Treatment depends on the cause of the spondylolisthesis:
- Congenital forms can usually be treated conservatively with physiotherapy for a long time. Surgery is only necessary if there is persistent pain or neurological failures.
- degenerative forms are primarily to be treated with pain relievers. Surgery should be performed without improvement or with neurological disorders.
- In the case of traumatic or pathological forms, depending on the cause and the extent of the damage, a decision must be made individually about conservative or surgical therapy.
The surgical procedure is discussed with the patient based on the described complaints and imaging:
- purely microsurgical decompression
- microsurgical decompression with stabilization (spondylodesis)
After the operation, the patient is quickly mobilized with back training through physiotherapy. There are no further restrictions.
What does spondylolisthesis mean?
The colloquial term "vertebral gliding" is technically known as spondylolisthesis (SL). "Spondyl olisthesis" comes from the Greek and means the sliding (olisthesis) of a vertebral body (spondylos). There is instability in the spine (animation).
If the upper vertebral body slides over the lower abdomen, there is an antero or ventrolisthesis. In the opposite case, this is called retrolisthesis.
Symptoms of spondylolisthesis
Expression of the spondylolisthesis - Meyerding grade
Spondylolisthesis without complaints
The congenital spondylolisthesis is often a coincidence in the imaging examination of the spine and is not necessarily associated with complaints. Degenerative spondylolisthesis is also often described in image diagnostics, whereby the patients are often asymptomatic.
Spondylolisthesis with complaints
Spondylolisthesis can lead to compression of individual nerve roots (radiculopathy) or a concentric narrowing of the spinal canal with or without back pain (lumbar pain).
How a spondylolisthesis becomes symptomatic depends on the anatomical classification and the etiology. The degenerative form of spondylolisthesis is often accompanied by narrowing of the spinal canal and compression of the nerve tube (spinal canal stenosis). Classically, this is noticeable by leg pain dependent on the walking distance (claudication spinalis). In the case of congenital or emerging forms of adulthood, on the other hand, the patient complains of clearly defined (dermatome-dependent) leg pain. Radiculopathy is present.
In both cases there may also be movement-dependent lumbar complaints, which may be an expression of instability caused by spondylolisthesis.
Neurological deficits with emotional disorders and paralysis up to loss of incontinence of the bladder and rectum (caudal syndrome) are rare.
Causes of spondylolisthesis
A spondylolisthesis can have different causes, which is why there are different classifications. The most common classification is shown in the table. Wiltse et al. take into account both anatomical and aetiological factors in their scheme. There are innate and acquired forms.
The congenital type I (Table 1) is due to a malformation in the area of the upper sacrum (Os sacrum) or the vertebral arch (Lamina) LWK5. Type I is associated with other malformations (spina bifida occulta) in 94% of cases.
An acquired spondylolisthesis can arise due to spondylolysis, degeneration, trauma or bone pathology (Table 1: Types II to V)
Type II is defined by a defect in the interarticular pars. In subtype A, a fatigue fracture of the pars interarticularis causes a vertebral glide. In adolescence and young adulthood this often occurs in athletes (gymnasts or footballers), whereby a pre-existing weakness in the pars interarticularis can be the cause. In other cases, the defect can be caused by recurrent trauma. Subtype B describes an elongation of the interarticular pars, which was caused by a previous fracture and subsequent healing. Subtype C is classified as a fresh fracture.
Type III is a degenerative change caused by long-standing instability of the vertebral segments. The LWK 4/5 segment is most frequently affected.
Type IV is traumatic in origin. In contrast to type II, the fracture lies outside the pars interarticularis.
Type V is associated with pathological changes in the bone. This can be the case with osteogenesis imperfecta. Spondylolisthesis in the cervical spine is rare and almost never occurs in the thoracic spine.
Diagnosis of spondylolisthesis
Depending on the cause of the spondylolisthesis, medical history asks about risk factors: family stress, sporting activities, previous operations or accident events. During the neurological examination, attention is paid to visible step formation in the continuity of the spine (hill phenomenon). Bad postures such as a hollow back (hyperlordosis), tipping of the pelvis or scoliosis, which can occur with pronounced forms of spondylolisthesis, are signs of compensation. Sensitivity, motor skills and reflexes are checked to prevent damage to the nerves. Provocation tests such as spraining the spine or straightening the upper body from a bent position (climbing phenomenon) serve to localize the origin of the pain.
The extent of the spondylolisthesis is classified according to the Meyerding graduation.
Magnetic resonance imaging (MRI) focuses on the soft tissue conditions and provides information about the neuronal conditions and where there is compression of the nerve structures.
In addition, or if an MRI is not possible, a computed tomography (CT) of the lumbar spine can be performed. It is also possible to display the nerve structures using contrast medium placed in the nerve tube. This examination is called myelography or CT myelography. Other types of imaging, such as SPECT (single photon emission computerized tomography), are only important for special questions.
Treatment of spondylolisthesis
What treatment options are there and when does surgery have to be carried out?
The decision on the type of treatment depends largely on the causes of spondylolisthesis.
Conservative therapy
As long as there is no neurological deficiency but "only" pain, good conservative treatment is always to be preferred. First, light painkillers are prescribed. If necessary, these can be increased in dosage or administered in combination with more effective pain relievers. Professional and targeted physiotherapy to strengthen the back and abdominal muscles is another important building block in conservative treatment. If necessary, supportive measures, such as wearing a corset, can improve the symptoms.
In many cases, conservative therapy alone is successful. Treatment management is also dependent on the causes (congenital / acquired) of spondylolisthesis. In some childhood, traumatic, and degenerative forms, surgery is superior to conservative treatment.
Surgical therapy of spondylolisthesis
Surgical intervention is necessary if there are neurological deficits or conservative treatment has failed.
Neurosurgery focuses on the gentle relief of the nerve structures. As a first step, this includes a pathology in imaging that correlates with the symptoms. The need for surgery (indication) must then be critically examined by the surgeon and a surgical procedure suitable for the individual patient selected. Basically, three operative goals should be pursued with a spondylolisthesis: decompression, stabilization and reduction. Decompression of the spinal canal and nerve roots under the microscope is a standard neurosurgical procedure and is usually sufficient for degenerative spondylolisthesis alone. If there are clinical complaints or imaging criteria for degenerative spondylolisthesis that suggest a relevant instability, a stabilizing operation (spondylodesis) may be necessary in addition to decompression.
With other forms of spondylolisthesis (for example spondylolysis, trauma, postoperative), a spondylodesis is usually primarily necessary to achieve a good long-term result.
The surgical techniques of stabilization are varied and are selected depending on the pathology and preference of the surgeon. Minimally invasive techniques are mostly used.
In some surgeries, especially when the spondylolisthesis is pronounced, open techniques must be used in order to be able to perform a safe repositioning of the vertebral bodies under visual control of the nerves.
When stabilizing the vertebral bodies, the preservation or reconstruction of the natural spinal curvatures (sagittal balance) must be taken into account. Unnatural positions of the spinal segments can otherwise lead to incorrect strain with further degeneration and pain due to overuse of the musculoskeletal system.
After the operation
Immediately after the operation, the patient wakes up from anesthesia. After a short monitoring phase of the vital parameters in the recovery room, they are moved to the bed station.
On the first postoperative day, the patient is mobilized with the help of physiotherapy without restrictions and can move independently. He is shown rules of conduct for back-relieving movements. After a few days postoperative checks of wound healing and neurological status, the exit occurs. Depending on the nature of the neurological disorders, the possibility of rehabilitation or leaving home is discussed with the patient.
At regular intervals, about which the patient is informed when the patient leaves the clinic, there is a clinical and imaging check in our office to monitor the healing process.
Evidence-based medicine
claims to make a patient-oriented therapy decision based on clinical studies and the case-related literature. For the treatment of spondylolisthesis, the higher-quality studies available in the literature are cited below.
In the low-grade degenerative and isthmic form of spondylolisthesis, surgical treatment is superior after the failure of conservative therapy.
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