Spondylolisthesis and back pain

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

It often occurs when there is a congenital intraarticular defect (spondylolysis).

[1], [2], [3]

Causes of spondylolisthesis

Spondylolisthesis is usually fixed. It usually occurs in L3-L4, L4-L5, L5-S1 segments. It can be the result of a serious injury, 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 in those who have frequent minor injuries. The reason for this is reduced vertebral strength, due to the presence of a congenital intra-articular defect. This defective area easily breaks down, the separation of fragments leads to subluxation. Spondylolisthesis can also occur with minimal trauma in patients over 60 years of age who have osteoarthritis.

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

I degree corresponds to the displacement from 0 to 25%; II degree from 25 to 50%, III degree from 50 to 75%, IV degree from 75 to 100%. Spondylolisthesis of I and II degrees in particular in young can cause only minimal pain. Spondylolisthesis may be a predictor of later stenosis of the spinal tunnel. Spondylolisthesis is diagnosed by radiography.

Usually the body of the upper vertebra is displaced forward compared to the body of the underlying vertebra, which causes narrowing of the spinal canal and back pain. In some cases, the body of the upper vertebra slides posteriorly, which narrows the intervertebral foramen.

[4], [5]

Symptoms of spondylolisthesis

The patient with spondylolisthesis complains of back pain when pulling, twisting and bending in the lumbar spine. Patients may complain of "wedging in the back," of radicular pain in the lower limbs, and often experience pseudo-intermittent claudication when walking. In rare cases, the displacement of the vertebrae is so pronounced that myelopathy or horse tail syndrome develops.

Patients suffering from spondylolisthesis complain of pain in the back while moving in the lumbar spine. The transition from sitting to standing is often painful. Many patients with spondylolisthesis experience radicular symptoms that are manifested during physical examination with weakness and a sensitivity disorder in the affected dermatome. More than one dermatome is often affected. Sometimes patients with spondylolisthesis experience compression of the lumbar roots and ponytail, which leads to myelopathy and horse tail syndrome. Patients with lumbar myelopathy or horse tail syndrome have weakness of varying degrees in the lower limb and symptoms of bladder and bowel dysfunction, which is an urgent neurosurgical situation and requires appropriate treatment.

Diagnosis of spondylolisthesis

Usually, radiocontrastless radiography is sufficient to diagnose spondylolisthesis. In the lateral projection, one vertebra is displaced relative to the other. MRI of the lumbar department provides the clinician with the best information about the condition of the lumbar spine. MPT is highly reliable and helps identify a pathology that can expose a patient to the risk of developing lumbar myelopathy, such as a three-leafed spinal canal with congenital stenosis. Patients who are contraindicated in MRI (presence of pacemakers) are justified in conducting CT or myelography. Radionuclide bone examination and contrastless radiography are indicated if there is a suspicion of fractures or other bone pathologies, such as, for example, metastatic disease.

The above survey methods give the clinician useful information on neuroanatomy, and electromyography and study of nerve conduction velocity provide information on neurophysiology that can establish the current status of each nerve root and lumbar plexus. Laboratory tests (general blood tests, ESR, blood biochemistry) should be performed if the diagnosis of spondylolisthesis is uncertain.

[6], [7], [8], [9]

Complications and Diagnostic Errors

Failure to accurately diagnose spondylolisthesis can expose the patient to the risk of developing myelopathy, which, if untreated, may progress to paraparesis or paraplegia. Electromyography helps to distinguish between plexopathy and radiculopathy and to identify a concurrent tunneling neuropathy that can distort the diagnosis.

Spondylolisthesis should be understood in any patient who complains of back pain or radicular pain or symptoms of pseudo-intermittent claudication. Patients with symptoms of myelopathy need to have an MRI for emergency indications. Physiotherapy helps prevent recurring episodes of pain, but in the future, surgical stabilization of the damaged segments may be required.

[10], [11], [12]

Differential diagnosis

Spondylolisthesis is an x-ray diagnosis, which is confirmed by a combination of anamnesis, physical examination, radiography and MRI. Pain syndromes that can mimic spondylolisthesis include lumbar radiculopathy, stretching of the lower back, lumbar bursitis. Lumbar fibromyositis, inflammatory arthritis and diseases of the lumbar spinal cord, roots, plexuses and nerves. MRI of the lumbar spine should be given to all patients with suspected spondylolisthesis. A laboratory test should be performed that includes a general blood test, ESR, antinuclear antibodies, HLA B-27 antigen and a biochemical blood test if the diagnosis of spondylolisthesis is uncertain to exclude other causes of pain.

[13], [14]

Treatment of spondylolisthesis

In the treatment of spondylolisthesis, an integrated approach is most effective. Physiotherapy, including bending exercises. Thermal procedures and deep relaxing massage in combination with NSAIDs and muscle relaxants (tizanidine) are the most preferred treatment start. With persistent pain, an epidural blockade is indicated. It is shown that caudal or lumbar epidural blockades with local anesthetics or steroids are highly effective in treating secondary pain in spondylolisthesis. In the treatment of background sleep disorders and depression, tricyclic antidepressants, such as amitriptyline, which can be started with 25 mg per night, are most effective.