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Spondylolisthesis
Spondylolisthesis
Your spine is made up of 24 bones that are known as vertebrae, which are arranged on top of one another. The medical condition known as spondylolisthesis affects the spine’s alignment in the sense that 1 or more of the spine’s bones begin to slip over the edge of the bone below it. These series of small bones that form the spinal column are known as the vertebra. The entire spinal column is comprised of 33 vertebrae. If a vertebra begins to slide forward, the surrounding tissues and nerves can become damaged and cause pain.
What parts of the spine are affected by spondylolisthesis?
The spinal column’s vertebrae are the structures of the spine that are negatively impacted by spondylolisthesis. The lower spine, known as the lumbar spine, is comprised of 5 vertebrae, which are referred to as L1, L2, L3, L4, and L5. The bottommost vertebra of the lumbar spine is L5. These spinal bones are stacked on one another to provide a slight inward curve of the lower back. L5, the last bone in the spine, connects your spinal column to the sacrum, which is the triangular bone that fits between the two pelvic bones.
Each of your spine’s vertebra are formed by a round block of bone that is called the vertebral body. A circular bone connects to the back of the vertebra’s body. This circular bone appears on each vertebrae, creating a hollow tube on the back of the spinal column. This hollow tube forms a protective cover known as the spinal canal. The spinal canal encases the spinal cord. The spinal cord extends to the second vertebra of your lumbar spine. Below L2, the spinal canal encircles a nerve bundle, which runs to the legs and pelvic area.
The spinal canal is made up of 2 sets of bone, including 2 pedicle bones and 2 lamina bones. The area where the pedicle and lamina bones meet is referred to as the pars interarticularis (often referred to as simply pars). The pars are thought to be the weaker portion of the spinal canal. Within the spinal canal is the spinal column. The spinal column is made up of vertebrae, which are separated by discs called intervertebral discs. These discs are designed to absorb shock from falling, jumping, or other activities that place stress on the spine.
The lower spine is sustained by spinal muscles and ligaments. Spinal ligaments connect spinal bones, are layered, and run in several different directions. Thicker ligaments securely anchor the lower spine to the pelvis and sacrum bone. Between each part of the vertebra within the spine, there are 2 facet joints that are positioned along the back of the spinal column. There is 1 facet joint on each side of the spinal column. Facet joints are comprised of bony knobs which align along the back of the spine. These knobs meet and form a joint that attaches the 2 adjacent vertebrae. The facet joints of the lower spine allow a wide range of motion and spinal mobility that permits forward and backward movement.
What causes spondylolisthesis?
It is rare that spondylolisthesis is present at birth. In adults, many cases stem from a spinal injury or spinal degeneration. Children may suffer from spondylolisthesis due to an accident; whereas older adults may suffer from spondylolisthesis due to wear and tear on the spinal column. Spondylolisthesis stemming from spinal degeneration usually occurs in patients 50 years and older. More common in women than in men, spondylolisthesis due to spinal degeneration often affects the lowest spinal vertebrae (L4 & L5).
In younger adolescents, spondylolisthesis often involves the lowest spinal vertebra (L5). Spondylolisthesis often occurs in the lowest vertebra for several reasons. Primarily, the lower vertebrae are naturally curved so that they are slightly bent forward. Additionally, L5, which connects the spinal column to the sacrum, is tilted even further due to the positioning of the sacrum. These points, combined with the natural effects of gravity, lead to the lower vertebrae being more susceptible to spondylolisthesis.
In a healthy spine, the facet joints of the lower vertebrae can securely hold the bones in place and eliminate the chance of vertebral slipping. If a problem occurs in the facet joints, spinal canal, or spinal discs, the lower vertebrae may begin to slip forward. While spondylolisthesis refers to the spine tilting or slipping forward, a similarly named condition known as spondylolysis can cause the symptoms of spondylolisthesis. Spondylolysis is a defect or fracture within the pars that occurs from repetitive stress or pressure being applied to the spinal column. Spondylolysis often occurs in children and adolescents partaking in sports that require the spine to continually bend backward (gymnastics). A defect in the pars can cause spondylolisthesis to occur. The severity of vertebral slipping is graded on a scale of 1 through 4. Mild slipping is denoted by a 1; moderate slipping is referred to as 2-3; severe vertebral slipping is signified by a 4.
What are the symptoms of spondylolisthesis?
The most common spondylolisthesis symptom is an aching in the lower back or upper buttocks. Spondylolisthesis pain may be worse when bending, standing, or walking. Patients often experience a relief of spondylolisthesis symptoms when they are lying down and resting. Muscle spasms in the lower back and tightening of the hamstring muscle are also possible spondylolisthesis symptoms. When a vertebra slips forward, extra pressure is placed on the nerves. The spinal nerves may be compressed where they exit the spinal canal. Symptoms of a pinched spinal nerve include tingling, reduced reflexes, and weakness in the back and legs.
If the bundle of spinal nerves at the end of your spine are compressed, they can also cause severe symptoms. These spinal nerves travel to the bladder and rectum. When this bundle of nerves is pinched, proper bladder and bowel functions may be disrupted. This can also cause lower back pain, numbness, a sensation of tingling, and radiating pain down the legs.
How can an orthopedist diagnose spondylolisthesis?
The first step to diagnosing spondylolisthesis is to undergo a full physical examination. Dr. Rozbruch may ask you to explain any symptoms you are feeling, what worsens or relieves these symptoms, and other information about your overall health. Dr. Rozbruch may examine your posture and reflexes to better understand your spinal health. An X-ray scan of the lower back is commonly ordered to view the spine in various positions. Spinal X-rays can help Dr. Rozbruch understand which vertebra or vertebrae are slipping forward and may require a spondylolisthesis treatment.
If Dr. Rozbruch still requires additional information, he may order a spinal CAT scan, which can help detect pinched nerves. This CT scan may be performed with myelography, which can detect conditions in the nerves, surrounding tissues, and spinal cord. During this spinal test, contrast dye is administered into the space around the spinal canal. This dye will be picked up during a CT scan and can help improve the overall accuracy of the CAT scan. If additional imaging is still needed, a spinal MRI scan can show a comprehensive view of the spine for the most accurate results.
What nonsurgical spondylolisthesis treatments are available?
The majority of patients suffering from spondylolisthesis due to spinal degeneration do not require spondylolisthesis surgery. Instead, prescription medications may be administered to help reduce the pain and symptoms of spondylolisthesis. Rest is often one of the most successful nonsurgical spondylolisthesis treatments, as your back needs time to heal properly. Resting and limiting strenuous activities can help to relieve the muscle spasms and inflammation.
If you have a pars fracture which is causing your spondylolisthesis, a specialized back brace may be prescribed to reduce spinal movement and promote healing. This back brace may be worn for 2-3 months or until the spine has finished healing. If a bone fracture is detected, a CT scan may help to determine if it is likely to heal without surgery. In cases where it seems it may heal on its own, a back brace is usually prescribed. This is often the case for children and adolescents. After 6-8 weeks of wearing the back brace, additional imaging will be ordered to check if the spine is properly healing. If it is not, Dr. Rozbruch will suggest to no longer wear the brace and attempt a new treatment.
For continuing pain, Dr. Rozbruch may suggest spondylolisthesis injections of an epidural steroid that can dramatically reduce inflammation and swelling. During an epidural steroid injection, medication is administered through a needle into the area around the bundle of spinal nerves. Spondylolisthesis injections may only provide temporary relief from spondylolisthesis symptoms.
If further treatment for spondylolisthesis is needed, physical therapy may be suggested to help manage the pain and inflammation. Physical therapy can help to stretch and strengthen the muscles of the back to reduce painful symptoms. Simple exercises can also help to improve the endurance and control of these spinal muscles. Stretching exercises can help reduce hamstring spasms or tightening. For athletes, your physical therapist may be able to suggest simple modifications to your activity that will allow you to continue your sport but also reduce the risk of future injury.
What spondylolisthesis surgeries are available?
Spondylolisthesis surgery may be required for severe vertebral slipping and recurring pain. If spondylolisthesis does not respond to any nonsurgical treatments, then spondylolisthesis surgery may be suggested. For patients suffering from severe spondylolisthesis symptoms, such as an abnormal walk, worsening nerve function, or a loss of healthy bowel and bladder function, spondylolisthesis surgery may be needed promptly to correct these symptoms. Spondylolisthesis surgeries include laminectomy surgery, spinal fusion, and posterior lumbar interbody fusion.
Laminectomy Surgery
If a slipping vertebra is causing pinched nerves, laminectomy surgery can reduce the pressure on these nerves and provide the spinal nerves with more room to move. This is achieved by surgically removing the lamina bone on the affected vertebra. While a laminectomy is a useful decompression surgery, it is often advised to undergo this surgery in addition to spinal fusion or posterior lumbar interbody fusion for the best results possible.
Spinal Fusion
Spinal fusion surgery is often performed following lamina removal. Spine fusion surgery for spondylolisthesis fuses 2 or more spinal bones together to create 1 larger bone. This fusion of spinal bones restricts the movement of spinal vertebrae, which reduces the slipping that causes spondylolisthesis. Lumbar spinal fusion helps to reduce pain and is often combined with a laminectomy to also ease nerve pressure. Small bone grafts will be harvested from another area of your body, commonly the hip. These bone grafts will be placed over the back of the problematic vertebra or vertebrae. Spinal fusion using only bone grafts is referred to as a spinal fusion without fixation. When spinal fusion surgery uses bone grafts and plates, rods, or screws, it is known as a spinal fusion without instrumentation. Instrumentation is commonly used during spine fusion surgery to ensure the bone graft takes properly and the vertebrae remain securely in place.
Posterior Lumbar Interbody Fusion
Posterior lumbar interbody fusion may be recommended for patients with moderate spondylolisthesis symptoms. During posterior lumbar interbody fusion, the slipping vertebra is fused in both the front and the back of the bone. By fusing the vertebra from the back and the front, Dr. Rozbruch can ensure a higher rate of success for spinal fusion. Dr. Rozbruch will begin this spinal fusion surgery from the back of the spinal column, where he will remove the spinal disc in between the problematic vertebra. A bone graft will then be placed at the back of the spine in the space from the recently removed disc. Instrumentation is often used during this type of spinal fusion surgery.
What should I expect after a nonsurgical spondylolisthesis treatment?
Physical therapy is often recommended in addition to a nonsurgical spondylolisthesis treatment. Dr. Rozbruch may suggest physical therapy for 4-6 weeks to help improve your symptoms of spondylolisthesis. Initially, your physical therapist will be concerned with helping you control any painful symptoms of spondylolisthesis. At this stage in physical therapy, you will be taught various exercises and movements to perform that may help reduce inflammation and discomfort. Learning proper stretching can also vastly improve muscular discomfort in patients who feel sore or like their muscles are cramping or constricting.
Your physical therapy sessions will slowly progress to more strength training and taxing exercises, which can help strengthen the muscles of the lower back. These exercises are specifically designed to limit the possibility of future pain or a flare-up of spondylolisthesis symptoms. At the conclusion of your physical therapy, your physical therapist will design an at-home exercise regimen for you to do to continue improving your spinal health. You will also be taught how to manage your symptoms with exercises if your spondylolisthesis symptoms return or worsen.
What should I expect after spondylolisthesis surgery?
Most patients stay in the hospital for a few days following spondylolisthesis surgery. A back brace may be prescribed to wear while you recover. For patients with severe spondylolisthesis, bed rest may be needed for a period of time following spinal surgery. Following your release from the hospital, physical therapy will also be suggested to recover properly, but patients may have to wait up to 4 months before beginning physical therapy. Physical therapy may last for 6-8 weeks, but some patients may need up to 12 months to fully recover from spondylolisthesis surgery.
How can I learn more about spondylolisthesis and a spondylolisthesis treatment?
To learn more about spondylolisthesis and a spondylolisthesis treatment, please request an appointment online or contact Dr. Rozbruch’s orthopedic office at 917.975.0061. Prior to an office visit, please fill out Dr. Rozbruch’s patient forms to expedite your first visit.