What is Spondylolisthesis?

Spondylolisthesis is a spine condition in which one vertebra slips forward or backward in relation to the vertebra below it. It most often occurs in the lumbar spine, or lower back, but it can also occur in the cervical or thoracic spine in selected cases.

Spondylolisthesis may be related to spinal instability, degenerative disc disease, facet joint disease, spinal stenosis, or a stress fracture called spondylolysis. Some patients have spondylolisthesis on imaging without major symptoms. Others may develop low back pain, leg pain, sciatica, nerve compression, or walking difficulty.

De Novo Brain & Spine evaluates adult patients with suspected or confirmed spondylolisthesis when symptoms suggest spinal instability, lumbar radiculopathy, spinal stenosis, neurogenic claudication, progressive weakness, or another spine-related condition that may require neurosurgical review.

Common Signs and Symptoms

Spondylolisthesis symptoms depend on the spinal level involved, degree of slippage, spinal stability, and whether nearby nerve roots or the spinal canal are compressed.

Common signs and symptoms may include:

• Low back pain
• Pain that worsens with standing, walking, bending, lifting, or extension
• Pain that improves with sitting, rest, or bending forward in some patients
• Pain that travels into the buttock, hip, thigh, calf, or foot
• Sciatica, meaning radiating leg pain along the sciatic nerve pathway
• Numbness or tingling in the leg or foot
• Weakness in the leg, ankle, or foot
• Foot drop or difficulty lifting the front of the foot in selected cases
• Tight hamstrings or reduced flexibility
• Muscle spasms in the lower back
• Difficulty standing upright or walking normally
• Neurogenic claudication, meaning leg pain, heaviness, cramping, or weakness that worsens with standing or walking
• Limited walking or standing tolerance
• Symptoms of spinal stenosis or lumbar radiculopathy when nerves are compressed

Seek urgent medical evaluation for progressive weakness, foot drop, worsening numbness, numbness in the groin or saddle area, new bowel or bladder problems, severe pain after trauma, fever, unexplained weight loss, history of cancer, or rapidly worsening neurological symptoms. Seek emergency medical care or call 911 for symptoms concerning for cauda equina syndrome, including loss of bowel or bladder control, severe leg weakness, or saddle anesthesia.

What Causes This Condition?

Spondylolisthesis occurs when one vertebra slips out of normal alignment. The cause depends on the type of spondylolisthesis and the structures involved.

Possible causes and related factors may include:

• Degenerative spondylolisthesis, caused by age-related changes in the discs, facet joints, ligaments, and spinal alignment
• Isthmic spondylolisthesis, often related to spondylolysis, which is a stress fracture or defect in part of the vertebra called the pars interarticularis
• Congenital or developmental spondylolisthesis, related to spinal anatomy present from development
• Traumatic spondylolisthesis, caused by fracture, dislocation, or significant injury
• Pathologic spondylolisthesis, related to tumor, infection, or bone disease in selected cases
• Iatrogenic spondylolisthesis, which may occur after prior spine surgery in selected patients
• Degenerative disc disease and loss of disc height
• Facet joint disease or arthritis
• Spinal stenosis
• Spinal instability
• Repetitive extension, loading, or stress on the lower back
• Prior spine injury or fracture

These causes and risk factors do not mean every patient with spondylolisthesis will have symptoms. Treatment planning depends on the type of spondylolisthesis, degree of slippage, nerve compression, spinal stability, symptoms, neurological examination, imaging findings, and overall health.

How It Is Diagnosed?

Spondylolisthesis is diagnosed through medical history, physical examination, neurological examination, and imaging. Imaging helps show the degree of vertebral slippage, spinal alignment, and whether nerves are compressed.

Common diagnostic steps may include:

• Medical history and symptom review to understand low back pain, leg pain, numbness, tingling, weakness, walking tolerance, injury history, prior treatment, and red-flag symptoms
• Physical examination to evaluate posture, spinal alignment, range of motion, tenderness, muscle spasm, gait, and painful movement
• Neurological examination to assess strength, sensation, reflexes, coordination, gait, balance, and signs of nerve root involvement
• Standing X-rays of the lumbar spine to evaluate vertebral slippage, alignment, disc space narrowing, arthritis, and deformity
• Flexion-extension X-rays to assess abnormal motion or spinal instability in selected cases
• MRI of the lumbar spine to evaluate nerve root compression, spinal stenosis, disc disease, facet joint changes, tumor, infection, or other soft-tissue findings
• CT scan to evaluate bone detail, pars defect, fracture, fusion status, or surgical planning when needed
• CT myelogram in selected cases when MRI is not possible or when additional detail around the spinal canal and nerve roots is needed
• Standing scoliosis or full-spine X-rays in selected cases when overall spinal alignment, sagittal balance, scoliosis, or deformity needs evaluation
• Electromyography and nerve conduction studies, also called EMG/NCS, when symptoms may overlap with lumbar radiculopathy, peripheral neuropathy, peroneal neuropathy, or another nerve disorder
• Blood tests in selected cases when infection, inflammatory disease, cancer-related concern, or another medical condition is suspected

The goal of diagnosis is to determine the type and severity of spondylolisthesis, identify whether spinal instability or nerve compression is present, and decide whether conservative care, injections, or surgical evaluation may be appropriate.

Treatment Options

Spondylolisthesis treatment depends on the type of slippage, degree of instability, severity of symptoms, neurological examination, imaging findings, walking tolerance, prior treatment, activity limitations, and overall health. Not every patient with spondylolisthesis needs surgery.

Treatment options may include:

• Observation and symptom monitoring for selected patients with mild symptoms and stable imaging
• Activity modification to reduce movements, lifting, bending, extension, or positions that worsen symptoms
• Physical therapy to improve core strength, flexibility, posture, walking mechanics, and spinal stability
• Home exercise and stretching when recommended by a clinician or therapist
• Heat, ice, or other comfort measures for short-term symptom relief
• Anti-inflammatory medication, acetaminophen, muscle relaxants, or nerve pain medication when medically appropriate
• Bracing in selected cases when temporary support is appropriate
• Treatment of posture, ergonomic, conditioning, or activity-related contributors
• Lumbar epidural steroid injection in selected cases involving nerve root inflammation, radiculopathy, or sciatica
• Selective nerve root block in selected cases when diagnostic or therapeutic nerve-targeted injection is appropriate
• Facet joint injection, medial branch block, or radiofrequency ablation in selected cases when facet joint pain overlaps with spondylolisthesis-related symptoms
• Lumbar decompression in selected cases when spinal stenosis or nerve compression is a major source of symptoms
• Lumbar fusion or stabilization in selected cases involving spinal instability, progressive slippage, deformity, significant nerve compression, or persistent symptoms despite appropriate non-surgical care
• Transforaminal lumbar interbody fusion, also called TLIF, in selected cases when decompression and stabilization are needed
• Anterior lumbar interbody fusion, also called ALIF, or lateral interbody fusion in selected cases depending on anatomy, alignment, and surgical goals
• Revision spine surgery in selected cases involving prior surgery, recurrent nerve compression, pseudoarthrosis, adjacent segment disease, or hardware-related concerns
• Rehabilitation and follow-up care to monitor pain, strength, walking, function, alignment, and neurological status

Surgery is not appropriate for every patient with spondylolisthesis. Neurosurgical treatment may be considered when spondylolisthesis causes significant nerve compression, spinal stenosis, progressive weakness, severe walking limitation, spinal instability, deformity, or symptoms that do not improve with appropriate non-surgical care.