A significant proportion of patients with clinical low back pain are classified as lumbar spine slippage. The term lumbar spine slippage refers to the forward slippage of the lumbar spine vertebrae on the vertebrae below. There are many causes of lumbar spine slippage, such as trauma, congenital developmental defects, chronic strain or stress injury, lumbar spine degeneration, pathological fracture, etc. Those occurring in adolescents are mostly due to congenital developmental defects, young adults are mostly due to trauma or strain, and middle-aged and elderly people are mostly due to degenerative factors.
Clinical manifestations of lumbar spondylolisthesis
1, lumbosacral pain: mostly dull pain, very few patients can have severe coccyx pain. It gradually appears after exertion, aggravates when standing and bending, and reduces or disappears after resting in bed.
2.Sciatic nerve involvement: the lumbar 5 or sacral 1 nerve root is strained, and radiating pain and numbness of lower limbs appear; straight leg raising test is mostly positive, and Kemp’s sign is positive. Pain and numbness symptoms may appear on both sides, but the twisted scoliosis after lumbar spine disorder may cause different degrees of damage on both sides, and the symptoms may be mild or severe, or even appear only unilaterally.
3, intermittent claudication: if the nerve is compressed or combined with lumbar spinal stenosis, intermittent claudication symptoms often appear.
4, the cauda equina nerve is strained or compressed symptoms: when the slippage is serious, the cauda equina nerve is involved and symptoms such as weakness of lower limbs, numbness in the saddle area and dysfunction of urination and defecation may appear.
Diagnosis of lumbar spondylolisthesis.
1, clinical symptoms and signs: lumbosacral pain, nerve compression, intermittent claudication, etc. Lumbar examination reveals increased lumbar anterior convexity, hip lordosis, or straightening due to nerve root compression. The lumbar movement is limited and the pain is increased with forward flexion. Pressure pain at the spinous process of the affected vertebrae can be palpated and the last spinous process can be moved forward, forming a local step feeling.
2.X-ray film: it should include frontal, lateral and left-right oblique position, and add power position film if necessary.
3. CT, MRI: combined with severe neurological symptoms, check the degeneration of the intervertebral disc.
4. Excluding diagnosis: the diagnosis of lumbar spondylolisthesis is not difficult, and the disease can be diagnosed according to what is clearly seen on X-ray, but attention should be paid to the concomitant disease.
Treatment of lumbar spondylolisthesis.
1.Treatment principles of lumbar spondylolisthesis
① Not all lumbar spondylolisthesis requires treatment. A significant proportion of patients with lumbar spondylolisthesis have no symptoms of lumbar pain throughout their lives and have not been diagnosed and treated
② Not all lumbar spondylolisthesis with lumbar pain requires surgery. For patients with lumbar spondylolisthesis with symptoms of low back pain, the location and nature of the pain should be clarified to determine whether it is related to the spondylolisthesis, because degeneration of the disc adjacent to the spondylolisthesis, small joint lesions or soft tissue injury can lead to low back pain; symptomatic treatment, such as braking and physiotherapy, should be carried out to address the causes; surgery should be considered when conservative treatment is ineffective or when the pain is determined to be related to the spondylolisthesis
③Select the appropriate surgical method according to the severity of the slippage. Pre-operatively, the patient’s age, the type of slippage, the degree of slippage, the state of the intervertebral disc and the spinal canal are evaluated comprehensively, and the appropriate surgical method is selected.
④Surgery includes decompression, repositioning, fusion and internal fixation. The ultimate goal is the decompression of the nerve and the fusion of the slipped vertebral body
2.Non-surgical treatment of lumbar spondylolisthesis
It is suitable for patients with short history, mild symptoms and no obvious slippage, patients with simple isthmic cleft and patients who are old and poor in health and cannot tolerate surgery. Non-surgical treatment mainly includes: rest physiotherapy, lumbar back muscle exercise, lumbar girth or brace, symptomatic treatment, etc. After standardized conservative treatment, most patients can have their symptoms relieved.
3.Surgery for lumbar spondylolisthesis
Indications for surgery:
(1) No or symptomatic; slippage greater than 50%; adolescents in the growth period
(2) Progressive slippage
(3) non-surgical treatment cannot correct the crestal deformity and gait abnormalities
(4) Non-surgical treatment cannot relieve pain
(5) Lower extremity neurological symptoms or cauda equina compression syndrome
The principles of surgery for talus are: decompression, repositioning, fusion and stabilization of the crest. The purpose of surgery is to relieve the patient’s symptoms, so we should accurately determine the cause, location and extent of the symptoms before surgery, and focus on several steps such as decompression, fixation and fusion, and then combine them with relevant imaging examinations to develop a reasonable surgical plan.