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What is Spondylolisthesis?
Spondylolisthesis is an orthopedic condition in which one vertebra slips over the other. When moving, the vertebra causes a misalignment of the spine, caused by a defect in the interarticular parts of the region.
The condition mainly affects the lumbar region, between levels L5-S1 (region of the last lumbar vertebra and sacral region), resulting in spinal instability, but there are not always symptoms or noticeable change in curvature. Thus, even if there is a change in the body axis, there is some difficulty in making the diagnosis.
When vertebral slippage is accentuated, is progressing or causes severe pain, surgery is the most suitable resource. But other approaches can alleviate the problem, such as physiotherapy and pilates .
The term, used since 1984, derives from the Greek spondylos , which refers to the vertebra, and olisthesis , which means to slide. It is currently listed under the ICD code M43.1 (International Classification of Diseases).
The spine
To better understand the condition of spondylolisthesis, it is necessary to look at the spine and its constitution as a whole.
The spine, which can also be called the backbone, consists of 24 flexible and 9 fused vertebrae, which make up the sacrum and coccyx, and extends from the skull to the pelvis.
Divided into 7 cervical vertebrae (located in the upper part, closest to the skull), 12 thoracic vertebrae (intermediate part, close to the chest), and 5 lumbar vertebrae (end region of the segment, close to the navel), the spine allows for relative flexibility and movement to the body.
Functions
One of the main functions of the spine is support, exercising a direct relationship with posture and locomotion. Therefore, any anomaly or condition that may compromise the correct vertebral articulation, impacts on the movement of the limbs, quality of flexibility or maintenance of the body axis.
Other column functions are:
- Protection of the spinal cord and spinal nerves;
- Body weight support;
- Fixation center for the ribs, pelvic girdle and dorsal muscles;
- Acting as a flexible axis, allowing movement and curvature of the body.
Spine structure
The cervical spine is composed of 7 vertebrae, which are the smallest of the entire spine. Each is numbered (cervical vertebra 1 to 7, or C1 to C7), and has narrower intervertebral discs than the others.
Below the cervical region is the thoracic spine , the middle part of the segment, which has 12 vertebrae called T1 to T12, 7 of which are articulated with the head of the ribs.
In the lower part of the spine, lumbar region , there are 5 vertebrae ranging from L1 to L5. In general, it is the region that receives the most pressure due to body weight, being a point quite affected by spinal problems, among them, spondylolisthesis.
Sacrum and Coccyx represent the last part of the spine segment, presenting fused vertebrae in a large triangular shape.
In addition to the bony structures (vertebrae), the spine has ligaments and shock absorbers that allow the fitting, connection and flexibility of the segment called intervertebral discs and facet joints .
Intervertebral discs are cartilaginous structures with little blood circulation, with size, thickness and shape that vary according to location, and can make up to 25% of the length of the spine.
The structure is responsible for the separation and cushioning between the bone bodies. Therefore, spinal problems, anomalies or injuries are usually related to wear, aging or dehydration of the cartilaginous layer.
The articular facets, or facet joints, are responsible for the ligament of the vertebrae and act in the stabilization of the spine in the proper movement of the lower limbs.
Spondylolisthesis and spondylolysis: what is the difference?
Both can cause pain and discomfort to the patient, however spondylolisthesis and spondylolysis are different conditions.
Spondylolysis is configured only as a wear, fragility or injury of the vertebral joint, presenting itself as a defect in the vertebral segment that causes bone discontinuity.
Spondylolysis does not cause vertebral slipping, but it is a condition that favors bone displacement.
When the vertebrae slide over the other, a picture of spondylolisthesis appears. Between 50% and 81% of spondylolysis cases evolve to vertebral slip.
Types of Spondylolisthesis
Spondylolisthesis can be classified according to degree and cause. The percentage of slipping comprises how much the vertebra is superimposed on the other and comprises 5 degrees.
- Grade I: from 0 to 25%;
- Grade II from 25% to 50%;
- Grau III from 50% to 75%;
- Grade IV from 75% to 100%;
- Grade V: vertebra totally off-axis.
However, the classification generally adopted by the medical field obeys 5 categories.
Displaced
It is a congenital abnormality (developed during pregnancy) of the elements of the vertebra. In most cases, there is an irregular formation of the neural arch (posterior vertebral part), which allows the L5 vertebrae (last lumbar vertebrae) to slide over S1 (upper part of the sacral region).
The incidence is higher in children and affects them in early childhood.
Isthmic
Repetitive movements of extension and torsion can cause stress to the joint, generating fatigue and wear of the connecting extremities (joint pairs).
The most frequent type of the disease, the condition affects mainly adolescents and young adults, being frequent at the L5-S1 level (end of the lumbar spine and beginning of the sacrum).
There are 3 subtypes of isthmic changes:
- Separation caused by stress due to repetition or impact;
- Elongated isthmus (the isthmus is a membrane that joins two walls of the organ or two organs. In stretching, it has fragility or little resistance);
- Separation due to severe trauma (blows or injuries).
Degenerative
The vertebral discs and facets undergo degenerative processes, showing instability between the vertebral segments. It occurs more frequently in women over 40 years of age and is the result of congenital conditions or diseases that affect the cartilage composition.
Traumatic
The causes are strikes or accidents in the vertebral area that generate acute fractures. In general, cases are diagnosed shortly after the injury and have a good response to immobilization treatment.
Pathological
Neoplastic processes (exaggerated cell development), metabolic and rheumatic diseases are the most frequent causes of spondylolisthesis. However, pathologies such as tuberculosis , syphilis , Paget’s disease, Albers-Schönberg’s disease and arthrogryposis (stiffness and malformation of joint tissues) can cause the vertebrae to slip, as there is a weakening of the intervertebral tissue.
Causes
Vertebral dislocation can be acquired , due to trauma or injury, or congenital, caused by poor formation and disposition of the vertebrae even in the gestational period.
Traumatic processes
Trauma is acquired and can cause acute fractures, resulting from high impact strikes, or stress fractures, in which intervertebral wear is caused by excessive repetition of movements.
They are frequent in athletes and athletes, who tend to demand a lot from the spine and perform intense and repeated movements.
Post-surgical process
Surgical intervention can cause or worsen vertebral slippage, accentuating the displacement. Incidences are rare and are usually caused by inadequate rest and recovery.
Congenital process
It comes from training and development during the gestation period. The bone constitution is incorrectly aligned, favoring vertebral slipping, which may show symptoms in early childhood or occur only in adulthood.
Degenerative process
Degeneration causes marked intervertebral wear. The condition is more common in the elderly due to age, but it can also be caused by degenerative diseases that accelerate cellular wear and tear.
Pathological process
It is the result of diseases, tumors or infections that cause weakening of the spine or decrease in cartilage tissues. The most common associations are with:
- Metastasis;
- Rheumatic diseases;
- Tuberculosis;
- Paget’s disease;
- Albers-Schönberg disease;
- Artrogripose;
- Syphilis.
Groups and risk factors
Slipping affects about 5% of the population, being more frequent in males, in a proportion of 2 men for every 1 woman diagnosed.
Patients diagnosed with spondylolysis, which is a lesion of the joint pairs without slipping, may be prone to progress to spondylolisthesis.
For practitioners of intense physical exercises, intervertebral wear is the result of repetition of movements that are not always intense, but are repetitive. Activities that force the lumbar region, such as gymnastics, diving and weight lifting increase the risk of fracture due to the effort and rotation of the intervertebral disc, causing more severe wear and favoring stress injuries.
In elderly people and people with degenerative diseases, the effort to keep the body aligned and stabilized may be excessive for the disc, as there is a weakening of the vertebral connections. The condition can cause the disruption or extension of the intervertebral layer.
In children up to 6 years old, there is an incidence of 2.6%, while in adults it is 5.4%. Under 40, the degenerative condition is rare. However, in the reported cases, women are the most affected, reaching 4 times more common in females.
Symptoms
When the displacement progresses, reports of pain are more frequent, but the degree of slipping does not necessarily imply pain or discomfort.
In general, spondylolisthesis has no symptoms, however, low back pain or sciatica in mild and moderate intensity are reported by some patients, which are linked to the condition (if there is only slipping of the vertebra or muscle shortening) and personal characteristics (weight, height , age, posture).
Vertebral misalignment can directly interfere with the amplitude of the trunk flexion movements, causing both an increase and a reduction in the vertebral curvature.
In higher cases of slipping (grade 2, 3 or 4), the deformity of the spine is quite accentuated, usually with shortening of the trunk, lordosis to a greater degree and alteration of the spacing of the ischia (bones of the lower hip).
Although rare, there may be cauda equina syndrome , which is the compression of the roots present in the spinal cord and spine, causing symptoms such as urinary and intestinal incontinence, decreased sexual functions, tingling or paralysis of the pelvis and even paralysis of the lower limbs.
In summary, symptomatic patients may have:
- Low back pain, reported as deep pain;
- Pain when standing, being relieved when the patient is at rest (sitting or lying down);
- Sciatica, which originates in the buttocks up to the back of the thighs;
- Tingling (due to compression of circulation);
- Muscle shortening, usually in the posterior region of the leg;
- Decreased strength and movement;
- Pain when walking or flexing the pelvis;
- Pain that starts below the knee and, in some cases, from the feet.
In children, the condition is usually asymptomatic, presenting only hyperlordosis (accentuated lumbar curvature). For adults who report the presence of symptoms, pain reaches 94%, paresthesia (tingling or numbness) reaches 63%, while 43% report weakness.
How is the diagnosis made?
Back pain from poor posture is common to most of the population, affecting up to 80% of people. Complaints show significant improvements with the adoption of simple measures, such as postural correction or adoption of physical exercises.
However, persistent low back pain deserves attention, as it may indicate a manifestation of more serious problems. The diagnosis of spondylolisthesis can be made by a general practitioner or an orthopedist through radiography, computed tomography and magnetic resonance imaging.
Examinations allow to identify the degree of slipping of the vertebra.
Physical exam
In the first visit, the orthopedist will draw a clinical profile of the patient, in which the existence and permanence of pains, the accentuation of muscle retraction (muscle shortening that causes less flexibility), and changes in joint movements in the lower limbs are investigated.
Imaging exams
Performing a simple radiograph is the most recurrent way of diagnosing the disease, showing the vertebral overlap. Complementation with lateral and oblique radiography may be requested, in which both draw a panoramic view of the spine and allow for a more accurate identification of isthmus defects and lesions between the vertebrae.
Bone scintigraphy and computed tomography are recommended to check for acute fractures, and can also indicate bone inflammation and changes in local blood flow, caused by vertebral displacement.
The magnetic resonance exam allows to evaluate the degree of degeneration of the intervertebral disc and its level of deformation, predicting the possibilities of disease progression.
Is there a cure?
-Yeah . Spondylolisthesis is curable through surgical treatments or non-invasive therapy, depending on the degree and condition of the disease. The faster the diagnosis is made and treatment begins, the better the body’s responses are.
What is the treatment?
There are still major clashes over the recommended treatments, as the spine makes up a complex structure. Studies indicate that there is no consensus among orthopedists, neurosurgeons and pediatricians for the most appropriate treatment, but among the medical community, conservative and surgical methods are well accepted.
Through non-invasive techniques, which can combine physiotherapy and medications, conservative treatment combines stretching and strengthening of the muscles. The exercises are mainly focused on the abdominal, oblique and back regions.
In addition to physical therapy practices, sessions of pilates, RPG and acupuncture can make up the conservative treatment. Exercises must be planned and directed specifically to patients affected by spondylolisthesis.
As for the use of medication, it is important to remember that they act on the consequences of spondylolisthesis, with no medication for the disease itself.
Pilates
Pilates aims, above all, to stabilize and strengthen the spine, focusing on the lumbar and pelvic region, promoting greater flexibility, mobility and pain relief.
In general, the sessions start with the “no mat” practices, known as solo pilates.
In this modality, accessories are not used, being practiced on the floor.
The types of exercises should be indicated by a specialized professional, based on the location and intensity of the spondylolisthesis. Particular conditions, such as flexibility and physical conditioning, are considered for planning the series and repetitions.
The main point of solo pilates is to improve flexibility through stretching, stabilizing the spine and light muscular resistance, combined with breathing and relaxation practices. With the insertion of devices and accessories, the levels of difficulty are increased according to the evolution of the situation.
The progression of activities must be monitored by physiotherapists or physical educators specialized in pilates.
RPG
The RPG (Global Postural Reeducation), promotes pain relief and better support of the spine. Treatment is based on stretching and joint corrections (posture correction) and should only be promoted by specialized professionals.
Postural re-education comprises the body in its entirety. Therefore, the sessions involve all the joints and much of the body musculature. But changes in posture have an effect if they are applied at all times, not just in sessions.
Acupuncture
Acupuncture treatment promotes physical and mental relaxation, leading to a reduction in muscle stress. Due to the release of endorphin and serotonin , the body can improve responses to pain, and increasing well-being.
In general, the practices of systemic needling (which is the application of needles throughout the body and, especially, at the site of pain), auricular (needles are placed in specific points of the ears) and electroacupuncture (application of electrical stimuli) are used. , which promotes faster results.
As with any treatment, acupuncture should only be performed by qualified professionals, and should consider the patient’s clinical condition.
Physiotherapy
Physiotherapy can combine exercises and electrostimulation for the treatment of spondylolisthesis. Generally, the activities involve strengthening the muscles of the lower back, stretching and applying electrical current to relieve pain (called neuromuscular electrical stimulation – NMES).
The progression of the exercises occurs according to the patient’s condition, and accessories (such as balls, elastic straps and ropes) can be used during the sessions.
In addition to alleviating pain, physical therapy is essential in surgical cases, in which the patient needs to resume activities and movements gradually.
Exercises of rotation of the lumbar spine, abdominal strengthening and stretching of the facets of the joints (stretching of the spine) are the most indicated, but only accompanied by the physiotherapist.
Exercises
The performance of progressive and specific exercises for the spine helps to improve pain and immobility. When spondylolisthesis is diagnosed, groups of exercises aimed at muscle work through strengthening and resistance may be indicated.
The weight for spondylolisthesis usually involves activities with greater load resistance and less application of force. That is, the repetitions and sets are greater and the weight is reduced, aiming at strengthening, but without overloading the region.
The planning and indication of the exercises must be carried out and monitored by trained physical professionals.
Strength exercises
The main function is to stabilize the spine by conditioning the patient. You can work the muscles of the abdomen, glutes, hamstrings (posterior thigh), erectors (back muscles) through the insertion of light loads and with progressive increase.
Cardiovascular resistance exercises
Cardiovascular activities improve physical fitness and contribute to reducing fatigue, improving breathing and decreasing fat.
Weight loss affects less load on the spine, which can reduce pain and discomfort. The activities favor blood circulation, improving irrigation even in the lumbar region.
Coordination and rehabilitation exercises
Rehabilitation works mainly with postural correction and strengthening of the back muscle. With the improvement of coordination and balance, the pressures exerted on the lower back are reduced, which can relieve pain.
In postoperative cases, strengthening exercises are necessary for correct recovery. In this case, the most suitable professional is the physiotherapist who determines the amount, variety and duration of the exercises according to the patient’s condition and the surgery.
Contraindicated exercises
The treatment of spondylolisthesis should be indicated by health professionals in conjunction with qualified physical professionals, considering the patient’s condition.
Clinical characteristics (causes and degree of slippage) and personal characteristics (physical conditioning, mobility impairment) determine which exercises are necessary.
Generally, it is not recommended to perform high impact activities, especially on the spine, that cause pain, discomfort or compromise the patient’s physical well-being. Activities such as running, athletics and Olympic gymnastics require great lumbar effort, which can result in greater vertebral stress.
Surgery for spondylolisthesis
Surgery is the most indicated treatment when the conservative method is not effective or there is a progression in the degree of vertebral slipping.
For cases of high-grade spondylolisthesis (when the slip exceeds 50% of the size of the vertebra) and for patients under 18 years of age with progression of vertebral sliding, surgery is necessary, usually a first attempt with conservative treatment is dispensed with.
Surgical intervention broadens the channels through which the nerves pass, and intervertebral stabilization. The procedure can be used through an open route (common surgical procedure), which presents recovery from 3 to 6 months, or minimally invasive techniques (procedure that makes small incisions parallel to the spine), which recover from 2 to 3 months.
Vertebral realignment can be done by placing screws (titanium metal implants) after intervertebral decompression, performing a bone fusion. Thus, the vertebra is fixed and prevents it from continuing to move.
There are cases in which the intervertebral disc is removed, being replaced by a graft that maintains the spacing of the vertebrae and prevents slipping.
Post-surgery care
In the minimally invasive procedure, rest is usually indicated after surgery, without the need to remain immobilized. Activities are resumed gradually and, normally, patients can perform small movements on the same day.
Post-surgical pain and discomfort are expected and minimized with painkillers and anti-inflammatory drugs.
In high-grade procedures, in which there is a major intervention in the spine, recovery can be more prolonged, limiting movements for months and requiring additional treatments (physiotherapy and medication) to be included in the routine.
In addition, invasive processes can involve risks for the patient.
Due to immunological deficiencies, infections can occur, affecting the operated site. There are reports of blood clots forming in the leg veins. The situation is called deep vein thrombosis .
Although uncommon, damage to the spinal nerves can occur and cause continuous pain after surgery. Symptoms involve discomfort, limited movement, numbness or tingling in the lower limbs, muscle weakness and, very rarely, difficulty in controlling bowel and bladder.
Medicines
Anti-inflammatories can help reduce the pain caused by intervertebral inflammation. They are given orally and can be indicated for different degrees of discomfort:
- Ibuprofen ;
- Naproxen .
Corticosteroids are usually administered via injection directly to the slipped vertebrae. The treatment period is shorter, on average for 5 days. Commonly indicated are:
- Dexa-citoneurin ;
- Hydrocortisone .
Attention!
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained in this website is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
Living together
Living with spondylolisthesis requires continuous treatment, associating physical therapies and, sometimes, medications to relieve pain. The condition can present asymptomatically, therefore, patients live well with the disease when it is stabilized.
By combining conservative therapies with routine, such as physiotherapy and stretching, there are significant improvements in quality of life and possible pain in the spine of those diagnosed.
Prognosis
When there is no indication for surgery, the disease is well tolerated and, in general, pain or difficulty are not very limiting to the patient, who lives well with mild spinal deviation.
People affected by the disease can present, throughout their life, low back pain without major complications. When physical activities, sports or intense exercises are practiced, the vertebral displacement can cause decreased movements or difficulty in flexion.
In cases treated surgically, the vertebral condition shows rapid improvement, eliminating pain and difficulty in locomotion. It is recommended that the patient temporarily withdraw from sports or impact activities until pain or discomfort is no longer perceived.
In general, the rehabilitation lasts between 2 to 4 months, and gradually physical therapy activities are inserted that help the recovery and strengthening of the lumbar region.
Complications
In more severe cases, spondylolisthesis can cause loss of sensation, tingling or lead to paralysis of the legs due to compression, causing temporary or permanent damage to the spinal nerve roots.
Pain and movement limitations are the biggest complication in athlete patients, who in some cases may have to abandon sports.
It is necessary to monitor the disease, identifying whether it is stabilized. When vertebral overlap progresses, patients are subject to severe spinal injuries, limiting locomotion.
How to prevent
Preventive measures for spondylolisthesis refer to the care and monitoring of risk conditions. People with a family history of the disease and practitioners of intense physical activity should be aware of symptoms of pain or difficulty in movement.
In cases of trauma to the spine, immediate examinations can identify serious injuries and prevent future worsening.
Although spondylolisthesis is uncommon, spinal problems affect the population on a large scale. Paying attention to good posture, practicing stretches and exercises are measures that help to prevent pain and spinal injuries.
For more tips and information on spine health, see our articles. When you feel uncomfortable or have difficulty moving, consult an orthopedist!
