Isthmic Spondylolisthesis

Isthmic spondylolisthesis is a spinal condition where one of the vertebrae slips forward over the bone below it due to a defect in a part of the vertebra called the pars interarticularis. This is commonly referred to as a “fracture”, but in all reality the defect in the bone is likely developmental and occurs sometime in the teenage years. The defect formation may be worsened or precipitated by repetitive hyperextension (backward bending) of the spine but also may occur spontaneously and without any injury.

Many people who play sports that require repetitive hyperextension of the lumbar spine like diving, weightlifting, gymnastics, wrestling, or American football develop spondylolysis and isthmic spondylolisthesis.  Genetics may also play a role as some individuals may have an inherent weakness in the pars interarticularis.

Patients are typically asymptomatic in mild forms. However, the hallmark of symptoms in more advanced disease include low back pain, leg pain, stiffness and muscle tightness, and reduced mobility.  Severe symptoms of pinched nerves including numbness, tingling or weakness are rare, fortunately.

Dr. Coleman will evaluate your medical history and assess your symptoms. He will perform a physical examination to evaluate the source of you pain, and test range of motion and neurological functions. He will order imaging studies. X-rays will reveal the presence of vertebral slippage, while more detailed imaging, such as MRI or CT scans, can assess nerve involvement and the integrity of the pars interarticularis. Occasionally, a nuclear medicine study known as a “bone scan” might be ordered.

The aim of treatment for isthmic spondylolisthesis in adolescents and adults focuses on relieving symptoms, improving function, and preventing further slippage.

Conservative management

Conservative management is intended to alleviate pain, reduce inflammation, promote healing, and prevent progression of slippage. It will include rest and activity modification, physical therapy to strengthen the core and back muscles and reduce pain, NSAIDS and pain relievers to manage pain and inflammation, and possibly a back brace to provide support. Most young adults are able to return to pain-free, unrestricted activities with conservative management.

Interventional pain management

Interventional pain management includes epidural steroid injections used to reduce inflammation and pain around the affected nerve roots, and facet joint or pars injections that target the joints around the affected vertebrae for pain relief.

Surgery

Surgery may be indicated in patients with persistent pain despite 3-6 months of conservative management depending on the severity of the symptoms and the presence of neurological symptoms. For severe isthmic spondylolisthesis, spinal fusion stabilizes the spine by fusing together two adjoining vertebrae, and placing bone grafts between the vertebrae which helps the vertebrae fuse together. In addition, spinal decompression which involves the removal of bone and a disk to relieve pain and provide more space in the spinal canal may be performed with fusion. Studies show that fusion with decompression may provide the best outcome.

Several surgical methods and techniques are available in the management of isthmic spondylolisthesis.

1. Pars repair without This is best employed in young patients without major instability who have spondylolysis (pars defects) at L4/5 or above. In other scenarios, repair may be possible but would be based on the specific factors of your case.
2. Anterior lumbar interbody fusion.
3. Posterior lumbar interbody fusion.

Recovery from spinal fusion and decompression surgery for isthmic spondylolisthesis includes a dedication to intense physical rehabilitation. Most patients most patients can return to normal activities, including work and recreational activities, within 3 to 6 months. However, high-impact activities and heavy lifting should be avoided for at least 6 months to a year.