Spondylolysis and Spondylolisthesis

Spondylolysis (spon-dee-low-lye-sis) and spondylolisthesis (spon-dee-low-lis-thee-sis) are frequent reasons behind low back pain in young athletes. That is why Dr. Kathleen Weaver of Audrain Orthopaedics in Mexico, MO wants you to learn more about them.

Spondylolysis is a crack or stress fracture in one of the spinal vertebrae, the tiny bones that make up the spinal column. The injury most often happens in kids and teenagers who take part in sports that involve recurring stress on the lower back, like gymnastics, football, and weight lifting.

In some instances, the stress fracture weakens the bone so much that it is not able to maintain its proper position in the spine—and the vertebra starts to shift or slip out of place. This problem is referred to as spondylolisthesis.

For many patients with spondylolysis and spondylolisthesis, back pain and other symptoms will improve with careful treatment. This always begins with a period of rest from sports and other strenuous activities.

Patients who have chronic back pain or extreme slippage of a vertebra, however, might need surgery to relieve their symptoms and allow a return to sports and activities.

Anatomy

Hip Sprain Internal Derangement of Knee dislocation Golf ElbowYour spinal column is made up of twenty four little rectangular-shaped bones, known as vertebrae, which are piled on top of one another. These bones connect to produce a canal that protects the spinal cord.

The five vertebrae in the lower back make up the lumbar spine.

Other parts of your spine include:

  • Spinal cord and nerves. These "electrical cables" travel through the spinal canal hauling messages between your brain and muscles. Nerve roots branch out from the spinal cord through openings in the vertebrae.
  • Facet joints. Between the back of the vertebrae are small joints that offer stability and help to control the movement of the spine. The facet joints work like hinges and run in pairs down the length of the spine on each side.
  • Intervertebral disks. Between the vertebrae are convenient intervertebral disks. These disks are flat and round and about a half inch thick. Intervertebral disks cushion the vertebrae and act as shock absorbers when you walk or run.

Description

Spondylolysis and spondylolisthesis are not the same spinal conditions—but they can be connected with one another.

Spondylolysis

In spondylolysis, a crack or stress fracture develops through the pars interarticularis, which is a little, slender area of the vertebra that attaches the lower and upper facet joints.

Most often, this fracture occurs in the fifth vertebra of the lumbar (lower) spine, although it sometimes occurs in the fourth lumbar vertebra. Fracture can occur on one side or both sides of the bone tissue.

The pars interarticularis is the most fragile area of the vertebra. Because of this, it is the area most in danger of injury from the repeated stress and overuse that characterize a lot of sports.

Spondylolysis can happen in people of all ages but, because their spines are still developing, children and adolescents are most susceptible.

Often, people with spondylolysis will also have some degree of spondylolisthesis.

Spondylolisthesis

When you fail to get treatment for it, spondylolysis can easily weaken the vertebra so much that it is not able to maintain its proper position in the spine. This issue is called spondylolisthesis.

In spondylolisthesis, the fractured pars interarticularis separates, allowing the injured vertebra to shift or slip forward on the vertebra immediately beneath it. In children and adolescents, this slippage generally takes place throughout periods of rapid growth—such as an adolescent growth spurt.

Doctors generally identify spondylolisthesis as either low-grade or high-grade, depending upon the amount of slippage. A high grade slip occurs when more than 50 percent of the width of the fractured vertebra slips forward on the vertebra below it. Patients with high-grade slips are more likely to experience immense pain and nerve injury and to need surgery to relieve their symptoms.

Cause

Overuse

Both spondylolysis and spondylolisthesis usually tend to take place in youngsters who take part in sports which require frequent overstretching (hyperextension) of the lumbar spine—such as gymnastics, football, and weight-lifting. Over time, this kind of overuse can weaken the pars interarticularis, leading to fracture or even slippage of a vertebra.

Genetics

Doctors believe that some people might be born with vertebral bone that is thinner than normal—and this might make them more susceptible to fractures.

Symptoms

In many cases seen throughout Central Missouri, patients with spondylolysis and spondylolisthesis do not have any obvious symptoms. The conditions may not even be revealed until an x-ray is taken for an unconnected injury or condition.

Whenever symptoms do manifest, the most common symptom is lower back pain. This pain may:

  • Feel just like a muscle strain
  • Radiate to the buttocks and back of the thighs
  • Worsen with activity and improve with rest

In patients with spondylolisthesis, muscle spasms may lead to additional signs and symptoms, such as:

  • Back stiffness
  • Tight hamstrings (the muscles in the rear of the thigh)
  • Issues standing and walking

Spondylolisthesis patients who have severe or high-grade slips may have tingling, numbness, or weakness in one or both legs. These symptoms are derived from pressure on the spinal nerve root as it exits the spinal canal close to the fracture.

Doctor Examination

Physical Examination

Your doctor will begin by taking a medical history and asking about your child's overall health and symptoms. They will want to know if your son or daughter takes part in sports. Children who take part in sports that put excessive stress on the lower back are more likely to have a diagnosis of spondylolysis or spondylolisthesis.

Your doctor will carefully examine your child's back and spine, looking for:

  • Areas of tenderness
  • Limited range of motion
  • Muscle spasms
  • Muscle weakness

Your doctor will also observe your child's posture and gait (the manner in which he or she walks). In some instances, tight hamstrings may cause a patient to stand awkwardly or walk with a stiff-legged pace.

Imaging tests can help confirm the diagnosis of spondylolysis or spondylolisthesis.

Imaging Tests

X-rays. These studies offer images of dense structures, such as bone. Your doctor may order x-rays of your child's lower back from a number of different angles to look for a stress fracture and to view the alignment of the vertebrae.

If x-rays show a "crack" or stress fracture in the pars interarticularis part of the fourth or fifth lumbar vertebra, it's an indication of spondylolysis.

If the fracture gap at the pars interarticularis has widened and the vertebra has shifted forward, it is an indication of spondylolisthesis. An x-ray taken from the side will help your physician find out the quantity of forward slippage.

Computerized tomography (CT) scans. More detailed than plain x-rays, CT scans can help your doctor find out more on the fracture or slippage and can be helpful in planning treatment.

Magnetic resonance imaging (MRI) scans. These reports provide better images of the body's soft tissues. An MRI can help your physician determine whether there is damage to the intervertebral disks between the vertebrae or if a slipped vertebra is pressing on spinal nerve roots. It may also help your physician determine if there's injury to the pars before it may be seen on x-ray.

Treatment

The goals of treatment for spondylolysis and spondylolisthesis are to:

  • Reduce pain
  • Allow a recent pars fracture to mend
  • Return the patient to sports and other daily activities

Nonsurgical Treatment

Initial treatment solutions are as a rule nonsurgical in nature. Most patients with spondylolysis and low-grade spondylolisthesis will develop with nonsurgical treatment.

Nonsurgical treatment might include:

  • Rest. Avoiding sports and other activities that place extreme stress on the lower back for a certain amount of time can frequently help improve back pain and other symptoms.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs like ibuprofen and naproxen can help reduce inflammation and reduce back pain.
  • Physical therapy. Particular exercises can help improve flexibility, stretch tight hamstring muscles, and strengthen muscles in the back and abdomen.
  • Bracing. Some people may have to wear a back brace for some time to restrict movement in the spine and provide an opportunity for a recent pars fracture to heal.

Over the course of treatment, your doctor will take periodic x-rays to determine whether the vertebra is beginning to change position.

Surgical Treatment

Surgery might be suitable for spondylolisthesis patients who have:

  • Serious or high-grade slippage
  • Slippage that's progressively deteriorating
  • Back pain that hasn't improved after a period of nonsurgical treatment
  • Spinal fusion between your fifth lumbar vertebra and the sacrum is the surgical procedure oftentimes utilized to treat patients with spondylolisthesis.

The goals of spinal fusion are to:

  • Avoid additional progression of the slip
  • Stabilize the spine
  • Alleviate significant back pain

Surgical Procedure

Spinal fusion is basically a "welding" process. The fundamental idea is to blend together the affected vertebrae so that they heal into one solid bone. Fusion eliminates movement between the hurt vertebrae and takes away some spinal versatility. The idea is that, if the painful spine segment does not move, it should not hurt.

During the surgery, your doctor will first realign the vertebrae in the lumbar spine. Small bits of bone—called bone graft—are then placed into the spaces between the vertebrae to be fused. Over time, the bones grow together—similar to how a broken bone mends.

Prior to placing the bone graft, your doctor might use metal screws and rods to help stabilize the spine and improve the chances of successful fusion.

Oftentimes, patients with high-grade slippage will also have compression of the spinal nerve roots. If this is the case, your doctor might first perform a procedure to open up the spinal canal and relieve pressure on the nerves before performing the spinal fusion.

Outcomes

Most patients with spondylolysis and spondylolisthesis are free from pain and other symptoms after treatment. In most cases, sports and other activities may be resumed progressively with few complications or recurrences.

To help prevent future injury, your doctor might recommend that your child do specific exercises to stretch and strengthen the back and abdominal muscles. In addition, regular check-ups are required to make certain that issues don't develop. If you do not already have a doctor who specializes in these kinds of orthopaedic injuries, consider going to Dr. Weaver at Audrain Orthopaedics. She has experience helping the people of Mexico, Moberly, Columbia, Fulton, and Centralia, Missouri with injuries like the ones reviewed in this article.

As a result of these positive experiences, I began seeing Dr Weaver as a patient. I’ve also trusted her with the care of my two young sons who have both needed treatment for fractures and sports injuries. I appreciate her approach to medicine.

K.W. age 38