Anatomy of the Spine
The spinal column supports your body and allows you to complete everyday movements like standing, bending down and twisting. The spine is made of 33 individual bones, known as vertebra. The vertebral column has a natural S-shaped curve, with each curve working to absorb shock, maintain balance and support your range of motion.
The vertebrae interlock with each other, but are split up into different sections, each of which has unique functions.
The cervical spine includes vertebrae C1 to C7, supports the weight of the head and allows neck movement.
The thoracic spine, or mid-back, holds the rib cage and protects the heart and lungs. The thoracic vertebrae are numbered T1 to T12.
The lumbar spine, or low back, includes the L1 to L5 and these vertebrae support the weight of the body.
Spondylolisthesis may occur anywhere within the spinal column, though, it is more prevalent in the lumbar spine.
What is Spondylolisthesis?
Spondylolisthesis is a spinal condition that results when one of the vertebrae slips forward or backward when compared to the vertebra adjacent to it.
The condition is most commonly diagnosed in adults and caused by degeneration of the discs and ligaments that bind and support the spine. Spondylolisthesis often begins in the teenage years, and with age, the intervertebral discs lose water content and ultimately height. As the vertebrae on either side of the disc come closer to each other, the upper vertebra slides forward over the sub-adjacent vertebra.
Spondylolisthesis can also be associated with deterioration of the facet joints that connect vertebrae. As the facet joints become arthritic due to deterioration, they enlarge in an attempt to maintain the stability of the spine.
As the two vertebral segments adjoining the spinal canal slide past each other, the spinal canal narrows in size. The combination of spinal canal narrowing and enlargement of the facet joints produces nerve compression problems found in degenerative spondylolisthesis.
What Causes Spondylolisthesis?
Men are more likely to develop spondylolisthesis than women. Some children under the age of five may also be pre-disposed to the condition. However, it is more common among children in the 7 to 10 years old range. Depending on the type, there are a number of different possible spondylolisthesis causes:
- Congenital condition
- Repetitive trauma
- Arthritic changes in the facet joints
- Direct trauma or injury to the vertebra
- Structural weakness of the bone
- Tumors or bone disease
Other risk factors that may lead to the development of spondylolisthesis include:
- Family history of back problems
- Previous back surgery
- Infections
- Chronic hypertension
- Playing high-impact sports
- Accident or trauma
- Arthritis
Depending on the type of spondylolisthesis, there are a number of different possible causes:
- Dysplatic spondylolisthesis: A congenital condition caused by a defect in the formation of part of the vertebra called the facet that allows it to slip forward.
- Isthmic spondylolisthesis: A defect and slip that exists in a portion of the vertebra called the pars interarticularis. (If there is a defect without a slip the condition is called spondylolysis.) Isthmic spondylolisthesis can be caused by repetitive trauma and is more common in athletes exposed to hyper-extension motions including gymnasts and football linemen.
- Degenerative spondylolisthesis: More common in older patients, degenerative spondylolisthesis occurs due to arthritic changes in the joints of the vertebrae due to cartilage degeneration.
- Traumatic spondylolisthesis: Caused by direct trauma or injury to the vertebrae, such as a fracture of the pedicle, lamina or facet joints that allows the front portion of the vertebra to slip forward with respect to the back portion of the vertebra.
- Pathologic spondylolisthesis: Caused by abnormal bone, such as from a tumor.
Types of Spondylolisthesis
There are several different types of spondylolisthesis with the most common being congenital spondylolisthesis, isthmic spondylolisthesis, and degenerative spondylolisthesis.
Congenital Spondylolisthesis
Congenital spondylolisthesis, also called dysplastic spondylolisthesis, indicates the condition is present at birth.
Spondylolisthesis can lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis). Persistent pain associated with spondylolisthesis can lead to reduced mobility and inactivity. There is also a risk of permanent nerve damage if a slipped vertebra is pressing on a spinal nerve root.
Isthmic Spondylolisthesis
Specifically, isthmic spondylolisthesis occurs in a portion of the vertebra called the pars interarticularis. Isthmic spondylolisthesis can be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions including gymnasts and football linemen. Isthmic spondylolisthesis can be the result of spondylolysis, a condition that leads to small stress fractures in the vertebrae.
Degenerative Spondylolisthesis
More common in older patients, degenerative spondylolisthesis occurs due to arthritic changes in the joints of the vertebrae due to cartilage degeneration. As you age, the spinal discs, which provide cushioning between the vertebrae, may lose water and be less able to resist movement by the vertebrae.
Less common forms of this condition include traumatic, pathological spondylolisthesis and post-surgical.
Symptoms of Spondylolisthesis
Spondylolisthesis can cause compressive or neurogenic symptoms. The forward slip of a vertebra also makes the spinal canal smaller, leaving less room for the nerve roots running between the vertebrae.
Compressive symptoms can also arise because the nerve roots at the segment involved are pinched with the narrow spinal canal. If there are compressive symptoms, there may be pain down the leg to the foot, numbness in the foot, and possibly weakness when trying to raise the foot.
The combination of spinal canal narrowing and enlargement of the facet joints produces the characteristics of nerve compression problems found in degenerative spondylolisthesis.
Common Symptoms of Spondylolisthesis
- Lower back pain
- Buttock pain
- Pain that runs down the back of the leg
- Weakness in the legs
- Tingling or numbness
- Pain that gets worse with a twist or bending over
- Muscle strain-like discomfort
- Muscle spasms in hamstring muscles
- Difficulty walking or standing
Examination and Diagnostic Studies
Most of the symptoms from spondylolisthesis are aggravated by standing, walking and other activities. The first step in diagnosing the condition is a physical examination. You may have difficulty lifting your leg or completing simple exercises.
Imaging studies such as an MRI and CT scan are used to confirm the condition and demonstrate the degree of slippage in spondylolisthesis. The doctor may also use x-rays to look for any possible bone fractures, which could be the cause of nerve impingement or spondylolisthesis.
Grading Spondylolisthesis
After a physical exam and imaging studies are completed, a radiologist will determine to what degree slippage occurred. Spondylolisthesis may fall into four grades.
- Grade I – Vertebral slip of up to 25%
- Grade II – Slip between 26% and 50%
- Grade III – 51% to 75% slip
- Grade IV – 76% to 100% vertebral slip
Treatment for Spondylolisthesis
Spondylolisthesis treatment will primarily depend on what type of spondylolisthesis it is and what symptoms the patient is displaying. Surgery may be necessary for spondylolisthesis treatment if medication, physical therapy, and exercise fail to keep the spondylolisthesis pain at a tolerable level.
Non-Surgical Treatment
Conservative treatment is common for Grade I and II spondylolisthesis. Treatment options may include:
- Decreased activity until pain subsides
- Over-the-counter anti-inflammatory drugs (NSAIDs), such as ibuprofen
- Epidural steroid injections
- Back support or brace
- Physical therapy for improving flexibility and muscle strength
Surgical Treatment
Surgical treatment for spondylolisthesis must address nerve compression symptoms if they are present. This usually means that the nerves that exit the spine must be freed of all pressure and irritation.
The Bonati Spine Procedures offer an array of surgical techniques to treat spondylolisthesis, which may include:
- A laminotomy/laminectomy, which is a decompression surgery for spinal stenosis and involves making an opening in the lamina to relieve pressure on the affected area and allow the nerve roots room to heal. This procedure is often utilized in order to give the surgeon the proper space to perform a foraminotomy/foraminectomy.
- A foraminectomy/foraminotomy, which is a decompression surgery, performed in order to increase the space of the foramen and hollow out the passageway where the nerve roots exit the spinal canal. The procedure involves the removal of bone or tissue that obstructs the neuroforamen and compresses the nerve roots leading to inflammation and radiating pain. During this procedure, the surgeons utilize specialized instrumentations to decompress the nerve roots as they exit through the foramen.
- A discectomy, which involves the removal of a portion of the intervertebral disc that is putting pressure on the spinal cord or radiating nerves. A discectomy may be performed as part of the treatment for spondylolisthesis if the disc at the affected level is herniated.
Prevention & Self-Care
As spondylolisthesis may be the result of congenital and genetics, it is not fully preventable. Still, there are many steps you can take to reduce the risk of a vertebral slip.
- Maintain the strength in your back and abdominal muscles
- Maintain a healthy weight
- Eat a well-balanced diet
- Protect your back during sports or rigorous activities
- Correct your posture
- Stop smoking and avoid excessive consumption of alcohol
- Learn to lift correctly
By following these tips, you can enjoy the benefits of a healthy spine at any age.
Spondylolisthesis Surgery
Spinal stenosis due to degenerative spondylolisthesis is a widespread condition and one of the most common reasons for spinal surgery. Spondylolisthesis is a condition in which one vertebra slides forward over the vertebra below it. This anterior slippage occurs most often in the lumbosacral area (lower back). This condition most commonly occurs at the L5-S1 level with an anterior translation of the L5 vertebral body on the S1 vertebral body. The second most common location for spondylolisthesis is the L4-L5 level.
The bones in your spinal cord, called facet joints, line up to support the spinal cord but also allow the back to move and be flexible. Spondylolisthesis occurs when one or more of the facet joints allows a vertebral bone to move out of line.
Does Spondylolisthesis Require Surgery?
When pain from spondylolisthesis does not respond to conservative treatment options, surgery may be required. The type and degree of spondylolisthesis have to be properly evaluated along with the symptoms caused by the condition in order to determine the best treatment option.
There are different types of spondylolisthesis as well as different grades of spondylolisthesis. The first three below are the most common forms.
Congenital Spondylolisthesis – this type is present at birth and is the result of abnormal bone formation that puts the vertebrae at greater risk for slipping.
Isthmic Spondylolisthesis – this type occurs in a patient with spondylolysis, a condition that causes small bone fractures in the vertebrae. These fractures can weaken the vertebrae so much that is slips out of place.
Degenerative Spondylolisthesis – a part of the normal aging process, this is the most common type of spondylolisthesis. As you age, your discs become less spongy and lose their ability to resist movement by the vertebrae, which means they are more likely to slip.
Other forms of Spondylolisthesis include:
Traumatic spondylolisthesis – when an injury causes a spinal fracture or slippage.
Pathological spondylolisthesis – when the spine is weakened by disease, infection, or tumor.
The Meyerding Grading System is used to classify the degree of vertebral slippage. Slips are graded on the percentage that one vertebral body has slipped over the vertebral body below it.
- Grade I: 1-24%
- Grade II: 25-49%
- Grade III: 50-74%
- Grade IV: 75%-99%
- Grade V: Complete slip (100%), known as spondyloptosis
When determining if a surgical procedure is required, doctors take into consideration the degree of slip, as well as other factors such as neurological symptoms and pain. As a general rule, slips rated at Grade III and above will most likely require surgery.
Although spondylolisthesis is not the same as a bulging disc or herniated disc, the conditions can coexist. Degenerative spondylolisthesis can cause foraminal narrowing and spinal stenosis.
Many people with spondylolisthesis have no symptoms and the disorder is discovered when seeing a doctor for other health issues. Some of the spondylolisthesis symptoms may include:
- Mild to severe lower back pain
- Sciatica and muscle spasms
- Leg weakness or tingling
- Back stiffness
- Tight hamstrings
- Irregular gait or limp
Surgery Options
Decompression surgery may be an option if you have tried conservative treatments but are still experiencing limited mobility and pain. The Bonati Spine Procedures offer an array of procedures to treat spondylolisthesis which may include:
Discectomy
A discectomy is performed to remove part of a bulging or herniated disc pressing on the spinal cord and/or spinal nerve roots, causing pain, radiculitis (pain that radiates to the extremities), numbness, tingling or weakness.
Laminectomy/Laminotomy
The Bonati Laminectomy/Laminotomy are decompression surgeries that relieve pressure on spinal nerves caused by narrowing of the spinal canal. The procedures are performed incrementally, one vertebral level at a time, to address the main cause(s) of pain first. A small incision is made through which a series of tubes, patented by Dr. Bonati, are inserted. The lamina is then accessed and small portions of the anterior or posterior lamina responsible for the nerve pressure are removed. Bone spurs may also be removed.
Foraminotomy/Foraminectomy
The Bonati Foraminotomy/Foraminectomy is performed to relieve pressure on compressed nerves at the site of the intervertebral foramina (neural foramen). The Bonati Foraminotomy involves a very small incision through which the patented Bonati tube system is inserted to view the surgical area using endoscopic assistance. Instrumentation is passed through the tubular system to remove the small portion of bone or disc material compressing the nerve(s).
Facet Thermal Ablation
The Bonati Facet Thermal Ablation (Rhizolysis) uses a laser to deaden sensory nerves that are irritating the facet joints and causing pain. During the procedure, our spine surgeons vaporize irritated and painful nerves around the facets of the vertebrae. Dilating Tubes and Laser are utilized to remove pain-inducing tissue in nerve branches above and below the affected facet joints on the spine.
Who Performs the Procedures?
One of the highly skilled Bonati spine surgeons will perform your procedure. All of the surgeons at The Bonati Spine Institute have trained extensively with Dr. Alfred Bonati. For more than 30 years, the surgeons at the Bonati Spine Institute have been considered leaders in advanced spine surgery techniques.
Before Surgery
Your surgeon will give you detailed instructions on how to prepare for your surgery. General guidelines include no food or drink after midnight the day before your surgery. Regular exercise can improve your recovery rate. If you are a smoker, try to quit, at least temporarily, before your surgery.
Some prescription medicine can increase your risk of bleeding and other complications during any surgical procedure. Your physician will give you specific instructions about any medications you take regularly. If you take any of the following medications, discuss with your surgeon whether or not you should take them before surgery.
- Aspirin, Plavix, and other blood thinners
- Anti-coagulants
- NSAIDs such as Ibuprofen, Aleve, Naproxen, and Advil
- Arthritis medications
- Vitamins and herbal medicines as they may interact with the anesthesia
Discuss all of your prescription medications with your surgeon for exact instructions on how to manage them before and after surgery.
During Surgery
The Bonati Spine Procedures do not use general anesthesia. Patients are made comfortable through the use of conscious IV sedation and local anesthesia so that they are responsive and able to provide feedback throughout the procedure. This allows our surgeons to target the source of pain with pinpoint accuracy. While in the operating room, the surgical team will confirm the patient is able to complete a series of mobility exercises and verify that the pain has been successfully treated.
After Surgery
After the procedure, the patient is transferred to the post-operative care unit for rest and observation, and then a post-operative consultation with the surgeon will help determine if any additional procedures are necessary. Follow-up surgeries are usually scheduled within a few days of the first surgery, to allow any swelling to subside. During this time, the patient will be given a regimen of walking therapy.
Recovery Time from Spondylolisthesis Surgery
The Bonati Procedures are completed using small incisions. This approach helps minimize scarring and nerve injury as well as reduces recovery time. Recovery time depends on the surgery and can vary from patient to patient, but is usually within days.
More than 75,000 the Bonati Spine Procedures have been successfully performed with a patient satisfaction rate of 98.75%.
Outlook
Persistent pain as a result of spondylolisthesis can reduce mobility and lead to inactivity that can result in weight gain, loss of bone density, muscle atrophy and loss of flexibility.
The outlook for someone with spondylolisthesis depends on the grade of the slip. In the case of a minor slip, the individual may not suffer from a recurrence of back pain related to the condition because the nerves are not being impinged.
If the slip causes nerve compression, surgery may be required to decompress the nerves that are causing the pain.
The Bonati Spine Institute encourages patients with spondylolisthesis to contact us to request a no-obligation MRI review or discuss your conditions with our medical professionals. Find out why The Bonati Spine Procedures are considered to be among the world’s best solutions when it comes to advanced spine surgery. Your pain from spondylolisthesis can become a thing of the past.
