Spondylolysis and Spondylolisthesis

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By: Thomas E. Hyde, DC, DACBSP, CKTP, FCCSS (Hon)

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Spondylolysis is a condition in which the there is a defect in a portion of

the spine called the pars interarticularis (a small segment of bone
joining the facet joints in the back of the spine). With the condition of
spondylolisthesis, the pars interarticularis defect can be on one side of
the spine only (unilateral) or both sides (bilateral). The most common
level it is found is at L5-S1, although spondylolisthesis can occur at L4-5
and rarely at a higher level.

Spondylolisthesis Video
Spondylolysis is the most common cause of isthmic spondylolisthesis,
in which one vertebral body is slipped forward over another. Isthmic

spondylolisthesis is the most common cause of back pain in

adolescents; however, most adolescents with spondylolisthesis do not
actually experience any symptoms or pain. Cases of either neurological
deficits or paralysis are exceedingly rare, and for the most part it is not a
dangerous condition. The most common symptom is back and/or leg
pain that limits a patient's activity level.

Since spondylolysis is the most common cause of spondylolisthesis, it

may be referred to as an isthmic spondylolisthesis and sometimes these
terms are used interchangeably, although this is not correct. There are
at least 6 recognized causes of slippage as seen in spondylolisthesis in
the literature. According to Dr. Leon Wiltse, these causes are listed as:
Dysplastic spondylolisthesis (which includes congenital)
Isthmic spondylolisthesis (which includes lytic or stress fracture, an
elongated but intact pars or an acute fracture of the pars)
Degenerative spondylolisthesis (Pseudospondylolisthesis)
secondary to long-standing degenerative arthrosis (degenerative disc
disease and degeneration of the facet joints)
Traumatic spondylolisthesis (secondary to a fracture of the neural
arch)
Pathologic spondylolisthesis (from bone disease such as metastatic
disease, tumor, osteoporosis, etc.)
Importantly, spondylolysis only refers to the separation of the pars
interarticularis (a small bony arch in the back of the spine between the
facet joints), whereas spondylolisthesis refers to anterior slippage of
one vertebra over another (in the front of the spine). Therefore, although
the terms are sometimes used interchangeably, this is incorrect and the
two are technically not interchangeable.
The underlying cause of spondylolysis has not been firmly established.
According to major researchers in spine medicine (including Wiltse,
Yochum and Rowe) there have been no recorded cases of
spondylolisthesis in a new born and therefore the condition is not
believed to be genetic. Some physicians believe that repetitive trauma
(such as from certain sports) may either cause or contribute to the
development of spondylolysis.

Spondylolysis or Isthmic Spondylolisthesis

Activity Restrictions
In the past, patients have often been advised to limit their activities
(especially participation in sports and active exercise) to avoid causing
advancement of the spondylolysis. However, new information
developed from modern imaging tests and recent research indicates
that reduced activity and/or rest to protect the spondylolysis from
slipping may not always be necessary. Rest is only necessary if the
patient becomes symptomatic. Rest can help eliminate the pain, and

when the pain resolves the patient can resume his or her normal
activities.
Often adolescents are pulled from their sports participation because of
fears that their spondylolysis will lead to spondylolisthesis (slippage of
the affected vertebra) and that the slippage will become so severe as to
cause permanent damage or paralysis. Adults with spondylolysis are
also often counseled to avoid rigorous exercise and/or physically
demanding jobs. However, in published medical literature, there are no
instances of a patient in a work, industrial, or sports-related environment
that has experienced trauma causing spondylolisthesis to slip further
and produce neurological deficit or paralysis.
Sophisticated imaging modalities such as single-photon emission
computed tomography (SPECT) bone scans and magnetic resonance
imaging (MRI) scans of the spine now provide the ability to evaluate
the physiological changes that are associated with spondylolysis. This
information allows for the important distinction between active and
inactive spondylolysis.

Active spondylolysis. On the SPECT scan an active spondylolysis

shows uptake, and an MRI scan shows bone marrow edema adjacent
to the pars defect. These findings indicate that there is
activity/movement associated with the pars defect, which is likely to
produce symptoms of low back pain.
Inactive spondylolysis. If there are no indications of activity with the pars
defect, then the spondylolysis is considered inactive and any low back
pain the patient is experiencing is probably incidental (meaning that
there is probably another cause of the patient's lower back pain, such
as a muscle strain).
Even though activity restriction is not always necessary, careful
management of spondylolysis is always advisable. Acute (active)
spondylolysis requires more intensive management, while symptoms
from spondylolysis that has moved into a chronic (inactive) phase can
be managed conservatively.1
References:

1.

Bergmann TF, Hyde TE, Yochum TR. Active or Inactive Spondylolysis

and/or Spondylolisthesis: What's the Real Cause of Back Pain? Journal
of the Neuromusculoskeletal System. 2002:10:70-78.

Spondylolysis Treatment
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By: Thomas E. Hyde, DC, DACBSP, CKTP, FCCSS (Hon)

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Spondylolisthesis Treatment Video

Clinical studies have found varying degrees of healing using
conservative (non-surgical) treatments (such as bracing) ranging from
73% healing of early-stage spondylolisthesis versus 38% healing in
those with progressive disease. One study of adolescent athletes found
that 37% of them showed signs of healing at the pars defects after 2 to
6 months of bracing.1

Treatments for Active Spondylolysis

The recommended treatment program for active spondylolysis is usually
a combination of the following:
2.
3.
4.
5.

Bracing to immobilize the spine for a short period (e.g. four months) to
allow the pars defect to heal
Pain medications and/or anti-inflammatory medication, as needed
Stretching, beginning with gentle hamstring stretching and
progressing with additional stretches over time
Exercise that is controlled and builds gradually over time.
On rare occasions, spondylolysis that is not healing or may have
neurological components can require surgery to provide internal fixation
and stability to the area. Usually, two procedures are performed as part
of the same surgery:
A decompressive laminectomy, which reduces irritation and
inflammation in the area (but increases spinal instability)

A spinal fusion to provide stabilization of the affected area.

Treatments for Inactive Spondylolysis

For inactive spondylolysis, bracing is usually not necessary. In many
cases, however, the spondylolysis will be discovered long after the pars
defect has already healed. This condition is often referred to as chronic
inactive spondylolysis and may produce symptoms of chronic or
recurring lower back pain or discomfort.
Medical literature indicates that once the lesion has healed and
becomes inactive, the likelihood of significant progression is minimal,
and only rarely does the slippage require surgical intervention.
For discomfort or pain associated with chronic inactive spondylolysis,
there are several treatment options available, including pain
medications, chiropractic or osteopathic manipulation, physical therapy
and exercise.

First Chiropractic Exam Video

For patients seeking chiropractic or osteopathic manipulation for
this condition, it is important to note that there is no evidence in the
medical literature that manipulation can reduce slippage or cause an
active site to heal. But there are some case studies to show that
manipulation will often provide temporary pain relief for the patient. This
is because appropriate manipulation treatment can relieve many of the
side effects of spondylolysis, such as lower back pain caused by
stresses on various spinal structures, including the facet joints.

In This Article:

Spondylolysis and Spondylolisthesis

Profile and Diagnosis of Spondylolysis
Spondylolysis Treatment
In general, most people with chronic inactive spondylolysis can find
sufficient pain relief through a combination of conservative treatments,
such as manual therapy, exercise, and lifestyle changes.
However, it is important to note that any therapeutic approach must take
into account that spondylolysis means that there is a potentially
unstable area of the spine, so caution and the skill of the treating spine
specialist are very important considerations.
References

6.
7.
8.

Bergmann TF, Hyde TE, Yochum TR. Active or Inactive Spondylolysis

and/or Spondylolisthesis: What's the Real Cause of Back Pain? Journal
of the Neuromusculoskeletal System. 2002:10:70-78.
Soler T, Calderon C. The prevalence of spondylolysis in the Spanish
athlete. Am J Sports Med. 2000:28(1)57-62.
Rossi F, Dragoni S. The prevalence of spondylolysis and
spondylolisthesis in symptomatic elite athletes: radiographic findings.
Radiography. 2000:28(1):57-62.