Most common area affected by this condition is lower lumbar spine, but it can affect any part of the spine. The degree of slippage of one vertebra over the other may be graded to 4 grades Spondylolisthesis. Grade one will be 25% slippage (very common) while grade 4 is 100% slippage(very rare)

The most common type of Spondylolisthesis is the Degenerative type, which is mostly affecting old age group, female are three times more affected than male. It mainly affects the L4/5 level but it can affect other area of the lumbar spine. More than 90% of the cases are grade one degenerative spondylolisthesis. The main cause behind it is the wear and tear in the facet joints of the spine and the intervertebral discs. It is a progressive condition and may lead to spinal canal stenosis(narrowing of the spinal canal)leading to significant pressure of the spinal nerves.

The other common type of spondylolisthesis is the Isthmic Spondylo, which is mostly affecting young age group and it refers to an abnormality of the so-called pars interarticularis (fracture in the small bone connecting facet joint of adjacent vertebrae). The fracture appears at some point in childhood with subsequent slippage in adolescence. It is uncommon but possible that the slippage worsens after the age of 20. The most common level (90%) is L5/S1.

Symptoms of spondylolisthesis 

Symptoms are range from asymptomatic, with only mild lower back pain (LBP) in isthmic grade one spondylolisthesis to very severe symptoms like sciatica, back pain or even cauda equine syndromes, mainly severe symptoms occur in higher grade  spondylolisthesis.

Symptoms can include:

• LBP which is usually aggravated by physical activities and extreme spinal movements.
• Neurological intermittent claudiaction of the lower limbs, which include pain, numbness and fatigue feeling spreading from your lower back down your legs aggravated by a short distance of walk. This is the main feature of spinal stensois and its related to the severity of the pressure on the spinal nerves
• Postural abnormalities like bending forward during walk, most of the patients with this condition, they prefer to use shopping trolley to bend forward which is increasing the dimension of the spinal canal and improvement of symptoms

The severity of these symptoms can vary from person to person.

• you have persistent back pain or stiffness
• you have persistent pain in your thighs or buttocks
• your back curves outwards

Diagnosis of Spondylolisthesis can easily be confirmed by taking an X-ray of your spine from the side while you’re standing. Some time flexion/extension movement of the spine is necessary to confirm the movement at the spondylolisthesis level. This will show whether a bone in your spine has slipped out of position or if you have a fracture.

The definitive diagnosis is through CT and MRI scans to confirm the type of the spondylolisthesis and the degree of compression of the spinal nerves..

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Treating spondylolisthesis

Most of the mild cases of  spondylolisthesis is treated conservatively depends on grade of slippage, entrapment of the nerves and the symptoms and how severe they are.

In most cases, non-surgical treatments will be recommended first.

Non-surgical treatments

Initial treatments for spondylolisthesis may include:

• a short period of rest, avoiding activities such as bending, lifting, contact sports and athletics
• NSAID such as Ibuprofen, Naproxen and Voltarol, or stronger painkillers available on prescription
• Physiotherapy exercises like simple stretching and strengthening exercises may help increase the range of motion in your lower back and hamstrings
• if you have pain, numbness and tingling in your legs, Spinal injections around the compressed nerve and into the centre of your spine may be recommended, however these may give temporary relieve of the symptoms without sorting the problem.

Although back braces may give some relieve of the symptoms by giving external spinal support, however, it’s not recommended as it may cause wasting of the paraspinal and core muscles and lead to expedited degeneration of the spinal column, worsening the condition in the long term. Short period of spinal support may be recommended in acute back pain.

Back surgery for spondylolisthesis

Surgery is the last resort of management if non-surgical treatments do not work or the symptoms are severe, persistent or if there is severe compression of the spinal nerves.

The type of operation you need depends on the type of spondylolisthesis, the grade of the disease, adjacent level status and whether there is significant pressure at the spinal nerves.

In summary surgical target is either to improve spinal stability, or to free the nerves from compression and/or both.

In most of the cases, simple posterior spinal decompression which involves taking part of the ligaments, bone and shave some of the large hypertrophied joints to give more space to the central spinal canal and free the nerves which will improve the leg pain and neurological claudication of the lower limbs but not the back pain which may get worse with this kind of surgery. However, the risk of complications is less than other type of surgery which is spinal fusion.

In case of spinal instability, the surgical targets are usually spinal fusion which involves fusing the slipped vertebrea using metal screws and rods, and a piece of your own bone taken from an area nearby called bone graft. The screws and rods are usually left in place permanently.

In some cases, the disc between the bones in your spine may also be removed. It’ll be replaced by a small “cage” containing a bone graft to hold the bones in your spine apart.

In both options, the operation is performed under general anesthesia, which means that the patient will be sleep during the procedure. The patient will be lying on his front for the procedure. Spinal fusion will relieve both back and leg pain, however there are slightly higher risks of complications. 

After surgery, most of the symptoms will improve, however, patients may need weeks to months to recover completely with some limitation of physical activities.

Spinal surgery for spondylolisthesis also carries a risk of potentially serious complications.

Risk of complications:

• Infection is less than 2 percent. It may affect the superficial tissues and skin, or may affect deep spinal structures, diskitis or vertebral osteomyelitis which is very rare.
• Bleeding which may lead to hematoma collection that needs further surgery.
• Cerebrospinal fluid (CSF) leak, inadvertent breach of the thecal sac may lead to leaking of the fluid surrounding the brain and the spinal cord. Instant repairs is possible, however, it may need an extended admission in the hospital or further procedures. There is also very small risk of meningitis.
• Neural tissue injury: the most serious complication may cause life changing consequences in form of weakness or paralysis of legs, sphincters, sensory or sexual changes. The risk is very small, <1%.
• Worsening of back pain which is about 15% in 5 years related to adjacent level accelerated degeneration.
• Failure of the fusion with loosening of the implants may need further surgery/extension of the fixation.
• Failure to improve symptoms.
• General anesthetic complications (heart attack, stroke)
• Deep venous thrombosis/pulmonary embolism (clots in legs / lungs).
• Small risk of blindness related to prone position during the surger