Spondylolisthesis and Spinal Slippage – Symptoms and Causes

Spinal slippage (medically known as spondylolisthesis) is a condition in which the vertebrae of the spine slip out of alignment with one another. It most commonly occurs in the lumbar spine. In severe cases, individual vertebrae can even compress the spinal nerves in the lower spinal cord. This compression of nerves often causes significant pain or sensorimotor deficits.

Over a long period of time, the slippage leads to the formation of adhesions in the posterior region of the spine. As a result, the spine’s stability can sometimes improve on its own, thereby stabilizing the condition.

Many patients experience no symptoms at all due to spondylolisthesis. This is referred to as asymptomatic spondylolisthesis, meaning vertebral slippage without symptoms.

Patients with symptomatic spondylolisthesis may be severely limited in their mobility. Some suffer from severe pain that is triggered by physical activity or certain body positions.

In most cases, the symptoms can initially be treated effectively with conservative measures (without surgery). Surgery is necessary only in very severe cases of spondylolisthesis.

The treating physician determines whether treatment is necessary. The indication for surgical treatment always depends on

• the severity of pain,
• the degree to which daily activities and quality of life are impaired,
• the subjective level of distress, and
• the combination of clinical and radiological findings

.

The specialist responsible for diagnosing vertebral slippage is a spine specialist (usually a neurosurgeon or orthopedic surgeon).

Any necessary surgeries are performed by a specialist in neurosurgery, orthopedics, or trauma surgery.

Ultimately, the treatment of spondylolisthesis always depends on the individual severity and the underlying cause. Classification systems for spondylolisthesis, such as the Wiltse or Meyerding classifications, help distinguish between a degenerative form, a traumatic cause, or spondylolisthesis vera.

Particularly in the lumbar spine, forward displacement of the vertebrae can lead to narrowing of the spinal canal and irritation of the nerve roots, such as the L5 nerve root. In cases of advanced spinal instability or neurological deficits, surgical treatment involving stabilization may be necessary, whereas conservative measures are often sufficient for mild spondylolisthesis.

The spine bears the entire weight of the body and keeps it upright. When overloaded, a vertebra can slip out of place. This happens primarily when

• the muscles,
• the joints, and
• the ligaments

are weakened

The most common cause is degenerative damage to the vertebrae. As we age, the intervertebral discs lose fluid, causing them to shrink in height. The vertebral bodies move closer together, disrupting the function of the muscles and ligaments. In untrained individuals, this leads to a reduced ability to compensate for intervertebral disc damage.

Excessive strain and backward hyperextension of the spine can lead to isthmic spondylolisthesis. Weightlifters and javelin throwers are particularly prone to this condition. Spinal injuries also reduce spinal stability and can lead to the development of this condition.

In some cases, the condition is congenital. The causes are still relatively unknown. However, there are familial clusters. This means that first-degree relatives of an affected individual have an increased risk of developing the condition as well.

Boys are three to four times more likely to be affected than girls. In girls, however, the condition tends to be more severe.

According to the German Society for Orthopedics and Orthopedic Surgery, up to forty percent of Germans are affected by spondylolisthesis. However, the condition is often mild.

Affected patients often suffer from pain that intensifies with certain movements. The pain often radiates from the back to the front and is perceived as a belt-like sensation. Some patients also experience a feeling of instability in the spine.

The pain is more severe in the morning when the back muscles are relaxed. If a nerve root is compressed, it can also lead to sensory and/or motor disturbances in the legs.

A brief overview of the symptoms:

• Back pain that sometimes radiates into the legs
• an unpleasant feeling of weakness in the legs
• Sensory disturbances in the legs

In advanced stages of the disease, there may also be

• restricted movement of the lumbar spine
• paralysis
• rectal and bladder dysfunction in cases of severely advanced spondylolisthesis with spinal cord compression

. However, these are rather rare exceptions.

In some cases, spondylolisthesis causes no symptoms. Treatment should be discussed with a doctor. Treatment may not be necessary as long as no pain occurs.

Anyone who frequently suffers from back pain should consult their primary care physician. If spondylolisthesis is suspected, the physician will refer the patient to a spine specialist.

Only in rare cases is spondylolisthesis an emergency requiring immediate treatment at a hospital. Emergencies that require immediate evaluation include

• severe sensory or motor disturbances, as well as
• difficulty urinating or having a bowel movement.

The diagnostic process begins with a medical history, i.e., an interview with the patient. The doctor will ask about the symptoms and medical history:

• Have you sustained an injury to the spine?
• What kind of sports activities do you engage in?
• Are there any known cases of similar symptoms in the family?
• Is the pain related to movement?
• Is there a feeling of instability in the spine?
• Have you noticed any motor or sensory disturbances?

This is followed by a physical examination.

The doctor will now assess the patient’s range of motion. He or she will observe whether the patient leans on something for support or appears unsteady.

He also examines the alignment of the spine. This reveals misalignments, such as an S-shaped curve, which indicates scoliosis. A “Schanze phenomenon” may also be detected if a bump is visible along the spine. Such steps are usually identified by palpating the spinous processes (posterior projections of the vertebrae).

By pressing and tapping, the doctor identifies painful areas. The position of the pelvis and the muscle tone around the spine are also assessed during the examination.

The so-called Schober sign can be used to assess spinal function. To do this, the examiner marks a point every ten centimeters, starting from the upper coccygeal angle. When the patient bends forward, they can feel the restriction in mobility.

More specialized examinations depend on the patient’s symptoms.

To obtain an accurate picture of the condition, X-rays are taken from two different angles. Sometimes the doctor may also order

• a computed tomography (CT) scan or
• a magnetic resonance imaging (MRI) scan

. This allows for a more precise assessment of the intervertebral discs and bones. 

To determine whether there is a dynamic component of spondylolisthesis, conventional lumbar functional X-rays in flexion and extension are often useful.

According to Meyerding, spondylolisthesis is classified into four different severity grades.

• Grade I: The vertebrae are displaced by up to 25%
• Grade II: The vertebrae shift between 25% and 50%
• Grade III: the vertebrae shift by 51% to 75%
• Grade IV: the vertebrae slip by more than 75%

If a vertebra becomes completely dislocated, the condition is referred to as spondyloptosis.

Symptoms and discomfort vary depending on the severity of the condition. With early treatment, the prognosis for symptom relief is very good.

The main goal is to relieve the patient’s pain and thereby ensure a better quality of life. This is achieved by stabilizing the vertebrae.

Treatment for spondylolisthesis consists of two cornerstones:

• conservative treatment
• surgical treatment, if conservative therapy is insufficient.

In milder cases, conservative treatment is usually sufficient. Only in very severe cases should surgery be considered immediately.

First, after thorough examinations, a detailed consultation takes place. During this consultation, the doctor explains to the patient how to specifically relieve pressure on the spine. In most cases, this alone leads to a significant improvement in symptoms.

The patient must avoid overstretching the spine through certain sports. If the patient is overweight, appropriate weight loss is recommended. This reduces the strain on the spine.

In addition, medication can help. Various pain relievers can be used effectively to manage pain. Muscle relaxants and anti-inflammatory medications are also available.