Salie292.....spondylolysthesis .my true story..

Spondylolisthesis "A Slipped Vertebra" The term spondylolisthesis is used to describe several different spinal disease processes where one vertebra is out of its normal alignment with the adjacent vertebra. The term means "spine slip". This is clearly seen and measurable on routine x-rays. It should not be confused with the chiropractic community's concept of a vertebra being "out" (without any imaging abnormalities, including x-rays). The typical appearance of spondylolisthesis is one vertebra slipping forward on the vertebra below. Retrolisthesis is a term used to describe when a vertebra is slipping backward on the vertebra below. Lateralolisthesis describes the vertebra that is displaced to the side of the vertebra below. Rotatory listhesis is a degenerative condition where a vertebra rotates on the vertebra below. Diagnosis Routine standing spinal x-rays are the best way to diagnose vertebral malalignment such as spondylolisthesis. Flexion and Extension (patient bending forward and backward with maximum effort) xrays of the spine are also helpful to assess whether the spine moves excessively and is unstable. Often, spinal stenosis (pinched spinal nerves) accompanies spondylolisthesis and additional imaging studies are required to detect the presence of nerve compression within the spinal canal. A MRI scan is an excellent test to show the soft tissues of the spine in a way not possible with x-rays. A myelogram combined with a CT scan is another excellent way to evaluate nerve compression, especially when it is related to bone spurs and other arthritic processes which can narrow the spinal canal and compress nerves. A CT scan by itself (without a myelogram) may be useful in diagnosing the type of spondylolisthesis caused by a stress fracture. This type, called "isthmic spondylolisthesis, can usually be diagnosed on the basis of oblique x-rays. Occasionally, isthmic spondylolisthesis is diagnosed with a CT scan. A bone scan can be helpful at identifying a recent stress fracture that could lead to spondylolisthesis. This has an important role in children who have back pain from an undiagnosed cause, and isthmic spondylolisthesis is suspected. Causes There are five general causes for spondylolisthesis. Isthmic spondylolisthesis results from a stress fracture in the back part of the spine, and most commonly develops between ages 5 and 8. It may or may not cause back pain. Five percent of the American population has it. Fifty percent of Eskimos and 10% of professional football linemen playing in the NFL have it. It is also a common source of back pain in highly competitive gymnasts, occurring in up to a third of these athletes. The most common type of spondylolisthesis is caused by degenerative changes in the spine, particularly in the facet joints. As these joints wear out, they become lax and fail to maintain normal spinal alignment. The same arthritic process that wears out the joints in the spine can also cause bone spurs to grow which then cause nerve compression and spinal stenosis. Stenosis and degenerative spondylolisthesis occur together very often. Rare causes of spondylolisthesis include tumors or infection that destroy the back part of the spine, and acute fractures through the back of the spine. These destructive processes disrupt spinal stability and

Salie292.....spondylolysthesis .my true story..

allow the affected vertebra to slide forward on the one below it. Somewhat rare is the congenital type of spondylolisthesis that features malformed joints in the back of the spine which allow the spine to slip. Signs and Symptoms Back pain is the most common complaint in people who have spondylolisthesis. The pain tends to correlate with the level of physical activity, with worsening pain with activity and improvement with rest. Most people find that the back pain is worse with standing and walking, and often better with sitting. Another common complaint is ache in the buttock region. This can be pain referred from the degenerative joints in the low back, or could be a symptom of nerve root compression. Buttock pain can accompany back pain or occur by itself. Leg pain that descends through the buttock, back of the thigh, past the knee, and into the calf or foot is a common sign of nerve root compression. When a spinal nerve is pinched or irritated, burning, numbness, and tingling can also be present. Muscle weakness can also result. The type of discomfort people have varies from person to person. In early stages, patients with spondylolisthesis may not have any pain. Pain may slowly increase to become intermittent, or even constant. Patients may also live their entire lives with this condition and not ever have any significant pain. Conservative Treatment Options Most people with spondylolisthesis will find improvement in their back pain with conservative care. The foundation of a conservative program typically includes a short course in physical therapy leading to a daily home exercise program. Developing a strong trunk (abdominal, oblique, and back muscles) is vital to removing stress and pain from the spine. Patients find that when they remember to do their back and abdominal exercises regularly, they have less back and buttock pain. The time commitment for exercises need not be longer than 10 minutes a day, in most cases. Medications can play a role in pain control. Pain killers such as Percocet, Vicodin, and other narcotics are used sparingly except in times of new onset of severe pain. These narcotics are best used short term. They are very addictive. Non-steroidal anti-inflammatory medications are the medications of choice. They can be helpful at controlling back and leg pain by reducing the inflammation from arthritic joints. Muscle relaxants are rarely helpful, with the possible exception in the case of an acute muscle strain. Surgical Options Who Needs Surgery - There is only one circumstance where surgery is an emergency: cauda equina syndrome. This is a condition where the nerve roots within the spinal canal are severely compressed. The end result is loss of bowel or bladder control, severe leg pain, and numbness in the genital region. If the pressure on the nerves is not released immediately, control of bowel and bladder may never be recovered. For this reason, we consider cauda equina syndrome a surgical emergency. For all other patients with spondylolisthesis, there is no emergency. Surgery is planned when symptoms or circumstances warrant it. Reasons to consider surgery include: Back pain failing to improve with conservative care

Salie292.....spondylolysthesis .my true story..

Leg pain failing to improve with conservative care Progressive leg or foot numbness or weakness Progression in the amount of vertebra slippage High grade spondylolisthesis (grades 3 - 5) Signs, symptoms, and presence of nerve compression failing conservative care

"What If I Don't Have Surgery?" Since surgery is usually done for relief of pain, the decision to postpone surgery is essentially a decision to live with the pain a bit longer. Most patients know very clearly when they are ready to have their spinal problem surgically corrected. Their pain is intrusive and constant, work is difficult, social life or hobbies are impossible, family life is compromised, and the level of function is in every way sub-optimal. Risks of Surgery - As with any surgery, there are risks with spinal surgery to correct spondylolisthesis. The risks depend on the procedure being performed, the complexity of the spinal problem, and the health of the patient. Some of the more common problems with posterior surgery (surgery from the back) include infection (1-3%), failure of fusion (3-15%), nerve root injury (1%), dural leak (1-5%), hardware failure (1%), and excessive blood loss (5%). Complications unique to anterior surgery (surgery through the abdomen) include prolonged resumption of bowel function, injury of blood vessels or bowel, incisional hernia, and retrograde ejaculation in males (1-3%). General complications that can occur with any surgery include blood clots, deep vein thrombosis, pulmonary embolus, heart attack, pneumonia, urine infection, incision infection, virus transmission through blood transfusion, and many others. The general health risk from surgery depends on the health of the patient. A complete physical is recommended for anyone with health problems before undergoing major spinal surgery. Possible Surgical Approaches POSTERIOR SPINAL FUSION - This approach involves placing bone graft on the back and/or sides of the slipped vertebra and the one below. When the bone heals, it will fuse and stabilize the slipped vertebra. Fusion rates in children are excellent. In adults, failure of fusion can approach 60% if spinal instrumentation is not used. As in all cases of spondylolisthesis, if nerves are compressed, a LAMINECTOMY is also performed. Performing a laminectomy and fusion without instrumentation is the historic approach for this disease and still has a place in current surgical practice for low-grade slips in children, and in degenerative listhesis in adults who do not have much back pain. POSTERIOR SPINAL FUSION with INSTRUMENTATION - This is the most common technique used today to address the instability caused from spondylolisthesis. Adding spinal instrumentation (screws in the vertebrae linked together with rods to immediately stabilize the spine) greatly increases the success of the fusion. Postoperative pain is improved and long term outcomes are better than with fusions without instrumentation. Fusion rates when instrumentation is used are about 95%. ANTERIOR INTERBODY FUSION - This technique was renewed in the mid 1990's and involves placing a titanium or plastic cage into the disk below the slipped vertebra. This is done through an incision in the abdomen. The cage or dowel contains the patient's own bone. Success rates are good if the procedure is limited to vertebrae that are not slipped more than a few millimeters in patients without significant nerve compression. Fusion rates are likely in the 85% range when bone is used and 95% or better if Bone Morphogenetic Protein is used. The rehab after surgery is quicker than with posterior procedures.

Salie292.....spondylolysthesis .my true story..

POSTERIOR INTERBODY FUSION - The spine is approached from the back and anything pinching the nerves is removed. The disc below the slip is removed from the same approach and a cage is inserted into the disc to fuse it. This technique has a higher fusion rate than the two above techniques, since it combines fusions on both the front and back of the spine. Spinal instrumentation is used to further stabilize the spine and add to the success rate. COMBINED ANTERIOR AND POSTERIOR - In complex cases involving revision surgery, or in instances of marked instability, there is an advantage to fusing the spine both from the front and from the back. When the spine is fused from the front, the disk can be distracted better than from the back. Distracting the disk maintains or improves the natural arch in the low back and allows patients to stand erect effortlessly. Spinal instrumentation is used posteriorly (in the back) to stabilize the spine. With bone in the front and back of the spine, fusion rates approach 98%. The tradeoff is in the increased complication rate from 2 different surgeries (front and back). REDUCTION OF THE SLIPPED VERTEBRA - With high grade or severe spondylolisthesis, there is significant trunk shortening, arching of the low back, and instability. Correction of the slip in these cases is generally thought to be superior to fusing the spine in the deformed position. Reduction is accomplished from posterior, and instrumentation is always required. In experienced hands, this technique provides very good results with few complications. RECOVERY FROM SURGERY Most patients leave the hospital 2 to 4 days after surgery. Help is needed at home for a few weeks with some of the more common activities of daily living. For patients who do not have help at home, a short stay at a rehabilitation center can be helpful in becoming more independent. From the first day home from the hospital, patients should be able to get in to the bathroom, and get in and out of bed or a chair on their own. If a patient wants to get back to work at a sedentary job, this can be done as soon as 4-6 weeks in a part-time status. During the first 3 months, walking is the only exercise permitted. After 3-4 months, physical therapy is started in an effort to regain trunk strength and stamina. Therapy usually lasts 4-8 weeks, culminating in a home exercise program to be done on a daily basis. By 6 to 9 months, most people are safe to release to unrestricted activities. Patients are followed on a yearly basis for several years. This is necessary to make certain the fusion is solid, and to watch for degenerative changes that can develop next to the fusion (15% risk). Spondylolisthesis occurs when one vertebra slips forward on the adjacent vertebrae. This will produce both a gradual deformity of the lower spine but also a narrowing of the vertebral canal. It is often associated with pain. Symptoms The most common symptom of spondylolisthesis is low back pain. Many times a patient can develop the lesion (spondylolysis) between the ages of five and seven and not present symptoms until they are 35-years-old, when a sudden twisting or lifting motion will cause an acute episode of back and leg pain. Usually the pain is relieved by extension of the spine and made worse when flexed. The degree of

Salie292.....spondylolysthesis .my true story..

vertebral slippage does not directly correlate with the amount of pain a patient will experience. Fifty percent of patients with spondylolisthesis will associate an injury with the onset of their symptoms. In addition to back pain, patients may complain of leg pain. In this situation, there can be associated narrowing of the area where the nerves leave the spinal canal that produces irritation of a nerve root. Diagnosis Many patients with spondylolisthesis will have vague symptoms and very little visible deformity. Often, the first physical sign of spondylolisthesis is tightness of the hamstring muscles in the legs. Only when the slip reaches more than 50 percent of the width of the vertebral body will there begin to be a visible deformity of the spine. There may be a dimple at the site of the abnormality. Sometimes there are mild muscle spasms and usually some local tenderness can be felt in the area. Range of motion is often not affected, but some pain can be expected on hyperextension. Laboratory test results are normal in patients with one or both disorders. Plain roentgenograms of the lumbar spine are best initial X-rays for diagnosing spondylolysis or spondylolisthesis. Spondylolisthesis is most easily seen on the lateral view of the spine, but in some cases specialized imaging studies such as a bone scan or CT scan (CAT scan) are needed to make the diagnosis. Patients with a dysplastic pars have an elongated interarticular region along with altered pedicles. This is usually best visualized by CT scan. A spondylolisthesis is graded according to the amount that one vertebral body has slipped forward on another. A grade I slip means that the upper vertebra has slipped forward less than 25 percent of the total width of the vertebral body, a grade II slip is between 25 and 50 percent, a grade III slip between 50 and 75 percent, a grade IV slip is more than 75 percent, and in the case of a grade V slip, the upper vertebral body has slid all the way forward off the front of the lower vertebral body. This is a special situation that is called a spondyloptosis. Differential Diagnosis The diagnosis of spondylolysis is confirmed by the discovery of a pars defect on a lateral roentgenogram and spondylolisthesis is confirmed by noting the forward position of one vertebral body on another. Flexion and extension views of the lumbar spine may help to identify the presence of instability of the spine. This subtle movement may be an important part of the pain experienced and be essential to the planning for further treatment. Treatment The conservative non-surgical treatment for spondylolysis and spondylolisthesis is most commonly rest, followed by trunk and abdominal strengthening exercises. A physical therapist is often helpful in getting you back on your feet and can instruct you in the proper way to do these exercises without exacerbating your symptoms. If there is significant leg pain, patients can also take an anti-inflammatory medication. Braces are rarely indicated but may be helpful in reducing symptoms. For patients with spondylolysis, surgery to repair the defect in the pars intra-articularis is indicated only after non-operative measures such as physical therapy and exercises have failed to relieve symptoms. In younger patients, surgery may be used to directly repair the pars defect; in older patients or in those with some degree of instability, a fusion may be required. If you have spondylolisthesis with the slippage greater than 50 percent of the width of the adjacent vertebral body, then a fusion is required to stop further slippage and provide relief from the associated

Salie292.....spondylolysthesis .my true story..

symptoms of instability and nerve root irritation. Surgeons using a technique called a "fusion in-situ" can do this. What this means is that the surgeon will fuse the two abnormal vertebra together to prevent further slippage, but no attempt will be made to bring the vertebrae back into their original alignment. This is an area of considerable debate among spine surgeons, because although there are now techniques available that will allow the surgeon to "reduce" the slipped vertebra back to is normal, "anatomic" position, these techniques carry the risk of causing an injury to the surrounding nerve roots in the process. You should discuss these issues carefully with your doctor before surgery.

Introduction Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. This guide will help you understand how the problem develops how doctors diagnose the condition what treatment options are available

Salie292.....spondylolysthesis .my true story..

Anatomy What parts of the spine are involved? The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body's main upright support. The section of the spine in the lower back is called the lumbar spine. The lumbar spine is made of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Each vertebra is formed by a round block of bone, called a vertebral body. A circle of bone attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord. The spinal cord only extends to L2. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse's tail. Two sets of bones form the spinal canal's bony ring. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is called the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Intervertebral discs separate the vertebral bodies. The discs normally work like shock absorbers. They
protect the spine against the daily pull of gravity. They also protect the spine during strenuous activities that put strong force on the spine, such as jumping, running, and lifting. The lumbar spine is supported by ligaments and muscles. The ligaments, which connect bones together, are arranged in layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis. Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back. The anatomy of the lumbar spine is often discussed in terms of spinal segments. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the facet joints that link each level of the spinal column.

Salie292.....spondylolysthesis .my true story..

Related Document: A Patient's Guide to Lumbar Spine Anatomy Causes Why do I have this problem? Spondylolisthesis may very rarely be congenital, which means it is present at birth. It can also occur in childhood as a result of injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis. Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected more often than men. The effect of the female hormone estrogen on ligaments and joints is to cause laxity or looseness. The higher levels of estrogen in women may account for the greater incidence of spondylolisthesis. Degenerative spondylolisthesis mainly involves slippage of L4 over L5. In younger patients (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this. First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction. Facet joints are small joints that connect the back of the spine together. Normally, the facet joints connecting L5 to the sacrum create a solid buttress to prevent L5 from slipping over the top of the sacrum. However, when problems exist in the disc, facet joints, or bony ring of L5, the buttress becomes ineffective. As a result, the L5 vertebra can slip forward over the top of the sacrum. A condition called spondylolysis can lead to the slippage that happens with spondylolisthesis. Spondylolysis is a defect in the bony ring of the spinal column. It affects the pars interarticularis, mentioned earlier. This defect is most commonly thought to be a stress fracture that happens from repeated strains on the bony ring. Participants in gymnastics and football commonly suffer these strains. Spondylolysis can lead to the spine slippage when a fracture occurs on both sides of the bony ring. This slippage is called spondylolisthesis. The slippage is graded from I through IV, one being mild, IV often causing neurological symptoms. The back section of the bony ring separates from the main vertebral body, so the injured vertebra is no longer connected by bone to the one below it. In this situation, the facet joints can't provide their normal support. The vertebra on top is then free to slip forward over the one below. View animation of spondylolisthesis Related Document: A Patient's Guide to Spondylolysis A traumatic fracture in the bony ring can lead to slippage when the fracture goes completely through both sides of the bony ring. The facet joints are no longer able to provide a buttress, allowing the

Salie292.....spondylolysthesis .my true story..

vertebra with the crack in it to slip forward. This is similar to what happens when spondylolysis (mentioned earlier) occurs on both sides of the bony ring, but in this case it happens all at once.

Degenerative changes in the spine (those from wear and tear) can also lead to spondylolisthesis. The
spine ages and wears over time, much like hair turns gray. These changes affect the structures that normally support healthy spine alignment. Degeneration in the disc and facet joints of a spinal segment causes the vertebrae to move more than they should. The segment becomes loose, and the added movement takes an additional toll on the structures of the spine. The disc weakens, pressing the facet joints together. Eventually, the support from the facet joints becomes ineffective, and the top vertebra slides forward.

Symptoms What does the condition feel like? An ache in the low back and buttock areas is the most common complaint in patients with spondylolisthesis. Pain is usually worse when standing, walking, or bending backward and may be eased by resting or bending the spine forward. Leaning on a counter top, piece of furniture, or shopping cart are common ways to alleviate (reduce) the symptoms. Spasm is also common in the low back muscles. The hamstring muscles on the back of the thighs may become tight.

Salie292.....spondylolysthesis .my true story..

The pain can be from mechanical causes. Mechanical pain is caused by wear and tear on the parts of the spine. When the vertebra slips forward, it puts a painful strain on the disc and facet joints. Slippage can also cause nerve compression. Nerve compression is a result of pressure on a nerve. As the spine slips forward, the nerves may be squeezed where they exit the spine. This condition also reduces space in the spinal canal where the vertebra has slipped. This can put extra pressure on the nerve tissues inside the canal. Nerve compression can cause symptoms where the nerve travels and may include numbness, tingling, slowed reflexes, and muscle weakness in the legs. Nerve pressure on the cauda equina (mentioned earlier), the bundle of nerve roots within the lumbar spinal canal, can affect the nerves that go to the bladder and rectum. When this happens, bowel and/or bladder function can be affected. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. Diagnosis How do doctors diagnose the problem? Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. Your doctor will also want to know what positions or activities make your symptoms worse or better. Next the doctor examines you by checking your posture and the amount of movement in your low back. Your doctor checks to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested. Doctors will usually order X-rays of the low back. The X-rays are taken with your spine in various positions. They can be used to see which vertebra is slipping and how far it has slipped. If more information is needed, your doctor may order computed tomography (a CT scan). This is a detailed X-ray that lets the doctor see slices of the body's tissue. If you have nerve problems, the doctor may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal, the subarachnoid space. During the CT scan, the dye highlights the spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the nerves. Your doctor may also order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It can help in the diagnosis of spondylolisthesis. It can also provide information about the health of nerves and other soft tissues. Treatment What treatment options are available? Nonsurgical Treatment

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Studies have not been done yet to determine the best treatment for this condition. Conservative care is preferred, especially when the vertebra hasn't slipped very far. Most patients with symptoms from degenerative spondylolisthesis do not need surgery and respond well to nonoperative care. Medications may be prescribed to help ease pain and muscle spasm. In some cases, the patient's condition is simply monitored to see if symptoms improve. Your doctor may ask that you rest your back by limiting your activities. This is to help decrease inflammation and calm muscle spasm. You may need to take time away from sports or other strenuous activities to give your back a chance to heal.

If your doctor diagnoses an acute pars fracture that has the potential to heal, it may be recommended that you wear a rigid back brace for two to three months. This usually occurs in children and teenagers who begin having back pain and see their doctor early on. X-rays may show a fresh fracture of the pars area of the vertebra on one, or both, sides. A CT scan or bone scan may be recommended to determine if the fracture is likely to heal. If so, a brace is recommended. X-rays or a CT scan may be ordered in six to eight weeks to see if the fracture is healing. IF not, the brace will be discontinued. Some patients who continue to have symptoms are given an epidural steroid injection (ESI). Steroids are powerful anti-inflammatories, meaning they reduce pain and swelling. In an ESI, medication is injected into the space around the lumbar nerve roots. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren't working. But ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.

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Patients often work with a physical therapist. After evaluating your condition, your therapist can assign positions and exercises to ease your symptoms. Your therapist can design an exercise program to improve flexibility in your low back and hamstrings and to strengthen your back and abdominal muscles. The use of a stationary bike can promote aerobic conditioning and puts you in the optimal position to open the spaces where the nerve roots exit. This type if exercise program can aid in reducing the painful symptoms. Surgery Surgery is used when the slip is severe and when symptoms are not relieved with nonsurgical treatments. Symptoms that cause an abnormal walking pattern, changes in bowel or bladder function, or steady worsening in nerve function require surgery. Deterioration of symptoms is common in patients with a history of significant neurologic symptoms who don't have surgery to correct the problem. If a reasonable trial of conservative care (three months or more) does not improve things and/or your quality of life is significantly reduced, then surgery may be the next best solution. The main types of surgery for spondylolisthesis include laminectomy (decompression) posterior fusion with or without instrumentation posterior lumbar interbody fusion Laminectomy When the vertebra slips forward, the nearby nerves that exit the spine can become pinched or irritated. In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal. To fix this, the lamina of the bony ring is removed to ease pressure on the nerves. The procedure to remove the lamina and release pressure on the nerves is called laminectomy. Decompression alone is usually not advised. Studies show much better results when the operation is combined with a fusion of the involved vertebrae (see below). Related Document: A Patient's Guide to Lumbar Laminectomy Posterior Fusion with Instrumentation A spinal fusion is normally done immediately after laminectomy for spondylolisthesis. The fusion procedure is designed to fuse the two vertebrae into one bone and stop the slippage from worsening. The fusion is used to lock the vertebrae in place and stop movement between the vertebrae, easing mechanical pain. When combined with laminectomy surgery (mentioned earlier), fusion helps relieve nerve compression. In this procedure, the surgeon lays small grafts of bone over the back of the problem vertebrae. Sometimes fusion is done just with bone graft material. This is a fusion without fixation (non-

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instrumentation). Instrumentation is the use of metal plates or screws to stabilize the segment during
healing. Most surgeons combine fusion with instrumentation to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.

Outcomes are improved when decompression is combined with fusion (compared with decompression alone). Fusion and functional improvement are even better when spinal instrumentation is used. There are fewer long-term problems with pain and pseudoarthrosis (formation of movement or false joints within the fusion). Related Document: A Patient's Guide to Posterior Lumbar Fusion Posterior Lumbar Interbody Fusion When fusion surgery is needed for mild spondylolisthesis (up to 50 percent slippage), posterior lumbar interbody fusion may be considered. In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back). Combining fusion of both portions of the spine increases the fusion surface area and improves the fusion rate. The surgeon works from the back of the spine and removes the disc between the problem vertebrae. Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage that spreads and holds the vertebrae apart. Surgeons usually apply some form of instrumentation (described above) on the back of the vertebrae. In some cases, additional strips of bone graft are placed along the back surfaces of the vertebrae to be fused. This increases the mechanical strength of the spine.

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Related Document: A Patient's Guide to Posterior Lumbar Interbody Fusion Fusion with Biologics New materials for fusion are being developed and tested. For example, bone morphogenetic proteins (BMP) mixed with bone graft in a putty is under investigation. This substance may help reduce the need for instrumentation with fusion. BMP helps promote faster and more bone growth in the unstable spinal segment. Studies of safety and effectiveness of this material have been very favorable so far. Without the need to harvest bone graft and place instrumentation, surgical time is much less with BMP putty. And the fusion rate is much higher with BMP alone compared with fusion alone or fusion with fixation. Motion-Sparing Technologies The Food and Drug Administration (FDA) is reviewing the use of devices inserted without invasive surgery to limit vertebral motion. For example, a special titanium implant has been designed to fit between the spinous processes of the vertebrae in your lower back. These motion-sparing devices are currently used with patients who have spinal stenosis (narrowing of the spinal canal or foramen). With spondylolisthesis, the goal is to reduce the load on the disc and facets while increasing the space inside the spinal canal and foramen, thus relieving your symptoms. The vertebral segment is stabilized enough to prevent further progression of the spondylolisthesis. Rehabilitation What should I expect as I recover? Nonsurgical Rehabilitation Back pain associated with spondylolisthesis will gradually improve in up to one-third of all patients. Slippage of one vertebra over the other does not increase in this group. Worsening of symptoms is not expected in patients who don't have neurologic symptoms at the time of diagnosis. Nonsurgical treatment for spondylolisthesis commonly involves physical therapy. Your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care. The first goal of treatment is to control symptoms. Your therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm. Patients are shown how to stretch tight muscles, especially the hamstring muscles on the back of the thigh.

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As patients recover, they gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move easier and lessens the chances of future pain and problems.

A primary purpose of therapy is to help you learn how to take care of your symptoms and prevent future problems. You'll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also describe strategies you can use if your symptoms flare up. After Surgery Rehabilitation after surgery is more complex. Patients who have surgery for spondylolisthesis usually stay in the hospital for a few days afterward. Some surgeons require patients to wear a rigid brace or cast for up to four months after fusion surgery for spondylolisthesis. Patients who've had fusion surgery for a severe slip may also be required to stay off their feet for four months. After lumbar fusion surgery for spondylolisthesis, patients must normally wait four months before beginning a rehabilitation program. This delay is needed to give the fusion a chance to start healing. Patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take at least 12 months.

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Ideally, patients are able to return to their previous activities. However, some patients may need to modify or discontinue certain activities to avoid future problems. When your treatment is well under way, regular visits to the therapist's office will end. The therapist will continue to be a resource for you. But you will be in charge of doing your exercises as part of an ongoing home program.

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Spondylolisthesis

Spondylolisthesis occurs when one vertebra slips forward on the adjacent vertebrae. This will produce both a gradual deformity of the lower spine but also a narrowing of the vertebral canal. It is often associated with pain. There are five major types of spondylolisthesis:

Type I is called dysplastic spondylolisthesis and is secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra. * Type II, isthmic or spondylolytic, in which the lesion is in the isthmus or pars interarticularis, has the greatest clinical importance in persons under the age of 50. If a defect in the pars interarticularis can be identified but no slipping has occurred, the condition is termed spondylolysis. If one vertebra has slipped forward on the other (horizontal translation), it is referred to as spondylolisthesis.

Type II can be divided into three subcategories: Type II A is sometimes called Lytic or stress spondylolisthesis and is most likely caused by recurrent micro-fractures caused by hyperextension. It is also called a "stress fracture" of the pars interarticularii and is much more common in males.

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Type II B probably also occurs from micro-fractures in the pars. However, in contrast to Type II A, the pars interarticularii remain intact but stretched out as the fractures fill in with new bone.

Type II C is very rare in occurrence and is caused by an acute fracture of the pars. Nuclear imaging may be needed to establish diagnosis.

Type III is a degenerative spondylolisthesis, and occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement. This type of spondylolisthesis is most often seen in older patients. In Type III, degenerative spondylolisthesis there is no pars defect and the vertebral slippage is never greater than 30%.

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Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis.

Type V, pathologic spondylolisthesis, occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases.

Symptoms The most common symptom of spondylolisthesis is low back pain. Many times a patient can develop the lesion (spondylolysis) between the ages of five and seven and not present symptoms until they are 35years-old, when a sudden twisting or lifting motion will cause an acute episode of back and leg pain. Usually the pain is relieved by extension of the spine and made worse when flexed. The degree of vertebral slippage does not directly correlate with the amount of pain a patient will experience. Fifty percent of patients with spondylolisthesis will associate an injury with the onset of their symptoms. In addition to back pain, patients may complain of leg pain. In this situation, there can be associated narrowing of the area where the nerves leave the spinal canal that produces irritation of a nerve root. Diagnosis Many patients with spondylolisthesis will have vague symptoms and very little visible deformity. Often, the first physical sign of spondylolisthesis is tightness of the hamstring muscles in the legs. Only when the slip reaches more than 50 percent of the width of the vertebral body will there begin to be a visible deformity of the spine. There may be a dimple at the site of the abnormality. Sometimes there are mild muscle spasms and usually some local tenderness can be felt in the area. Range of motion is often not affected, but some pain can be expected on hyperextension. Laboratory test results are normal in patients with one or both disorders. Plain roentgenograms of the lumbar spine are best initial X-rays for diagnosing spondylolysis or spondylolisthesis. Spondylolisthesis is most easily seen on the lateral view of the spine, but in some cases specialized imaging studies such as a bone scan or CT scan (CAT scan) are needed to make the

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diagnosis. Patients with a dysplastic pars have an elongated interarticular region along with altered pedicles. This is usually best visualized by CT scan. A spondylolisthesis is graded according to the amount that one vertebral body has slipped forward on another. A grade I slip means that the upper vertebra has slipped forward less than 25 percent of the total width of the vertebral body, a grade II slip is between 25 and 50 percent, a grade III slip between 50 and 75 percent, a grade IV slip is more than 75 percent, and in the case of a grade V slip, the upper vertebral body has slid all the way forward off the front of the lower vertebral body. This is a special situation that is called a spondyloptosis. Differential Diagnosis The diagnosis of spondylolysis is confirmed by the discovery of a pars defect on a lateral roentgenogram and spondylolisthesis is confirmed by noting the forward position of one vertebral body on another. Flexion and extension views of the lumbar spine may help to identify the presence of instability of the spine. This subtle movement may be an important part of the pain experienced and be essential to the planning for further treatment. Treatment The conservative non-surgical treatment for spondylolysis and spondylolisthesis is most commonly rest, followed by trunk and abdominal strengthening exercises. A physical therapist is often helpful in getting you back on your feet and can instruct you in the proper way to do these exercises without exacerbating your symptoms. If there is significant leg pain, patients can also take an anti-inflammatory medication. Braces are rarely indicated but may be helpful in reducing symptoms. For patients with spondylolysis, surgery to repair the defect in the pars intra-articularis is indicated only after non-operative measures such as physical therapy and exercises have failed to relieve symptoms. In younger patients, surgery may be used to directly repair the pars defect; in older patients or in those with some degree of instability, a fusion may be required. If you have spondylolisthesis with the slippage greater than 50 percent of the width of the adjacent vertebral body, then a fusion is required to stop further slippage and provide relief from the associated symptoms of instability and nerve root irritation. Surgeons using a technique called a "fusion in-situ" can do this. What this means is that the surgeon will fuse the two abnormal vertebra together to prevent further slippage, but no attempt will be made to bring the vertebrae back into their original alignment. This is an area of considerable debate among spine surgeons, because although there are now techniques available that will allow the surgeon to "reduce" the slipped vertebra back to is normal, "anatomic" position, these techniques carry the risk of causing an injury to the surrounding nerve roots in the process. You should discuss these issues carefully with your doctor before surgery. Spondylolisthesis Introduction

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There are 33 vertebrae in the human spine: 7 in the neck area (cervical), 12 in the chest area (thoracic), 5 in the lumbar (lower back), 5 fused vertebrae in the pelvic area (sacrum) and 4 fused vertebrae forming the tailbone (coccyx). The cervical, thoracic and lumbar vertebrae are held in place, one above the next, by projections on each vertebra called superior and inferior processes. The inferior (lower) process of the top vertebra fit into the superior (upper) process of the lower vertebra, forming a joint that holds the vertebrae in place. Between each vertebra (except in the sacrum and coccyx) intervertebral (between the vertebrae) discs cushion and separate the vertebrae. What is spondylolisthesis? Spondylolisthesis is a Latin term meaning improper forward movement of a vertebra over the vertebra below it. Most often, this forward slip of the vertebra occurs in the lumbar area of the spine. This slippage and herniation (deformity) of the disc places pressure on the nerve roots associated with the affected vertebrae, causing pain and dysfunction. While the herniation of the disk causes pain, discectomy alone is unable to provide relief . The reduction in disk space height and abnormal amount of movement allowed by the joint also causes pressure on the nerves. This intervertebral space must be restored in order to provide adequate space for the nerves. What causes spondylolisthesis? Spondylolisthesis occurs only in people who are able to stand upright and walk, so is virtually nonexistent among newborns. The upright position of human walking seems to have a direct effect on the development. It is more common in persons who participate is sports such as diving, weight lifting, wrestling and gymnastics. All these activities require repetitive hyperextension, which can contribute to instability of the spine.

Can spondylolisthesis be prevented?

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Good spinal care, both in developing good musculature and in preventing overuse or injuries, is key into reducing the chance of developing spondylolisthesis. Athletes, especially, need to be knowledgeable about body mechanics and the importance of both strengthening and resting the muscles of the back. What treatment options are there for spondylolisthesis?

1. Anterior or Posterior Decompression with fusion cages The goals of surgery are to remove pressure on spinal nerves (decompression), and to provide stability to the lumbar spine. Decompression involves removing the damaged structures that are causing the spondylolisthesis. In most cases of spondylolisthesis, lumbar decompression is accompanied by the uniting of one spinal vertebra to the next (spinal fusion) with spinal instrumentation (implants that are used to assist the healing process). Surgery can be performed from the back of the spine (posterior) or from the front of the spine (anterior). A structural graft is inserted into the place previously occupied by the removed structure. The purpose of this graft is to hold the disc space open until the fusion is complete. The graft is often held in place by a "cage" device, such as the BAK cage. 2. Laminectomy decompression with graft In the laminectomy procedure, the spine is approached through a two-inch to five-inch incision in the midline of the back, and the left and right back muscles are detached from the lamina on both sides. The lamina are flat bone projections on each side of the vertebra. After this is accomplished, the lamina is removed (laminectomy), allowing the doctor to see the nerve roots. The facet joints, which are directly over the nerve roots, may then be trimmed to give the nerve roots more room. Once the nerve roots have adequate space made by the removed lamina and facet joint trimmings, pressure is eliminated, thereby alleviating pain. Bone graft chips may be placed between the vertebrae to create a solid section of bone, preventing motion that may detract from healing.

3. Posterolateral fusion The posterolateral fusion involves placing bone graft in the posterolateral portion of the spine (behind and to one side of the spine).The surgical approach to the spine is from the back through a midline incision that is approximately three inches to six inches long. First, bone graft is obtained from the pelvis (the iliac crest). Most surgeons work through the same incision to obtain the bone graft and perform the spinal fusion.

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Next, the harvested bone graft applied to the posterolateral portion of the spine. This region lies on the outside of the spine and is rich in blood to supply the nutrients for it to grow. A small extension of the vertebral body in this area (transverse process) is a bone that serves as a muscle attachment site. The large back muscles that attach to the transverse processes are elevated to create a bed to lay the bone graft on. The back muscles are then laid back over the bone graft, creating tension to hold the bone graft in place. After surgery, the body uses a natural process to repair itself, which usually means growing bone. As the harvested bone graft grows and adheres to the transverse processes, the spinal fusion is achieved and motion at that segment is stopped. Spine surgery instrumentation (medical devices) is sometimes used as an adjunct to obtain a solid fusion. 4. Spinal instrumentation with pedicle screws For spine operations to be successful, solid healing of bone across the spine must be achieved. Spine Group Beverly Hills makes use of metal devices, also called instrumentation (screws, rods, plates, cables, wires) that can help correct a deformed spine and will also increase the probability of obtaining a solid spinal fusion. Spinal instrumentation can be placed in the front or in the back portion of the spine. The devices are usually made of metal, commonly stainless steel or titanium. In order to place this instrumentation into the spine, the spine is at first exposed by making a skin incision, and then gently clearing the muscles, ligaments and other soft tissues from the levels of the vertebrae to be fused. Specific tools are used to carefully prepare the bone in such a way to obtain good seating of the implants (screw, rod, wire, cable or other). When these devices are in the proper position, a rod (or plate) is positioned to link the implants together. Screws are inserted into the pedicles, which are part of the arch of the vertebra. This essentially forms a rigid scaffolding to hold the spine in the desired position. The bone graft which has been placed into the area of fusion gradually solidifies over several months. The spinal instrumentation is gradually covered by scar tissue and sometimes bone which the body lays down. Isthmic Spondylolisthesis Isthmic spondylolisthesis is a caused by a stress fracture in a part of a vertebra. (A crack in a vertebra, without slippage, is called spondylolysis.) A crack in a vertebra often doesnt heal because of the constant stress on the lower back. Sports (such as gymnastics, football, and weightlifting) that place repetitive, excessive stress on the lower vertebrae and/or involve hyperextension of the spine increase the risk of stress fractures. Sometimes a genetic weakness or malformation in part of the vertebrae leaves a person predisposed to stress fractures.

Not all stress fractures in a vertebra result in slippage.

A stress fracture in a vertebra may cause it to disconnect from the facet joints. This results in the vertebra slipping forward over the vertebra below it - resulting in misalignment and narrowing in the spinal canal. Spinal nerves may be compressed. The degree of slippage can vary. An X-ray can show the degree of slippage. The slippage may or may not progress.

Isthmic Spondylolisthesis starts with a stress fracture in a part of a vertebra called the pars interarticularis (a narrow piece of bone connecting the facet joints). Facet joints are hinge-like joints attached to the

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back of each vertebra (in pairs - one on each side of the back of the vertebrae) that link the vertebrae together and allow the vertebrae to move on one another. About 5% of adults have isthm ic spondylolisthesis, though m any are not aw are of it.
Some people are surprised to find out they have a slipped vertebra after having it show up on an x-ray. The stress fracture most often occurs in early childhood but the slippage often occurs later - during periods of rapid growth. Slippage is uncommon after adolescence. Sometimes the slippage occurs in childhood, is present for years without symptoms, but often accelerates disc degeneration later in life. Isthmic spondylolisthesis most commonly affects the bottom vertebra in the lower back just above the sacrum (a triangular shaped solid base consisting of 5 fused vertebrae). Symptoms of Isthmic Spondylolisthesis There may be no symptoms at all or there may intermittent or chronic symptoms. Pain is the main symptom. There may also be tingling, weakness or numbness radiating down the buttocks and leg (sciatica), caused by compression or irritation of nerve roots. Inflammation may trigger muscle spasms, which cause pain, stiffness in the back and sometimes an abnormal gait. Tightness in the hamstrings is another fairly common symptom of isthmic spondylolisthesis that can cause difficulty walking. The symptoms usually flare up after prolonged standing or walking and are relieved by rest. The symptoms may be chronic or intermittent.

Spondylolisthesis does not alw ays cause sym ptom s.

Treatment Treatment depends on severity of slippage, the cause of the slippage, the severity of the symptoms, and age of the person. When a child diagnosed with spondylolisthesis, x-rays are taken routinely to see if the slippage is progressing. Though spondylolisthesis is a chronic condition, conservative treatment is usually adequate. Surgery is rarely needed. If symptoms are severe, a few days of bed rest may be necessary. Prolonged bed rest, however, weakens the muscles that support the spine and is counterproductive.

Avoid activities that stress the low er back such as lifting heavy objects.
Exercise

Consult a physician before starting an exercise plan. Do not do any exercise that causes pain.
Stretching the muscles of the lower back relieve muscle spasms. Stretching the hamstrings also helps. Strengthening the muscles that support the lumbar spine both back and abdominal muscles are particularly helpful. Strong muscles and ligaments help hold the vertebrae in place. Low impact aerobics tone the muscles in the back without placing undue stress on the spine. Low impact aerobics include walking, swimming, or riding a stationary bike or elliptical trainer. Aerobics also help keep ones weight under control; being overweight increases stress on the lower back.

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Medication Anti-inflammatory medications are useful for short-term pain and inflammation. See Medications for Pain and Inflammation. Cold When there is a flare up of symptoms, applying ice packs to the area every three to four hours for two to three days can reduce pain and inflammation. Do not apply ice for over 20 minutes at a time to prevent frostbite. Place a cloth between the ice and the skin. Heat Applying heat to the area can relieve muscle spasms. Apply heat for 20 - 30 minutes at a time, waiting at least an hour between each application to prevent overheating of tissues. Moist heat penetrates the tissues more quickly, and penetrates more deeply than dry heat. A hot bath or shower also helps to relax muscles Bracing Some physicians recommend wearing a lumbosacral brace. Bracing relieves symptoms for some people. Epidural Steroid Injections An injection of steroids into the epidural space surrounding the spinal cord may reduce pain and other symptoms caused by compression or irritation of nerve roots. An epidural steroid injection is a minimally invasive procedure with rare but serious risks. It is used only after conservative therapies have not provided adequate relief. Surgery Surgery may be recommended when conservative treatment fails to bring adequate relief and symptoms are severe enough to interfere with everyday life. Surgery may also be recommended when the affected vertebra continues to slip further. Fusing the affected vertebra to the vertebra below it (or fusing the lowest lumbar vertebra to the sacrum) prevents further slippage. If a nerve root is being compressed, bone or tissue compressing the nerve can be removed make more room for the nerve. Fortunately, the majority of cases respond to conservative treatment. What is spondylolisthesis? Spondylolisthesis is a Latin-derived term meaning slipped vertebral body (spinal bone). "Spondylo"= vertebrae "listhesis"=slippage

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Spondylolisthesis in the lumbar spine is most commonly caused by degenerative spinal disease (degenerative spondylolisthesis), or a defect in one region of a vertebra (isthmic spondylolisthesis).

What are the types of spondylolisthesis? Spondylolisthesis can be classified by into five groups (Newman (1976)): Group 1: dysplastic o o developmental malformation of the L5S1 joint usually slight slippage

Group 2: isthmic o stress fractures of the pars interarticularis (bridge of bone), which is critical for lumbar stability o usually increased slippage

Group 3: traumatic o o severe separation of the laminae from the spinous process as a result of fractures marked slippage may occur

Group 4: degenerative o this usually results from wear on the discs and facet joints

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sometimes occurs or increases after decompressive surgery (laminectomy) for lumbar stenosis

a variable degree of slippage may occur

Group 5: pathological o o local disease weakens the pedicles, and a slip occurs tumour and infection are the usual causes

Which types of spondylolisthesis are the most common? Degenerative spondylolisthesis is very common, and occurs as a result of due to degeneration or wear and tear of the intervertebral discs and ligaments. Osteoarthritis of the facet joints can also play an important role in the development of instability and slippage. Degenerative spondylolisthesis usually occurs in people over 60 years of age. In degenerative spondylolisthesis, what usually happens is that ongoing degeneration weakens the facet joints and disc, and (typically) the L4 vertebral body slips forward on the L5 vertebral body. The L4-L5 segment is the one in the lumbar spine with the most movement under normal circumstances, and is therefore most likely to slip when this process occurs. The next most common levels affected by degenerative spondylolisthesis are L3-L4 L5-S1. Isthmic spondylolisthesis occurs most often at L5-S1, and is frequently seen in younger adults than degenerative spondylolisthesis. The cause is a defect in the pars interarticularis (an important bridge of bone) of L5. How is spondylolisthesis graded? Spondylolisthesis is graded according to the severity of the slippage (Mayerding classification): Grade 1- <25% slip Grade 2- 25-50% slip Grade 3- 50-75% slip Grade 4- 75-100% slip

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When one vertebra slips entirely off the one below (>100% slip), this is known as spondyloptosis (see picture).

What are the symptoms of spondylolisthesis? Spondylolisthesis is usually asymptomatic, and is commonly seen on X-rays and CT scans as an incidental finding. It may, however, produce significant symptoms and disability. Back pain is the most common symptom of spondylolisthesis. This pain is typically worse with activities such as bending and lifting, and often eases when lying down. As the spine attempts to stabilise the unstable segment, the facet joints enlarge (hypertrophy) and place pressure on the nerve root causing lumbar spinal stenosis and lateral recess stenosis. Furthermore, as one bone slips forward on the other, narrowing of the intervertebral foramen may also occur (foraminal stenosis). Severe nerve compression can therefore occur with pain, numbness and weakness in the legs. Sometimes loss of control of the bladder and/or bowels can occur due to pressure on the nerves going to these important structures. How is spondylolisthesis diagnosed? Imaging studies including MRI and CT can show a slip, as well as narrowing (stenosis) or compressed nerves in the spinal canal.

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The CT and MRI scans are usually obtained with the patient lying flat, however sometimes a slip may only be obvious when standing or bending forwards. This is why your neurosurgeon will sometimes obtain flexion, extension and standing X-rays, and occasionally a CT myelogram. What are the treatment options for spondylolisthesis? Treatment for symptomatic spondylolisthesis is similar to treatments for other causes of mechanical and compressive back pain. It is usually non-operative, and surgery is only necessary in a small percentage of patients. Your specialist may prescribe modification of physical activities, including avoidance of certain recreational and work-related activities, to help settle symptoms from mechanical back pain. Special braces are occasionally prescribed to ease back pain. Strict bed rest is rarely needed, however short periods of bed rest may help with acute painful episodes. A well-rounded physical rehabilitation program assists in settling pain and inflammation, improving mobility and strength, and helping you to do your daily activities more easily. A combination of physiotherapy, hydrotherapy and clinical pilates is usually recommended. Positions, movements, and exercises are prescribed to reduce pain. Hamstring flexibility is addressed, along with strength and coordination exercises for the low back and abdominal muscles (core stability exercises). The aims of these physical therapies are to assist you in: managing your condition and controlling your symptoms correcting your posture and body movements to reduce back strain improving your flexibility and core strength

Some patients also benefit from chiropractic treatment osteopathy, remedial massage, and acupuncture. Review by a clinical psychologist is often useful. Strategies to manage pain may include cognitive behavioural therapy and mindfulness-based programs. It is important to treat any associated depression or anxiety, as these conditions may increase your experience of pain.

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Medications play an important role in controlling pain, easing muscle spasms, and helping to regain a normal sleep pattern. Long-term medication usage should not be undertaken lightly, and should be closely supervised in order to avoid problems such as tolerance and dependence (addiction). Surgery is needed only if conservative treatments fail to keep your pain at a tolerable level. Surgical treatment for spondylolisthesis must address both the mechanical (instability) and compressive (nerve pressure) issues. Nerve pressure generally requires surgical decompression, also known as a decompressive laminectomy. In order to deal with the compressive issues by taking pressure off the nerves, your surgeon may need to remove some or all of one or both facet joints, as well as portions of the lamina. The facet joints in particular normally provide stability in the lumbar spine. Removal of either or both can cause the spine to become loose and unstable, especially when a degree of slippage has already occurred. A fusion is therefore usually recommended. Similarly, a fusion is necessary to adequately deal with the mechanical issues of instability in spondylolisthesis.

Four types of fusion surgery are commonly recommended for the treatment of spondylolisthesis, depending upon individual patient factors: 1. Transforaminal lumbar interbody fusion (TLIF)

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2. Posterior lumbar interbody fusion (PLIF) 3. Instrumented posterolateral fusion (pedicle screw fixation and posterolateral bone graft) 4. Anterior lumbar interbody fusion (carried out through the abdomen, rather than from the back)

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