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Although the human spine looks delicate, it is anything but. This complex of bones, ligaments, and cartilage withstands hundreds of pounds of force every day. Just standing up puts over 200 pounds of force on the spine; so imagine what running, jumping, and lifting weights can do. It is no wonder, then, that over time the spine steadily falls out of alignment. Lower back pain and neck pain can be a sign the spine is imbalanced.
Spondylolisthesis occurs when one of the bones slides out of place. It sounds bad, but most people with a slipped vertebra do just fine by modifying their activities and taking the occasional pain reliever. Surgery can help in many of the worst cases.
What is spondylolisthesis?
Spondylolisthesis is when a spinal bone, or vertebra, slips forward out of place relative to the bone below it. Vertebral slippage most commonly occurs in the lower back (lumbar spine) because of excess loads the spine may bear. However, spondylolisthesis is also common in the neck, particularly among young athletes. In many cases, this slippage produces no symptoms and people go on with their activities. However, in the majority of cases, the immediate result is neck or low back pain.
In the spine, individual vertebrae are held in place by facet joints that join individual vertebrae. These joints not only keep the vertebrae aligned, they allow the spine to move forward and backward and limit how much the spine can rotate. Every time the back moves, however, stress is put on these joints, and one part of the facet joint, the pars interarticularis, bears most of that stress. The pars interarticularis keeps the vertebra lined up with the vertebra below, and when it fractures, the spine becomes imbalanced, a condition called spondylolysis. If the pars interarticularis breaks in half or is severely damaged, then the vertebra slips forward.
Besides causing neck or low back pain, a slipped vertebra might also squeeze the nerve roots that emerge through openings between the vertebrae. Or worse, the spinal cord itself might get squeezed, a potentially serious condition called myelopathy. Both these conditions, collectively called spinal stenosis, can cause arm, buttocks, or leg pain. Muscles that are controlled by those nerves can become weak and even paralyzed.
Spondylolisthesis is graded on the amount of the slipped vertebra that is “uncovered.” Low-grade spondylolisthesis (grades I and II) involves up to half the vertebra slipping forward out of place. High-grade spondylolisthesis (grades III and IV) means half or more of the vertebra is out of place. Spondyloptosis occurs when the entire bone has slipped forward off the bone below. About three in four cases are assigned the lowest grade.
There are many causes of spondylolisthesis: spinal degeneration, overuse injury, trauma, infections, or tumors. Some people are born with facet joint defects and a few cases have no discernible cause.
- Isthmic spondylolisthesis results from defects in the pars interarticularis due to overuse injuries and stress fractures caused by athletic activities such as golfing, football, swimming, tennis, and weightlifting. It is usually first diagnosed in children and teens. It is a common condition and anywhere from 4% to 8% of the American population has some form of isthmic spondylolisthesis.
- Degenerative spondylolisthesis results from the degeneration of intervertebral discs and facet joints. About one in 20 adults have degenerative spondylolisthesis. It is, however, mostly seen in people over the age of 50, so the prevalence climbs to almost two out of five in people over the age of 60. Almost all cases are low-grade and do not worsen over time.
- Traumatic spondylolisthesis, called fracture-dislocation, is a rare condition caused by a fracture of the vertebra or facet joint. Traumatic spondylolisthesis is usually caused by car accidents.
- Dysplastic spondylolisthesis occurs when children are born with abnormal facet joint alignment, eventually leading to spinal instability and slippage. It is a comparatively rare condition and often worsens when a child enters puberty.
- Pathologic spondylolisthesis is due to causes such as bone disorders, connective tissue problems, infection, or cancer.
Spondylolisthesis may or may not worsen over time. Adults with low-grade degenerative spondylolisthesis will often not experience further slippage. High-grade spondylolisthesis, however, carries a high risk of further slippage. Children with isthmic spondylolisthesis may see the slippage worsen in adolescence but only a small percentage will experience further slippage in adulthood. Many young athletes can fully return to sports after a few months of recovery.
How is spondylolisthesis diagnosed?
A physical and medical history will help point a general practitioner or orthopedist to the right diagnosis, but spondylolisthesis is primarily diagnosed by an X-ray of the slipped vertebra.
Spondylolisthesis is primarily indicated by intermittent localized back or neck pain. Also, back muscles may be tight or stiff. If a nerve root or the spinal cord is compressed, pain may radiate outwards to the arms, buttocks, or down the legs (sciatica). This pain usually improves when sitting. Tight hamstrings and trouble walking are also classic symptoms of lower back spinal stenosis.
When talking to a healthcare professional, be prepared to answer questions about when the pain started, what triggered, any activities you engage in, and any recent injuries. Age, sex, athletic activities, and excess weight are all risk factors that may help determine the correct diagnosis.
For most patients, an X-ray of the affected area of the spine is sufficient to make a diagnosis, assign a grade to the condition, and start treatment. An orthopedist may order a CT scan to get a more detailed picture of the problem as well as evidence of other spinal issues. An MRI is required to determine if there’s any nerve root or spinal cord compression.
Spondylolisthesis treatment options
Spondylolisthesis is primarily treated conservatively with activity modification, physical therapy, and pain medications. For patients with progressive slippage or unmanageable pain, surgery will be used to stabilize the spine and relieve nerve root or spinal cord compression.
Conservative treatment
Nonsurgical treatment including activity modification, nonsteroidal anti-inflammatory medications (NSAIDs), physical therapy, and epidural steroid injections to manage pain is successful in most spondylolisthesis patients. In the first weeks, bracing may be also used for patients who must perform daily or work-related activities that cause pain.
Physical therapy
Physical therapy is used to develop muscles that stabilize the spine and increase flexibility to improve range of motion. A key component of physical therapy is teaching correct postural awareness and body mechanics. Physical therapy might include core exercises, stretching, yoga, and flexibility exercises.
Surgery
In cases where conservative treatment does not succeed in reducing pain or the slippage increases, an orthopedic surgeon will stabilize the spine by either repairing the fractured joint or performing a spinal fusion. If nerve compression is producing significant loss of function, a neurosurgeon or orthopedic surgeon will perform a surgical decompression and fusion surgery to relieve pressure on the spinal cord or nerve roots.
- Pars repair involves fixing the fractured pars interarticularis. This will involve mechanically joining the two pieces with wires or screws so that they can heal. The surgeon may need to use a bone graft to provide extra strength to the healed bone.
- Spinal fusion is the surgical procedure used to stabilize the spine. The slipped vertebra will be mechanically joined to the vertebra below with rods or hooks. A bone graft will be inserted between the joined vertebrae. The bone graft will eventually fuse with both vertebrae, both stabilizing and immobilizing the spine at that location.
- Decompression surgery directly removes pressure from the nerve by either widening the opening through which it exits the vertebra or by cutting away entire sections of the vertebra to increase the size of the spinal canal. The vertebra will then be fused to the one below it.
Spondylolisthesis medications
For spondylolisthesis, medications are used to manage pain and swelling.
NSAIDs
Most healthcare professionals will advise over-the-counter pain NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin, ibuprofen, or naproxen to reduce swelling and relieve pain associated with spondylolisthesis. Over-the-counter acetaminophen will effectively relieve pain for patients who cannot take NSAIDs.
Corticosteroids
Pain due to a pinched nerve root may be treated with a corticoid steroid injection of methylprednisolone or cortisone to rapidly bring down swelling and provide pain relief. Some physicians may use oral corticosteroids, such as prednisone, but this is rare.
Neuropathic agents
For patients with spinal stenosis, some doctors may treat a pinched nerve root using drugs that specifically relieve nerve pain, called neuropathic agents. The most commonly used are gabapentin and Lyrica (pregabalin).
Muscle relaxants
Localized back or neck pain due to spondylolisthesis is caused by muscle contractions and spasms. A physician might treat neck or muscle pain with a few days of muscle relaxants such as methocarbamol, metaxalone, or orphenadrine. These medications reduce muscle pain by interfering with the nerve signals that cause them to contract and spasm.
Opioids
The last option for pain management are opioids such as hydrocodone or oxycodone. Because of their potential for abuse, opioids are very rarely used for spondylolisthesis and only after all other options have been exhausted. Opioids will be prescribed at a low dose for only a few days.
What is the best medication for spondylolisthesis?
There is no “best” medication for spondylolisthesis. A combination of activity modification, physical therapy, and pain medications is required to manage pain and maintain the highest quality of life. Adequate pain relief may be achieved for some with over-the-counter pain medications, but other patients may require stronger prescription medications.
| Best medications for spondylolisthesis | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Motrin (ibuprofen) | NSAID | Oral | Two 200 mg tablets every four hours | Nausea, bleeding, stomach pain |
| Aleve (naproxen) | NSAID | Oral | One 220 mg tablet taken with food or water every 8 to 12 hours | Nausea, bleeding, stomach pain |
| Aspirin | NSAID | Oral | One or two 325 mg capsules or tablets every 4 hours with water per day | Upset stomach, heartburn, bleeding |
| Tylenol (acetaminophen) | Analgesic | Oral | Two tablets every four hours (max of 3000 mg per day) | Nausea, stomach pain, loss of appetite |
| Prednisone | Corticosteroid | Oral | Dosage will vary. Initial dose will be high and taper off daily over one to two weeks | Behavior and mood changes, acne, fluid retention |
| Depo-Medrol (methylprednisolone acetate) | Corticosteroid | Injection | 1/20 to 1/8 ml injection of 80 mg/ml solution | Mood changes, edema, increased blood pressure |
| Norflex (orphenadrine) | Muscle relaxant | Oral | One 100 mg tablet twice a day, once in the morning and once at night | Dry mouth, fast heart rate, blurred vision |
| Neurontin (gabapentin) | Neuropathic agent | Oral | One to three 300 mg capsules daily | Headache, eye problems, coordination problems |
| OxyContin (oxycodone) | Opioid | Oral | Lowest dose possible for the shortest duration possible | Constipation, nausea, sleepiness |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of spondylolisthesis medication?
Spondylolisthesis medications have some side effects, but side effects will vary based on the type of medication. This is not a complete list, so please consult with a healthcare professional for possible side effects and drug interactions based on your specific situation.
NSAIDs interfere with the body’s ability to protect the digestive system tissues from stomach acid, so common side effects include stomach pain, ulcers, and gastrointestinal bleeding. NSAIDs also suppress blood clotting, so bruising and bleeding problems are also common. For this reason, patients who may not be able to tolerate most NSAIDs may be prescribed celecoxib, an NSAID that does not interfere with blood clots or reduce the stomach’s protection against acid. Acetaminophen does not interfere with blood clots, but it will not help reduce swelling. The greatest risk in taking acetaminophen is overdose, so always follow the directions on the packaging.
Most people given corticosteroid injections will experience injection site reactions such as pain and redness. However, treatment typically involves a single, highly-localized, low-dose injection, so commonly-experienced side effects are minimized.
Oral corticosteroids, however, are a different matter. Taken over one to two weeks, oral corticosteroids can cause mood changes, behavior changes, aggressiveness, fluid retention, appetite changes, weight gain, and acne. The most serious side effects include high blood pressure, high blood sugar, glaucoma, and potentially severe allergic reactions.
Muscle relaxants either block nerve signals to muscles (anticholinergics) or act as sedatives (benzodiazepines). Because they interfere with involuntary nerve signals, anticholinergics very commonly cause dry mouth, constipation, blurred vision, and a certain amount of sedation. Because of the high risk for abuse and addiction, doctors avoid prescribing benzodiazepine sedatives for back pain.
Neuropathic agents and opioids block pain signals by slowing down nerve impulses in the brain and spinal cord. As a result, many people who take these drugs will feel sleepy, tired, foggy, and even disoriented and confused. The most serious side effects of both types of drugs are drug abuse and overdose. Nerve pain agents are less likely to produce dependence, but an overdose of either type of drug can be fatal.
What is the best home remedy for spondylolisthesis?
The most important home remedy for spondylolisthesis is to take care of the spine by avoiding activities that hurt it. Other home remedies can manage the pain, but activity modification is the key to getting better.
Activity modification
For the first few weeks, give the spine a rest. Not bed rest, just take it easy. After the initial rest, avoid any activity that causes pain. Don’t pick up heavy objects and avoid extending the spine, that is, pushing the lower back spine forward.
Use warm compresses
A warm compress or heating pad will help relieve muscle pain and muscle spasms.
Use ice
Periodically icing the affected area of the spine will help reduce swelling.
Use over-the-counter pain relievers
When the pain is too much, over-the-counter ibuprofen or acetaminophen will help, but avoid using pain relievers every day.
Lose excess weight
Excess weight puts stress on the spine and increases pain and discomfort.
Exercise
Spondylolisthesis pain often results from spinal instability. Many stretches and exercises can develop muscles in the back and abdomen that stabilize the spine. You can learn these from your physical therapist or view them online.
Frequently asked questions about spondylolisthesis
Can a chiropractor help with spondylolisthesis?
A chiropractor does not directly attempt to treat or manipulate a slipped vertebra joint but rather manipulates the spine around the slipped joint to restore spinal balance and reduce pain. Many patients experience significant pain relief and increased mobility from chiropractic manipulation, so many back clinics and doctors will refer patients to a chiropractor.
Does spondylolisthesis get worse over time?
Spondylolisthesis can worsen over time but this is not common. Spondylolisthesis in children commonly gets worse as they enter puberty, but adults with low-grade degenerative spondylolisthesis often do not advance to higher grades.
What should you not do with spondylolisthesis?
The most important treatment for spondylolisthesis is to avoid activities that put stress on the spine. While spondylolisthesis cannot always be reversed, it can get worse. Heavy lifting, weightlifting, contact sports, sit-ups, and high-impact exercises are to be avoided. Try also to avoid activities that twist the back, as these, too, can throw off spinal alignment.
What is the best treatment for spondylolisthesis?
Most people successfully manage the condition with conservative treatment involving activity modifications, special exercises, and over-the-counter pain relievers.
How long does it take to recover from spondylolisthesis?
Recovery depends on the type of spondylolisthesis. Recovery is more likely if disc slippage is due to injury than degeneration. From the start of treatment, it typically takes four to eight weeks to reduce pain enough to start rehabilitation therapy. The goal of rehabilitation therapy is to return as much pain-free movement and flexibility to the spine as possible. This process typically takes several months, but a full recovery may not be possible.
How fast does spondylolisthesis progress?
Most patients with low-grade spondylolisthesis do not progress to more advanced stages. Children with isthmic spondylolisthesis often experience increased slippage during adolescence. Later disc degeneration may cause even greater slippage as these patients enter their 30s, but this is uncommon.
How should I sleep with spondylolisthesis?
Most people with lower back degenerative disc disease find the best symptom relief by reducing the arch in their lower back. Increasing the arch pushes the slipped vertebra farther forward and can worsen symptoms. For this reason, sleeping on the stomach is the worst position for lumbar spondylolisthesis. Bending the legs forward reduces the lumbar arch. Sleeping on your back in a reclining position, sleeping on your back with a small pillow under the knees, or sleeping on one’s side with the legs slightly bent forward should be enough to reduce pain for a good night’s sleep.
How do you fix spondylolisthesis?
Most people with spondylolisthesis are successfully treated with conservative treatment involving activity modification, physical therapy, and over-the-counter pain relievers. Chiropractic manipulation and bracing may help in the early stages. A minority of patients, however, may need surgery to relieve nerve root compression and stabilize the spine.