase the risk of developing spondylolisthesis.

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What Are the Causes of Spondylosis?

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 a Latin term meaning slipped vertebral body (spinal bone).

“Spondylo”= vertebrae “listhesis”=slippage

Spondylolisthesis in the lumbar spine is most commonly caused by degenerative spinal disease (degenerative spondylolisthesis), or a defect in one region of a vertebra (isthmic spondylolisthesis).

ON THIS PAGE

• What are the types of spondylolisthesis?
• Which type is most common?

WHAT ARE THE TYPES OF SPONDYLOLISTHESIS?

Spondylolisthesis can be classified by into five groups (newman (1976)):.

• Group 1: dysplastic
• Group 2: isthmic
• Group 3: traumatic
• Group 4: degenerative
• Group 5: pathological

WHICH TYPE IS MOST COMMON?

Degenerative spondylolisthesis is very common, and occurs as a result of due to degeneration or wear and tear of the intervertebral discs and ligaments. Osteoarthritis of the facet joints can also play an important role in the development of instability and slippage. Degenerative spondylolisthesis usually occurs in people over 60 years of age.

In degenerative spondylolisthesis, what usually happens is that ongoing degeneration weakens the facet joints and disc, and (typically) the L4 vertebral body slips forward on the L5 vertebral body. Under normal circumstances, the L4-L5 segment is the one in the lumbar spine with the most movement. It is therefore most likely to slip when this process occurs. The next most common levels affected by degenerative spondylolisthesis are L3-L4 and L5-S1.

Isthmic spondylolisthesis occurs most often at L5-S1, and is more often seen in younger adults than degenerative spondylolisthesis. The cause is a defect in an important bridge bone (the pars interarticularis) of L5.

HOW IS SPONDYLOLISTHESIS GRADED?

Spondylolisthesis is graded according to the severity of the slippage. This is known as the Mayerding classification:

• Grade 1: <25% slip
• Grade 2: 25-50% slip
• Grade 3 50-75% slip
• Grade 4: 75-100% slip

When one vertebra slips entirely off the one below (>100% slip), this is known as spondyloptosis (see picture).

Spondylolisthesis doesn’t usually have any symptoms. In fact, it is commonly seen on X-rays and CT scans as an ‘incidental’ finding. It may, however, produce significant symptoms and disability.

Back pain is the most common symptom of spondylolisthesis. This pain is typically worse with activities such as bending and lifting, and often eases when lying down.

As the spine attempts to stabilise the unstable segment, the facet joints enlarge and place pressure on the nerve root causing lumbar spinal stenosis and lateral recess stenosis.

As one bone slips forward on the other, a narrowing of the intervertebral foramen may also occur (foraminal stenosis). Severe nerve compression can therefore occur with pain, numbness and weakness in the legs. Sometimes loss of control of the bladder and/or bowels can occur due to pressure on the nerves going to these important structures.

Imaging studies including MRI and CT can show a slip, as well as narrowing (stenosis) or compressed nerves in the spinal canal.

The CT and MRI scans are usually obtained with the patient lying flat, however sometimes a slip may only be obvious when standing or bending forwards. This is why your neurosurgeon or spinal surgeon will sometimes obtain flexion, extension and standing X-rays, and occasionally a CT myelogram.

Treatment for spondylolisthesis is similar to treatments for other causes of mechanical and compressive back pain. It is usually non-operative, and surgery is only necessary in a small percentage of patients.

MODIFIED ACTIVITIES

Your specialist may suggest that you modify some of your usual physical activities, this will help to help settle symptoms from mechanical back pain. Special braces are occasionally prescribed to ease back pain. Short periods of bed rest can sometimes help with very painful episodes.

PHYSICAL REHABILITATION

A comprehensive physical rehabilitation program can assist in settling pain and inflammation, as well as improving mobility and strength. A combination of physiotherapy, hydrotherapy and clinical Pilates typically works well and is often recommended. The aims of these physical therapies are to assist you in:

• managing your condition and controlling your symptoms
• correcting your posture and body movements to reduce back strain
• improving your flexibility and core strength

Some patients also benefit from chiropractic treatment osteopathy, remedial massage, and acupuncture.

PSYCHOLOGIST REVIEW

Having a review by a clinical psychologist can be helpful in for creating strategies to manage pain. It is also important to address any associated feelings of depression or anxiety, as these conditions can heighten your experience of pain.

MEDICATIONS

Medication often plays an important role in controlling pain and easing muscle spasms. It can also help you to get back to a normal sleep pattern. Long-term medication usage should be closely supervised as problems such as tolerance and dependence (addiction) are known to occur.

Surgery is only needed only if other non-surgical treatments are not keeping your pain at a manageable level. Surgical treatment for spondylolisthesis need to take into account both mechanical (instability) and compressive (nerve pressure) issues. Nerve pressure usually involves surgical decompression, also known as a decompressive laminectomy. In order to deal with the compressive issues by taking pressure off the nerves, your surgeon may need to remove some or all of one or both facet joints, as well as portions of the lamina.

As the facet joints typically provide stability to the lumbar spine, the spine can spine to become loose and unstable, especially after some slippage has already occurred. A fusion is usually therefore recommended.

Similarly, a fusion is necessary to adequately deal with the mechanical issues of instability in spondylolisthesis.

Six types of fusion surgery are commonly recommended for the treatment of spondylolisthesis, depending upon individual patient factors:

• Transforaminal lumbar interbody fusion (TLIF)
• Posterior lumbar interbody fusion (PLIF)
• Instrumented posterolateral fusion (pedicle screw fixation and posterolateral bone graft)
• Anterior lumbar interbody fusion (carried out through the abdomen, rather than from the back)
• Extracavitatory lateral interbody fusion (XLIF)
• Oblique lateral interbody fusion (OLIF)

Healthcare Services

• Anatomy of the Spine
• Brachialgia (Cervical Radiculopathy)
• Cervical Spinal Stenosis
• Degenerative Disc Disease
• Herniated Disk
• Facet Joint Pain
• Failed Back Surgery
• Lower Back Pain
• Lumbar Spinal Stenosis
• Spinal Tumours
• Trauma (fractures, dislocations, instability)