Spondylolisthesis is a pathological situation characterized by the sliding of one vertebra with respect to the other. This sliding can occur for several reasons that are the basis of the classification of spondylolisthesis:
- Dysplastic: it is associated with dysplasia of the last lumbar vertebra and of the upper part of the sacrum with hypoplasia of the posterior elements, which are no longer able to provide stability, thus favoring vertebral sliding.
- Isthmic: it is the most common type and is due to a lesion of the interarticular part.
- There are three subtype: 1) consists of the separation of the internal part of the articular facets, the laminae, and the spinous processes posteriorly from the vertebral body, the peduncles, and the upper facets anteriorly. 2) there is an elongation of the interarticular part without separation; it is often the consequence of repeated microfractures. 3) is instead due to an acute fracture of the joint.
- Degenerative: especially in the elderly where there are erosion phenomena affecting the articular facets and loss of integrity of the intervertebral disc.
- Post-Traumatic: arises after a traumatic injury to the spine in the absence of a fracture of the pars interarticularis
- Pathological: when there are pathological processes affecting the peduncles, the interarticular part, and the facets, as well as the iatrogenic forms arising after surgery on the spine
About 5-10 percent of patients who complain of back pain have spondylolysis or spondylolisthesis, but the fact that they are on a lumbar spine X-ray does not necessarily mean that they are the cause of the symptoms. Sometimes a patient develops the lesion (spondylolysis) at a young age and has no symptoms until a sudden movement or strain in adulthood results in an episode of low back pain or acute lumbosciatica.
When spondylolisthesis causes complaints, they can be low back pain and/or root pain (sciatica). The severity of low back pain reflects the degree of instability of the slipped vertebra, while radicular pain expresses the degree of stretching or compression of the nerves.
It must be considered that the rapidity of the sliding determines the clinical picture, in the sense that the subject can well tolerate even very important but slow aggravations. In contrast, rapid aggravations often cause severe and disabling disorders.
The pain usually relieves with the extension of the spine and worsens with flexion. The degree of slipping is not directly correlated with the intensity of the pain.
In addition to low back pain, these patients may also have radicular pain. In these cases, the sliding is associated with narrowing the area of the conjugation foramen, which is the bony canal through which the nerve roots exit the vertebral canal. This narrowing (stenosis) results in pinching or compression of the nerve root.
Diagnosis of Spondylolisthesis
Conventional x-ray is still the most used examination in the diagnosis of spondylolisthesis and remains the most accessible and most widespread method to follow its evolution over time. The most used classification is, as stated, that of Meyerding; the degree of sagittal rotation, being appreciable in high degree listesis (> 50%), is used in other forms of listesis but not in the degenerative one.
The comparison between the radiograms performed in flexion and extension – a so-called dynamic study – evaluating the stability of the listesis helps to discern the role of this from that of the stenosis in the genesis of the symptoms and consequently directs the therapy.
CT and MRI complete the evaluation of the lumbosacral tract in the terms already described for the other pathologies.
Dynamic radiographs and lumbosacral MRI are essential for diagnosis.
What treatments are available for Spondylolisthesis?
Treatment can be conservative or surgical. Conservative treatment consists of a physiatric visit with subsequently targeted physiotherapy. The success of this therapy is not negligible so much so that it is the first option where there are no neurological deficits or the clinical picture is not particularly serious.
The intervention is reserved only in cases of severe clinical or frank instability and consists in stabilization with pedicle screws and in the positioning of an interbody spacer (cage) in the disc space; when there are also root symptoms, then decompression of the vertebral canal (laminectomy) is also indicated. On the other hand, the usefulness of the realignment of the two vertebrae is under discussion, as it does not seem necessary for the disappearance of symptoms. Moreover, in some cases, the risk of iatrogenic neurological damage also increases.
After the surgery, the patient is made to get up the following day and discharged after three days. You can resume regular activity immediately, avoiding great efforts for about one or two months at the most.
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