Spondylolisthesis ยท St. Louis
One vertebra has slipped forward on the one below. The slip is not the pain.
Spondylolisthesis is one vertebra slipped forward on the one beneath it, most often L4 on L5 or L5 on S1. How far it has slipped matches poorly with how much someone hurts. What matters is whether the segment is stable. It also matters whether anything is being squeezed.
What is spondylolisthesis?
Spondylolisthesis is a forward shift of one vertebral body on the one beneath it, most often L4 on L5 or L5 on S1. It is graded I to IV by how far it has moved. There are two common causes. One is a stress fracture in the bony bridge behind the joint, typically from teen extension sports (sports that bend the back backward). The other is degenerative change in the facets that lets the segment drift with age.
Grade I and II are the vast majority. They are often found by chance on imaging done for something else. Many people carry one for decades without symptoms.
What causes spondylolisthesis pain?
- Segmental instability — the slip moves between flexion (bending forward) and extension (bending back) X‑ray views. That is not the same finding as a slip that sits still.
- Foraminal narrowing at the level. It squeezes the nerve root as it exits and causes leg symptoms.
- Facet-mediated pain at that segment. It is common, and we can test for it. Facet syndrome.
- Central canal narrowing, which limits how far you can walk. Stenosis.
Notice that none of those is the slip itself. A stable grade I slip with no compression is something seen on an X‑ray, not a diagnosis. Treating the number instead of the mechanism is how people end up with fusions that do not change their day.
How is spondylolisthesis treated?
- Flexion and extension X-rays to find out whether the segment really moves. This is the question that changes the plan. It is skipped surprisingly often.
- Examine for nerve root involvement. Also look for the pattern where walking distance is limited.
- Test the facets at that level with a diagnostic block where axial pain dominates.
- Give the segment a better wall of muscle — deep abdominal wall, multifidus, hip extensors. A segment held steady by muscle does better than one left to its ligaments.
- Reserve fusion for demonstrated instability with matching symptoms. Or reserve it for a neurological deficit that keeps getting worse.
Extension is the provocative direction here. It is the motion that sets the pain off. Programs built on repeated extension — some yoga, some gym work, some sports — often make this worse. Flexion-biased work (favoring forward bending) is usually better tolerated. That is the reverse of the advice a back without facet pain gets.
Frequently asked questions
Will my slip get worse?
Most stable slips progress slowly or not at all. This is particularly true in adults whose slip is degenerative rather than from a fracture. Watch for progression. Do not assume it.
Do I need surgery?
Most people do not. Surgery has a clear role in demonstrated instability. It also has one in a deficit that keeps getting worse, and in stenosis at that level when conservative care has failed. Read this before you agree to surgery.
Can I still exercise?
Yes, and you should. Lean toward work that tolerates flexion and steadies the core. Steer away from repeated end-range extension (bending back as far as you can). Avoiding movement altogether takes away the muscle support the segment most needs.
What causes spondylolisthesis?
Two causes account for most cases. The first is a stress fracture in the bony bridge behind the joint, usually from extension sports in the teenage years. The second is degenerative change in the facet joints that lets the segment drift forward with age. Either way, one vertebra has moved forward on the one below, most often L4 on L5 or L5 on S1.
Can spondylolisthesis be fixed without surgery?
Most people never need surgery, because the slip itself is not the pain. Treatment goes after what is actually hurting. Flexion and extension X-rays show whether the segment moves. A diagnostic block tests the facet joints. Then we strengthen the deep abdominal wall, multifidus and hip extensors. Fusion is reserved for proven instability with matching symptoms, or a nerve deficit that is getting worse.
What should you not do if you have spondylolisthesis?
Avoid programs built around repeated backward bending, such as some yoga, some gym work and some sports. That is because extension is the direction that aggravates a slip. Do not stop moving altogether either. That is because it strips away the muscle support the segment needs most. And do not accept a fusion based on the grade number alone, without evidence that the segment is unstable.
Related reading
- Spinal stenosis
- Lumbar facet syndrome
- What your imaging actually showed
- Physical therapy for back pain
Ask whether your slip actually moves
Flexion and extension views answer it, and the answer changes everything downstream. Bring whatever imaging you already have.
12174 Natural Bridge Rd, Suite 301
St. Louis, MO 63044
At DePaul Hospital on Natural Bridge Road, inside the I-270 and I-70 interchange, on the west side of the airport.
Sources
- Bydon M et al. Degenerative Lumbar Spondylolisthesis: Definition, Natural History, Conservative Management, and Surgical Treatment. Neurosurgery clinics of North America, 2019. PubMed 31078230
- Mohile NV et al. Spondylolysis and Isthmic Spondylolisthesis: A Guide to Diagnosis and Management. Journal of the American Board of Family Medicine : JABFM, 2022. PubMed 36526328
- Gadjradj PS et al. Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2023. PubMed 36609887
- Chan AK et al. Summary of Guidelines for the Treatment of Lumbar Spondylolisthesis. Neurosurgery clinics of North America, 2019. PubMed 31078236