This is an excerpt from Back Exercise by Brian Richey.
Spondylolisthesis is a spinal condition in which one vertebra slips off another, most often in the lumbosacral region between the L4 and L5 vertebrae. It is rarely seen in people under the age of 50 because degeneration seems to be a primary cause of the condition. Women are about five times more likely than men to have spondylolisthesis.1 Spondylolisthesis is the condition that most people neglect to mention when relaying their MRI results to me. Why? Many times, they don’t know what it is, they can’t pronounce it, and therefore, they forget about it.
The etymology of the word spondylolisthesis comes from the Greek word for dislocation or slipping. This means that in a particular spinal segment (two vertebrae and the disc in between), the top vertebra has slipped off the bottom one. The most common version of this is called an anterolisthesis, where the top vertebra have slipped anteriorly over the bottom one (see figure 9.1). If you think about the natural lordosis (curve) to the lumbar spine, the bodies of the vertebrae angle downward in the lower portion of the lumbar spine. Gravity is constantly pulling on them and one theory shows a correlation between a higher body mass index and the development of spondylolisthesis in females.2 More research is needed, but increased spinal loading may be a contributing factor to anterolisthesis.3
Spondylolisthesis is often diagnosed with a “grade” indicating the degree of slippage in order to classify its severity. Grades I through V are classified as follows:
- Grade I: 1 to 25 percent slip
- Grade II: 26 to 50 percent slip
- Grade III: 51 to 75 percent slip
- Grade IV: 76 to 100 percent slip
- Grade V: Complete dislocation, greater than 100 percent
According to the Cleveland Clinic, grade I and grade II slips usually don’t require surgical intervention and a more conservative approach to treatment is considered first. However, grades III and IV, and especially grade V, may require surgery if pain remains persistent and function is compromised.4
The two most common forms of spondylolisthesis are traumatic and degenerative. Traumatic spondylolisthesis is a result of an acute traumatic injury involving either bony or soft tissue posterior spinal elements accompanied with slippage of one vertebral body over another.5 In other words, some type of trauma struck the spine with such force that there is a slippage of one vertebra over another. Most often this occurs during traffic accidents and serious falls—an event that places a lot of shearing force on the body and especially the spine. The most common area of occurrence is at the very bottom of the spine at L5 to S1, the lumbosacral junction. This type of spondylolisthesis is often accompanied by a spinal fracture in the area leading to the instability that causes the slippage.
A second type of spondylolisthesis—the most common type—is degenerative. This is most often age-related and caused by the accumulation of a lifetime of spinal stresses resulting in the degeneration of the disc and spine. We usually see this type of spondylolisthesis at L4 to L5. Believe it or not, this form of spondylolisthesis is often fairly stable and patients can have it for a long time without knowing until something triggers the low back pain. Interestingly, the greater the degeneration in the disc—meaning, the less disc height you have—the more stable the area. One hypothesis is that the degenerative process acts with “self-limiting inhibitory control on further slip progression.”6 The more degenerated the disc, the less slippage there is. However, this doesn’t mean that the person will have no pain. In chapter 10, we’ll discuss stenosis, a condition in which the disc degenerates and the disc space narrows, causing pain.
The primary symptom for traumatic spondylolisthesis is pain. Approximately half of those with spondylolisthesis are also affected by a neurologic issue, whether it is motor (involving muscle) or sensory (numbness, tingling, or radiating pain), often caused by the compression of the nerve root in the foramen exiting the spine.7 The symptoms we often see with degenerative spondylolisthesis is generalized lower back pain or spasm, muscle cramping, numbness, tingling, or radiculopathy pain down the leg. These symptoms can be intermittent or constant.
Spondylolisthesis is usually diagnosed with an X-ray, but an MRI will show much greater detail and provide a better picture of what is actually happening with the nerves and tissues.
Conservative, nonsurgical treatments are often the first course of action. These may include an anti-inflammatory medication (NSAID), epidural or steroidal injections, and physical therapy. The NSAIDS and epidurals help to reduce the inflammation and calm the area down. Physical therapy reeducates and wakes up the muscles to allow them to stabilize the spine better, which is precisely what you will be doing with your exercises. Again, these exercises do not take the place of physical therapy, but can enhance and build upon what you have learned during a course of physical therapy.
For the most part, patients should only consider surgery when conservative options have been exhausted. Surgery will often be a type of laminectomy or a spinal fusion (see chapter 11 for more information about spinal surgeries). A laminectomy will help decompress the nerves, while the fusion will stabilize the joint by fixating it in place. A spinal fusion can be done many different ways, and your physician will typically determine the method based on the severity of the case. This is a very serious surgery—as drastic as a joint replacement—and should not be taken lightly. The spinal structure is forever changed by replacing the disc with a man-made object.
However, not all cases of spondylolisthesis result in pain. Remember, if the instability isn’t great enough to cause any nerve compression then there may not be any resultant pain from this condition. If you have this diagnosis, however, you will still benefit from the exercises in this section—the fact that you don’t currently have pain doesn’t mean you never will. Think of it as preventative maintenance. A Chinese proverb says, “The best time to plant a tree was 20 years ago. The second-best time is now.” I can’t tell you how many clients wish they had started years ago, before the pain got bad.
When I see spondylolisthesis documented on someone’s MRI, a red flag goes up in my mind because this condition will dictate the client’s pelvic bias and has some of the strictest contraindications. Anyone with spondylolisthesis needs to be kept in a posterior pelvic tilt, meaning that your pelvic “bowl” needs to be tipped so that if it were holding water, the water would tilt out the back of the bowl (see figure 9.2). Another way of thinking about it is if you are lying down you would want to flatten your back to the floor by tucking your pelvis.
Think of your pelvis as the face of a clock with 6 o’clock being at the belly button and 12 o’clock being between the thighs (see figure 9.3). At the center of the clock where the hands rotate around, imagine there is a marble. Tuck your pelvis such that the marble will roll toward 6 o’clock. Then return it back to the center of the clock. DO NOT tilt your pelvis the other direction! That’s where danger lies. Your happy place will be with your tail tucked and your back flattened out.
The main contraindication is arching the back. Don’t do it! If you keep your pelvis tilted posteriorly you will keep your back and spine safe. You will work on how to do this in the exercises given. The progression of exercises is as follows: lying on your back in the supine position, lying prone on your stomach, being on all fours, being seated, and finally standing.
I do realize that standing and walking around with a posterior tilt conjures up the visual of an old man with his belt pulled up under his chest, but that is the extreme. We want your spine a little flatter and your pelvis slightly tucked under. What you might feel in your spine is a softening of your back. It will be a slight stretch for these muscles, especially if you are a person who has a pretty large lordosis, or curve to the spine. Those spinal muscles are under constant tension, remaining in a shortened position all the time. We want them to be softened and supple, even relaxed. But this will take time. Have patience: These muscles may have been under this continuous tension for many years. It may take time to reverse years of muscle memory.