Lumbar Spondylolisthesis: Causes, Symptoms and Treatment

• Spondylolisthesis is a spinal condition that can cause back pain, especially when standing or walking. Treatment options include rest, medication, physical therapy, and in severe cases, surgery. If you experience persistent back pain or other spondylolisthesis symptoms, consult a doctor for proper diagnosis and treatment.  
• Lumbar spondylolisthesis with nerve compression often causes pain when standing, walking, or twisting the body, with radiating pain in the lower back, hips, and down the thighs to the legs. Symptoms of the radiating pain usually improve through sitting and resting.  
• Surgical treatment for lumbar spondylolisthesis is considered when there is significant displacement or a tendency for it to worsen, or when the patient experiences severe back pain that does not respond to other treatment methods.

Derived from the Greek words spondylo, meaning vertebra, and olisthesis, meaning slip, lumbar spondylolisthesis is a condition where the upper vertebrae shift forward, compressing the nerves. This can affect daily activities, such as making it difficult to walk long distances, causing the patient to walk uneasily, or making the patient more prone to falls. Spondylolisthesis with nerve compression occurs in approximately 6% of the general population, with a higher incidence in women than in men, and it typically appears in middle-aged individuals over the age of 50. However, the condition is also found in 2.6% of children under 6 years old, with a genetic and familial correlation of 26%.

The cause of back pain in patients with spondylolisthesis with nerve compression is often due to the instability of the spinal alignment. This begins with degeneration of the intervertebral discs and spinal joints, causing the vertebrae to shift out of alignment, and the narrowing of the spinal canal, which compresses the nerves.

• Age: The likelihood increases after the age of 50
• Gender: Women are more likely to develop lumbar spondylolisthesis than men  
• Daily activities: Activities that put pressure on the spine, such as cycling or long-distance driving, increase the risk
   

Lumbar spondylolisthesis can be classified into six types:

• Type 1: Dysplastic – A congenital condition caused by genetic factors, found in about 20% of patients with lumbar spondylolisthesis and more commonly in women.  
• Type 2: Isthmic – A defect in the pars interarticularis, which connects the vertebral body to the lower part of the spine, causing the vertebrae to shift forward. This type accounts for up to 50% of cases.  
• Type 3: Degenerative – Found in about 25% of cases, this type is caused by degeneration due to instability of the vertebral structures and changes in the joints, typically seen in individuals over the age of 40.  
• Type 4: Traumatic – Occurs due to injury, resulting in fractures around structures such as the pedicle, laminas or facets, excluding the pars interarticularis.  
• Type 5: Pathological – Caused by certain diseases, such as the spread of cancer, tumors or osteoporosis.  
• Type 6: Post-surgical – Occurs after surgery, due to excessive posterior compression.  

In children
Symptoms are often absent and discovered incidentally through X-rays or during activities related to lower back pain. Common symptoms include:  

• Tightness of the Achilles tendon (most common) and contraction of the knees  
• Pain caused by nerve root compression or irritation (L5 root lesion)  
• Severe back pain that subsides with rest  

In adults
The most common symptoms include:  

• Pain that is relieved with rest and sitting  
• Nausea, vomiting and leg pain

Other common symptoms include:  

• Pain in the hips and legs when standing or walking 
• Pain that is relieved when sitting, similar to the symptoms of leg vascular blockage, which can occur simultaneously 

• Physical examination, review of medical history, and inquiry into the nature of the pain, which differs from herniated disc pain. In lumbar spondylolisthesis with nerve compression, pain typically occurs when standing, walking, or twisting the body, with the pain radiating from the back and hips down to the thigh and legs. It can affect one or both sides and improves with sitting and rest.
• Examination of the external appearance of the spine
• X-rays, in both static and dynamic views
• MRI for a more detailed analysis of which part of the vertebrae is compressing the nerves
• CT scan to assess bone density
• Nerve study, which involves safely applying electrical currents to stimulate the suspected affected nerve pathways

Doctors can determine the severity of lumbar spondylolisthesis based on x-ray results using the Meyerding classification, which divides the condition into 5 levels:

• Level 1: Vertebral displacement less than 25%
• Level 2: Vertebral displacement between 25-50% 
• Level 3: Vertebral displacement between 50-75%
• Level 4: Vertebral displacement between 75-100%
• Level 5: Complete vertebral displacement or osteoporosis

• Non-surgical treatment: Most cases of lumbar spondylolisthesis with nerve compression begin with non-surgical approaches, including:  
  • Rest from activities or sports that strain the back 
  • Taking pain relief medication as prescribed by the doctor  
  • Physical therapy focusing on flexibility and strengthening the muscles of the back, abdomen, hips and hamstrings 
  • Steroid injections into the area around the compressed spinal nerve to reduce nerve inflammation 
  • Wearing a lumbar support to limit movement of the lower spine for 2-16 weeks
• Surgical treatment: If the patient does not respond to non-surgical treatments, the doctor may consider surgery. Indications for surgical treatment of lumbar spondylolisthesis include:  
  1. Significant vertebral displacement or a tendency for the displacement to worsen  
  2. Severe back pain that does not respond to other treatments 
  3. Severe nerve compression symptoms
  4. Lumbar spondylolisthesis with nerve compression 

Surgical options to treat lumbar spondylolisthesis with nerve compression include:

• Open laminectomy: This involves making a central incision in the back and dissecting the muscles around the spine in order to cut the lamina, which creates more space for the nerves by widening the spinal canal. However, this method can cause significant muscle damage, blood loss, and may lead to spinal instability.
• Minimally invasive spine surgery: This technique uses smaller incisions and special equipment to minimize muscle damage around the spine. Patients recover more quickly compared to open surgery and can return home sooner. Minimally invasive spine surgery can be performed using the following techniques:
  • Microscopic decompression: Using a microscope to expand the spinal canal, this method results in minimal blood loss and scarring, enabling faster recovery.
  • Endoscopic decompression: This technique offers clearer and more precise visualization than microscopic surgery. The endoscope is very small at just 7.9-10.5 mm and is equipped with a light and a high-magnification lens. It provides a clear view inside the spine to enable removal of the bone compressing the nerves. This method causes less damage to surrounding tissue, resulting in less postoperative pain, reduced medication needs, quicker wound healing, faster recovery and an earlier return to normal activities.
  • Posterior lumbar decompression alone: This surgery relieves nerve compression caused by spinal stenosis or herniated discs and is used to alleviate pain, numbness and weakness caused by the nerve compression. It also improves nerve function by reducing pressure. The benefit of this surgery is effective pain relief in the back and legs without the need for spinal fusion, allowing for quicker recovery. This method is commonly used to treat nerve compression in the lumbar spine.

Patients should prepare for surgery as follows:

• Undergo a full body examination as prescribed by the doctor to ensure the body is ready for surgery 
• For patients with underlying conditions who regularly take medication, especially blood thinners, it is necessary to stop taking these medications 5-7 days before surgery  
• Consult the doctor regarding any regular medications, vitamins or herbal supplements being taken
• Get plenty of rest and sleep 
• Refrain from smoking

After surgery for lumbar spondylolisthesis with nerve compression, patients should follow these guidelines:

• The wound can get wet once fully healed, which typically takes about 10-14 days. The healing process depends on the size, depth, and location of the wound, as well as the blood circulation in the area. Other factors, such as the patient's strength, age, nutritional status, and underlying conditions like diabetes may slow the healing process.
• Avoid lifting heavy objects or engaging in activities such as bending, twisting, or arching the back for one month after surgery.
• Driving is allowed from at least two weeks after surgery but long-distance driving or driving for extended periods must be avoided.
• Engage in light movement, such as walking for 10-15 minutes and sitting, but avoid sitting for more than 20 minutes at a time, as it may affect the spine.
• Attend follow-up appointments and strictly follow the doctor's recommendations.
• Patients should return to see their doctor immediately after surgery if the wound pain does not decrease over time, or there is swelling, redness, heat, fever, unusual back pain or discharge from the wound.

Many patients often have questions and concerns about side effects after surgery, such as radiating pain down the leg, fear of losing mobility, or persistent back pain. However, the risk of nerve damage is very low, as surgical techniques have improved significantly in recent years, resulting in minimal or no side effects.

Nevertheless, as with any treatment, there are risks and possible complications, including:

• Blood loss or infection at the surgical site 
• Side effects from medications used during treatment, such as allergic reactions
• Blood clots, which may cause blockage in the leg veins and lead to deep vein thrombosis
• Numbness or tingling, which may occur in the area where the nerve was compressed before surgery
• Weakness in the muscles controlled by the affected nerve, which may be temporary or permanent
• Spinal imbalance or instability, which may result in instability or imbalance of the spine after surgery
• There is a possibility that pain or pain-related problems could recur 

To prevent side effects from surgery, doctors must thoroughly assess the patient before the procedure. This includes reviewing the patient’s medical history, conducting a detailed physical examination, and using diagnostic imaging such as MRI or CT scans to evaluate the condition of the spine and nerves. The most suitable surgical method for the patient can then be chosen based on this assessment. Modern surgical techniques and medical technology are used to enhance precision and reduce the risk of injury to nerves and other critical tissues. Guidance is provided on recovery, exercise and activities to avoid in order to prevent recurrence of the problem. 
If any abnormal symptoms occur after surgery, the patient should consult their doctor immediately for appropriate care and treatment.

• Physical therapy plays a key role in recovery after spinal surgery. It helps reduce pain, strengthen muscles, improve flexibility, and enhance spinal movement and function. A rehabilitation specialist will assess the patient's physical condition, strength, flexibility and mobility before beginning postoperative physical therapy, which includes:
• Light exercises to improve blood circulation and reduce swelling
• Low-impact movements, such as light walking and leg stretching
• Exercises to strengthen back, abdominal and core muscles
• Stretching exercises to improve flexibility and reduce tissue adhesion
• Balance and movement training to improve body coordination and stability
• Samitivej has a team of specialists who work together to care for patients with lumbar spondylolisthesis and nerve compression. In addition to spinal and orthopedic surgeons who specialize in both treatment and surgery, the hospital also has a team of rehabilitation doctors who are experts in postoperative care. The hospital is also equipped with advanced medical-grade rehabilitation tools. This includes a hydrotherapy pool, where the therapeutic properties of water are used to aid in recovery, as water buoyancy reduces the load on joints and bones, making movement easier and less painful. The water’s viscosity also provides resistance to help strengthen muscles. Through comprehensive care, patients can be assured that after surgery and treatment, their pain will improve or be alleviated, leading to an enhanced quality of life.