Slipped vertebra – spondylolisthesis

In order to assess the severity of a slipped vertebra, the classification according to Myerding is used. Spondylolisthesis is divided into 5 grades in a lateral X-ray.

Myerding 1: 0 – 25%
Myerding 2: 26 – 50%
Myerding 3: 51 – 75%
Myerding 4: 76 – 100%
Myerding 5: > 100%

Pathogenesis

The most common type of spondylolisthesis is isthmic spondylolisthesis affects the segment L5/S1segment, the transition between the lumbar spine and the sacrum. In addition to genetic factors, mechanical mechanical stress also plays a central role in the development and progression of the disease.

Spondylolisthesis is particularly common in groups who repeatedly put a lot of strain on their lower lumbar spine. These include, for example Turner, cricketer or weightlifter. It is assumed that the combination of repetitive overuse and a genetic predisposition (e.g. inferior bone quality) increase the risk of defects in the pars interarticularis significantly increased. These defects can then lead to the development of isthmic spondylolisthesis in the long term (1).

Only about 50% of all patients with bilateral spondylolysis (defect in the area of the pars interarticularis) also exhibit spondylolisthesis. In the case of unilateral spondylolysis, the probability of a slipped vertebra is unlikely (2).

The presence of a slipped vertebra does not necessarily mean that symptoms such as pain or restricted movement will occur. It is still unclear why some spondylolyses remain asymptomatic and others trigger back pain or radicular pain.

In the case of degenerative spondylolisthesis mainly affects the L4/L5 segment.
The degenerative processes (disc degeneration, facet joint arthrosis, etc.) lead to a change in the biomechanics of the affected vertebral segment. It is assumed that disc degeneration in particular leads to incorrect loading of the facet joints and potentially ultimately ends in a sliding process. In the case of degenerative spondylolisthesis, too, it is still unclear which factors are actually involved.

Typical symptoms

Not all patients who show a listhesis on an MRI or X-ray develop symptoms at all. It depends very much on the degree of spondylolisthesis – how far the vertebra has already slipped forward. Those affected often remain with a lower degree of severity (Myerding 1 – 2) asymptomatic (3).
Classic symptoms of a slipped vertebra are Back pain, stiffness, pain during prolonged sitting or standing and in some cases radiating pain. The pain typically worsens when the back is stretched. Spondylolysis and isthmic spondylolisthesis rarely cause neurological deficits However, it is possible that both sensory and motor deficits occur in severely affected patients (3).

Treatment options

The treatment of spondylolisthesis depends on the severity of the vertebral displacement, the symptoms and the individual needs of those affected. Treatment also depends heavily on whether the spondylolisthesis is isthmic or degenerative.

For isthmic spondylolisthesis

In most cases, conservative measures are initially used with the aim of relieving pain, stabilizing the spine and improving mobility. Surgery is only necessary if neurological deficits occur (including cauda equina syndrome) or pain persists.

In the acute phase Rest and protection (possibly with an orthosis) of the lumbar spine and a ban on sports ban in the foreground. As soon as the clinical condition allows, a gradual increase in exercise is introduced in order to restore the necessary resilience for sporting activities. The focus here is on Strengthening the local and global musculatureimproving muscular control and the mobility of adjacent joints. Stretching relevant muscle groups, such as the ischiocrural muscles, and sport-specific exercises also play an important role (4).

For degenerative spondylolisthesis

As with isthmic spondylolisthesis, the focus here is on an initial conservative approach. This includes Adjustments to everyday activities, pain reduction through anti-inflammatory medication and various physiotherapeutic measures. Training therapy exercises that focus on flexion of the spine show particularly good results, as they can relieve pain and improve functionality. Passive measures such as electrotherapy, ultrasound or spinal manipulation may be helpful, but these measures have not been sufficiently studied to make recommendations (5).

Conclusion

Spondylolisthesis is a complex disease whose development is influenced by both genetic and mechanical factors. Its symptoms and severity vary greatly, meaning that treatment must be tailored to the individual. Conservative measures such as physiotherapy, strengthening exercises and pain management are the main focus in most cases, while surgery is only considered in severe cases with neurological deficits or persistent symptoms. A structured therapeutic approach that improves both the stability of the spine and the quality of life of those affected in the long term is crucial.

Sources:

S. Kroppenstedt AH. S2k guideline “Specific low back pain”. German Society for Orthopaedics and Trauma Surgery e.V.; 2024.

Kreiner DS, Baisden J, Mazanec D, Patel R, Bess RS. Diagnosis and Treatment of Adult Isthmic Spondylolisthesis.

Mohile NV, Kuczmarski AS, Lee D, Warburton C, Rakoczy K, Butler AJ. Spondylolysis and Isthmic Spondylolisthesis: A Guide to Diagnosis and Management. J Am Board Fam Med. Dec 23, 2022;35(6):1204-16.

Selhorst M, Allen M, McHugh R, MacDonald J. REHABILITATION CONSIDERATIONS FOR SPONDYLOLYSIS IN THE YOUTH ATHLETE. Intl J Sports Phys Ther. April 2020;15(2):287-300.

Bydon M, Alvi MA, Goyal A. Degenerative lumbar spondylolisthesis. Neurosurgery Clinics of North America. July 2019;30(3):299-304.

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