If, for congenital or acquired reasons, one of the lumbar vertebrae slips forward relative to the adjacent lumbar vertebrae, it is called lumbar spondylolisthesis. If the continuity of the lumbar vertebral body and the vertebral arch or small articular process is interrupted due to degeneration, trauma or congenital factors, it is called lumbar isthmus collapse; if the continuity of the vertebral body is prolonged due to dislocation of the vertebrae, so that the superior vertebral body, the vertebral arch, the transverse process and the superior articular process are displaced forward together above the inferior vertebral segment, it is called lumbar isthmus collapse combined with lumbar spine slippage. The degenerative factors causing lumbar spondylolisthesis account for more than 60% of the cases. The age of onset is 20~50 years old.
Diagram of lumbar spondylolisthesis
Etiology
The etiology of lumbar spondylolisthesis is still not very clear, and a lot of studies have shown that congenital developmental defects and chronic strain or stress injury are two possible important causes, and the latter is generally considered to be the main cause.
The cause of lumbar spine slippage can be congenital (present at birth), with collapse of the lumbar isthmus, resulting in damage to the stable structures of the lumbar spine and consequent slippage. Such patients often develop symptoms of chronic lumbar pain at a young age, with progressive aggravation, increasing frequency of attacks and increasing severity of symptoms from year to year until symptoms of nerve damage occur, all of which eventually require surgery; slippage can also be acquired, occurring in childhood or later. It is mainly caused by various excessive mechanical stresses, and triggers include heavy lifting, weightlifting, soccer, sports training, trauma, abrasion and tearing, and eventually also requires surgical treatment. There is another type of lumbar spondylolisthesis that is degenerative in nature, i.e., structural abnormalities that occur due to aging of various structures of the lumbar spine. This type of spondylolisthesis is usually accompanied by lumbar spinal stenosis, which we often call degenerative lumbar spondylolisthesis and mostly requires surgery.
Degenerative lumbar spondylolisthesis usually occurs around the age of 50 and is most often seen in women. The causes of lumbar spine slippage are mainly the following: degenerative changes: due to dehydration and degeneration of the intervertebral disc, its volume shrinks and the corresponding vertebral space narrows so that the anterior and posterior longitudinal ligaments become relaxed. During forward flexion and backward extension, the normal movement of the vertebral body cannot be restrained, resulting in excessive forward or backward movement of the upper vertebral body, causing vertebral slippage. Endocrine disorders: endocrine changes in women during menstruation or menopause cause osteoporosis while causing ligaments and joint capsules to relax and become less elastic and lumbar spine slippage occurs, so it is more common in women after menopause. The symptoms of slippage are not obvious in mild cases, but in severe cases, there is more lumbar pain, pain points are mostly in the lumbar area and buttocks, pain characteristics are soreness, pulling pain, swelling pain, the patient feels as if the lumbar area is broken, especially after standing for a long time is more obvious. Due to the instability of the vertebral body, most of them are reluctant to stand for a long time or rely on other objects or hold their waist with both hands to reduce the load on the lumbar region.
Predisposing factors
The etiology of lumbar spondylolisthesis is still not very clear, and a large number of studies have shown that congenital developmental defects and chronic strain or stress injury are two possible important causes, and the latter is generally considered to be the main cause.
Traumatic
Acute fractures of the lumbar isthmus can occur as a result of acute trauma, especially posterior extension trauma, and are most often seen in athletic sports sites or strong labor porters, high falls or car accident injuries.
Congenital inheritance
The lumbar spine is born with vertebral body and arch ossification centers, and each side of the arch has two ossification centers, one of which develops into the superior articular eminence and arch root, and the other develops into the inferior articular eminence, plate, and half of the spinous process. If the two do not heal, a congenital isthmus (spondylolysis), also known as an isthmic discontinuity, is formed, resulting in localized pseudoarticular-like changes. Spondylolisthesis can also occur due to abnormal development of the upper sacral or L5 arches, without isthmus breakdown.
Fatigue fracture or chronic strain injury
From a biomechanical point of view, the human body is in a standing position with a high weight-bearing lower lumbar spine. The force that causes forward displacement acts on the isthmus where the bone is relatively weak, and the long-term repeated action can lead to fatigue fracture and chronic strain injury.
Degenerative factors
As a result of prolonged and continuous lower back instability or stress increase, the corresponding small joints wear and degenerative changes occur, the joint protrusion becomes horizontal, coupled with intervertebral disc degeneration, intervertebral instability, anterior longitudinal ligament relaxation, thus gradually occurring slippage, but the isthmus remains intact, so also known as pseudoslip. The incidence of slippage is mostly seen after the age of 50, and the incidence in women is three times higher than that in men, mostly in L4, followed by L5 vertebrae, and the degree of slippage is generally within 30%.
Pathological fracture
Pathological fractures occur when a systemic or local lesion involving the vertebral arch, isthmus, and superior and inferior synapses destabilizes the posterior structure of the vertebral body and causes pathological slippage. Local bone lesions can be tumors or inflammatory conditions.
Symptoms
After the occurrence of lumbar spondylolisthesis, the patient may have no symptoms and only be detected when it is photographed; or may have various related symptoms, such as back pain, lower limb pain, numbness, weakness, and in severe cases, abnormal urination and defecation. Patients with more severe slippage may experience depression of the lumbar region, convexity of the abdomen, and even shortening of the trunk and swaying when walking. If there is no significant aggravation of lumbar spondylolisthesis, conservative treatment can be adopted, and lumbar spine X-rays can be reviewed regularly to understand the condition of the spondylolisthesis. If there is back pain and leg discomfort, the symptoms can usually be relieved after rest
Lumbar spondylolisthesis X-ray performance
MRI of lumbar spondylolisthesis
Treatment
What is the treatment for lumbar spondylolisthesis? If there is no significant aggravation of lumbar spondylolisthesis, conservative treatment can be adopted and lumbar spine X-ray can be reviewed regularly to understand the slippage. If there is low back pain and leg discomfort, the symptoms can usually be relieved after rest.
Conservative treatment includes bed rest, prohibition of activities that increase the weight-bearing of the lower back, such as lifting heavy objects and bending over, combined with physical therapy such as infrared and heat therapy, and oral anti-inflammatory and pain-relieving drugs such as ibuprofen and fenbendazole. In addition, you can also wear a lumbar brace or support, which can reduce the burden on the lumbar region and relieve the symptoms. Patients with more severe slippage may experience lumbar depression, abdominal foreshortening, and even trunk shortening and swaying when walking. If a patient with lumbar spondylolisthesis has long-term chronic back pain, which affects work and quality of life, or has neurological symptoms, and the symptoms are not significantly relieved by regular conservative treatment, and still has long-term back pain and other concomitant symptoms of spondylolisthesis, i.e. conservative treatment is ineffective and seriously affects life and work, surgery should be considered. There are many surgical methods for lumbar spondylolisthesis, and the most common and effective methods are posterior slippage repositioning, pedicle screw internal fixation, intervertebral implant fusion, etc.
Precautions
If there are symptoms of nerve root compression, decompression of the nerve root canal and spinal canal is also required to eliminate the pain and numbness of the lower limbs caused by lumbar spondylolisthesis.
Treatment of lumbar spondylolisthesis
Prevention
(1) Strengthen the functional exercise of the lumbar back muscles. Strong lumbar back muscles can increase the stability of the lumbar spine and antagonize the tendency of lumbar spine slippage. Exercise of the lumbar back muscles can be used in the following two ways. One is the prone position, the two upper limbs in an abducted position, head up, chest up, upper limbs out of bed, while the lower limbs are also straightened and lifted backwards in a swallow-like position. The second is supine position, both knees flexed, both feet on the bed, inhalation chest and waist, so that the buttocks leave the bed, exhale recovery.
(2) reduce excessive rotation of the waist, squatting and other activities to reduce excessive weight bearing on the waist. This can reduce the excessive strain and degeneration of the small joints of the lumbar spine, and to a certain extent avoid the occurrence of degenerative lumbar spondylolisthesis.
(3) reduce body weight, especially to reduce the accumulation of abdominal fat. Excess weight increases the burden and strain of the lumbar spine, especially the accumulation of abdominal fat, which increases the tendency of the lumbar spine slipping forward on the sacrum.
Case 1: Li XX, female, 60 years old, with 2° slipped lumbar 4 vertebrae.
Preoperative radiographs Preoperative MRI examination Postoperative radiographs Postoperative radiographs