Spondylolisthesis and Its Treatment

Spondylolisthesis is the displacement of a vertebra, usually forwards, relative to the vertebra below it. If the slip is stable and there are no neurological findings, physiotherapy, bracing and injections are first-line treatments. With mobile slippage and significant nerve-compression-related symptoms, screw-and-fusion surgery to stabilise the vertebrae is considered.

What Is Spondylolisthesis, and What Causes It?

In a healthy spine, the vertebrae are arranged in precise alignment. Normally, the front and back edges of each vertebra line up exactly with those above and below. The vertebrae are firmly connected by discs at the front and facet joints at the back. Spondylolisthesis occurs when damage to these connecting structures allows one vertebra to move over another, usually forwards. The most common causes are:

• Degeneration: Age-related wear of the discs and facet joints.
• Trauma: Falls, accidents or sudden excessive spinal loading.
• Previous Spinal Operations: Loss of spinal stability following certain earlier surgeries.

What Are the Symptoms of Spondylolisthesis?

Not every patient develops symptoms; in some, the condition is found incidentally on imaging. If the spinal canal and the channels through which nerve roots exit narrow at the slipped level (spinal stenosis), the roots become compressed. Nerve compression causes lower back and leg pain, numbness, burning and marked difficulty walking (neurogenic claudication).

Treatment of Spondylolisthesis

The treatment strategy depends on whether the slip is “mobile”:

• Mobile Spondylolisthesis: If the amount of slippage changes markedly with movement on dynamic X-rays, the spine is moving at that level. Mobility alone is not sufficient to decide on surgery; pain, nerve compression, neurological findings, daily limitations and the degree of slippage are assessed together. Fusion and screws (instrumentation) are considered for mobile slips with significant symptoms.

• Stable Spondylolisthesis (Spontaneous Fusion): In some patients, disc-space narrowing and degenerative changes gradually restabilise the slipped segment on their own (spontaneous fusion). If nerve compression is the main problem in these patients, screws are unnecessary. They are assessed according to spinal stenosis treatment protocols, and decompression without screws is sufficient in a stable spine.

Non-Surgical Treatments and Interventional Pain Procedures

Non-surgical methods are the first step for stable slips without neurological findings:

• Physiotherapy and exercises strengthening the lower back and abdominal muscles
• Short-term bracing during an acutely painful period
• Epidural injection (targeted treatment) for leg pain from nerve root compression
• Radiofrequency denervation for facet-joint-related lower back pain

Spondylolisthesis Surgery: Spinal Instrumentation and Fusion

The primary aim is to immobilise the two slipped, unstable vertebrae so the bones permanently unite (fusion). This biological union develops over the months following surgery. In patients scheduled for fusion, the mobile vertebrae are fixed together with screws (fixation) to support the segment while union occurs. The surgical elements used are:

• Spinal Instrumentation: Mechanical stabilisation of the spine with screw-and-rod systems, commonly referred to as placing metal implants.
• Transpedicular Fixation and Interbody Fusion: This combined technique provides strong stabilisation using screws and special cages placed within the disc space.

The Modern Approach: Minimally Invasive Spondylolisthesis Surgery (MIS-TLIF)

In suitable patients, spondylolisthesis surgery can also be performed using a minimally invasive TLIF approach, with less disruption of muscle tissue. See the minimally invasive spondylolisthesis surgery page for details.

Outcomes of Surgical and Non-Surgical Treatment

The condition remains unchanged for many years in most non-operated patients: 76% of those without neurological findings still had none after 10 years. In contrast, 83% of patients with neurological findings such as weakness who declined surgery deteriorated [1]. Non-surgical treatment is therefore the first step for slips without neurological findings [2].

Among patients needing surgery, those operated on improved more in pain and daily functioning than those managed non-surgically, and this difference lasted 4 years [3, 4]. Whether screws are needed is determined individually: adding screws in mild slippage improved quality of life in one study [5], whereas a larger study found the same outcome with surgery without screws [6].

🩺 Physician’s Insight & Clinical Experience

“As a physician who has worked for many years with both microsurgery and interventional pain treatments for spinal conditions, and who always prioritises non-surgical treatment, I would like to say this: if a slip is mobile, none of the non-surgical treatments we use provides these patients with substantial, lasting relief. In my clinical practice, I have found these treatments do little beyond postponing the problem. At the same time, I fully understand patients’ fear of paralysis when I tell them in clinic that screws need to be placed in their lower back. I place screws using my microsurgical experience and neuromonitoring, which tracks nerve signals live during surgery. In mobile spondylolisthesis, screws act as an internal cast protecting the spine. The aim is not to leave the back immobile but, on the contrary, to free the nerves from compression and let the patient walk freely again.”

Frequently Asked Questions

Does Spondylolisthesis Cause Leg Pain?

Yes, leg pain is one of its most challenging symptoms. As slippage occurs, the canal containing the nerves narrows and mechanically compresses the roots. This causes pain extending from the buttock to the heel, sciatica-like symptoms and numbness.

Can Spondylolisthesis Improve Without Surgery?

The slipped bone does not return to position without surgery, but non-surgical treatments can reduce pain and nerve-related symptoms. In some patients, the slipped segment gradually restabilises on its own.

Am I at Risk of Paralysis If I Do Not Have Surgery?

No, not every slip causes paralysis; most patients without neurological findings remain stable for a long time. However, progressive weakness, pronounced walking difficulty or new bladder/bowel control problems require urgent assessment.

Does Spondylolisthesis Affect Disc Herniation?

Yes, it can: slippage increases the load on the disc and facet joints at that level. However, not every slip leads to a disc herniation.

Can Someone with Spondylolisthesis Exercise?

Yes, but the choice of sport should depend on the type, grade and stability of the slip and current symptoms. Repetitive excessive backward bending that worsens pain, high-impact contact sports and heavy loading may be restricted in some patients. It is preferable for a rehabilitation specialist or physician experienced in spinal conditions to individualise the exercise programme.

Is Swimming Helpful?

Yes, for most patients: water’s buoyancy reduces spinal loading. There is no single “best sport”; exercise should be chosen according to the degree of slippage and symptoms.

Are Metal Implants Always Necessary?

No, mobility alone does not determine the need for screws. The decision considers symptom severity, neurological findings, nerve compression, slip grade and the effect of the planned decompression on spinal stability together. Screw-and-rod systems are considered when marked mobility is accompanied by significant symptoms.

Can a Brace Treat Spondylolisthesis?

No, a brace does not treat the slip; it supports the lower back and restricts movement during painful periods. Prolonged use weakens the back muscles.

How Does It Differ from Lumbar Disc Herniation?

A disc herniation is displacement of the soft disc between vertebrae. Spondylolisthesis is displacement of the entire vertebral bone itself. Compared with a herniation, slippage is a more structural problem that usually disrupts stability.

Why Are Dynamic X-Rays (Flexion & Extension) Requested?

Only X-rays taken while bending forwards and backwards show whether the slip is mobile; static MRI or X-rays do not show this. Mobility is an important finding considered when deciding on surgery.

How Effective Are Non-Surgical Methods (Epidural Injection, Radiofrequency) for Pain?

They provide temporary relief by easing leg and lower back pain, but do not treat the slip. They are valuable options for patients who do not want surgery or whose surgical risk is high.

Which Specialist Treats Spondylolisthesis in Istanbul?

One of the physicians treating spondylolisthesis in Istanbul is M. Levent Deniz, MD, a specialist in brain, nerve and spine surgery.

How Much Does Treatment Cost?

As treatment costs vary according to the patient and hospital conditions, a definite fee can only be determined after examination and review of imaging.

References

1. Matsunaga S, Ijiri K, Hayashi K. Nonsurgically managed patients with degenerative spondylolisthesis: a 10- to 18-year follow-up study. J Neurosurg. 2000;93(2 Suppl):194-198. PMID: 11012048.
2. Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17(3):327-335. PMID: 18026865.
3. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007;356(22):2257-2270. PMID: 17538085.
4. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009;91(6):1295-1304. PMID: 19487505.
5. Ghogawala Z, Dziura J, Butler WE, et al. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med. 2016;374(15):1424-1434. PMID: 27074067.
6. Austevoll IM, Hermansen E, Fagerland MW, et al. Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis. N Engl J Med. 2021;385(6):526-538. PMID: 34347953.

• 👨‍⚕️ Author and medical reviewer of this content: M. Levent Deniz, MD – Brain, Nerve and Spine Surgeon
• ⚠️ Medical Disclaimer: This page is for information only; consult your doctor for diagnosis and treatment.