Spondylolisthesis | Spondylolysis | Spondylisis Fusion Alternatives
When an injury, degenerative disc disease, or spinal ligament weakness cause spinal instability to the extent that the vertebrae are unable to maintain their proper position, a vertebra can slip out of place. This can occur on a single level or on multilevels of the spine.
The condition of “slipped disc” or “slipped vertebra,” usually seen in young athletes and women over 40 years old is called by various names and diagnosis labels including degenerative Spondylolisthesis. As new research points out “despite the fact that an absolute indication for this surgery is still unclear, decisions about performing lumbar fusion for degenerative Spondylolisthesis should be undertaken by considering not only the patient’s condition but also the social circumstances, medical insurance system, economic effects, and the surgeon’s preference and experience. “1 In other words if you have good insurance, can take a lot of time off from work, do not need to provide for you or your family. and have been prepared for a long rehabilitation period with compromised quality of life – then you are a good candidate for a surgery recommendation that is unclear and imprecise. Please see my article on exploring options before the Spinal Fusion Surgery.
Many other terms for Spondylolisthesis: What does spondylosis and spondylitis mean?
Other terms are often used to describe the same symptoms of Spondylolisthesis. These are Spondylisis or spondylosis of the spine, what do they mean?
These are sometimes confusing terms that act as a catch all phrase or umbrella term to describe neurological or degenerative or inflammatory disorders caused by spinal defects which can occur in the cervical, thoracic, and lumbar regions. Spinal defects meaning stress fractures from wear and tear and in young athletes from stress on the spine caused by sports. This can also be called isthmic spondylolisthesis – a fracture of the pars interarticularis; a bone which connects the upper and lower facet joints.
The terms can also be linked to degrees of severity such as mild or moderate or advanced spondylisis or severe spondylisis that can cause local or diffuse pain. Sometimes everything is just thrown into one term spondylotic. It is sometimes difficult for the to understand all these definitions.
One problem is when the problem is difficult to understand – patients opt for surgery.
Understanding Lumbar spondylosis
Again we point out how confusing come of these diagnostic labels can be.
The survey consisted of questions designed to assess patient understanding of the role of radiological imaging (MRI for low back pain) in the diagnosis and treatment of low-back and leg pain, and patient perception of the indications for surgical compared with conservative management.
- A total of 121 surveys were included in the analysis. More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms; more than 40% of patients indicated the same for plain radiographs.
- Similarly, a large proportion of patients (33%) believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain.
- Nearly one-fifth of the survey group (17%) also believed that back injections were riskier than back surgery.
These results show that a surprisingly high percentage of patients have misconceptions regarding the diagnosis and treatment of lumbar spondylosis, and that these misconceptions persist in patients with a history of spine surgery.
- Specifically, patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management.
These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance. While these results are preliminary, they highlight a need for improved communication and patient education during surgical consultation for degenerative lumbar spondylosis.
Spondyloliosthesis grading is based on amount of “slippage”
- grade I: 0-25%
- grade II: 26-50%
- grade III: 51-75%
- grade IV: 76-100%
- grade V (spondyloptosis): >100%
Typically grades 1 and 2 are treated successfully with Prolotherapy injections see below.
Unilateral vs. Bilateral Spondylolysis?
In new research, doctors at the Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, South Australia compared surgical versus non-surgical treatments for Spondylolisthesis.3
Historically, spondylolysis injuries were thought to be mostly bilateral (both sides of vertebrae) ; however advances in lumbar spine imaging have shown that in certain athlete groups, unilateral spondylolysis is highly prevalent.
Here is another term to describe what is going on in the back. In the Spondylolysis patient. as mentioned above) a defect in the segment of bone joining the facet joints of the spine is called the pars interarticularis defect (pars fracture) and it can be on one side of the spine (unilateral) or both sides (bilateral). You can also add anterior spondylolisthesis, a fracture towards the back of the vertebrae.
In the study, the doctors examined previously published papers researching athletes with symptomatic unilateral spondylolysis of the lumbar spine who had spondylolisthesis surgery which attempted a direct repair of the pars interarticularis, compared to conservative management.
What they were really looking for was what got the athlete back to the sport quickly. The effectiveness of surgery on pain and overall function were secondary outcomes of interest.
Five studies reporting results for the outcomes of interest were critically appraised and included in the review. The limited evidence on the effectiveness of surgical treatment versus conservative treatment for unilateral spondylolysis in athletes does not allow any conclusions to be drawn about the relative effectiveness of surgery versus conservative treatment for facilitating rapid return to sport or a high level of post injury sporting level/performance.
It does suggest, however, that for adult athletes for whom conservative treatment has not been successful, surgery is likely to enable return to sport, reduce pain and promote overall function.
Spondylolisthesis misalignment of the vertebrae due to ligament weakness in the athlete
Genetics plays a large role with this condition. A very thin vertebral bone points to a precondition for the disease. Fast growth spurts, a ligament injury or ligament laxity can also result in bone slippage. Overuse is another culprit. Gymnastics, weight lifting and football, as well as other sports that put pressure on the lower back, can also be a catalyst. In addition, the constant hyperextension of the spine required of these sports can be very hard on the bones.
The misalignment of the vertebrae is due to ligament laxity of the spine.4
Conventional treatments may include physical therapy, nonsteroidal anti-inflammatories and surgery. In some cases a back brace or a body cast for up to six months may be recommended. Not only is this a very unpopular treatment, but immobility and casting are tremendously detrimental to ligament healing.
In fact, ligament laxity, pre-strain, can account for significant altered spinal biomechanical movement and spinal instability. 5 The casting/brace process can then be seen as making spinal instability worse.
Interesting to note is that research suggests that the most common location of Spondylolysis (lumbosacral spondylosis) was at the L5/S1 level, nearly three times as frequent as Spondylolysis at the L4 level. Yet the L4 because of it may be more unstable or cause clinical symptoms more frequently can lead to more surgeries. 6,7
Return to play after surgery, recovery and rehabilitation
Doctors at the Joint Reconstruction Research Center, Tehran University of Medical Sciences, have released their findings in the Asian Journal of Sports Medicine on treatment options for athletes with low back pain.
Here is the summary of their research:
Low back pain in athletes is common and has a broad spectrum of differential diagnoses that must be taken in to account when a clinician approaches the patient. We discussed that above.
The physicians should take into account spinal and extra-spinal causes of low back pain in athletes. The two most common causes of low back pain arising from the spine, in athletes are degenerative disc disease and spondyloysis with or without listhesis (the slippage of the vertebra over another).
Although most athletes, with low back pain whether resulting of degenerative disc disease or spondylolysis respond well to conservative treatment, when conservative treatment fails, surgical treatment is indicated.
On the other hand, intractable pain, progressive listhesis in spite of conservative treatment, or development of neurologic deficit, especially if it is progressive, are the surgical indications in athletes.
There are different kinds of surgical technique, including spinal fusion. Recently minimally invasive techniques instead of conventional techniques are developing fastly, which might have benefits for athletes to return to play earlier in comparison to conventional techniques.
It should be emphasized that with any kind of surgical technique the patients need time for fusion and healing, which is a year according to most references
The major concern in athletes with low back pain is return to play and previous level of their activity after treatment. There is insufficient data regarding this issue in literature to define the optimal time to return to play following treatment.
For patients who underwent fusion whether due to DDD or spondylolysis, with any kind of surgical technique, either conventional or new minimaly invasive techniques, Return to Play RTP guidelines recommend waiting time of at least one year before return to play.7
Prolotherapy for spondylolisthesis
Prolotherapy is an excellent treatment for spondylolisthesis because it strengthens the ligaments surrounding the slipped vertebrae causing proper alignment to be restored.
Prolotherapy is given to the ligaments on the back of the spine. By tightening the ligaments in the back of the spine Prolotherapy helps stabilize the area thereby giving pain relief and allowing for other structures to heal. Typically a patient will require 3-6 visits, although some patients require more visits depending on their overall health status and the extent of their injury.
Please see our article on Prolotherapy for low back pain for a more indepth discussion of all conditions treatable with Prolotherapy.
References for this article.
1 Takahashi T, et al. Current Status of Lumbar Interbody Fusion for Degenerative Spondylolisthesis. Neurologia medico-chirurgica. 2016;56(8):476-484.
2. Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. Epub 2015 Feb 27.
3. Scheepers MS, Streak Gomersall J, Munn Z. The effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review. JBI Database System Rev Implement Rep. 2015 Apr 17;13(3):137-73. doi: 10.11124/jbisrir-2015-1926
4. Carbajal BH. Treatment in spondylolisthesis with a dynamic percutaneous lumbar external fixator. A three year experience. Acta Ortop Mex. 2008 Mar-Apr;22(2):90-6.
5. Robertson DJ, Von Forell GA, Alsup J, Bowden AE. Thoracolumbar spinal ligaments exhibit negative and transverse pre-strain. J Mech Behav Biomed Mater. 2013 Jul;23C:44-52. doi: 10.1016/j.jmbbm.2013.04.004. Epub 2013 Apr 17.
6. Hirano K, Imagama S, Matsuyama Y, et al. Surgically Treated Cases of Lumbar Spondylolysis and Isthmic Spondylolisthesis: A Multicenter Study. J Spinal Disord Tech. 2012 Dec 3. [Epub ahead of print]
7. Scheepers MS, Streak Gomersall J, Munn Z. The effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review. JBI Database System Rev Implement Rep. 2015 Apr 17;13(3):137-73.
8. Mortazavi J, Zebardast J, Mirzashahi B. Low Back Pain in Athletes. Asian Journal of Sports Medicine. 2015;6(2):e24718. doi:10.5812/asjsm.6(2)2015.24718.