Of the many musculoskeletal conditions we treat, spondylolisthesis is one of them. With over two decades of practice in the Irvine and Orange County area, I have treated my fair share of spondylolisthesis conditions and if you are reading this blog, you or someone you know has been diagnosed with spondylolisthesis or suspected to have it.
Well, you’ve come to the right place for answers. This blog will tell you:
- What spondylolisthesis means
- What causes spondylolisthesis
- How spondylolisthesis is diagnosed
- How spondylolisthesis is treated
- Are spondylolisthesis and spondylolysis the same thing
- When surgery is necessary
- Posture and spondylolisthesis
- Spondylolisthesis and the pelvic floor!
We will even discuss something that most people don’t realize about spondylolisthesis!
Does it have to do with the spine or spinal cord and more importantly, how the heck do you pronounce it? So let’s get into things!
What Spondylolisthesis Means
Okay, sound it out with me, spon-dee-low-lis-thee-sis. Alright, now that we’ve taken care of that, let’s get down to the serious stuff. Spondylolisthesis is a condition in which a vertebral bone (bones in the spine) shifts anteriorly (forward) or posteriorly (backward) sometimes due to a fractured pars interarticularis of the vertebrae (part of the vertebra that keeps it connected to the ones above and below).
Too much? Let me break it down for you with some anatomy, just a little, I promise.
You have 24 bones called vertebrae, that make up your spine, which you can see in the image above. Each of these bones is separated by gel-like discs that provide a cushioning between the bones. Just like the other bones in your body, the vertebrae are connected to each other via joints, but in the spine, we call them facet joints.
In the image above you see three vertebrae stacked on top of each other and you can see where each connects, as well as the empty facet joints where the other vertebra would sit. The pars interarticularis is the narrow part of the bone that connects the upper and lower facet joints on one vertebra.
I hope you have a clear image of what we are dealing with now so you can better understand the injury. Spondylolisthesis occurs when the pars interarticularis (labeled below) is fractured and there is a shift in the body of the vertebra. Spondylolisthesis is typically seen in the lumbar spine, specifically L4 and L5, but can occur anywhere in the spine.
Photo By: My Central Fitness
Are Spondylolisthesis and Spondylolysis the Same?
You’ve been given a diagnosis so you do a google search to learn more, but you see all these other terms such as spondylitis, spondylolysis, and spondylosis. These are similar terms and related to the area affected but are indeed different.
The most common mix up is between spondylolisthesis and spondylolysis. If one or both of the pars interarticularis become fractured this is called a spondylolysis. This is different from spondylolisthesis given that there has been no shift from the fracture site. The two are related conditions, but not the same.
A spondylolysis can be a precursor to spondylolisthesis, but spondylolisthesis can occur independently but bear in mind that a vertebra with spondylolysis is always at risk for spondylolisthesis.
Fun Fact: A spondylolysis is commonly referred to as a scotty dog fracture because if you outline the vertebrae from the correct view (as seen in the photo below), it looks like a scotty dog. The fracture occurs at the neck of the scotty dog (red line in photo). So now imagine an anterior (forward) shift of only the head of the dog. This is why a spondylolisthesis is referred to as a decapitated scotty dog. If you didn’t grasp much of the above, hopefully the use of a dog in the situation was able to clear things up.
Now that you understand the condition a little better, we can dive into what causes it and how best to treat it.
What Causes Spondylolisthesis?
There are a few different causes of spondylolisthesis occurrence but the most common are:
- Congenital
- Isthmic
- Traumatic
Believe it or not, genetics plays a huge role here. The majority of spondylolisthesis cases have a hereditary component. A genetic weakness of the pars interarticularis is the main contributing factor and can be referred to as congenital spondylolisthesis. You can have this genetically weakened structure and not be aware of it because you are pain-free.
Isthmic spondylolisthesis is a case in which spondylosis occurs first. The fracture or fractures are so damaging that a shift of the vertebrae is the end result.
Spondylolisthesis can also be acquired through traumatic injury, but that is rarely the case. The common mechanism of injury for this is the excessive extension of the spine. For example athletes at risk for spondylolisthesis, would be football lineman or gymnast.
Constantly being forced into lumbar extension at the line of scrimmage or repetitive backflips would be enough to cause a spondylolysis and even a shift, wouldn’t you say? There have even been cases of occurrence from car accidents.
Now that we’ve covered the various causes of spondylolisthesis, we can discuss how this condition is diagnosed.
How is a Spondylolisthesis Diagnosed?
Typically spondylolisthesis is diagnosed only once symptoms are present, but you can be asymptomatic and have it. Don’t be fooled by all the pictures of bones, the slippage can cause damage to the muscles, ligaments, and nerves that exit at that spine level where it occurs. Common symptoms include:
- Lower back pain
- Back muscle stiffness
- Muscle spasms in the hamstring and back
- Pain from the back that runs down the legs
After an initial exam collecting history such as previous injuries, assessing gait, and a spine check, a common test ordered is an X-ray. An X-ray will show any fracture or slippage of the vertebrae. If the x-ray shows positive signs, an MRI or CT scan may be necessary to determine if there was any soft tissue damage to nerves or ligaments.
Spondylolisthesis is graded between 1 and 4, based on the amount of slippage as follows:
- Grade I: 1% to 25% slip
- Grade II: 26% to 50% slip
- Grade III: 51% to 75% slip
- Grade IV: 76% to 100% slip
After a diagnosis is made and your doctor has assessed the damage done, a treatment plan can be made and surgery is hardly ever the answer!
How is Spondylolisthesis Treated?
Treatment is dependent on the severity of slippage and damage. In most cases, physical medicine or rehabilitation should always be the first form of treatment. Surgery may be suggested in the case of grade three or four slippages, but should always be a last resort.
The goal is to avoid surgery and spinal fusion if you can. In some cases, due to the amount of tissue damage, instability, and nerve irritation surgery may be the only option. What is important is to seek care by someone who is accustomed to STABILIZE the area by establishing a strong POSTURAL presentation. What does that mean? Here is more info.
As I said, the goal is to keep people away from surgery and this can be accomplished by stabilizing/strengthening the abdominal muscles, especially the lower ab, and I’m not talking about doing crunches! Well if not crunches, then how do I help patients with Spondylolisthesis?
This video shows the correct way to strengthen your abs so you never do crunches again and gives a sneak peek of what I consider to be the most effective treatment for Spondylolisthesis. Developmental Kinesiology is the name of the game which you can read about as a separate blog.
Another important part of spondylolisthesis treatment is maintaining the segmental movement of your vertebrae. What does that mean? Each vertebra in your spine is capable of moving (to a certain degree) independently of each other. This movement can be lost through injury, sedentary lifestyle, and surgery. Maintaining this function is vital to moving properly and preventing further damage and loss of function.
Stretching is another important part of treatment. Although, I am not a fan of isolating one muscle to stretch. Stretching in movement is the best way to do it. Using Dynamic Neuromuscular Stabilization we go through the patterns of movement that we all did as babies to strengthen and stretch the muscles the right way.
This also allows us to address and prevent any contributing or lingering issues in other areas due to failed posture. Remember, the muscles work and the bones move as a result. The issues arise when we don’t have the strength nor the proper functions in the muscle and a decline in posture happens. This decline can mean spondylolisthesis in some cases.
One thing I want to clarify is that physical therapy or Chiropractic in the forms most practiced are NOT going to do the job long term. Treatment of spondylolisthesis cannot stop at the point of pain being gone, nor limited to the area of spondylolisthesis. That means if the lower back is where Spondylolisthesis occurred, the treatment is not just to the area of the lower back because your body functions as a whole.
When one area is injured the surrounding joints apart to accommodate this area and the functionality is compromised. This is why it’s necessary to address posture and functional movement.
Posture and Spondylolisthesis
The most important factors to avoiding spine and back injuries such as spondylolisthesis are proper posture and spinal alignment. For those aware of their genetic component before experiencing symptoms, this is vital!
We have natural curves in our spine at the neck, mid-back, and lower levels. These natural curves are commonly accentuated through lifestyle and poor posture. Accentuation of these curves are referred to as lordosis (in the lower back and neck) and kyphosis (in the mid-back) and are accompanied by a forward head posture. These signs of failed posture cause compression of the vertebrae, weakening the bones, ligaments, and muscles, and result in spinal misalignment, so you see how this can contribute to spondylolisthesis.
Correct posture is not achieved using a posture brace or some sort of a device! Those gimmicks are as effective as creams are to get rid of cellulite!! The one thing that we need to come to accept is that there is no one time shot, or a short term routine that gets us the long term goal we are looking for!!
Let’s use common sense: If ALL babies in the world are born with hardly any muscle strength or ability to move on demand and regardless of the gender, geographical location, religion, etc. they (including all of us when we were at that age) walk through the same paths of developmental stages, then that path MUST be the right path. We MUST be programmed that way at birth.
So why do we constantly look for a solution and want to reinvent the wheels?!! Every baby breathes EFFECTIVELY. We now know how that is and we know breathing is obviously the fundamental of living. This means that we first need to bring in the initial requirement CORRECTLY and then start the movement the same way.
That does NOT mean it is going to take us as long as it takes a baby to start moving on-demand and walking correctly. Thankfully my practice and my patients prove that it takes less time and with much more ease than it took us as babies.
One of the ways we do this is by establishing a strong core with proper breathing shown in the video below.
To learn more about posture correction and core stabilization to prevent injury visit our website and youtube channel for some great exercises and information.
Pelvic Floor Dysfunction and Spondylolisthesis
When people think of pelvic floor dysfunction they think urinary incontinence or fecal incontinence, but incontinence is not the only symptom of pelvic floor dysfunction and pelvic floor issues in general… so what does the pelvic floor have to do with your spondylolisthesis?
Specifically, when it comes to an occurrence in the lumbar (lower back) spine, the muscles of the pelvis are impacted which includes the psoas and illiacus, shown in the image below. Therefore all movements in this area compromised as well as the stability.
Photo By: Somatic Movement Center
In the treatment section, we mentioned that reinforcing proper stabilization is key. Well… the pelvic floor plays a huge role in core and pelvic stabilization, so much so that I wrote a blog on that alone!
I highly suggest reading this blog on How to Get a Healthier Pelvic Floor and Pelvic Diaphragm to learn all about it and why you should ask about our pelvic floor treatment that works exactly on that!
Get the Spondylolisthesis Treatment That Works
Remember, surgery is always the last resort and ordinary care simply delivers ordinary results. Instead of reinventing the wheels, let’s see how nature walked all of us through the path of movement and re-walk the same paths to create the best movement results.
We are the Designers and the Directors of our own life so we should design and direct it the way we wish to live it.
Dr. Shakib