28% of My Patients With Severe Low Back Pain Have This Problem. Do You?
By Dr. Rick Morris
Laura has a Grade II Spondylolisthesis and tried every treatment possible. She was "exhausted" from the pain and told by several surgeons that she needed a fusion. She found a better answer.
When it comes to our bodies, we count on few things to last--not our hair color, height or even body composition. But, is it too much to expect our vertebrae to stack properly upon one another, without sliding forward a bit too far or hanging off the vertebrae below it?
I suppose it is for about 6% of us. When it does, we call it a Spondylolisthesis (Latin: a slipping vertebra).
While many “Spondylo People” live their lives with little difficulty, about a third find it necessary to move on to surgery (with varying results). When it's in the lower spine, patients often complain of low back pain made worse from being on their feet too long, turning in bed and repetitive bending. When the "Spondylo" is in the neck, many complain their heads feel too heavy. In either area, spondylolisthesis can lead to pain shooting down the extremities and is usually associated with disc damage.
What Causes A Spondylolisthesis?
Actually, the entire vertebra doesn’t usually slide forward, just the front half, often breaking at a thin, stress point, called the Pars Interarticularis (see figure on the left). The break most often occurs from a fall on the buttocks usually as a kid. Typically, the pain is short lived and the parents never know of the injury. With time, the fracture usually fills in with tough, fibrous tissue. Sometimes a spondylolisthesis causes chronic back pain, and sometimes not.
The back half of the spine may slide slightly backward. When this occurs, a slight “bump” can be felt when massaging that part of the back.
The Pars Interarticularis is the weakest part of the spine and most prone to fracture, because it connects the front and back halves of our spine and is made of cartilage. It takes years, after we’re born, to fully calcify and become bone. In fact, sometimes (even without a trauma) the two halves don’t properly unite due to a lot of bending or heavy lifting when we are young. This is called a Spondylolysis. If the front half slides forward, it’s called a Spondylolisthesis.
Genetics seem to play a factor, since one has a up to a 5 times greater chance of developing a “Spondylo” if a relative already has one. Spondylolistheses is also related to another, genetically based, spinal abnormality called a Spina Bifida Occulta (normally occurring about 15% of the time). The figure on the left illustrates how, in these people, the back or posterior portion of their spine, called the lamina and spinous processes, never form. In fact, hair often grows on the skin directly over it.
Since the ligaments that stabilize the spine attach to these missing pieces, their absence causes instability and may lead to slippage--creating a Spondylolisthesis. Statistics bear this out. Those with a Spondylolisthesis have up to five times the Spina Bifida Occultas than does the average person.
It’s not always the child falling on his “behind” that get’s a spondylo. So do teenagers (especially during an intense growth spurt). The elderly may develop it from arthritis and disc disease. The degeneration, even without a fracture, may allow slippage.
Repetitive weight lifting, forward or backward bending, gymnastics, deep squats and dead lifts are all known causes. Anything excessive in frequency or intensity can cause the pars to fracture or degenerate, causing the spine to slip forward.
Hormones are occasionally blamed for this condition, since Spondylos occurs twice as frequently in males as females. But, since boys more frequently engage in contact sports, the hormone theory isn't a "slam dunk."
Although this condition usually affects our lower backs, it can also affect our necks—usually from a car accident or severe arthritis. Stabilization in the neck is essential and Spondylos in the neck and low back must be treated by doctor specifically trained in treating this condition.
So, I Know What It Is and Why It Occurs, But How Do I Treat It?
The first and most important thing to find out is whether the Spondylolisthesis is unstable. Most are not, but when it is—it’s best treated surgically.
It’s simple to find out, yet is often overlooked. I’ve seen many, many spondylolisthesis patients who’ve been told they needed a fusion, when, in fact, they didn’t.
The doctor simply needs to take a side view x-ray (called a lateral view), while the neck or back is completely bent forward and backward. If the vertebra with the “Spondylo” slides more than 4-5 mm from one position to the other, it’s considered unstable and will probably respond better to a fusion. But, if it slides less that 4-5 mm, it nearly always responds better to proper, conservative care by a specialist trained at non-surgical Spondylo treatment.
The treatment includes strengthening the stabilizing muscles, in the correct ratio, mobilizing and correcting the alignment of the adjacent vertebrae and correcting faulty movement patterns that have developed unconsciously.
Here are a few more things you should know:
Most cases of Spondylolistheses don't require surgery and are best helped by conservative treatment. As you know, we have a nationally known Spinal Stenosis and severe disc disorder clinic. We fully understand all the non-surgical methods of treating this condition and know when surgery is, and is not, your best option.