What is Spondylolysis and Spondylolisthesis?

Spondylolysis  and spondylolisthesis  are fairly known causes of pain in the lower back pain, especially in youth athletes.  Spondylolysis is a stress fracture or crack in any vertebrae. This type of injury generally occurs in youth who play sports that cause continuous stress on the lower back area. Example include football, lifting weights and gymnastics.

In some instances, the fracture can weaken the bone to the point that it is not able to hold its normal spine position. This can cause the vertebra to slip or move out of it’s normal position. We call this condition spondylolisthesis. For the majority of patients with these conditions, the back pain and other symptoms will generally get better with conservative therapy.  This normally starts with taking a rest from activities and sports.

Patients with continued back pain or a significant slippage of a vertebra, may need spine surgery to alleviate their symptoms and resume sports and activities.

There are 24 individual vertebrae or bones in the spine.  The vertebra are interconnected to form a spinal canal that protects your delicate spinal cord. The lumbar spine consists of five vertebrae in the lower back.
Your spine also consists of:

• Intervertebral disks. In between each vertebrae are flexible sponge-like intervertebral disks. These disks are flat and round and act as a cushion. They are the shock absorbers when you perform an activity like walking or running.
• Spinal cord & nerves. You can think of your spinal cord and spinal nerves as “electrical cables”. They carrying messages through your spinal canal between your muscles and brain.  In between each vertebrae are nerve roots.
• Facet joints. Between the back of the vertebrae are tiny joints that stabilize and help the spine maintain control. A facet joint works like a hinge and runs down the left and right side of the spine.

Although spondylolisthesis and Spondylolysis  are considered different spinal conditions—they are commonly related to one another.

Spondylolysis

The upper and lower facet joints are connected by a small thin portion of the vertebra known as the pars interarticularis. In spondylolysis, a small crack or fracture develops in this area.  Generally, this fracture occurs in L5 of the lower lumbar spine, although it sometimes occurs in L4. Fracture can occur on either the left or right side or even on both sides of the bone.

The weakest portion of the vertebra is the pars interarticularis. As a result, it is the area most susceptible to injury due to repeated stress and overuse.
Spondylolysis can occur at any age however youth are most probable since their spines are still developing.  Often times, patients diagnosed with spondylolysis will have some level of spondylolisthesis.

Spondylolisthesis

If not diagnosed and treated, spondylolysis can make the vertebrae weak the to a point that it is unable to maintain its normal position in the spine. This condition is better known as spondylolisthesis. When spondylolisthesis occurs, the pars interarticularis fractures and separates. This then allows the injured vertebra to slip forward on the vertebra directly below it. In youth, this slippage frequently occurs during growth spurts.

Doctors generally define spondylolisthesis as either low grade or high grade. This depends on the amount of slippage in the vertebrae. When more than 50 percent of the width of the fractured vertebra slips forward on the vertebra below it, this is considered a high-grade slip. These patients are more likely to experience a greater amount of pain and even nerve injury. They commonly need spine surgery to relieve their symptoms.

Overuse

The conditions of both spondylolysis and spondylolisthesis are more likely to occur in youth athletes who participate in sporting activities that require frequent overstretching or what we call (hyperextension) of the lower lumbar spine. These sporting activities include but are not limited to lifting weights and rigorous personal training, gymnastics, and football. Over a period of time, this type of overuse can weaken the pars interarticularis, leading to slippage of a vertebra and or a spine fracture.

Family Genetics

Physicians believe that certain people may be born with vertebrae that are thinner than normal. This thin bone may make them more susceptible to spine fractures.Usually, patients with spondylolysis and spondylolisthesis do not display any common symptoms. The conditions may not even be found until an scan is performed for a different injury.

Lower back pain is the most typical symptom. This pain may:
• Feel like a muscle pull or strain
• Radiate down to buttocks area and also radiate to the thigh in the back
• Feel worse with activity and improve by resting

In patients that have spondylolisthesis, muscle spasms can lead to further symptoms & signs, including:

• Hamstrings that become tight
• Stiffness in the back
• Difficulty walking and standing

Tingling, weakness, or numbness in 1 or 2 legs can also occur in patients with Spondylolisthesis that have severe or high-grade slips.

The Importance of a Physical Examination

Dr. Paraiso will start by taking a medical history and also ask questions about your child’s overall symptoms and health. He will want to know if your child plays sports. As indicated earlier, youth who participate in sporting activities that place significant stress on the lower back area have a greater chance of being diagnosed with spondylolisthesis or spondylolysis.

Dr. Paraiso will perform an examination of  your child’s spine, looking for:

• Tender areas
• Limiting range of motions
• Muscle weakness
• Muscle spasms

Dr. Paraiso will carefully observe the posture of your child. They will also observe the gait.  (The gait is the way your child walks. In certain cases, hamstrings that are tight can cause a patient to standup in an awkward fashion or walking with a stiffed-leg.

Imaging tests can help determine accurate diagnosis of spondylolisthesis or spondylolysis.

Imaging Tests performed for spondylolisthesis or spondylolysis

X-rays. These common studies provide an image of bone which are considered dense structures. Dr. Paraiso can order an x-ray of your child’s lumbar spine from a variety of different views to determine if a stress fracture exists. Also x-rays can be ordered to ensure the vertebrae is aligned properly.  If x-rays display a stress fracture in the portion of the pars interarticularis of L4 or the L5 vertebra, it is considered to be spondylolysis. If the fracture size at the pars interarticularis has increased and there has been a forward shift of the vertebra, it is considered spondylolisthesis. Lateral view x-rays can help Dr. Paraiso determine the amount of forward slippage.

CT scans or Computerized tomography .  CT scans provide more details then x-rays and can help Dr. Paraiso further about the slippage or spine fracture.

Magnetic resonance imaging (MRI) scans. MRI studies provide improved and more detailed imaging of the body’s soft tissues. These advanced images can help Dr. Paraiso uncover if there has been injury to the intervertebral disks between each vertebrae or if there is compression on nerve roots in the spine. It can also help Dr. Paraiso determine if there is injury to the pars before it can be seen on a regular x-ray image.

Treatment goals for spondylolisthesis and spondylolysis are:

• Reduce or eliminate the pain
• Achieve healing of a recent pars fracture
• Return the athlete to sport and other normal activity

Non-surgical Treatment

Non-surgical treatments is usually always the first treatment plan. Many if not most patients with low grade spondylolisthesis and spondylolysis and will get better with non-surgical treatment. Non-surgical treatment can include:

Rest. Avoiding all sport and any activity that places major stressors on a lower back for a prelonged time period of time will generally help improve back pain.

Non-steroidal anti-inflammatory drugs (NSAIDs).  Motrin and Aleve are commonly used NSAIDs that can help reduce swelling and provide back pain relief.

Physical therapy. Certain prescribed exercises can help loosen the tight hamstring muscles improve flexibility & strengthen the back and abdominal muscles.

Back Bracing. Certain patients may need to put on a back brace for a length of time. This is worn to limit spine movement  which can allow the healing of a recent pars fracture.

Over the course of your treatment plan, Dr. Paraiso will take several x-rays to determine whether the vertebra’s position is changing.

Surgical Treatment for Spondylolisthesis or Spondylolysis

Spine Surgery can be suggested for spondylolisthesis patients that have:

• Slippage considered high-grade
• Slippage continuously getting worse
• Back pain that does not improve after rest

Spinal fusion between the L5 vertebra and the sacrum (S1) is the most common surgical procedure used to treat patients that suffer from spondylolisthesis.

The goals in spinal fusion are:

• Avoid further slip progression
• Spine Stability
• Alleviate and improve significant lower back pain

The Surgical Procedure

A Spine fusion fuses together the injured vertebrae so that it can heal into a solid piece of single bone. A fusion eliminates the motion between the vertebrae that is damaged and takes away some flexibility os the spine. The idea is if the spine segment that is painful can’t move, it shouldn’t hurt.

In the procedure, Dr.Paraiso will start off by realigning the vertebrae in the lumbar area. Small bone pieces—known as bone graft—are then inserted into the space between vertebraes that will fused together. In time, the bones will grow—similar to the way a broken bone heals.

Before the bone graft is placed, Dr. Paraiso may use metal rods & screws to further stabilize the spine which can increase the chances of a successful spine fusion.  In certain cases, a patient with  a high grade slippage will also have  spinal nerve root compression. In this case, Dr. Paraiso may first perform a procedure to relieve pressure on the nerve and nerve roots prior to the the spinal fusion.

In most patients with spondylolisthesis and spondylolysis, the spine fusion will help them be free of pain & other symptoms. In the majority of  cases, sporting and other activity can gradually resume with minimal complications.

To help avoid future injury, Dr. Paraiso usually recommends that your athlete perform certain exercises to strengthen and stretch the muscles in the back and abdomen. In addition, follow-up visits are required to ensure that problems don’t develop in the future.