spondylolisthesis was ist das

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Spondylolisthesis

Clemens Gödel ist freier Mitarbeiter der NetDoktor-Medizinredaktion.

Martina Feichter hat in Innsbruck Biologie mit Wahlfach Pharmazie studiert und sich dabei auch in die Welt der Heilpflanzen vertieft. Von dort war es nicht weit zu anderen medizinischen Themen, die sie bis heute fesseln. Sie ließ sich an der Axel Springer Akademie in Hamburg zur Journalistin ausbilden und arbeitet seit 2007 für NetDoktor (zwischenzeitlich als freie Autorin).

Bei einer Spondylolisthesis (Spondylolisthese, Wirbelgleiten, Gleitwirbel) sind die Wirbelgelenke instabil. Dadurch verschieben sich die Wirbel leicht, insbesondere im Lendenbereich. Betroffene leiden unter Schmerzen und Bewegungseinschränkungen, die sich aber gut lindern lassen. Nur in schweren Fällen ist eine Operation erforderlich. Lesen Sie hier mehr über Spondylolisthesis.

Kurzübersicht

• Prognose: In einigen Fällen Stabilisierung von alleine; Therapie verhindert Voranschreiten; konservative Therapie lindert oft die Symptome; in schweren Fällen nach Operation Symptomlinderung
• Symptome: Zunächst oft ohne Symptome; mit zunehmender Schwere Rückenschmerzen , unter Umständen Bewegungs- und Sensibilitätsstörungen bis in die Beine
• Ursachen und Risikofaktoren: Angeborene oder erworbene Spaltbildung zwischen Wirbelgelenken; Überlastung oft bei Risikosportarten wie Kunstturnen oder Speerwerfen; nach Operationen; Verletzungen der Wirbelsäule
• Diagnose: Krankengeschichte, körperliche Untersuchung, Röntgen , Magnetresonanztomografie, Einteilung der Spondylolisthesis in Meyerding-Grade
• Behandlung: Meist konservative Behandlung mit Physiotherapie, Krankengymnastik, Elektrotherapie sowie Gabe von Schmerzmitteln; Operation in schweren Fällen meist mit Versteifung der betroffenen Wirbel
• Vorbeugen: Keine Vorbeugung bei angeborener Form; bei ersten Anzeichen Risikosportarten vermeiden, rückenschonendes Arbeiten und Tragetechniken

Was ist Spondylolisthesis?

Wenn ein Wirbel aus seiner eigentlichen Position rutscht, spricht der Arzt von einer Spondylolisthesis oder von Wirbelgleiten. Ein solcher sogenannter Gleitwirbel verschiebt sich im Verhältnis zu den anderen Wirbeln nach vorn ("ventrale Spondylolisthesis" oder "Ventrolisthesis") und nach hinten ("dorsale Spondylolisthesis" oder "Retrolisthesis").

Die Wirbelsäule – Aufbau und Funktion

Die Wirbelsäule trägt die Last des Körpers und überträgt sie auf die Beine. Sie besteht aus 33 Wirbelkörpern und 23 Bandscheiben. Einige Wirbel sind miteinander verwachsen. Ein starker Muskel- und Bandapparat stärkt die Wirbelsäule.

Je zwei Wirbel bilden zusammen mit der dazwischenliegenden Bandscheibe ein sogenanntes Bewegungssegment. Sie sind über Bänder, Muskeln und Gelenke verbunden. Sind diese Verbindungen geschwächt, ist es möglich, dass der Wirbel nach vorn oder auch nach hinten rutscht. Meist befinden sich die betroffenen Wirbel im Lendenbereich. Da der unterste Lendenwirbel fest mit dem Becken verbunden ist, betrifft die Spondylolisthesis vor allem den vorletzten Lendenwirbel (L4).

Was ist Spondylolisthesis bei LWS?

Die Wirbelsäule gliedert sich in die Halswirbelsäule HWS (mit sieben Wirbeln), die Brustwirbelsäule BWS (mit zwölf Wirbeln) und die Lendenwirbelsäule LWS (mit fünf Wirbeln) (sowie die miteinander verwachsenen Wirbel des Kreuzbeins und des Steißbeins). Die Diagnose Spondylolisthesis LWS bedeutet also, dass es sich um ein Wirbelgleiten im Bereich der Lendenwirbelsäule handelt — die häufigste Form. Häufigster Gleitwirbel ist der unterste Lendenwirbel, der direkt über dem Kreuzbein (Os Sacrum) liegt. Das ist das Segment L5 S1.

Die weltweit weitaus am häufigsten betroffene Ethnie sind die Inuit. Rund 40 Prozent von ihnen haben Gleitwirbel. Außerhalb dieser Ethnie leiden besonders Leistungssportler, deren Wirbelsäule besonders durch Überstrecken belastet wird, unter Spondylolisthesis. Dazu zählen zum Beispiel Speerwerfer oder Ringer. Auch sportliche Übungen wie Trampolinspringen, Turnen oder Delfinschwimmen zählen als "Risikosportarten" für das Wirbelgleiten.

Krankheitsverlauf und Prognose

Nicht jede Spondylolisthesis schreitet voran. Es ist möglich, dass sich das Wirbelgleiten von alleine stabilisiert.

Das Fortschreiten einer diagnostizierten Spondylolisthesis lässt sich außerdem durch eine konsequente Therapie verhindern. Verschlimmert sich eine Spondylolisthesis, nehmen in der Regel die Beschwerden, Bewegungs- und Nervenstörungen zu. Wenn die Probleme sich schnell verschärfen, ist ein entschlossenes therapeutisches Eingreifen notwendig.

Stärkere Beschwerden schränken die Lebensqualität oft sehr ein. Daher ist es wichtig, Betroffenen früh Möglichkeiten zur Abhilfe aufzuzeigen und konsequent zu therapieren. Allerdings sollte eine operative Therapie nicht vorschnell erfolgen. Bereits eine Anpassung der körperlichen Belastung und unterstützende Physiotherapie lindern meist die Symptome.

Durch eine dreimonatige, intensive konservative Therapie der Spondylolisthesis bessern sich die Beschwerden in den allermeisten Fällen deutlich. 

Wie lange ist man bei Spondylolisthesis arbeitsunfähig?

Ob man infolge einer Spondylolisthesis arbeitsunfähig ist, hängt vom Einzelfall ab. Zum einen davon, wie ausgeprägt die Symptome sind, und zum anderen welcher Tätigkeit der Betroffene nachgeht.

Lassen sich mit konservativer Therapie die Symptome lindern, ist der Zeitraum der Krankschreibung und Arbeitsunfähigkeit unter Umständen kürzer. Nach einer Operation ist man je nach beruflicher Tätigkeit in der Regel zwischen zwei und zwölf Wochen krank geschrieben.

Eine Spondylolisthesis verläuft oft ohne Beschwerde. Andere Betroffene wiederum leiden unter Schmerzen, die vor allem unter Belastung und bei bestimmten Bewegungen auftreten. Die durch eine Spondylolisthesis verursachten Schmerzen breiten sich dann oft gürtelförmig von hinten nach vorne aus. Hinzu kommt ein Gefühl der Instabilität in der Wirbelsäule.

Besonders am Morgen, wenn die Rückenmuskulatur entspannt ist, sind die Schmerzen stark. In schweren Fällen kommen Reflexausfälle, Sensibilitäts- und Motorikstörungen hinzu, die sich unter Umständen bis in die Beine erstrecken. Diese Symptome treten auf, wenn der Wirbel durch eine Spondylolisthesis eine Nervenwurzel quetscht.

Spezielle Gleitwirbel-Symptome gibt es allerdings nicht, da die Beschwerden denen anderer Rückenprobleme, wie zum Beispielen Bandscheibenvorfällen, oft ähneln. Manche Betroffene berichten von einem "Knacken".

Bei der angeborenen Form der Spondylolisthesis haben die Betroffenen zumeist keine oder nur leichte Symptome, da es sich um einen langsam fortschreitenden Prozess handelt. So haben die Nerven die Gelegenheit, sich den veränderten Verhältnissen anzupassen.

Ursachen und Risikofaktoren

Damit der betroffene Wirbel die Möglichkeit hat, nach vorne zu gleiten, muss sich in der sogenannten Interartikularportion ein Spalt bilden. Dies ist der Bereich zwischen den Gelenkfortsätzen der Wirbel nach oben und unten, die eine flexible Verbindung zwischen den Wirbeln bilden. Wenn diese Gelenkverbindungen geschädigt sind, ist der Wirbel beweglicher, rutscht somit möglicherweise aus der Wirbelsäulenachse – eine Spondylolisthesis entsteht.

Die häufigste Ursache für Wirbelgleiten sind abnutzungsbedingte (degenerative) Schäden der Wirbel. Dies betrifft vor allem den Lendenwirbelbereich. Im Laufe des Lebens verlieren die Bandscheiben durch Flüssigkeitsverlust an Höhe. Dadurch nähern sich die Wirbelkörper an, was die Funktion des Band- und Muskelapparats stört. Bei wenig trainierten Menschen kompensieren die Muskeln Bandscheibenschäden zudem schlechter. Dann haben die Wirbel noch weniger Halt.

Eine hohe Belastung der Wirbelsäule, verbunden mit starkem Überstrecken nach hinten, führt gegebenenfalls zu einer isthmischen Spondylolisthesis. Zu den Risikosportarten zählen Speerwerfen, Kunstturnen und Gewichtheben. Oft gibt es dabei eine genetische Veranlagung.

Auch schwere Verletzungen (Traumata) der Wirbelsäule mindern die Stabilität erheblich und münden so unter Umständen in eine Spondylolisthesis.

In Verbindung mit bestimmten Erkrankungen des Knochens, wie der Glasknochenkrankheit , ist es möglich, dass eine sogenannte pathologische Spondylolisthesis auftritt. Diese ist jedoch sehr selten.

Auch nach Operationen an der Wirbelsäule ist eine Spondylolisthesis als Komplikation möglich (postoperative Form).

Manchmal hat eine Spondylolisthesis jedoch angeborene Ursachen. Dies ist vor allem bei Fehlbildungen (Dysplasien, Spondylolyse) des Wirbelbogens der Fall. Die Auslöser dafür sind fast immer unklar. Verwandte ersten Grades von Betroffenen haben ebenfalls ein erhöhtes Risiko für angeborene Fehlbildung. Bei Jungen treten diese Schäden drei- bis viermal häufiger als bei Mädchen auf. Bei Mädchen ist die Spondylolisthesis jedoch meist stärker ausgeprägt.

Eine sogenannte Pseudospondylolisthesis verursacht ähnliche Symptome wie eine Spondylolisthesis. Dabei handelt es sich um das leichte Vor- oder Rückwärtsgleiten eines Wirbels aufgrund einer Bandscheibenabnutzung.

Untersuchungen und Diagnose

Wenn Sie unter starken Rückenbeschwerden leiden, wenden Sie sich zunächst an Ihren Hausarzt. Dieser wird Sie bei Verdacht auf eine Erkrankung der Wirbelsäule, gegebenenfalls eine Spondylolisthesis, an einen Orthopäden überweisen. Bei starken Schmerzen, schweren Störungen der Motorik oder Sensibilität sowie Problemen beim Stuhlgang oder Wasserlassen sollten Sie jedoch umgehend eine Klinik aufsuchen.

Eine Spondylolisthesis ist jedoch nur in seltenen Fällen ein Notfall. Zumeist ist somit der niedergelassene Orthopäde der richtige Spezialist, der unter anderem folgende Fragen stellen wird:

• Sind die Schmerzen abhängig von Belastung oder Bewegung?
• Haben Sie Sensibilitäts- oder Motorikstörungen?
• Fühlt sich Ihre Wirbelsäule instabil an?
• Treiben Sie Sport?
• Haben Sie sich an der Wirbelsäule verletzt?
• Gibt es ähnliche Beschwerden in Ihrer Familie?
• Waren Sie wegen Ihrer Beschwerden schon bei anderen Ärzten?
• Haben Sie schon irgendwelche Behandlungen gegen Ihre Beschwerden versucht?

Körperliche Untersuchung

Nach dem Gespräch schließt sich die körperliche Untersuchung an. Der Arzt wird darauf achten, wie die Wirbelsäule verläuft und wie sich der Patient bewegt und abstützt, um so Erkenntnisse über die Art der Wirbelsäulenprobleme zu gewinnen. Dabei fallen in der Regel offensichtliche Fehlstellungen der Wirbelsäule auf, wie zum Beispiel eine Skoliose . Darunter verstehen Mediziner einen S-förmigen Verlauf der Wirbelsäule.

Es ist möglich, dass bereits beim Betrachten der Wirbelsäule ein Höcker im Verlauf der Wirbelsäule sichtbar ist (Schanzenphänomen). Solche Stufen findet der Arzt auch durch Abtasten der hinteren Fortsätze der Wirbel (Dornfortsätze). Außerdem erfasst er so den Muskelstatus um die Wirbelsäule und definiert die Position des Beckens. Durch Klopfen und Drücken identifiziert er schmerzhafte Regionen.

Funktionstest der Wirbelsäule

Dem schließen sich körperliche Tests an, mit denen sich die Funktion der Wirbelsäule überprüfen lässt. Dazu dient unter anderem das Schober-Zeichen. Der Arzt markiert dazu einen Abstand von zehn Zentimetern ausgehend vom obersten Steißbeinwirbel. Der Patient wird dann gebeten, sich maximal vorzubeugen. Die zuvor definierte Strecke sollte sich um fünf Zentimeter vergrößern. Bei einer eingeschränkten Bewegung oder überstreckter Wirbelsäule bleibt der Abstand geringer.

Anschließend prüft der Arzt eventuell den sogenannten Stauchungsschmerz. Dieser Schmerz tritt auf, wenn die Wirbelsäule durch leichten Druck gestaucht wird. Die körperliche Untersuchung beinhaltet auch Untersuchungen der Reflexe, der Sensibilität und Motorik. Welche speziellen Untersuchung sich anschließen, hängt von der Symptomatik ab.

Bildgebende Untersuchungen

Zur anschließenden Klärung fertigt der Arzt ein Röntgenbild aus verschiedenen Richtungen (Ebenen). In bestimmten Fällen ist es notwendig, diese Bilder durch speziellere Verfahren wie Kernspintomografie (Magnetresonanztomografie, MRT), vor allem zur Beurteilung der Bandscheiben, und Computertomografie (CT) zur genaueren Untersuchung der Knochen zu ergänzen.

Weitere Maßnahmen

In Ausnahmefällen ist eine nuklearmedizinische Untersuchung (wie eine Skelett-Szintigrafie) notwendig. Ebenfalls in Einzelfällen sind neurologische elektrophysiologische Untersuchungen sinnvoll, etwa wenn (möglicherweise) durch das Wirbelgleiten eine Nervenwurzel gereizt wird und die Schmerzen ausstrahlen.

Gibt es Hinweise, dass der Patient unter psychischen Begleiterkrankungen (wie Depression ) leidet oder die Schmerzen chronisch werden, ist eventuell ein Besuch bei einem Psychotherapeuten angezeigt.

Einteilung in Schweregrade

Die Spondylolisthesis teilt man in verschiedene Schweregrade ein. Diese Klassifikation stammt vom US-Mediziner Henry William Meyerding aus dem Jahr 1932:

• Grad I: Wirbelgleiten < 25 Prozent
• Grad II: 25 bis 50 Prozent
• Grad III: 51 bis 75 Prozent
• Grad IV: 75 bis 100 Prozent

Bei einem Wirbelgleiten von mehr als 100 Prozent haben die beiden benachbarten Wirbelkörper keinen Kontakt mehr zueinander. Mediziner sprechen dann von einer Spondyloptose. Sie wird manchmal auch als Grad V der Schweregrad-Skala bezeichnet.

Hauptziel der Therapie ist die Verbesserung der Lebensqualität, insbesondere eine Verminderung der Schmerzen. Dies erreicht man vor allem durch Stabilisierung der Wirbel. Die Wirbelgleiten-Therapie basiert auf zwei Pfeilern, der konservativen und der chirurgischen Behandlung. Während in leichten Fällen Beratung und konservative Therapie in der Regel ausreichen, ist manchmal als zweite Stufe eine stationäre Behandlung erforderlich. Nur in schweren Fällen ist eine Operation nötig.

Konservative Therapie

Zu Beginn einer Gleitwirbel-Therapie steht immer eine umfassende Beratung. Dabei erfährt der Patient, wie er seine Wirbelsäule gezielt entlastet. Vermindert er die körperliche Belastung im privaten und beruflichen Rahmen, bessern sich die Beschwerden oft bereits deutlich. Besonders bestimmte Sportarten, die durch häufiges Überdehnen die Wirbelsäule belasten, müssen bei einer Spondylolisthesis vermieden werden.

Tritt besonders bei Kindern, die sich in einer Sportart wie etwa Kunsturnen, Speerwerfen oder anderen Risikosportarten betätigen, eine Spondylolisthesis auf, raten Mediziner, diese Sportarten nicht mehr auszuüben. Entsprechend empfehlen Ärzte dann rückenschonende Sportarten. Dazu zählen etwa Rückenschwimmen oder Kraulen, Radfahren, Yoga und andere.

Patienten mit erhöhtem Körpergewicht rät man im Rahmen der Spondylolisthesis-Therapie, ihr Gewicht zu reduzieren.

Um die Schmerzen in den Griff zu bekommen, stehen verschiedene Schmerzmedikamente zur Verfügung. Außerdem helfen oft antientzündliche und muskelentspannende Medikamente. Teilweise werden diese Medikamente bei einer Spondylolisthesis lokal in die schmerzhaften Regionen gespritzt.

Krankengymnastik in verschiedener Form und Intensität soll die Schmerzen verringern. Eine starke Muskulatur ist ein Garant für eine stabile Wirbelsäule und wirkt dem Wirbelgleiten entgegen. Das lässt sich am besten durch Gymnastik erreichen.

Im Rahmen einer Rückenschule erlernen die Betroffenen Strategien zum Training und Umgang mit der Erkrankung. Die Patienten lernen unter anderem günstige Körperhaltungen und Gleitwirbel-Übungen zur Entlastung. Die Therapie soll vor allem Hilfe zur Selbsthilfe leisten. Übungen konsequent nach Abschluss der angeleiteten Krankengymnastik fortzuführen, ist für den Therapieerfolg entscheidend.

Auch eine Elektrotherapie hilft oft bei Spondylolisthesis. Dabei vermindern Stromflüsse den Schmerz und aktivieren die Muskulatur.

In manchen Fällen verschreibt der Arzt Hilfsmittel wie Schuheinlagen oder Rumpforthesen, die der Orthopädietechniker individuell anpasst.

Bei Kindern mit Spondylolisthesis liegt der Fokus zunächst auf einem guten Muskeltraining. Bis zum Abschluss des Knochenwachstums werden bei ihnen engmaschige Kontrollen des Krankheitsverlaufs durchgeführt. Eine besondere Belastung der Wirbelsäule sollten die Kinder vermeiden.

Bei schwereren Verläufen ist in manchen Fällen eine Operation zur Versteifung des betroffenen Wirbelsäulenbereichs sinnvoll.

Operative Therapie

Operative Verfahren zur Behandlung einer Spondylolisthesis nennt man Spondylodese . Durch eine Operation stabilisiert der Chirurg die Wirbel in ihrer korrekten Position, versteift sie und entlastet so die Nerven. Diese Stabilisierung ist auch für die Biomechanik der gesamten Wirbelsäule und der richtigen Lastenverteilung von besonderer Bedeutung.

Ein operativer Eingriff ist nicht zwangsläufig notwendig. Faktoren, die für eine Operation sprechen, sind:

• Die Belastung aufgrund der Spondylolisthesis ist hoch.
• Die konservative Therapie hilft nicht ausreichend.
• Das Wirbelgleiten schreitet voran oder ist sehr ausgeprägt.
• Es tauchen neurologische Symptome auf wie etwa Reflexausfälle, Sensibilitäts- oder Motorikstörungen.
• Die Patienten sind noch nicht alt.

Gegen eine Operation sprechen ein hohes Alter und eine starke Osteoporose . Diese beiden Faktoren erhöhen das Operationsrisiko und senken die Erfolgswahrscheinlichkeit deutlich. Dennoch ist eine Operation unter Umständen auch in diesen Fällen empfehlenswert. Beispielsweise ist eine operative Versorgung bei anhaltenden, fortschreitenden oder wiederkehrenden Beeinträchtigungen sinnvoll. Eine in der Regel klare Indikation für eine Operation sind Nervenstörungen wie zum Beispiel eine Sensibilitäts- und Motorikstörung.

Risiken einer Operation sind vor allem allgemeine Komplikationen wie Wundheilungsstörungen oder Gefäß- und Nervenverletzungen. Die Beweglichkeit der Wirbelsäule ist im Anschluss an die Operation in manchen Fällen reduziert.

Nach einer Wirbelgleiten-OP erfolgt in der Regel eine krankengymnastische Nachbetreuung. Zudem ist es manchmal nötig, für einige Zeit ein medizinisches Korsett zur Stabilisierung zu tragen.

Angeborenen Formen lässt sich nicht vorbeugen. Der häufigen Ursache Überlastung und Abnutzung lässt sich allerdings durch ein rückenfreundliches Verhalten am ehesten vorbeugen. Das umfasst etwa "richtiges" Sitzen bei sitzenden Tätigkeiten (möglichst aufrecht) oder rückenschonende Trage- und Hebetechniken (aus den Knien statt aus der Hüfte).

Treten besonders bei sportlich engagierten Kindern Symptome auf, raten Ärzte, Risikosportarten nicht mehr auszuüben, um eine Verschlimmerung der Spondylolisthesis zu vermeiden.

Autoren- & Quelleninformationen

Dieser Text entspricht den Vorgaben der ärztlichen Fachliteratur, medizinischen Leitlinien sowie aktuellen Studien und wurde von Medizinern geprüft.

• Dt. Ges. f. Orthopädie und orthopäd. Chirurgie + BV d. Ärzte f. Orthopädie (Hrsg.): Leitlinien der Orthopädie, Dt. Ärzte-Verlag, 2. Auflage, Köln 2002
• Gille, O.: Degenerative lumbar spondylolisthesis. Cohort of 670 patients, and proposal of a new classification. Orthopaedics & Traumatology: Surgery & Research, Volume 100, Issue 6, Supplement, October 2014, Pages S311-S315
• Grifka, J. & Krämer, J.: Orthopädie Unfallchirurgie. Springer Verlag, 10. Auflage 2021
• Müller, M.: Orthopädie und Unfallchirurgie: Für Studium und Praxis 2020/21. Med. Verlags- und Informationsdienste, 2020
• S2k-Leitlinie der Deutschen Gesellschaft für Orthopädie und Orthopädische Chirurgie et al.: Spezifischer Kreuzschmerz (Stand: 2018), unter: www.awmf.org

Spondylolisthesis

Most low back pain gets better without treatment, but some conditions that cause recurrent back pain may require medical or surgical care. A herniated disc is one such condition that many people are familiar with, but there are many others, including spondylolisthesis. It is important to get the correct diagnosis for any spine problem.

What is spondylolisthesis?

What is spondylolysis vs. spondylolisthesis.

• What causes it?
• What are the symptoms?
• How is it treated?
• What happens if it is left untreated?
• What is the surgery for it?

Spondylolisthesis is a condition where spinal vertebrae slips over one another. Forward slippage (anterolisthesis) is far more common than backward slippage (retrolisthesis).

These are separate but sometimes related conditions with similar sounding names. Spondylolysis is a particular type of spine fracture that, in some cases, can lead to spondylolisthesis, in which there is an incorrect movement and positioning (usually forward) of one or more spine vertebrae.

Spondylolisthesis animation

What causes spondylolisthesis.

Spondylolisthesis occurs most commonly in older adults as a result of osteoarthritis of the spine. This is known as degenerative spondylolisthesis. But there are several other types of spondylolisthesis, each having a distinct underlying cause.

Types of spondylolisthesis

• Degenerative spondylolisthesis, as noted above, is caused by spinal osteoarthritis, also known as spondylosis, in which facet joints and discs of the spine deteriorate over time. This is the most common form on spondylolisthesis
• Isthmic spondylolisthesis is caused by a pars interarticularis defect, also known as a pars fracture or spondylolysis . The crack of a pars fracture affecting both sides of the connection between the lamina and pedicles leads to slippage of the vertebrae.
• Congenital or dysplastic spondylolisthesis is a birth defect in which there is a growth abnormality of the spine.
• Traumatic spondylolisthesis is where a trauma to the spine forces vertebrae out of alignment.
• Pathologic spondylolisthesis is caused by a separate bone disease, such as a spinal tumor or osteoporosis.
• Iatrogenic (postsurgical) spondylolisthesis is caused by spinal destabilization resulting from a prior spinal decompression surgery without instrumentation.

What are the symptoms of spondylolisthesis?

Symptoms of spondylolisthesis can include localized lower back pain and/or – if there is associated nerve compression – pain and/or numbness (neuropathy) that radiates down to the legs.

Is spondylolisthesis serious?

Spondylolisthesis is generally not a serious or dangerous condition. Most patients with spondylolisthesis have few or no symptoms. Spondylolisthesis only becomes a concern when patients develop associated symptoms due to nerve compression ( radiculopathy ), disc degeneration or osteoarthritis . 

How is spondylolisthesis treated?

Treatments vary by individual case. Nonsurgical treatments may include activity reduction, a back brace, physical therapy and/or corticosteroid injections . In severe cases, spine surgery may be required to alleviate chronic pain or nerve damage.

What happens if spondylolisthesis is left untreated?

Most cases of spondylolisthesis do not cause any symptoms. If patients have limited or no symptoms, it is typically not dangerous to leave spondylolisthesis untreated.

What is the surgery for spondylolisthesis?

Operative treatments may involve some type of spinal decompression surgery , spinal fusion surgery (primarily an ALIF , PLIF , or TLIF  surgery), or both. Learn more from the content below, or find an HSS physician or orthopedic surgeon who treats spondylolisthesis.

Articles on spondylolisthesis and related conditions

• Spondylolysis and Spondylolisthesis in the Pediatric Patient
• Lumbar and Cervical Spondylosis: Symptoms and Treatments

Spondylolisthesis clinical trials at HSS

• Predicting Clinical and Patient-Centered Outcomes after Surgery for Degenerative Spondylolisthesis

Spondylolisthesis Success Stories

• Derman PB, Albert TJ. Interbody Fusion Techniques in the Surgical Management of Degenerative Lumbar Spondylolisthesis. Curr Rev Musculoskelet Med. 2017 Dec;10(4):530-538. doi: 10.1007/s12178-017-9443-2. PMID: 29076042; PMCID: PMC5685965.
• Morse KW, Steinhaus M, Bovonratwet P, Kazarian G, Gang CH, Vaishnav AS, Lafage V, Lafage R, Iyer S, Qureshi S. Current treatment and decision-making factors leading to fusion vs decompression for one-level degenerative spondylolisthesis: survey results from members of the Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery. Spine J. 2022 Nov;22(11):1778-1787. doi: 10.1016/j.spinee.2022.07.095. Epub 2022 Jul 23. PMID: 35878759.
• Samuel AM, Moore HG, Cunningham ME. Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence. Curr Rev Musculoskelet Med. 2017 Dec;10(4):521-529. doi: 10.1007/s12178-017-9442-3. PMID: 28994028; PMCID: PMC5685964.

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Updated: 3/9/2023

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• Pediatric Orthopedic Surgery

Spondylolisthesis: Definition, Causes, Symptoms, and Treatment

by Dave Harrison, MD • Last updated November 26, 2022

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What is Spondylolisthesis?

The spine is comprised of 33 bones, called vertebra , stacked on top of each other interspaced by discs . Spondylolisthesis is a condition where one vertebra slips forward or backwards relative to the vertebra below. More specifically, retrolisthesis is when the vertebra slips posteriorly or backwards, and anterolisthesis is when the vertebra slips anteriorly or forward.

Spondylosis vs Spondylolisthesis

Spondylosis and Spondylolisthesis are different conditions. They can be related but are not the same. Spondylosis refers to a fracture of a small bone, called the pars interarticularis, which connects the facet joint of the vertebra to the one below. This may lead to instability and ultimately slippage of the vertebra. Spondylolisthesis, on the other hand, refers to slippage of the vertebra in relation to the one below.

Types and Causes of Spondylolisthesis

There are several types of spondylolisthesis, often classified by their underlying cause:

Degenerative Spondylolisthesis

Degenerative spondylolisthesis is the most common cause, and is due to general wear and tear on the spine. Overtime, the bones and ligaments which hold the spine together may become weak and unstable.

Isthmic Spondylolisthesis

Isthmic spondylolisthesis is the result of another condition, called “ spondylosis “. Spondylosis refers to a fracture of a small bone, called the pars interarticularis, which connects the facet joint of the vertebra to the one below. If this interconnecting bone is broken, it can lead to slippage of the vertebra. This can sometimes occur during childhood or adolsence but go unnoticed until adulthood when degenerative changes cause worsening slippage.

Congenital Spondylolisthesis

Congenital spondylolisthesis occurs when the bones do not form correctly during fetal development

Traumatic Spondylolisthesis

Traumatic spondylolisthesis is the result of an injury such as a motor vehicle crash

Pathologic Spondyloslisthesis

Pathologic spondylolisthesis is when other disorders weaken the points of attachment in the spine. This includes osteoporosis, tumors, or infection that affect the bones and ligaments causing them to slip.

Iatrogenic Spondylolisthesis

Iatrogenic spondylolisthesis is the result of a prior surgery. Some operations of the spine, such as a laminectomy, may lead to instability. This can cause the vertebra to slip post operatively.

Spondylolisthesis Grades

Spondylolisthesis is classified based on the degree of slippage relative to the vertebra below

• Grade 1 : 1 – 25 % forward slip. This degree of slippage is usually asymptomatic.
• Grade 2: 26 – 50 % forward slip. May cause mild symptoms such as stiffness and pain in your lower back after physical activity, but it’s not severe enough to affect your everyday activities.
• Grade 3 : 51 – 75 % forward slip. May cause moderate symptoms such as pain after physical activity or sitting for long periods.
• Grade 4: 76 – 99% forward slip. May cause moderate to severe symptoms.
• Grade 5: Is when the vertebra has slipped completely of the spinal column. This is a severe condition known as “spondyloptysis”.

Symptoms of Spondylolisthesis

Spondylolisthesis can cause compression of spinal nerves and in severe cases, the spinal cord. The symptoms will depend on which vertebra is affected.

Cervical Spondylolisthesis (neck)

• Arm numbness or tingling
• Arm weakness

Lumbar Spondylolisthesis (low back)

• Buttock pain
• Leg numbness or tingling
• Leg weakness

Diagnosing Spondylolisthesis

Your doctor may order imaging tests to confirm the diagnosis and determine the severity of your spondylolisthesis. The most common imaging tests used include:

• X-rays : X-rays can show the alignment of the vertebrae and any signs of slippage.
• CT scan: A CT scan can provide detailed images of the bones and soft tissues in your back, allowing your doctor to see any damage or abnormalities.
• MRI: An MRI can show the spinal cord and nerves, as well as any herniated discs or other soft tissue abnormalities.

Treatments for Spondylolisthesis

Medications.

For those experiencing pain, oral medications are first line treatments. This includes non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, acetaminophen, or in severe cases opioids or muscle relaxants (with extreme caution). Topical medications such as lidocaine patches are also sometimes used.

Physical Therapy

Physical therapy can help improve mobility and strengthen muscles around your spine to stabilize your neck and lower back. You may also receive stretching exercises to improve flexibility and balance exercises to improve coordination.

Surgery is reserved for severe cases of spondylolisthesis in which there is a high degree of instability and symptoms of nerve compression.

In these cases a spinal fusion may be necessary. This surgery joins two or more vertebra together using rods and screws, in order to improve stability.

Reference s

• Alfieri A, Gazzeri R, Prell J, Röllinghoff M. The current management of lumbar spondylolisthesis. J Neurosurg Sci. 2013 Jun;57(2):103-13. PMID: 23676859.
• Stillerman CB, Schneider JH, Gruen JP. Evaluation and management of spondylolysis and spondylolisthesis. Clin Neurosurg. 1993;40:384-415. PMID: 8111991.

About the Author

Dave Harrison, MD

Dr. Harrison is a board certified Emergency Physician with a part time appointment at San Francisco General Medical Center and is an Assistant Clinical Professor-Volunteer at the UCSF School of Medicine. Dr. Harrison attended medical school at Tufts University and completed his Emergency Medicine residency at the University of Southern California. Dr. Harrison manages the editorial process for SpineInfo.com.

What Is Spondylolisthesis?

Spondylolisthesis is a spine condition caused when one vertebra slips over another. This condition's symptoms sometimes mimic those of other back pain conditions.

The complex design of the spinal column is a biological wonder. It comprises 33 bones at birth – some eventually fusing to become 24 bones in most adults – 23 discs and more than 40 muscles and ligaments. The spine is genuinely nature's stage for the human body's performance. And all those bones, discs, muscles and ligaments must work together perfectly for our bodies to function correctly.

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Sometimes, the mighty machinery of the spine breaks down. Many spinal conditions can affect a person throughout their lifetime, from simple back pain to spinal tumors . With so many working pieces, plenty can go wrong when the anatomy of the spine isn't quite right.

A spinal condition called spondylolisthesis occurs when one vertebra of the spine slips forward over the one beneath it. This vertebra becomes out of alignment with the rest of the spinal column. The condition appears most commonly at the base of the spine in the low back vertebrae, also known as the lumbar spine.

There are three main types of spondylolisthesis:

• Congenital : appears in the womb, before birth, when a baby's spine doesn't properly form. 
• Degenerative : happens over time, usually with advanced age.  
• Traumatic : occurs due to direct injury to the spine.

Diagnosis and Symptoms

Spondylolisthesis is graded by diagnosing physicians on a percentage severity scale from 1 and 5, with five being the most severe degree of vertebral slippage. An MRI is typically required to diagnose spondylolisthesis fully and to help rule out other spinal conditions, since its symptoms closely match those experienced by people with other spine issues.

In some people who have spondylolisthesis, especially those with a lower degree of vertebral slippage, the condition may cause no symptoms. However, in those who have a higher vertebral slippage score, or when the slipped vertebra is pressing on a nerve, a variety of symptoms can result, including:

• Back pain that seems to worsen with activity.
• Difficulty standing or walking, especially for long periods.
• Numbness, stiffness or tightness in the muscles of the spine, especially those in the lower back, or tightness in the hamstrings.
• Pain in the low back or buttocks, which may radiate down the legs, and is known as sciatica pain.

Exercise with Spondylolisthesis

Because certain types of activity can make spondylolisthesis symptoms worse for some people, this diagnosis can lead to inactivity. However, it's crucial to note that certain types of regular movement can help   relieve the symptoms associated with spondylolisthesis. Moving the body regularly helps to strengthen the spine and core muscles , which ultimately create better support for the spine in the long run.

When the symptoms of spondylolisthesis begin to impair mobility or proper body mechanics, that is when people should evaluate activities for safety. For example, heavy weightlifting, backbends or high-intensity sports that involve running or jumping should likely be avoided because they can make spondylolisthesis worse, which could lead to a condition called spinal stenosis.

There are still plenty of alternative activities a person with spondylolisthesis can engage in that may help provide back pain relief from the condition. These activities include gentler core exercises such as planks, yoga and gentle stretching. The key is to modify activities to reduce stress or strain on an already irritated spine.

Physical Therapy and Treatment Options

If you're unsure of what to do that won't worsen the condition, physical therapy can be a powerful and effective place to start. Under the trained guidance of a physical therapist, many people with spondylolisthesis develop the proper technique to perform exercises that help alleviate their symptoms and allow them the confidence to continue those activities at home.

From physical therapy to specific medications, most spine experts agree that conservative options are effective best places to start for spondylolisthesis treatment. Surgery is only considered when such alternatives fail to provide adequate relief or are ineffective in helping someone with spondylolisthesis return to active living.

As a complex spinal condition, it's always recommended to seek care and treatment for spondylolisthesis by a trained and experienced spine specialist .

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Spondylolisthesis is slippage of a lumbar vertebra in relation to the vertebra below it. Anterior slippage (anterolisthesis) is more common than posterior slippage (retrolisthesis). Spondylolisthesis has multiple causes. It can occur anywhere in the spine and is most common in the lumbar and cervical regions. Lumbar spondylolisthesis may be asymptomatic or cause pain when walking or standing for a long time. Treatment is symptomatic and includes physical therapy with lumbar stabilization.

There are five types of spondylolisthesis, categorized based on the etiology:

Type I, congenital: caused by agenesis of superior articular facet

Type II, isthmic: caused by a defect in the pars interarticularis (spondylolysis)

Type III, degenerative: caused by articular degeneration as occurs in conjunction with osteoarthritis

Type IV, traumatic: caused by fracture, dislocation, or other injury

Type V, pathologic: caused by infection, cancer, or other bony abnormalities

Spondylolisthesis usually involves the L3-L4, L4-L5, or most commonly the L5-S1 vertebrae.

Types II (isthmic) and III (degenerative) are the most common.

Type II often occurs in adolescents or young adults who are athletes and who have had only minimal trauma; the cause is a weakening of lumbar posterior elements by a defect in the pars interarticularis (spondylolysis). In most younger patients, the defect results from an overuse injury or stress fracture with the L5 pars being the most common level.

Anterolisthesis requires bilateral defects for type II spondylolisthesis. For type III (degenerative) there is no defect in the bone.

Spondylolisthesis is graded according to the percentage of vertebral body length that one vertebra subluxes over the adjacent vertebra:

Grade I: 0 to 25%

Grade II: 25 to 50%

Grade III: 50 to 75%

Grade IV: 75 to 100%

Spondylolisthesis is evident on plain lumbar x-rays. The lateral view is usually used for grading. Flexion and extension views may be done to check for increased angulation or forward movement.

Treatment of spondylolisthesis is usually symptomatic. Physical therapy Physical Therapy (PT) Physical therapy aims to improve joint and muscle function (eg, range of motion, strength) and thus improve the patient’s ability to stand, balance, walk, and climb stairs. For example, physical... read more with lumbar stabilization exercises may be helpful.

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Spondylolisthesis

Spondylolisthesis is a displacement of a vertebra in which the bone slides out of its proper position onto the bone below it. Most often, this displacement occurs following a break or fracture.

Surgery may be necessary to correct the condition if too much movement occurs and the bones begin to press on nerves.

Other complications may include:

• Chronic back pain
• Sensation changes
• Weakness of the legs
• Temporary or permanent damage of spinal nerve roots
• Loss of bladder control

When a vertebra slips out of proper alignment, discs can be damaged. To surgically correct this condition, a spinal surgeon removes the damaged disc. The slipped vertebra is then brought back into line, relieving pressure on the spinal nerve.

Types of spondylolisthesis include:

• Dysplastic spondylolisthesis , caused by a defect in part of the vertebra
• Isthmic spondylolisthesis , may be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions
• Degenerative spondylolisthesis , occurs with cartilage degeneration because of arthritic changes in the joints
• Traumatic spondylolisthesis , caused by a fracture of the pedicle, lamina or facet joints as a result of direct trauma or injury to the vertebrae
• Pathologic spondylolisthesis , caused by a bone defect or abnormality, such as a tumor

Symptoms may vary from mild to severe. In some cases, there may be no symptoms at all.

Spondylolisthesis can lead to increased lordosis (also called swayback), and in later stages may result in kyphosis, or round back, as the upper spine falls off the lower.

Symptoms may include:

• Lower back pain
• Muscle tightness (tight hamstring muscle)
• Pain, numbness or tingling in the thighs and buttocks
• Tenderness in the area of the vertebra that is out of place
• Weakness in the legs
• Stiffness, causing changes in posture and gait
• A semi-kyphotic posture (leaning forward)
• A waddling gate in advanced cases
• Lower-back pain along the sciatic nerve
• Changes in bladder function

Spondylolisthesis may also produce a slipping sensation when moving into an upright position and pain when sitting and trying to stand.

Spondylolisthesis may appear in children as the result of a birth defect or sudden injury, typically occurring between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis).

In adults, spondylolisthesis is the result of abnormal wear on the cartilage and bones from conditions such as arthritis , trauma from an accident or injury, or the result of a fracture, tumor or bone abnormality.

Sports that place a great deal of stress on bones may cause additional deterioration, fractures and bone disease, which may cause the bones of the spine to become weak and shift out of place.

A simple X-ray of the back will show any cracks, fractures or vertebrae slippage that are the signs of spondylolisthesis.

A CT scan or an MRI may be used to further diagnose the extent of the damage and possible treatments.

Treatment for spondylolisthesis will depend on the severity of the vertebra shift. Stretching and exercise may improve some cases as back muscles strengthen.

Non-invasive treatments include:

• Heat/Ice application
• Pain medicine (Tylenol and/or NSAIDS)
• Physical therapy
• Epidural injections

Surgery may be needed to fuse the shifted vertebrae if the patient has:

• Severe pain that does not get better with treatment
• A severe shift of a spine bone
• Weakness of muscles in a leg or both legs

Surgical process realigns the vertebrae, fixing them in place with a small rod that is attached with a pedicle screw, adding stability to the spine with or without the addition to an interbody (bone graft or cage) placed between the vertebra from the side or front.

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Spondylolisthesis

What is Spondylolisthesis?

Patient education video.

Types of Spondylolisthesis

What Are the Signs and Symptoms of Spondylolisthesis?

How is it diagnosed.

• Grade I – Less than 25 percent slippage
• Grade II – Between 25 and 50 percent slippage
• Grade III – Between 50 and 75 percent slippage
• Grade IV – More than 75 percent slippage
• Grade V – The upper vertebral body has slipped all the way off the front of the lower vertebral body. This is a rare situation that is called a spondyloptosis.

How is it Treated?

Surgery & treatment for spondylolisthesis, what are you looking for.

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Spondylolisthesis is a condition in which one of the vertebrae (bones) in the spine slips out of the proper position onto the vertebra below it. The word spondylolisthesis is derived from the Greek words spondylo , meaning spine, and listhesis , meaning to slip. Spondylolisthesis can occur in both children and adults, for different reasons. The condition varies in severity form patient to patient, and the  severity will determine the course of treatment.

With spondylolisthesis, there is malalignment of the vertebra. It is not the same as a herniated disc, although the two can coexist. (Read more about herniated discs .) With spondylolisthesis, the slippage is of the bony vertebra. With a herniated or ruptured disk, it’s the soft interior of the spinal disc that “slips,” or bulges through a tear in the outer layer of the disc.

What Causes Spondylolisthesis?

When spondylolisthesis occurs in children or teens, it is usually due to a birth defect or a traumatic injury. (In fact, spondylolisthesis is the most common cause of back pain in teens.) In adults, the most common cause of spondylolisthesis is natural wear and tear due to aging and arthritis.

The various types of spondylolisthesis include:

Congenital spondylolisthesis occurs when a birth defect causes the bones of the spine to grow abnormally. When this happens, the misaligned spine puts pressure on the disc, resulting in slippage. This type of spondylolisthesis occurs primarily in children and teens, especially during a growth spurt.

Isthmic spondylolisthesis occurs when a condition called spondylosis puts pressure on the spine, causing the vertebrae to slip. The condition can be triggered by certain sports that put a great deal of stress on the back, such as football, gymnastics, and weight lifting.

Degenerative spondylolisthesis occurs when the natural wear and tear due to aging and arthritis causes a vertebra to slip out of place. This form of spondylolisthesis usually occurs in people over 40.

Traumatic spondylolisthesis occurs when an acute, traumatic injury such as a car accident leads to spondylolisthesis.

Pathological spondylolisthesis occurs when a disease of the spine, such as tumors or infection, weaken the vertebrae, resulting in increased pressure and slippage.

Post-surgical spondylolisthesis is very rare, and happens when a disc slips as the result of surgery

Spondylolisthesis should be treated at a major medical center with advanced facilities and experts experienced in treating complex spine disorders (see Doctors Who Treat Spondylolisthesis ).

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Spondylolysis & Spondylolisthesis

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Explore Spondylolysis & Spondylolisthesis

What is spondylolysis.

Spondylolysis is a condition when the fifth (last) vertebra of the lumbar (lower) spine is fractured.

What is Spondylolisthesis?

Spondylolisthesis is a condition when the spondylolysis (fracture of the fifth lumbar vertebra) weakens the bone so much that it cannot maintain proper position and vertebrae start to shift out of place.

Who is affected by Spondylolysis and Spondylolisthesis?

Adolescent athletes, especially football players, gymnasts and weight lifters, are prone to spondylolysis. Sports that require athletes to put a great deal of stress on their lower backs, and athletes that are required to constantly overextend their back are more prone to spondylolysis.

Symptoms of spondylolysis and spondylolisthesis often do not present right away, and when they do present, it can feel like muscle strain across the lower back. Spondylolisthesis can also cause muscle spasms.

After taking a medical history and performing a thorough physical exam, your doctor probably will request that you have an x-ray, CT scan or an MRI scan, which will be able to show the spondylolysis or spondylolisthesis.

Nonsurgical treatment

For most people with spondylolysis or spondylolisthesis, your doctor will try nonsurgical treatments first. Resting and taking a break from any sports or other physical activities is a good idea to give the fracture time to heal. Your doctor also might recommend physical therapy and exercise to strengthen muscles in your back and abdomen, which can help stabilize your spine. Anti-inflammatory medications (like ibuprofen) may be recommended to reduce pain, discomfort and inflammation.

In more severe cases, a back brace or back support might be used to stabilize the spine. And epidural steroid injections can help reduce inflammation and pain. The steroid is injected into the space surrounding the spine.

Surgical treatment

Surgery may be recommended if none of the nonsurgical treatment options help keep the pain at a tolerable level. Surgery for spondylolisthesis typically is a spinal fusion and sometimes involves screws and rods to hold everything together as the fusion heals. Another type of surgery that is used sometimes is called a vertebral body replacement.

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Spondylolisthesis

1 Medical College of Wisconsin

John Scofield

2 Louisiana State University Shreveport

Payton Mangham

Joshua cooper, william sherman.

3 Tulane University Department of Orthopaedic Surgery

Alan D. Kaye

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam, along with appropriate imaging tests are useful in making the diagnosis. Conservative therapy is first-line and includes pain management with physical therapy. Patients who fail conservative therapy may consider surgical decompression, stabilization, and fusion. This review aims to discuss the epidemiology, pathophysiology, presentation, and treatment options of spondylolisthesis.

Introduction

Spondylolisthesis is a broad term used to describe the anterior, lateral, or posterior slippage of one vertebral body over another. Isthmic spondylolisthesis occurs when anterior displacement of the vertebra is caused by a defect in the pars interarticularis, commonly due to previous spondylolysis at the L5-S1 joint. 1–4 While isthmic spondylolisthesis is the most common form of spondylolisthesis in children, degenerative spondylolisthesis predominates in adults, which can occur independent of pars interarticularis injury and has a tendency to present in female patients. 1,2,5 The presentation of spondylolisthesis can vary widely, including but not limited to compressive neurologic defects (i.e. spinal stenosis), mild-to-severe back pain, a cosmetic defect, and as an incidental finding. 1 The standard classification of spondylolisthesis is the Meyerding system (graded I through V), which correlates with the percentage of superior disc translocation over the inferior disc. The degree of Meyerding grading is generally associated with symptom severity. 1,3,6 Grade IV and V spondylolisthesis indicates severe disc translation and is usually due to isthmic spondylolisthesis since significant damage to the pars interarticularis is generally required for impressive degrees of translation. 3 While many patients respond to conservative management (NSAIDs, injections, bracing), many cases often require decompression, fusion, reduction, fixation, among other surgical interventions. 2,3 Surgical treatment for spondylolisthesis should be considered it patients with persisting, debilitating symptoms that have not responded to conservative management. 7

Epidemiology/Risk factors

Spondylolisthesis is typically categorized into isthmic and degerative spondylolisthesis. Isthmic (i.e. spondylolytic) spondylolisthesis is classically precipitated by progression of previous spondylolysis. Spondylolysis is exceedingly rare in individuals who do not bear weight (i.e. infants, children with disabilities), with incidence and risk of progression to spondylolisthesis continually increasing from birth until age 18, with relatively stable incidence rates thereafter. 4 The incidence of spondylolysis in adults has been estimated to be between 3-8% with a prevalence of 11.5%. 8–10 Spondylolisthesis is less prevalent than spondylolysis, with an estimated prevalence of 3.1%. 11,12 Interestingly, most patients with these conditions are asymptomatic, with only 23% of patients reporting clinical complaints prior to the age of 20. In fact, studies have estimated that between 2.5-3.5% of children undergoing CT scans or MRI for unrelated abdominal or pelvic pathologies discover spondylolysis and isthmic spondylolisthesis as incidental findings. 13 Additionally, the extent of disc slippage in spondylolisthesis has not been strongly correlated with symptomatic severity. Both progression from spondylolysis to isthmic spondylolisthesis, as well as symptomatic onset are often correlated with periods of rapid pubertal bone growth in adolescents between 10-15 years old. 8

Young athletes have been well-documented to have increased risk for developing spondylolysis and subsequently progressing to spondylolisthesis. These patients typically present with unilateral low back pain that is relieved by rest, and interestingly usually do not exhibit neurologic deficits. 14 Athletes participating in sports with high torsion in their lumbar spine are at particularly increased risk of developing spondylolysis due to either unilateral or bilateral damage to the lumbar pars interarticularis. 4,15 Harvey et al. reported a spondylolysis incidence rate of between 23-63% of young athletes participating in high risk sports, which include football, gymnastics, hockey, diving, wrestling, pole vaulting, racquet sports, and body building. 14,16 Medical conditions may also predispose to development of spondylolysis. Inherent spinal disease such as scoliosis, kyphosis, and spina bifida occulta have been correlated with increased risk of development of spondylolysis. 4,8,17 Additionally, studies suggest an element of heritability, with 15-70% of patients with spondylolysis also possessing first-degree relatives who have spondylolysis. 18 Additional genetic risk factors include Native Alaskan heritage. 9,14

In contrast to isthmic spondylolisthesis, degenerative spondylolisthesis is most commonly seen in adults, with increased risk associated with progression of age. Degenerative spondylolisthesis is almost six times more common in females than males. 5,19 In a prospective study of 142 women, Aono et al. reported that 12.7% of previously healthy women developed degenerative spondylolisthesis over a period of 8 years. Retrospective analysis of baseline radiographs suggested that the pelvic incidence, vertebral inclination angle, degree of lumbar lordosis, as well as baseline vertebral sizes were all additional risk factors for development of degenerative spondylolisthesis. 5,20

Pathophysiology

Spondylolisthesis is the anterior, lateral, or posterior translation of a superior vertebral segment over the adjacent inferior vertebra. 3 Spondylolisthesis may progress from spondylolysis, which is the degeneration of the pars interarticularis. In fact, up to 70% of patients with bilateral pars defects progress to isthmic spondylolisthesis. This slippage most commonly occurs during periods of rapid growth. 11 Disc slippage most often occurs at the L5-S1 joint. 1–4 Severity of disc slippage is often quantified with the Meyerding grading system and is graded from I through V. 1,3,6 High grade spondylolisthesis with greater than 50% disc slippage corresponds to Meyerding grade III or higher and presents with higher risk of neurological complications due to spinal cord and neural compression. High grade spondylolisthesis is most often due to isthmic rather than degenerative spondylolisthesis, as severe translation is enabled by pars interarticularis fracture. 3

Degenerative spondylolisthesis is considered a disease of aging with a predilection for females, hypothetically due to both the increased laxity in female ligaments as well as other hormonal factors. 5 Most cases of degenerative spondylolisthesis are low grade and classified as either Meyerding grade I or II. 5 Low back and lower extremity pain may be observed due to focal disc slippage and degeneration as well as nerve impingement and ensuing spinal stenosis.

There exist numerous other etiologies of spondylolisthesis in addition to the isthmic and degenerative subtypes. A rarer etiology of spondylolisthesis includes dysplastic (i.e. congenital) spondylolisthesis, and is due to a congenital anomaly of the pars interarticularis which subsequently results in early anterior disc translocation, most commonly at L5-S1. 21 Early disc slippage can also result in spondylolysis due to increased stress on the pars interarticularis. Congenital disease is often multifactorial and made worse by repetitive movements of the lower back. Traumatic spondylolisthesis is caused by trauma that fractures a part of the posterior column of the spine besides the pars, and usually coexists with other injuries. 8 Pathologic spondylolisthesis is similar to traumatic, but is however due to infection, neoplasm, autoimmunity, or another pathology unrelated to trauma. 8 Iatrogenic spondylolisthesis can cause all of the aforementioned variants of the disease, and usually occurs following a large spinal decompression (laminectomy). This procedure can cause destabilization of the vertebrae, with subsequent disc slippage. 8

Classification and Grading

The symptomatic severity of spondylolisthesis has been weakly correlated with the degree of vertebral slippage. 22–24 The most common grading scale to describe the degree of vertebral slippage in spondylolisthesis patients was proposed by Meyerding. 23,25–28 Specifically, this scale correlates the degree of anterior displacement of a vertebral body to a numerical score. 25 The grading scale of the Meyerding scale is as follows: Grade I is equivalent to a <25% slippage of the vertebral body, grade II is equivalent to a 25% to 50% slippage of the vertebral body, grade III is equivalent to a 50% to 75% slippage of the vertebral body, grade IV is equivalent to a 75% to 100% slippage of the vertebral body, and grade V equivalent to a complete slippage of the vertebral body. 23,25,26 The majority of cases usually fall into either grade I or grade II. 25 This grading system is invaluable for continual assessment of both the current degree of disc slippage as well as the progression of the displacement of the vertebrae, thus providing valuable prognostic information and assisting in determination of the most appropriate future management. 23,29 However, studies have suggested that additional factors including etiology, lumbopelvic measurements, sacral structure, and global spinal alignment are also important in determination and prediction of spondylolisthesis progression, and grading scales which take these variables into account ought to be developed in order to optimize future treatment. 1

Another useful grading scale was proposed by Wiltse et al and functions by separating the different etiologies of spondylolisthesis into five distinct categories. 30,31 Type I of the Wiltse system corresponds to dysplastic spondylolisthesis resulting from congenital dysplasia that causes anterior and superior rounding of the S1 vertebrae, which allows the L5 vertebrae to slip anteriorly. 31 Type II correlates with isthmic spondylolisthesis and is further divided into types IIA and IIB. Type IIA is the result of a stress fractures of the pars interarticularis and causes anterior slipping of the vertebrae. Type IIB is the result of repeated fractures and healing resulting in lengthening of the pars interarticularis. Both subtypes result in anterior slippage of the vertebrae. Type III correlates with degenerative spondylolisthesis and is most commonly due to arthritis, which leads to weakening of the ligamentum flavum which then allows anterior slipping of the vertebrae. 31,32 Type IV correlates with traumatic spondylolisthesis caused by high energy trauma. Type V correlates with pathologic spondylolisthesis and can be caused by various pathologies such as osteoporosis, lytic neoplasms of the bone, and osteopetrosis. Type VI is iatrogenic in origin and is usually caused by spinal surgery such as laminectomy. 31 The categorization proposed by Wiltse et al is helpful in many scenarios, it does not describe the severity of each subtype of spondylolisthesis, and also does not allow for monitoring for progression of disease.

Clinical Features

A vast majority of patients with spondylolisthesis are asymptomatic. 33 Symptoms typically derive from either mechanical etiology or spinal stenosis, and patients frequently complain of intermittent neurogenic claudication; a consequence of spinal stenosis which presents with low back pain with radiation to the proximal bilateral lower extremities, with associated paresthesia and weakness while ambulating or standing. 25,28 Isthmic spondylolisthesis patients most commonly experience symptoms including hamstring tightness and lower back or buttock pain that is worse with spinal extension. 23,29 This radiculopathy is due to compression of the nerve roots in the area of the anterior slippage of the vertebral body. 31 Similarly, clinical features of degenerative spondylolisthesis predominantly include lower back pain, radiculopathy, or neurogenic claudication. 23 This pain often worsens with activity and/or spinal extension, but the pain may be relieved by movements that cause spinal flexion such as sitting or leaning forward. 25,27,34,35 Progressively worsening spondylolisthesis may present with new or augmented neurogenic symptoms, such as radicular pain, bowel and bladder dysfunction, and even cauda equina syndrome. Patients may also report a preceding traumatic event prior to onset of symptoms; however, many cases are correlated with insidious onset. Nighttime pain may also occur and is usually concerning for malignancy. 26

Diagnostics

Although spondylolisthesis is most often asymptomatic, a detailed history taking and a thorough musculoskeletal and neurologic physical exam are helpful in accurately diagnosing spondylolisthesis. 26,29 Isthmic spondylolisthesis often presents with a palpable step-off which may be felt at the level below the affected segment, while degenerative spondylolisthesis presents with a step-off occurring at the level above the affect spinal cord segment. 23 Patients may also present with varying degrees of lumbar lordosis, with stooped posture, spinal muscle atrophy, tight hamstrings, and hip flexion contraction. 28,29 Children with advanced spondylolisthesis may present with shortened stride length with excessive hip and knee flexion, and thus work up within the pediatric population should include extensive gait analysis. 26,29 Additionally, children with isthmic spondylolisthesis with associated scoliosis may present with a positive stork test, which is a one-legged hyperextension maneuver and indicates impaired mobility of the sacroiliac joint. 24,36

When working up patients with clinical suspicion for spondylolisthesis, useful imaging includes supine oblique views of the lumbosacral spine as well as standing posteroanterior and lateral x-rays of the thoracolumbar spine. 25,26,37 These views allow for optimal evaluation of the affected level of spondylolisthesis by judging the degree of anterior vertebral slippage. 26 When possible, supine radiographs should be avoided, as they potentially allow for the pathologic vertebra to temporarily reduce into an anatomically correct position. 25

When there is a high clinical suspicion of spondylolysthesis in spite of normal imaging results, single-photon emission CT of the lumbosacral spine is useful for further workup. 26,38–40 Additionally, MRI is often used in patients who present with neurologic deficits, although MRI has been shown to possess a low positive predictive value and is therefore not preferable as a primary diagnostic tool. 26,41 Thin-section CT with reverse gantry angle may also be useful in determining the degree of spondylolisthesis. 26,42 Preoperative two-dimensional and three-dimensional CT reconstruction can be used in severe cases to further define the anatomy of the region of interest. 26

Treatment Options

Conservative management.

Although there have been no prospective randomized clinical trials which outline the optimal conservative management algorithm, conservative modalities are widely considered the first line treatment for most cases of low-grade spondylolisthesis. 28 In fact, between 70-90% of athletes with spondylolisthesis can expect to return to athletic activities within 3-6 months with only conservative management. 37 The mainstay for conservative treatment is activity restriction, bracing, physical therapy, and pain control. Pain control can be achieved with either NSAIDs, narcotics, or muscle relaxants. 29,31 If a patient elects to undergo conservative management, they are closely followed with full physical exams and repeat imaging to monitor treatment efficacy. 29 Vibert et al. has stated that most physicians initially start with a 1- to 2- day trial of rest followed by a short course of anti-inflammatory medication. If the patient’s symptoms have not resolved within two weeks, physical therapy is an appropriate next step in management. The benefits of activities such as cycling, swimming, and elliptical machines have been well documented to avoid further vertebral injury and are considered superior to other forms of high impact aerobic exercises such as running. 27,43 Additionally, Kalichman and Hunter have referenced numerous other studies that have examined the efficacy of various conservative treatment modalities such as physiotherapy, bracing, flexion/extension strengthening exercises, and stabilization exercises. 27 If the patient fails to see improvement in symptoms after completing a 4-6 week course of physical therapy or other treatment modalities, it is often appropriate to consider more aggressive treatment options such as epidural steroid injections or selective nerve blocks. 27,29,43 If the patient continues to fail conservative therapies and more invasive procedures such as epidural corticosteroid injections, further surgical management may be indicated. 34

Surgical Management

Although spondylolisthesis management has generally trended toward more conservative options in effort to minimize risk and maximize outcomes, surgical treatment should be considered in patients with persisting and debilitating symptoms with inadequate response to conservative management. 44–46 Historically, degenerative spondylolisthesis was treated aggressively with focus on neural decompression, reduction, fixation, and fusion. Treatment has evolved throughout the years with emergence and re-emergence of techniques arriving in conjunction with the development of new technologies. Initially, isolated neural decompression was a popular procedure but resulted in increased likelihood of slippage progression in younger patients with dynamic instability due to lack of fusion. 47,48 Posterior fusion using a posterior lumbar interbody fusion (PLIF) was described in the early-20 th century, but was discouraged at the time due to high risk of complications and procedural difficulty. It was not until the advent of transpedicular screwing and the development of spinal instrumentation that led to breakthrough of transforaminal lumbar interbody fusion (TLIF) and other interbody fusion techniques. More recent advances including minimally invasive surgery (MIS) and stereotactic spinal guidance. MIS procedures has been shown to decrease muscular injury and perioperative pain, leading to faster recovery and improved quality of life. Similarly, stereotactic spinal guidance provides invaluable guidance of intraoperative anatomical landmarks and have been correlated with decreased likelihood of complications related to screw misplacement. 48

Surgical treatment of spondylolisthesis usually involves a combination of decompression, stabilization, and fusion. Although decompression is discouraged in patients with dynamic instability, it remains a viable option in the elderly and patients without dynamic instability due to lower associated morbidity and mortality. 44 Stabilization with spinal instrumentation is often utilized to correct deformity and prevent deformity progression. 49 There currently remains a lack of consensus on the decision to reduce slippage versus in-situ fusion during surgical management. Those in favor of reduction prior to arthrodesis argue that while patients report improvement following in-situ fusion, there is a greater risk of decompensation and pseudoarthrosis due to uncorrected positive sagittal balance, especially in high grade slips. One study investigating this found that pseudoarthrosis was more frequent in the fusion in-situ group versus the reduction group (17.8% vs 5.5%). 50 Conversely, those in favor of in-situ fusion argue that patients demonstrate compensation for uncorrected positive sagittal balance through reduced thoracic kyphosis and pelvic retroversion. They also site literature emphasizing a greater likelihood of neurological impairment with reduction, though there is also evidence denying any additional risk. Despite ongoing debate, treatment has begun focused on correcting segmental lordosis and global sagittal balance. It is proposed that reduction with anterior and posterior fixation results in improved outcomes and allows for optimal correction of deformity, indirect neuroforaminal decompression, greater surface area for arthrodesis, and increased biomechanical stability. 51–55

With recent recognition of the importance of slip angle and spinopelvic alignment to global sagittal alignment, more evidence suggests that at least partial reduction of slip angle should be considered in the setting of a high-grade slip. Interbody fusion is also favored in these cases to provide greater stability and increase fusion rates. 54–56 There is a lack of randomized controlled trials confirming or negating the generally accepted techniques of reduction and anterior column support for treatment of high-grade spondylolisthesis, but smaller studies are frequently performed. 57 Nonetheless, the benefits of surgery are typically significant for patients with regard to health-related quality of life, especially in patients who can tolerate the procedures. 58

Newer techniques for surgical intervention and evaluation continue to arise for patients with high-grade slips. One example of innovative surgical techniques includes the extreme lateral interbody fusion, which has shown promising improvement in clinical outcomes with isthmic spondylolisthesis patients at each postoperative evaluation (1, 3, and 12 months), along with no signs of hardware loosening or failure. 59 Another novel technique to evaluate post-surgical outcomes includes a 3D finite element model (FEM) used to analyze the biomechanics of the spine after spinal fusion for spondylolisthesis at L5-S1. This model was described by Wang et al with an objective to determine the advantages of reduction versus no reduction in patients with “unbalanced” and “balanced” spines, which are defined by measurement of spinal parameters such as sacral slope and pelvic tilt. The “unbalanced” spine was correlated with high pelvic tilt and low sacral slope and showed significant improvements in pelvic alignment post-reduction, likely due to inherent inability to compensate through spinal extension. However, FEM showed a significantly increased incidence of lumbosacral deformation and adjacent disc stress in “unbalanced” spines following reduction. Similarly, although the “balanced” spine (correlated with low pelvic tilt and high sacral slope) also exhibited improvements in spinal alignment post-reduction, there was no increase in incidence of lumbosacral deformation or adjacent disc stress. Further research is necessary to determine if the efficacy of reduction in treatment of spondylolisthesis in patients with “unbalanced” spinal alignment. 60

Care must also be taken to factor other spinal pathologies into the surgical treatment of spondylolisthesis. The current literature has not fully investigated the combination of spondylolisthesis and spinal tumors. In patients with concomitant tumors and spondylolisthesis, the location of one relative to the other is important in guiding treatment. Oncological treatment takes priority, however if that treatment involves spinal fixation, an adjacent spondylolisthesis can be included in the fusion construct and potentially reduced depending on symptomology and instability. 61 Furthermore, congenital deformities of the spine, traumatic spondylolisthesis, and osteoporosis can pose unique challenges to surgical management of spondylolisthesis due to the complex presentations, peri-operative planning, and recovery. 62,63

There remains a significant degree of variability between providers regarding appropriate surgical recommendations. A survey of 445 U.S. spine surgeons sought to determine patterns in the treatment of spondylolisthesis and posed clinical/radiographic case scenarios on patients with spondylolisthesis, neurogenic claudication with and without mechanical back pain. Results showed that 64% and 71% of surgeons disagreed with regards to proper treatment of spondylolisthesis with and without mechanical back pain, respectively. Many factors influence operative decision making for a given condition, but awareness of this variability can guide research to develop better practice guidelines. 64 Data analysis from surgical registries may also prove invaluable in guiding future studies and improving outcomes of spondylolisthesis treatment. Examination of present management and outcomes can lead future studies in the right direction. There are several surgical options for treatment of spondylolisthesis which branch into a multitude of specific approaches and techniques. There is a need for a comprehensive surgical classification and treatment algorithm that would lead to a unified standard of care for patients with spondylolisthesis. 65,66 Current management appears to exhibit positive outcomes and subjective improvements in most surgical patients, regardless of the specific procedure. However, many of the studies lack the power to provide strong evidence as a foundation for universal recommendation guidelines. Thus, further randomized trials and large-scale registry analysis will guide future research to demonstrate optimal surgical treatments and improve outcomes for all patients with spondylolisthesis. 58,67

Finally, although surgical management has been shown to be efficacious in treatment of spondylolisthesis, an often-overlooked aspect of surgery is cost effectiveness with respect to the patient. Although research is scarce in this area, operative treatment has been shown to be significantly more expensive than non-operative management due to fusion, instrumentation, and labor adding to the cost. Patients who receive surgical interventions do report improvement in quality of life, although more data needs to be gathered and analyzed to determine the appropriate cost/benefit between various surgical treatment options in patients with limited finances. 68

Spondylolisthesis refers to the anterior, lateral, or posterior slippage of a superior vertebral disc over the adjacent inferior disc, and is often separated into categories based on the causative etiology. Isthmic spondylolisthesis occurs due to damage to the pars interarticularis, resulting in instability and slippage between the lamina, pedicle, facet joints, and transverse process. Incidence of isthmic spondylolisthesis plateaus after age 18 and occurs most commonly at the L5-S1 joint. In contrast, degenerative spondylolisthesis occurs due to chronic degenerative processes such as arthritis and is observed in adults, with incidence directly correlated with age. Spondylolisthesis is most commonly described with the Meyerding classification system, with each grade corresponding to a given degree of disc slippage. Other classification scales have been proposed, such as one by Wiltse et al which categorizes spondylolisthesis based on the causative etiology. Spondylolisthesis is often asymptomatic but may present with low back pain and neurogenic claudication which is worsened with spinal extension and activity. A detailed history and physical exam is imperative in diagnosing spondylolisthesis, and evidence of disc slippage may be found on spinal xrays, single-photon emission CT, and MRI. Conservative therapy is first line and includes symptomatic management such as NSAIDs, narcotics, and muscle relaxants, as well as physical therapy, low impact exercises, and steroid injections. If a patient fails conservative therapy, surgical interventions such as decompression, stabilization, and fusion may be considered at that time.

Funding & Conflict of Interest

The authors did not receive any funding or financial support or potential sources of conflict of interest.

The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.

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Spondylolisthesis

What is spondylolisthesis.

Spondylolisthesis occurs when a vertebra in the lower spine shifts out of place and onto the bone below it, often because of weakness or a stress fracture. It is more common in young athletes and older adults who suffer from arthritis. It can cause pain, stiffness, and muscle spasms.

Non-surgical options are often successful in relieving the symptoms, but sometimes surgery is needed. Spinal fusion is one of the more common options.

Causes of Spondylolisthesis

Usually spondylolisthesis results from spondylolysis, a crack or stress fracture in the pars interarticularis, the thin portion of the vertebra that connects the upper and lower facet joints.

In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. The injury is most commonly seen in children and adolescents who participate in sports that involve repeated stress on the lower back, including football, weightlifting, and gymnastics. Repetitive stress can cause a fracture on one or both sides of the vertebra. It also may be caused by a birth defect in the lumbar spine or an acute injury.

In adults, the most common cause is abnormal wear on the cartilage and bones, such as through arthritis. The condition affects people over the age of 50 and is more common in women than in men. Bone disease and fractures also can cause lumbar spondylolisthesis. Genetics may play a role, as some people are born with thinner-than-normal vertebral bone.

Early Signs of Spondylolisthesis and Diagnosis

Symptoms of spondylolisthesis may vary from none to mild to severe. The most common symptom is low back pain.

The condition can cause lordosis (swayback). In later stages it may result in kyphosis (roundback) as the upper spine falls off the lower spine. General symptoms are lower back pain; muscle tightness in the hamstrings; pain, numbness, or tingling in the thighs and buttocks; tenderness in the area of the vertebra that is out of place; weakness in the legs; and difficulty standing and walking.

Our spine specialists diagnose spondylolisthesis by taking a thorough medical history, conducting a physical exam, and asking you to undergo imaging studies that may include X-ray, CT scan, or MRI scan.

Treatments for Spondylolisthesis

Your doctor may use X-rays, CT scans, or an MRI, as well as a physical exam, to determine the severity of your condition. Initial treatment may include rest, physical therapy, nonsteroidal anti-inflammatory drugs, oral corticosteroids, and/or bracing that limits movement of the spine and allows the fracture to heal.

Surgery may be recommended for patients who have severe or high-grade slippage of the vertebra, such as when more than 50% of the fractured vertebra slips forward on the vertebra below it. The procedures most often recommended for people with lumbar spondylolisthesis are spinal fusion or a laminectomy to decompress the nerves.

What You Can Expect at UTHealth Neurosciences

The UTHealth Neurosciences Spine Center brings together a multidisciplinary team of board-certified, fellowship-trained neurosurgeons, neurologists, researchers, and pain management specialists who work together to help provide relief for even the most complex problems. Your team will share insights, leading to better treatment decisions and outcomes.

We first investigate nonsurgical treatment options, including medical management, pain management, physical therapy, rehabilitation, and watchful waiting. When surgery is needed, our neurosurgeons routinely employ innovative minimally invasive techniques. Throughout the treatment process, we will work closely with the doctor who referred you to ensure a smooth transition back to your regular care. While you are with us, you will receive expert care, excellent communication, and genuine compassion.

Anatomy of the neck and spine

• The cervical region (vertebrae C1-C7) encompasses the first seven vertebrae under the skull. Their main function is to support the weight of the head, which averages 10 pounds. The cervical vertebrae are more mobile than other areas, with the atlas and axis vertebra facilitating a wide range of motion in the neck. Openings in these vertebrae allow arteries to carry blood to the brain and permit the spinal cord to pass through. They are the thinnest and most delicate vertebrae.
• The thoracic region (vertebrae T1-T12) is composed of 12 small bones in the upper chest. Thoracic vertebrae are the only ones that support the ribs. Muscle tension from poor posture, arthritis, and osteoporosis are common sources of pain in this region.
• The lumbar region (vertebrae L1-L5) features vertebrae that are much larger to absorb the stress of lifting and carrying heavy objects. Injuries to the lumbar region can result in some loss of function in the hips, legs, and bladder control.
• The sacral region (vertebrae S1-S5) includes a large bone at the bottom of the spine. The sacrum is triangular-shaped and consists of five fused bones that protect the pelvic organs.

Spine Disease and Back Pain

Arthrodesis Artificial Disc Replacement Cauda Equina Syndrome  Cervical corpectomy Cervical disc disease Cervical discectomy and fusion Cervical herniated disc Cervical laminectomy Cervical laminoforaminotomy Cervical radiculopathy Cervical spondylosis (degeneration) Cervical stenosis Cervical spinal cord injury Degenerative Disc Disease Foraminectomy Foraminotomy Herniated discs Injections for Pain Kyphoplasty Laminoplasty Lumbar herniated disc Lumbar laminectomy Lumbar laminotomy Lumbar radiculopathy Lumbar spondylolisthesis Lumbar spondylosis (degeneration) Lumbar stenosis

Neck Pain Peripheral Nerve Disorders Radiofrequency Ablation Scoliosis Spinal cord syrinxes Spinal deformities Spinal injuries Spinal fractures and instability Spinal Cord Stimulator Trial and Implantation Spinal Fusion Spinal Radiosurgery Spine and spinal cord tumors Spondylolisthesis Stenosis Tethered spinal cord Thoracic herniated disc Thoracic spinal cord injury Transforaminal Lumbar Interbody Fusion Vertebroplasty

At UTHealth Neurosciences, we offer patients access to specialized neurological care at clinics across the greater Houston area. To ask us a question, schedule an appointment, or learn more about us, please call (713) 486-8100, or click below to send us a message. In the event of an emergency, call 911 or go to the nearest Emergency Room.

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Orthopedic Surgery

Spondylolisthesis.

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In spondylolisthesis, one of the bones in your spine — called a vertebra — slips forward and out of place. This may occur anywhere along the spine, but is most common in the lower back (lumbar spine). In some people, this causes no symptoms at all. Others may have back and leg pain that ranges from mild to severe.

(Left) In spondylolysis, a fracture often occurs at the pars interarticularis. (Right) Because of the pars fracture, only the front part of the bone slips forward.

What are the different types of spondylolisthesis?

Many types of spondylolisthesis can affect adults. The two most common types are degenerative and spondylolytic. There are other less common types of spondylolisthesis, such as slippage caused by a recent, severe fracture or a tumor.

What is degenerative spondylolisthesis?

As we age, general wear and tear causes changes in the spine. Intervertebral discs begin to dry out and weaken. They lose height, become stiff, and begin to bulge. This disc degeneration is the start to both arthritis and degenerative spondylolisthesis (DS).

As arthritis develops, it weakens the joints and ligaments that hold your vertebrae in the proper position. The ligament along the back of your spine (ligamentum flavum) may begin to buckle. One of the vertebrae on either side of a worn, flattened disc can loosen and move forward over the vertebra below it. This can narrow the spinal canal and put pressure on the spinal cord. This narrowing of the spinal canal is called spinal stenosis and is a common problem in patients with DS.

Women are more likely than men to have DS, and it is more common in patients who are older than 50. A higher incidence has been noted in the African-American population.

What is spondylolytic spondylolisthesis?

One of the bones in your lower back can break and this can cause a vertebra to slip forward. The break most often occurs in the area of your lumbar spine called the pars interarticularis.

In most cases of spondylolytic spondylolisthesis, the pars fracture occurs during adolescence and goes unnoticed until adulthood. The normal disc degeneration that occurs in adulthood can then stress the pars fracture and cause the vertebra to slip forward. This type of spondylolisthesis is most often seen in middle-aged men.

Because a pars fracture causes the front (vertebra) and back (lamina) parts of the spinal bone to disconnect, only the front part slips forward. This means that narrowing of the spinal canal is less likely than in other kinds of spondylolisthesis, such as DS in which the entire spinal bone slips forward.

What are the symptoms of degenerative spondylolisthesis?

Patients with DS often visit the doctor's office once the slippage has begun to put pressure on the spinal nerves. Although the doctor may find arthritis in the spine, the symptoms of DS are typically the same as symptoms of spinal stenosis. For example, DS patients often develop leg and/or lower back pain. The most common symptoms in the legs include a feeling of vague weakness associated with prolonged standing or walking.

Leg symptoms may be accompanied by numbness, tingling, and/or pain that is often affected by posture. Forward bending or sitting often relieves the symptoms because it opens up space in the spinal canal. Standing or walking often increases symptoms.

What are the symptoms of spondylolytic spondylolisthesis?

Most patients with spondylolytic spondylolisthesis do not have pain and are often surprised to find they have the slippage when they see it in x-rays. They typically visit a doctor with low back pain related to activities. The back pain is sometimes accompanied by leg pain.

How is a spondylolisthesis diagnosed?

Doctors diagnose both DS and spondylolytic spondylolisthesis using the same examination tools.

After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side- to-side to look for limitations or pain.

Other tests which may help your doctor confirm your diagnosis include:

X-rays. These tests visualize bones and will show whether a lumbar vertebra has slipped forward. X-rays will show aging changes, like loss of disc height or bone spurs. X-rays taken while you lean forward and backward are called flexion-extension images. They can show instability or too much movement in your spine.

Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, discs, nerves, and the spinal cord. It can show more detail of the slippage and whether any of the nerves are pinched.

Computed tomography (CT). These scans are more detailed than x-rays and can create cross-section images of your spine.

How is spondylolisthesis treated without surgery?

Although nonsurgical treatments will not repair the slippage, many patients report that these methods do help relieve symptoms.

Physical therapy and exercise . Specific exercises can strengthen and stretch your lower back and abdominal muscles.

Medication . Pain killers and non-steroidal anti-inflammatory medicines may relieve pain.

Steroid injections . Cortisone is a powerful anti-inflammatory. Cortisone injections around the nerves or in the "epidural space" can decrease swelling, as well as pain. It is not recommended to receive these, however, more than three times per year. These injections are more likely to decrease pain and numbness, but will not relieve weakness of the legs.

When should someone with degenerative spondylolisthesis be treated with surgery?

Patients should consider surgery for degenerative spondylolisthesis if they have tried the nonsurgical treatments for 3 to 6 months with no improvement.

Before committing to surgery, your provider will take a close look at the extent of the arthritis in your spine and whether your spine has excessive movement.

DS patients who are candidates for surgery are usually not able to walk or stand, and have a poor quality of life due to the pain and weakness.

When should someone with spondylolytic spondylolisthesis be treated with surgery?

Patients should consider surgery for spondylolytic spondylolisthesis if they have tried the nonsurgical treatments for at least 6 to 12 months with no improvement.

If the slippage is getting worse or the patient has progressive neurologic symptoms, such as weakness, numbness, or falling, and/or symptoms of cauda equina syndrome, surgery may help.

How is spondylolisthesis treated with surgery?

Surgery for both DS and spondylolytic spondylolisthesis includes removing the pressure from the nerves and spinal fusion.

Removing the pressure involves opening up the spinal canal. This procedure is called a laminectomy. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

Departments and Programs Who Treat This Condition

Spine surgery.

Was ist passiert?

Was war die ursache, gibt es tote oder verletzte.

• Was sind die wirtschaftlichen Folgen?    

Gegen ein Uhr nachts verließ das Frachtschiff Dali den Hafen von Baltimore auf dem Fluss Patapsco. Ziel war der Website MarineTraffic zufolge Colombo auf Sri Lanka. Kurz nachdem das Schiff ausgelaufen war, fiel der Strom aus. Die Besatzung setzte einen Notruf ab.

Um etwa 1.30 Uhr soll der fast 300 Meter lange Frachter den Pfeiler der mehr als 2,5 Kilometer langen Francis Scott Key Bridge gerammt haben. Die vierspurige Autobahnbrücke stürzte ein. Videos zeigen, wie die Brücke in nur wenigen Sekunden in sich zusammenfällt, erst der Teil über dem Frachter, dann der Rest der kilometerlangen Konstruktion.

Nachdem der Notruf der Besatzung die Behörden erreicht hatte, versuchten Polizisten umgehend, die Brücke zu räumen. Anfahrende Autos hätten sie gestoppt, bevor sie auf die Brücke fahren konnten, sagte der Gouverneur von Maryland , Wes Moore. Viele Leben hätten sie dadurch gerettet. "Sie sind Helden", sagte Moore.

Nach oben Link Link zum Beitrag

Nach Angaben von Gouverneur Moore deuten die bisherigen Ermittlungen auf einen Unfall hin. Die genaue Ursache ist jedoch noch ungeklärt.  

Das Schiff sei mit einer schnellen Geschwindigkeit von acht Knoten unterwegs gewesen, als der Strom ausfiel, sagte Moore. Das entspricht etwa 14,5 Kilometern pro Stunde. Ingenieure seien am Ort, um die Trümmer zu untersuchen. Es gebe keine Anzeichen dafür, dass die Brücke nicht intakt gewesen sei.

Es lägen zudem "absolut keine Hinweise" dazu vor, dass das Schiff die Brücke absichtlich gerammt habe, sagte der Polizeipräsident von Baltimore , Richard Worley. Auch deute nichts auf einen terroristischen Hintergrund hin. Das FBI hat Ermittlungen aufgenommen. Baltimore liegt unweit der US-Hauptstadt Washington, D. C.

Wie die New York Times mit Bezug auf die Plattform Equasis berichtete, war das Schiff seit dem Jahr 2015 insgesamt 27-mal in Inspektion. Im vergangenen Jahr seien dabei in Chile Mängel an den Antriebs- und Hilfsmaschinen festgestellt worden. Bei einer Inspektion in San Antonio hätten Inspekteure dabei spezifiziert, dass es sich um Mängel an Messgeräten und Thermometern handele. 

Nach routinemäßigen Wartungsarbeiten am Motor im Hafen von Baltimore seien den Behörden aber keine Probleme gemeldet worden, teilte Konteradmiral Shannon Gilreath von der US-Küstenwache am Mittwoch (Ortszeit) mit.

Bislang wurden zwei Leichen geborgen , vier weitere Menschen gelten noch als vermisst. Für sie besteht aber nach Behördenangaben keine Hoffnung mehr.

Es wird angenommen, dass mindestens acht Menschen bei dem Unglück ins Wasser stürzten. Bei allen handele es sich um Bauarbeiter, die zum Zeitpunkt des Unglücks Schlaglöcher auf der Brücke ausgebessert hätten, sagte der Verkehrsminister von Maryland, Paul Wiedefeld. Zwei Personen hätten gerettet werden können, einer davon sei in kritischem Zustand in ein Krankenhaus gebracht worden.    

Am Mittwochvormittag (Ortszeit) bargen Taucher dann zwei Tote aus dem Wasser. Die Suche nach den vier weiteren Vermissten wurde eingestellt, weil es für die Taucher zu gefährlich wurde.

Die Besatzung des Frachters soll unversehrt sein. Das berichtete unter anderem die New York Times , die sich auf eine Bestätigung des Frachtereigentümers bezog.

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Was sind die wirtschaftlichen Folgen?

US-Verkehrsminister Pete Buttigieg zufolge stehen den USA durch den Vorfall umfassende Lieferkettenprobleme bevor. Diese beträfen dann nicht nur die Region um Baltimore, "sondern die gesamte US-Wirtschaft". Die Brücke war bis zu ihrem Einsturz eine der wichtigsten Verkehrsadern an der Ostküste der USA. Nach Angaben von US-Präsident Joe Biden überquerten sie täglich rund 30.000 Fahrzeuge. 

Noch schwerer wirken vermutlich die Folgen für den überwiegend hinter der Brücke gelegenen Hafen der Stadt. Die zuständige Hafenbehörde hatte den Schiffsverkehr nach dem Vorfall bis auf Weiteres ausgesetzt. Nach Angaben Bidens handelt es sich um eine der wichtigsten maritimen Anlaufstellen der USA – insbesondere für den Import und Export von Autos und Kleinlastern. Demnach werden rund 850.000 Fahrzeuge pro Jahr über den Hafen von Baltimore verschifft. Rund 15.000 Arbeitsplätze hängen davon ab.

Mit Material der Nachrichtenagenturen dpa und AFP

Baltimores Bürgermeister Brandon Scott sprach von Aufnahmen wie aus einem Actionfilm – und einer "unfassbaren Tragödie": In der Nacht zum Dienstag rammte ein Frachter den Pfeiler einer vierspurigen Autobahnbrücke in der Stadt im US-Bundesstaat Maryland. Kurz darauf stürzte die Brücke ein. Was bislang über das Unglück und seine Ursache bekannt ist: 

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Tanzverbot an Karfreitag: Ist das noch zeitgemäß?

Kritik am "stillen feiertag" : tanzverbot an karfreitag: ist das zeitgemäß.

Karfreitag gilt als sogenannter stiller Feiertag. Es gilt unter anderem ein Tanzverbot. Wie aktuell ist das in einem Land, in dem nicht mal die Hälfte der Menschen christlich ist?

Karfreitag: Ein "stiller" Feiertag

Stiller feiertag: so unterschiedlich regeln die bundesländer, tanzverbot: so unterschiedlich sind die regeln.

• Baden-Württemberg: Ab Gründonnerstag, 18 Uhr bis Karsamstag, 20 Uhr
• Bayern: Ab Gründonnerstag, 2 Uhr bis Ostersonntag, 0 Uhr
• Berlin: An Karfreitag von 4 Uhr bis 21 Uhr
• Brandenburg: Ab Karfreitag, 0 Uhr bis Karsamstag, 4 Uhr
• Bremen: An Karfreitag von 6 Uhr bis 21 Uhr
• Hamburg: Ab Karfreitag, 5 Uhr bis Karsamstag, 0 Uhr
• Hessen: Ab Gründonnerstag, 4 Uhr bis Ostermontag 12 Uhr
• Mecklenburg-Vorpommern: Ab Karfreitag, 0 Uhr bis Karsamstag, 18 Uhr
• Niedersachsen: Ab Gründonnerstag, 5 Uhr bis Ostersonntag, 0 Uhr
• Nordrhein-Westfalen: Ab Gründonnerstag, 18 Uhr bis Karsamstag, 6 Uhr
• Rheinland-Pfalz: Ab Gründonnerstag, 4 Uhr bis Ostersonntag, 16 Uhr
• Saarland: Ab Gründonnerstag, 4 Uhr bis Ostersonntag, 0 Uhr
• Sachsen: An Karfreitag ganztägig
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• Schleswig-Holstein: Ab Karfreitag, 2 Uhr bis Karsamstag, 2 Uhr
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Tanzverbote treffen Diskotheken - Kritik an Umsatzeinbußen

Ein Tanzverbot greift in die unternehmerische Freiheit der Diskothekenbranche ein und zwingt sie, den Betrieb einzuschränken oder ganz niederzulegen, obwohl die Nachfrage besteht.

Bundesverband deutscher Discotheken

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Kino-Verbot betrifft nur etwa ein Prozent der Filme

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Behörden verweisen auf christliche Prägung

Der Sonn- und Feiertagsschutz ist für die Bayerische Staatsregierung ein ganz wichtiges Anliegen.

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Aus heutiger Sicht ist die gesetzliche Beschränkung an stillen Feiertagen für Filme im Kino kaum noch nachvollziehbar.

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Die lange unter Verschluss gehaltenen Dokumente des Robert-Koch-Instituts haben viele Fragen aufgeworfen. Mit der NZZ spricht der Mediziner Hendrik Streeck über die «RKI-Files», seinen Rivalen Christian Drosten und darüber, was für die nächste Krise wichtig ist.

Der Virologe Hendrik Streeck.

Herr Streeck, die Veröffentlichung der Corona-Protokolle des Krisenstabs vom Robert-Koch-Institut hat ein Jahr nach dem Auslaufen der Pandemie für eine neue Debatte gesorgt. Sind die Schwärzungen in den Protokollen Geheimniskrämerei des RKI oder ein nachvollziehbarer Vorgang einer Behörde?

Man muss die Protokolle chronologisch und als ein Zeitdokument betrachten. Die Erkenntnisse von damals waren andere als heute. Es sollte nicht als Dokument gelesen werden, in dem endgültige Entscheidungen getroffen wurden. Das Positive ist doch erst einmal: Die Dokumente zeigen, dass das RKI verschiedene Meinungen und Einschätzungen ergebnisoffen diskutiert hatte. Mit den Schwärzungen hat sich das RKI jedoch keinen Gefallen getan. Es heizt Verschwörungstheorien an. Insgesamt ist es ein kommunikatives Desaster. Minimale Schwärzungen, beispielsweise Mitarbeiter-Namen, hätte jeder nachvollziehen können.

Die veröffentlichten Protokolle fallen in die Amtszeit des ehemaligen CDU-Gesundheitsministers Jens Spahn. Der derzeitige Minister Karl Lauterbach hat nun eine «weitestgehende» Entschwärzung der Corona-Protokolle des RKI gefordert.

Das ist ein guter Schritt. Allerdings hoffe ich, dass Karl Lauterbach das zum Anlass nimmt, auch die Protokolle aus seiner Amtszeit freizugeben, um eine vollumfassende Aufarbeitung zu ermöglichen. Alles andere wäre auch ein bisschen unfair seinem Vorgänger gegenüber.

Zurück zu den Protokollen: Als besonders brisant gilt eine Einstufung Mitte März 2020: Plötzlich ging die Risikoeinschätzung von mässig zu hoch. Was halten Sie davon?

Die genauen Umstände dazu kenne ich nicht, allerdings war das ein Zeitpunkt, an dem die WHO bereits die pandemische Notlage ausgerufen hatte. Die Entscheidung mag damals also sinnvoll gewesen sein. Es zeigt aber, dass wir mehr Transparenz brauchen, um zu wissen, wie es zu den Entscheidungen gekommen ist. Ich kann das so aus den Protokollen jedenfalls nicht beurteilen.

Sie sind selbst Wissenschafter und haben sich mit den Protokollen beschäftigt. Wie lautet Ihr Fazit?

Die Protokoll zeigen, dass die Mitarbeiter im RKI in alle Richtungen und offen diskutiert haben. Leider war jedoch die Botschaft, die nach aussen gesendet wurde oftmals sehr eindeutig: «Die Wissenschaft sagt uns». Während Experten im RKI und in der Öffentlichkeit unterschiedliche Auffassungen hatten, vermittelte das RKI, es gäbe nur den einen richtigen Weg. Zudem zeigen die Protokolle die starke Abhängigkeit der Behörde von der Politik. Ich habe in den letzten Jahren mehrfach gefordert, dass es wichtig ist, dass wir ein starkes und vor allem unabhängiges Robert-Koch-Institut brauchen.

Als Behörde ist das RKI dem Bundesgesundheitsministerium unterstellt. Plädieren Sie für eine Entkopplung?

Ja, das tue ich. Zumindest braucht es mehr Freiräume. Als unabhängiges Institut könnte es freier kommunizieren, unabhängig die Politik beraten und forschen.

Nach den RKI-Files ist plötzlich die Aufarbeitung der Corona-Pandemie, die mit vielen Freiheitseinschränkungen einherging, in aller Munde. Ist es glaubwürdig, wenn Politiker sich nun kritisch äussern?

Es ist schon erstaunlich, dass es erst die Freigabe der RKI-Protokolle brauchte, damit wir darüber reden. Ich habe vor über einem Jahr in mehreren Gastbeiträgen und Interviews immer wieder eine Aufarbeitung angeregt und bin damit nicht durchgekommen. Ich habe dann für mich irgendwann die Schlussfolgerung gezogen, dass eine Aufarbeitung essenziell ist – deswegen habe ich vor einigen Monaten angefangen, ein Buch über die Lehren, die wir aus der Pandemie ziehen können, zu schreiben.

Ihr Vorgänger an der Universität Bonn, der Virologe Christian Drosten, hat die Regierung während der Pandemie als Berater unterstützt. Vor einigen Tagen sagte er: «Aus medizinischer Sicht sind wir gut durch die Pandemie gekommen.» Hat er recht?

Ich weiss nicht, wie er auf diese Aussage kommt. Man kann verschiedene Bewertungsgrundlagen anlegen und sich anschauen, ob ein Land besonders gut oder schlecht durchgekommen ist. Die Sterblichkeitsrate ist so ein Parameter, den man heranziehen kann. Die Analyse zeigen aber, dass Schweden besser durchgekommen ist als Deutschland. Wenn man einfach sagt: Das eine Land hat es gut gemacht, ist das eine sehr eindimensionale Sicht auf die Pandemie und ignoriert die psychischen, wirtschaftlichen und gesellschaftlichen Folgen. Das ist also eher eine Verteidigung der eigenen Ansicht.

Was sollte Deutschland für die nächste Pandemie lernen?

Es muss ja nicht gleich eine neue Pandemie sein. Wir können aber für andere Krisen, seien es Krieg oder Naturkatastrophen, lernen. Während Corona spielten das Virus und die Virologen die Hauptrolle, dabei hat Krisenbewältigung nur ganz wenig mit Virologie zu tun. Der Faktor Mensch – wie geht es den Kindern, den Alten, den Schwachen in der Gesellschaft psychisch und physisch–ist zum Teil viel wichtiger.

Professor «Ruhigbleiben»

Viele stellen geschwärzt, lange unter verschluss gehalten – was hat es mit den rki-protokollen auf sich, schuld an der verfehlten deutschen corona-politik sind immer die anderen, das robert-koch-institut hat sich in seiner corona-studie eine gute note ausgestellt - die studie weist allerdings viele fehler auf, mehr von beatrice achterberg (bta), «direkt ins gehirn senden»: auf tiktok hängt die afd alle anderen parteien ab – warum eigentlich, «brauchen schlanke strukturen»: ostdeutsche landtage schlagen vor, öffentlichrechtliche sender zu streichen, «sprache muss klar und verständlich sein»: bayern verbietet das gendern, wird aus «bürgergeld» die «neue grundsicherung» cdu will sozialleistung für arbeitslose in der jetzigen form abschaffen, das märchen von der schweigenden mehrheit: die teilnehmer der deutschen demos «gegen rechts» sind vor allem grün und links, mehr zum thema coronavirus, wenn natalie feuerstein mit der arbeit fertig ist, bleiben ein leeres konto, gescheiterte träume und manchmal ein abgelaufenes schweinshalssteak, sport bei long covid: weshalb sich betroffene nicht überfordern dürfen und wie sie das richtige mass finden, ringier-chef marc walder unterliegt in zwei fällen dem sonderermittler peter marti, ursprung des coronavirus: ein laborunfall war eher der auslöser der pandemie als eine zoonose – sagen australische forscher, die corona-welle ende 2023 war eine der höchsten seit beginn der pandemie. was folgt daraus, wird ueli maurer zum letzten aushängeschild der corona-skeptiker die massnahmenkritiker kneifen bei kantonalen wahlen.

• Karl Lauterbach

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Bundeskanzler Olaf Scholz hat anlässlich der Osterfeiertage erneut die deutsche Unterstützung für die Ukraine bekräftigt und das auch mit deutschen Sicherheitsinteressen begründet.

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