Spondylolisthesis and back pain

Spondylolisthesis is a subluxation of the lumbar vertebrae that usually occurs in adolescents.

It often occurs in the presence of a congenital intra-articular defect (spondylolysis).

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Causes of Spondylolisthesis

Spondylolisthesis is usually fixed. It usually occurs in the L3-L4, L4-L5, L5-S1 segments. It can be a consequence of severe trauma, such as high-speed braking. Patients with spondylolisthesis due to severe trauma may have spinal cord compression or other neurological deficits, but this is rare. Spondylolisthesis usually occurs in young athletes or those who have frequent minor injuries. It is caused by decreased strength of the vertebrae due to the presence of a congenital intra-articular defect. This defective area easily breaks, separation of the fragments leads to subluxation. Spondylolisthesis can also occur with minimal trauma in patients over 60 years of age with osteoarthritis.

Spondylolisthesis is divided into degrees according to the degree of subluxation of the adjacent vertebral bodies.

Grade I corresponds to a displacement of 0 to 25%; Grade II from 25 to 50%, Grade III from 50 to 75%, Grade IV from 75 to 100%. Grade I and II spondylolisthesis, particularly in young people, can cause only minimal pain. Spondylolisthesis can be a predictor of later spinal canal stenosis. Spondylolisthesis is diagnosed by radiography.

Typically, the body of the upper vertebra shifts forward compared to the body of the vertebra below, causing narrowing of the spinal canal and back pain. In some cases, the body of the upper vertebra slides backward, narrowing the intervertebral openings.

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Symptoms of Spondylolisthesis

A patient with spondylolisthesis complains of back pain when pulling, twisting, and bending the lumbar spine. Patients may complain of "locking in the back," radicular pain in the lower extremities, and often experience pseudo-intermittent claudication when walking. Rarely, the vertebral displacement is so severe that myelopathy or cauda equina syndrome develops.

Patients with spondylolisthesis complain of back pain with movement of the lumbar spine. Moving from a sitting to a standing position often causes pain. Many patients with spondylolisthesis experience radicular symptoms, which are manifested on physical examination by weakness and sensory disturbances in the affected dermatome. Often, more than one dermatome is affected. Occasionally, patients with spondylolisthesis experience compression of the lumbar nerve roots and cauda equina, leading to myelopathy and cauda equina syndrome. Patients with lumbar myelopathy or cauda equina syndrome have varying degrees of lower extremity weakness and symptoms of bladder and bowel dysfunction, which are neurosurgical emergencies that require appropriate treatment.

Diagnosis of spondylolisthesis

Usually, non-contrast radiography is sufficient to establish the diagnosis of spondylolisthesis. The lateral view shows the displacement of one vertebra relative to the other. Lumbar MRI provides the clinician with the best information about the lumbar spine. MRI is highly reliable and helps identify pathology that may put the patient at risk for lumbar myelopathy, such as trifoliata in congenital stenosis. In patients for whom MRI is contraindicated (presence of pacemakers), CT or myelography is justified. Radionuclide bone scan and non-contrast radiography are indicated if fractures or other bone pathology, such as metastatic disease, are suspected.

These tests provide the clinician with useful information about the neuroanatomy, and electromyography and nerve conduction velocity studies provide neurophysiological information that can establish the current status of each nerve root and lumbar plexus. Laboratory tests (complete blood count, ESR, blood chemistry) should be performed if the diagnosis of spondylolisthesis is in doubt.

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Complications and diagnostic errors

Failure to accurately diagnose spondylolisthesis may expose the patient to the risk of developing myelopathy, which, if untreated, may progress to paraparesis or paraplegia. Electromyography helps differentiate plexopathy from radiculopathy and identify a coexisting entrapment neuropathy that may confound the diagnosis.

Spondylolisthesis should be considered in any patient complaining of back or radicular pain or symptoms of pseudo-intermittent claudication. Patients with symptoms of myelopathy should undergo an MRI as an emergency. Physical therapy helps prevent recurrent episodes of pain, but surgical stabilization of the affected segments may be required in the long term.

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Differential diagnosis

Spondylolisthesis is a radiographic diagnosis confirmed by a combination of history, physical examination, radiography, and MRI. Pain syndromes that may mimic spondylolisthesis include lumbar radiculopathy, low back strain, lumbar bursitis, lumbar fibromyositis, inflammatory arthritis, and disorders of the lumbar spinal cord, roots, plexuses, and nerves. Lumbar MRI should be performed in all patients suspected of having spondylolisthesis. Laboratory testing should include complete blood count, erythrocyte sedimentation rate, antinuclear antibodies, HLA B-27 antigen, and serum chemistry panel if the diagnosis of spondylolisthesis is in doubt to exclude other causes of pain.

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Treatment of spondylolisthesis

In the treatment of spondylolisthesis, a multimodal approach is most effective. Physical therapy, including flexion exercises, heat treatments, and deep relaxation massage in combination with NSAIDs and muscle relaxants (tizanidine) are the most preferred initial treatment. In cases of persistent pain, epidural blocks are indicated. Caudal or lumbar epidural blocks with local anesthetics or steroids have been shown to be highly effective in treating secondary pain in spondylolisthesis. In the treatment of underlying sleep disorders and depression, tricyclic antidepressants such as amitriptyline are most effective, and can be started with 25 mg at night.