Spondylolisthesis: Definition, Manifestations, and Treatment of the Displacement of Spinal Vertebra

Spondylolisthesis is a condition in which a vertebra of the spine is displaced relative to another vertebra.

It is the cause of various problems, such as unpleasant pain and its radiation to the limbs. It causes incorrect posture or restriction of mobility.

Vertebral shift is not a modern problem.

It was described in the medical literature by Herbiniaux in 1782, and the term spondylolisthesis was coined by Kilian in 1854. The causes of its origin have been debated for more than 100 years, during which several classifications have emerged.

The word "spondylolisthesis" is of Greek origin and consists of two parts:
Spondylos - vertebra
Olisthanein - shift, displacement 

About the spine and vertebrae

The spine is a support for the body, it is part of the musculoskeletal system and its role is also to protect the spinal cord, which leads from the brain to approximately the level of the second lumbar vertebra.

The spine, also called the backbone and the vertebral column, or in Latin "columna vertebralis".

The spine is physiologically curved. The forward curvature is called lordosis, located in the cervical (neck) and lumbar (lower back) regions.

The backward curvature is referred to as kyphosis, which is in the thoracic (torso) and sacral areas (low back) of the spine. This curvature is physiological, i.e. natural.

Scoliosis is an unnatural, therefore pathological, sideways curve of the spine. However, a slight physiological curvature to the side is present in every person.

Temporary curvatures of the spine to the side can be observed when standing on one leg, when transferring weight to one limb or while carrying a heavier load in one upper limb.

The spine consists of vertebrae, of which there are 33 to 34.

The vertebrae are connected to each other. Their connection is fixed, yet movable.

The connection of vertebrae is ensured by cartilage, ligaments or intervertebral joints.

Table: the interconnection is formed by several mechanisms

Among the vertebrae there are 23 intervertebral discs.

The first disc is located between the 2nd and 3rd cervical vertebrae and the final segment between the final lumbar and first sacral vertebra.

Intervertebral discs are also referred to as intervertebral discs. Their task is to dampen the impacts of other vertebrae during the movement of the body.

They also have other functions:

• shock absorption when moving, running, jumping
• stabilise the spine
• maintain balance
• balance compressive and tensile forces, they spread it over the whole area
• they are cooperative in any movement of the spine, twisting or rotation of the body

Their shape copies the body of the vertebrae and they are of different heights. They are higher between the cervical and lumbar vertebrae, with the highest plate being between the L5 and S1 vertebrae.

Plates can have several problems, such as the article on disc herniation.

A more detailed and technical view on the vertebrae

Vertebrae are technically referred to as vertebrae.

Most people have either 33 or 34 vertebrae. 

Table: Spinal segments

The vertebrae are the bearing support of the human body. Their vertebral foramen (opening), also called foramina vertebralis, form the spinal canal through which the spinal cord passes.

They are bones with a specific shape.

Stavec sa skladá z tela stavca, oblúku a výbežkov.

1. The vertebral body, or in Latin corpus vertebrae, is located in front. It is the main supporting part of the vertebra. Its upper and lower surfaces are flat. The vertebral discs are placed here.

The height of the vertebrae varies, with the cervical vertebrae being the narrowest. The widest ones are located in the lumbar spinal segment. Their height decreases again towards the coccyx.

2. The vertebral arch attaches at the back to the body of the vertebra. Its role is more or less protective, as it protects the spinal cord.

The arch has two parts.

One of them is called the lamina of vertebral arch, or in Latin lamina arcus vertebrae. It points towards the vertebral body. It is attached to the body of the vertebra with two pedicles, or in Latin pediculus arcus vertebrae.

The arches of the vertebrae form the vertebral foramen, or in Latin foramen vertebrae. Together they form the spinal canal - canalis vertebralis.

The pedicles have notches on their edges,i.e. at the top and bottom. These are referred to as incisura vertebralis superior (superior vertebral notch) et  inferior (inferior vertebral notch). They form a structure denoting intervertebral foramen (foramina intervertebralia).

The intervertebral foramen are important due to the passage of spinal nerves exiting the spinal cord.

3. The vertebral processes protrude from the vertebral arches. Their role is important because they connect the vertebrae and enable the body to move.

Table: The vertebrae have several types of processes

So what is spondylolisthesis?

Spondylolisthesis is defined as a pathological displacement of the vertebral body relative to an adjacent lower vertebra, towards the centre of the body, and thus towards the abdomen - ventrally.

+ In a later stage of the shift also in the ventrocaudal direction - pointing to the abdomen and down. 

It most commonly affected area isthe lower back, more specifically the lumbar segment of the spine. The cervical segment (neck) less so.

Vertebral displacement can occur in various forms, with the types of spondylolisthesis being important in terms of the cause, causing difficulties and also in the treatment.

A simple classification is congenital and acquired spondylolisthesis. Congenital listhesis is also divided into low-grade or high-grade dysplasia. Acquired for traumatic or post surgical or pathological and degenerative.

Various forms of classifications have been developed in the history of spondylolisthesis. Today, the Newman, Wilts, and MCnab classifications are used.

Table: Classification of spondylolisthesis

Spondylolisthesis is also classified by vertebral displacement percentage:

• grade I- 25 % displacement
• grade II - 25 - 50 % displacement
• grade III - 50 - 75 % displacement, more than 50 % = high-grade
• grade IV - above 75 %

Spondyloptosis = the body of the upper vertebra gets in front of the body of the second vertebra = above 100 %.

Spondylolysis

Spondylolysis refers to a vertebral defect in a section of its arch. The vertebral arch is damaged at the site of narrowing, which is referred to as an isthmus of the vertebral arch.

Isthmus = zúženie, úžina.

There is a congenital and an acquired form which has a higher occurrence. It can be present on one side, i.e. unilaterally, but also on both sides of the vertebra, i.e. bilaterally.

The most frequently affected part of the spine is the lumbar part, more precisely L4 and L5 less often L3.

The acquired form appears in childhood and adolescence. The cause is spinal congestion and sports activities.

It contributes to long-term repetition and sudden changes in the position of the spine during sports, namely forward bending, tilting along with rotation.

It is more common in boys.

Back pain in the affected area is one of the symptoms. However, it can be completely asymptomatic, i.e. without signs and symptoms. It is usually detected by accident during X-ray examinations.

The cause of spondylolisthesis, i.e.the shift, is not completely clear.

Various factors are suspected to play a role, for example heredity, age, race or degenerative process of the vertebrae, or even the degree of physical activity. In this context, it is further classified into specific forms.

Adolescents are reported to suffer from the condition most frequently. Before adolescence, the condition may take its course asymptomatically, i.e. without symptoms.

Progression is associated with a time of intense growth, from the age of 8 - 20 years. Later on, in adulthood, the risk of vertebral shifting decreases. However, the risk rises again after about the age of 60.

It affects girls to a greater extent.

Sports, such as gymnastics, dancing and figure skating, are also reported to contribute to a higher incidence among girls. The cause is frequent flexion in the back in terms of hyperextension. The condition is also referred to as stress fracture.

This type falls under the traumatic form. The post-surgical type is also included here. It arises as a result of surgery in the spine, i.e. the intervertebral disc.

Example:

In the isthmic form, it is a defect of isthmus - in Latin pars interarticularis. This is an interruption of the vertebra in place. The cause has not been fully understood yet.

It also depends on the type. There may be a complete interruption of the isthmus or an extension (elongation) thereof. In the elongated form, the probability of shift is slightly lower.

Degenerative changes cause damage in several parts of the vertebra. Alternatively, it may be a pathological process on the bone tissue or joint surfaces, but also due to damage to the intervertebral disc.

The pathological form occurs in other diseases, such as various congenital syndromes or systemic bone diseases, rheumatoid arthritis or the oncological process on the spine.

Learn more: 
Low back pain - acute block of the spinal cord
Sciatica, or sciatic nerve inflammation

The symptoms of spondylolisthesis are influenced by several factors. Of course, the occurrence of difficulties also depends on the specific form of olistesis.

As mentioned, in most cases, the development of pathological changes begins in childhood. However, the difficulties progress mainly during adolescence. The reason is more intensive growth.

Up to this age, spondylolistesis can be asymptomatic. Subsequently, various health problems develop as the progression progresses.

Symptoms of spondylolisthesis include:

• chronic pain in the spine - lumbar and sacral areas
• low back pain after physical activity
• pain radiating to the limb
• pain worsens standing, walking
• reducing the distance walked without pain - claudication interval
• posture disorders - severe kyphosis, lordosis and scoliosis
  • when walking or standing
  • deepening of lumbar lordosis
  • bending at the knees
• limitation of movement of the affected part of the spine
• back muscle stiffness
• muscles weakness in the limb
• tingling - paraesthesia in the limb
• in severe forms of nerve root irritation, sphincter issues may arise, as in the case of cauda equina syndrome

Most frequently, relief comes after bending forward.
Back pain in children is rather rare.

Problems may have a neural character, which means that there is an irritation of the nerve root. Nerve root pain is characterised by a sharp or burning character, high intensity and radiating pain to the dermatoma area.

Learn more: Nerve root irritation - radicular syndrome, radiculopathy

The dermatome is part of the innervation of the relevant nerve.

There are also other neurological problems associated with the condition, including tingling sensations, i.e. paresthesia, or a loss of sensitivity or strength. The neurologist also may identify other motor, sensory and reflex disorders.

Another type of pain is pseudoradicular pain, which is characterised by pain in a specific area. As with nerve root irritation, the location of this condition is not clear and uncertain.

It can be felt on the hips, on the sides of the thighs or lower legs.

The main difference from the root syndrome is also the absence of impaired sensitivity and motor skills or weakened reflexes.

Examining vertebral displacement is not difficult. The patient's medical history is the initial identificatin of the condition. A person with spondylolisthesis begins to complain of pain. In other cases, the finding is accidentally made during another examination (e.g. X-ray).

Next, the patient's clinical picture: neurological examination, the specialist examines the spine visually or by palpation. Mobility, posture, posture, gait, and reflexes are evaluated.

It is important to assess the mental condition. As chronic difficulties reduce the quality of life and significantly affect the mental state of the person.

Imaging methods are important:

• X-ray
• CT
• MRI 
• perimyelography (PMG) using a contrast agent
• densitometry - examination of bone tissue quality, especially in people over 70 years
• scintigraphy

Imaging methods help to evaluate the overall state of the vertebral displacement. The percentage displacement and the degree of spondylolisthesis (stages 1 to 4) of the upper vertebra compared to the lower, but also the angle of displacement are evaluated.

Differential diagnosis is important. Its role is to distinguish the condition from other causes, for example inflammatory processes, disorders of the cardiovascular system, coxarthrosis, and serious oncological diseases.

The course of the disease, depending on the form, is rather slow. As already described, a pathological disparity can arise in childhood for a variety of reasons.

Thus, spondylolisthesis can progress for a longer period unnoticed, i.e. it is asymptomatic. Pain is only associated as a result of higher growth rates during adolescence.

Affected persons are known to have posture disorders both when standing and walking.

At higher degrees of shift, there are also other neurological difficulties, ie the radiation of pain to impaired sensitivity or movement.

Back pain occurs between the lower edge of the ribs and the lower part of the sciatic muscles. The muscles of the spine are affected by spasms, they are stiff. Pain gets worse with movement or physical exertion.

Claudicationis defined as pain in the legs or arms that comes on with walking or using the arms. Muscle pain occurs at a higher rate of shift at about 50%.

It is associated with sensory impairment. It is understood that problems with skin sensitivity occur during the innervation of the affected nerve.

Similarly, motor properties weaken. An example is the reduction of muscle strength or tension.

Cauda equina syndrome is a serious condition.

Question: What kind of a condition is it? 

It is a serious problem that arises as a result of nerve compression. This bundle of nerves is referred to as the cauda equina.

The spinal cord runs through the spinal canal along the vertebrae L1 to L2. Cauda equina, meaning "the horse's tail", is the lowest part of it.

Cauda equina syndrome is characterized by a significant impairment of motor and sensory functions. The disorder occurs at the level of the pelvic organs, pelvic floor and lower limbs.

The cause is the medial disc herniation in the area of the lumbar spine lower than the L2 vertebra. The symptoms are varied and depend on the location or extent of the compression.

An example is a sensitivity disorder in the genital area and the rectum.

An example is motor dysfunction and weakening of muscles in the lower limbs, but also a disorder in the regulation of the sphincter (opening/closing muscle) or the association of incontinence, i.e. involuntary excretion of urine and stool.

In this case, sexual dysfunction also develops.