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Spondylolysis – Spondylolisthesis

What is spondylolysis?

Spondylolysis refers to a fracture of the pars interarticularis of a lumbar vertebra, most commonly at L5. Its prevalence is about 5–10% in the general population and nearly double in athletes.

It is also the most common cause of lower back pain in children, and is usually treated conservatively with bracing, pain medications, physical therapy, and activity modification.

Approximately 25% of spondylolysis cases are associated with spondylolisthesis, which occurs when a vertebra slips or shifts forward over the vertebra below it, most often L5 over S1.

Spondylolisthesis is usually low-grade (first or second degree), but more rarely can be high-grade (third or fourth degree, or complete vertebral displacement called spondyloptosis), which typically requires surgery.

Spondylolisthesis often appears in childhood, usually at the L5–S1 level.

It is classified into two main types:

1. Isthmic spondylolisthesis

2. Degenerative spondylolisthesis

Isthmic Spondylolisthesis

Isthmic spondylolisthesis (along with dysplastic type) appears in childhood, usually at L5–S1.

Dysplastic spondylolisthesisis caused by malformation of L5.
Isthmic spondylolisthesisinvolves a fracture of the posterior elements of the vertebra, most often L5 (this fracture is called spondylolysis). This fracture can then lead to slippage of L5 over S1.

Spondylolysis is a very common condition and is the leading cause of back pain in children. Among Indo-European populations, prevalence is at least 5% (up to 15% in athletic children), and 25% of these patients may eventually develop spondylolisthesis.

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Main Symptoms

1. Spondylolysis is painful, but spondylolisthesis may be painless.

2. If the slip is significant:

– Pain in the buttocks, especially during exercise

– Muscle spasms

– Weakness in the lower limbs

– Tight hamstrings

– Gait disturbances

3. In severe spondylolisthesis, body posture changes, leading to walking with bent knees and hips.

Diagnosis

History of pain related to age and activity is key.
In spondylolysis, symptoms often follow intense athletic activity, with pain localized to the lower back.
Severe slippage presents with a characteristic posture, inability to bend forward, and possible neurological signs (muscle weakness or numbness in legs).

Imaging:

Plain X-raysfor assessing spondylolisthesis and degree of slippage
Advanced imaging(CT, MRI, or SPECT CT) for spondylolysis

Classification of Spondylolisthesis

Traditionally graded from 1 to 4, with 5 indicating complete vertebral displacement (spondyloptosis).

Conservative Treatment

Most cases of spondylolysis, and Grade 1–2 spondylolisthesis, are treated with:

Rest and activity modification
Anti-inflammatory drugs or painkillers
Physical therapy

Surgical Treatment

Surgery is indicated for:

Patients not responding to conservative therapy
Slippage greater than Grade 3
Common procedure: nerve decompression via laminectomyand spinal fusion with instrumentation

Degenerative Spondylolisthesis

What is it?

Degenerative spondylolisthesis is slippage of one vertebra over the one below, usually L4 over L5, due to degeneration of discs and facet joints.
Common in women around 60 years old.

Symptoms

– Pain in the spine, possibly radiating to the buttocks or legs

– Thigh muscle spasms

– Weakness in the legs

– Gait disturbances, possibly intermittent claudication in severe cases

Diagnosis

Similar approach as spinal stenosis: typically discovered incidentally on imaging(X-ray or MRI) during evaluation for the above symptoms.

Conservative Treatment

– Rest and activity limitation

– Anti-inflammatory or pain medications

– Optional lumbar support belt

Degenerative spondylolisthesis is progressive; symptoms worsen over time.

Surgical Treatment

– Indicated when symptoms are not controlled conservatively

– Typical procedure: nerve decompression, with or without spinal fusion

– Mild slips may only require decompression, depending on patient activity level

– Larger degenerative slipsoften require fusion to prevent further progression after decompression

– Candidates for fusion also include patients with severe back painor coexisting scoliosis

Χειρουργός Σπονδυλικής Στήλης

Ο Χειρουργός Σπονδυλικής Στήλης/ Σκολίωσης Δρ. Ηλίας Χαρ. Παπαδόπουλος γεννήθηκε και μεγάλωσε στην Αθήνα. Αποφοίτησε με Άριστα από την Ιατρική Σχολή Αθηνών το 1994 και στη συνέχεια ειδικεύτηκε στην ορθοπαιδική, στην Α’ Ορθοπαιδική Κλινική του Πανεπιστημίου Αθηνών.