Lower back pain (LBP) affects up to 80% of the population. There are many causes that contribute to lower back pain. One condition causing back pain is spondylolisthesis (spondy-low-liss-thesis). This can occur at anytime during one’s life. It is essentially the slipping forward of one vertebra on the other. The most common area for this to occur is the lower back. It can also occur in the neck or cervical spine but that is significantly less common. Research has found up to 6% of the adult population may have spondylolisthesis. Since this condition is not found in the newborn it suggests that spondylolisthesis is a developmental or acquired condition. In a landmark study 4.4% of 6 year olds were found to have the condition and it increased to 6% by adulthood. It is rare under age 5. Spondylolisthesis is nearly unheard of in the middle back.
How Does Spondylolisthesis Happen?
The pre-spondylolisthesis condition is called spondylolysis. It is defined as a defect from direct trauma or continuous micro trauma. This results in softening or weakening of the bone and develops into a stress fracture. When the vertebra slips forward, it results in spondylolisthesis. Many people who have spondylolysis do not know they have the defect. The defect is more significant if it is bilateral compared to unilateral or on just one side of the vertebral segment.
Not all spondylolisthesis cases are from direct or micro trauma. Degenerative spondylolisthesis occurs in the aging spine. This problem develops most commonly in females above age 40. It seems to have a predilection for the L4/L5 motion segment. The disc is degenerating and the facet joints are arthritic.
The vertebra gradually shifts forward resulting in the spondylolisthesis. It has been thought that diabetes and osteoporosis are contributing factors for this condition. Abnormal joint development has been cited as a contributing factor; it is called facet tropism. This condition has the potential for the vertebra to continue to slip and create lower back pain. It can lead to instability of the spine in the low back resulting in increased lower back and leg pain. Degenerative spondylolisthesis is the most common type to occur in the cervical spine. The mechanism is the same to include disc degeneration and facet joint arthritis due to aging and trauma. Segments C4, C5 and C6 (cervical) are the most common.
What are the Signs and Symptoms?
There are additional symptoms other than lower back pain. Initially, and in many cases, there may be no or little lower back pain. Conversely, lower back pain may be the only symptom that brings you to the doctor. The following symptoms are commonly associated with spondylolisthesis:
- Lower Back Pain and Stiffness – There is midline lower back pain that can radiate out over the pelvic bones and into the buttocks on one or both sides.
- Leg Pain – Irritation of the lumbar nerves can cause pain to radiate into the upper legs. The pain infrequently goes below the knees with spondylolisthesis unless there may be a disc herniation with nerve root compression.
- Leg Weakness – The legs feel weak when walking or standing for even short periods. Common comments include “my legs get tired so easy” or “I can’t stand very long before my legs tire”.
- Increased Lordosis – Noticeable “swayback” or the curve seen on a side view of the lower back has increased.
- Hamstring Tightness – Backs of the upper legs feel tight and walking seems easier with the knees slightly bent.
Research has found that the symptoms from spondylolisthesis generally begin around a mean age 20. Incredibly, an article by Olsen TL, Anderson RL, et al, Am J Public Health, Apr 1992:82 commented on the prevalence of LBP in athletes aged 11-17 years; spondylolisthesis has been reported as high as 30.4% among adolescents participating in sports. Lumbar spondylolysis must be considered in the differential diagnosis of LBP in this population. Additional information from Beutler WJ, Fredrickson BE, et al, Spine, May 15 2003:28 reports in a study that there was a 4.4% incidence of spondylolysis in 500 first grade children, which increased to 6% in adulthood with a 45 year follow up. Morita T, Ikata T, et al did a screening study in Japan on children who presented with LBP. They found 32% of the patients younger than 19 years had at least one or more defects that contributed to the development of spondylolisthesis!! Duggleby T, Kumar S, Disabil Rehabil. Dec 1997:19 reported within competitive sports, increasing age and training more than 15 hours a week correlates with a higher incidence of spondylolytic defects. The most common level of a spondylolytic lesion is at L5 (85-95%), followed by L4 (5-15%). Soler, et al, Am J of Sports Med, Jan-Feb 2000 state that spondylolysis occurs in 3-7% of the general population. Rossi, et al, J Sports Med Physical Fitness, Dec 1990 state that the condition is higher in competitive athletes than the general population.
How is Spondylolisthesis Diagnosed?
When presenting to a doctor with lower back pain, a history and physical examination will be performed. X-ray studies may be necessary depending upon the doctor’s findings. The severity of the slippage of the vertebra is graded 1-4 with 1 the least slippage and 4 the most. The history is significant for athletes. Research has found that pre-spondylolytic college athletes have a very high incidence of spondylolisthesis. Some activities that can cause this condition, but are not limited to, are:
- Gymnastics – There may be a mild increase compared to the non-gymnastic population.
- Weightlifting – Nearly 30% of weighlifters have been reported to have this condition. Lifting puts a shear force through the lower back contributing to the spondylolisthesis.
- Wrestling – Straining in awkward positions puts a shear force through the lower back.
- American Football – Straining in the blocking position by linemen has been thought to contribute to the problem. Most linemen also lift weights during training.
- Excessive Throwing Motion – Hyperextension during the throw stresses the lower back.
- Figure Skating – Trauma to the lower spine may occur from falls to the ice.
- Rowing – Hyperextension of the spine under full weight of the oar in the water.
- Soccer – Collision with other players and falls in awkward positions may place a shear stress through the lower vertebrae.
Any sport or work activity that puts repetitive strain to the lower spine may be a contributing factor to the development of spondylolysis.
What Can Happen to You if You Have a Spondylolisthesis?
Grades 1 and 2 are generally treated conservatively. This is true unless the spondylolisthesis is found to be unstable. Grades 3 and 4 may need surgical intervention and stabilization if conservative management has not been successful in controlling the symptoms. Lower back pain, leg pain and numbness, weakness of the legs and loss of daily function may occur.
Please visit the article on the Coon Rapids Chiropractic website for information on conservative care and management of spondylolisthesis. The doctors at Coon Rapids Chiropractic have experience in the conservative management of this condition. The doctors understand the condition and if necessary will co-manage your spondylolisthesis with an orthopedic surgeon.