VERTEBRAE OUT OF ALIGNMENT IN THE LOWER BACK

Vertebrae out of alignment (Spondylolisthesis) in the Lower Back

The lower back (lumbar spine) is the most common area for spondylolisthesis (vertebral misalignment) to occur, specifically at the L3-L4 and L4-L5 levels. The lumbar spine is especially susceptible to this condition because it supports nearly half of the body’s weight and is the most flexible region of the spine; therefore, it degenerates more quickly than the less-stressed neck, upper back, or middle back. Over time, the intervertebral discs and facet joints in the lower back weaken and are less able to maintain the structural integrity of the spinal column, making it possible for a vertebra to slip forward and over the vertebra beneath it.

Sciatica Caused by Spondylolisthesis

Spondylolisthesis in the lower back is a common cause of sciatica, which is a term used to describe a group of symptoms that occur when the sciatic nerve becomes compressed by an anatomical abnormality. The sciatic nerve is the longest and largest nerve in the body, starting in the lower back and branching off into the buttocks, legs, and feet. If the vertebra slips forward far enough, it may press on the sciatic nerve or one of its nerve roots, causing symptoms of:

• Pain

• Tingling

• Numbness

• Muscle weakness

• Cramping or spasms

These symptoms may stay localized at the site of vertebral slippage, though it is more likely that they will travel throughout your lower back, buttocks, hips, legs, and feet. Severe spondylolisthesis in the back may cause changes in posture or gait.

Treatment for Lumbar Spondylolisthesis

Treatment for spondylolisthesis will begin conservatively, most likely with over-the-counter, non-steroidal anti-inflammatory drugs, heat therapy, ice compresses, behavior modification, and gentle stretching. Physical therapy, epidural steroid injections, prescription medication, and endoscopic procedures may also become options. The aim of these treatments is not to force the vertebra back into place, but rather to relieve the symptoms that are caused by nerve compression. Realignment of the vertebrae in the form of surgery will only become an option in rare cases, where the pain of vertebral slippage is severe, debilitating, and unresponsive to several months of non-invasive treatment.

The Meyerding System – Determining the Severity of Spondylolisthesis

Spondylolisthesis can occur at varying levels of severity, and the severity of this condition is typically measured by the degree to which a vertebra has slipped out of place. Classifying the degree of vertebral slippage is extremely important when forming a treatment plan. The standard system for “grading” spondylolisthesis was created by a man named Henry William Meyerding, an orthopedic surgeon who joined the Mayo Clinic in 1911. Meyerding classified vertebral slippage of:

• 0-25 percent – Grade 1

• 25-50 percent – Grade 2

• 50-75 percent – Grade 3

• 75-99 percent – Grade 4

Although not technically part of the Meyerding system, specialists refer to Grade 5 spondylolisthesis when there is 100 percent slippage, meaning the vertebra slips entirely off the vertebra beneath it.

How Does the Meyerding Grade Affect Spondylolisthesis Treatment Options?

In general, the more severe the vertebral slippage (Grades 3 and 4), the higher the likelihood is that a patient will need surgery. Grades 1 and 2 can usually be treated with conservative techniques. While each patient’s treatment plan will be at the discretion of his or her individual doctor, common approaches to pain relief may include:

• Grade 1 – Over-the-counter pain medication (such as aspirin, ibuprofen, or naproxen), hot/cold compresses, periods of rest, behavior modification, gentle stretching, low-impact exercise, physical therapy, and minimally invasive surgical procedures treat the compression of a nerve root or the spinal cord.

• Grade 2 – Prescription anti-inflammatory drugs such as oral steroids or muscle relaxants, bracing, corticosteroid injections, TENS (transcutaneous electrical nerve stimulation), and the possibility of a minimally invasive surgical procedure to treat spinal nerve compression.

• Grade 3 – Surgery in the form of a laminotomy with spinal fusion, though surgery should not become a consideration until a combination of the above conservative treatments has been attempted. Some patients with Grade 3 slippage may still be candidates for minimally invasive procedures.

• Grade 4 – Surgery in the form of a posterior or anterior interbody fusion is usually required. Minimally invasive procedures are generally not effective for this degree of slippage.

Treatment Based on Symptoms

The goal of any spondylolisthesis treatment is to relieve a patient’s pain. In many instances, patients with Grade 1 or Grade 2 vertebral slippage may not even experience symptoms and, therefore, will not require any type of treatment. However, if you do have symptomatic spondylolisthesis, you should know that finding an effective treatment plan will involve trial and error. Be patient as you try a wide range of treatments, and only consider surgery if non-operative techniques have proven ineffective over a period of three months or longer.

Spondylolisthesis – Causes and Classifications

Spondylolisthesis causes are wide ranging. Vertebral slippage may result from a congenital defect (that someone was born with), or from degeneration that accompanies the aging process. Traumatic accidents or injuries can also cause spondylolisthesis, as can certain diseases. Because there are so many possible causes of the condition, a classification system was devised by an orthopedist named Dr. Leon Wiltse. The classifications include dysplastic spondylolisthesis, isthmic spondylolisthesis, degenerative spondylolisthesis, traumatic spondylolisthesis, pathologic spondylolisthesis, and iatrogenic spondylolisthesis.

Exploring the Wiltse Classification System

The Wiltse classification system for spondylolisthesis causes is as follows:

• Dysplastic spondylolisthesis – congenital defect of the L5 and S1 vertebrae

• Isthmic spondylolisthesis – a stress fracture involving the pars interarticularis

• Degenerative spondylolisthesis – osteoarthritis of the spinal facet joints

• Traumatic spondylolisthesis – a fracture of the vertebral arch

• Pathologic spondylolisthesis – bone diseases like Paget’s disease or osteosarcoma

• Iatrogenic spondylolisthesis – occurring after a lumbar spine surgery like fusion

Other Components of the Diagnostic Process

In addition to diagnosing the cause of your spondylolisthesis, your doctor will also need to determine the severity of your condition. Vertebral slippage is generally classified as Grade 1, 2, 3, or 4, based on the Meyerding classification system. Grades 1 and 2 are generally mild to moderate forms of spondylolisthesis, while Grades 3 and 4 are moderate to severe. Once the exact location, severity, and cause of your condition are determined, your doctor will prescribe an appropriate treatment regimen. This may include prescription or over-the-counter pain medication, hot/cold compresses, behavior modification, bracing, and physical therapy. Surgery generally only becomes a consideration for severe cases that are drastically reducing the patient’s quality of life.

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