Spondylolisthesis (Vertebral Slippage) and Its Treatment

What Is Spondylolisthesis?

Spondylolisthesis is displacement of one vertebra, usually forwards, relative to the vertebra below it. The vertebrae are firmly connected by discs at the front and facet joints at the back; damage to these structures permits the slip.

What Causes Spondylolisthesis?

The most common cause is age-related wear of the discs and facet joints (degeneration).

• 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?

The most typical symptoms are pain in the lower back, buttock and both legs.

• Lower back, buttock and leg pain
• Numbness in the legs
• Burning sensations
• Marked difficulty walking (neurogenic claudication)

Not every patient has symptoms; sometimes slippage is found incidentally on imaging. If the spinal canal and nerve exit openings narrow at the slipped level (spinal stenosis), nerve roots become compressed.

How Is Spondylolisthesis Diagnosed?

Spondylolisthesis is recognised through the patient’s history and examination; X-rays and MRI establish the diagnosis. Only dynamic X-rays taken while bending forwards and backwards show whether the slip is mobile.

How Does Spondylolisthesis Improve?

Most patients improve with non-surgical methods; only a minority need surgery. Treatment 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 Algology 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

How Is Spondylolisthesis Surgery Performed? (Spinal Instrumentation and Fusion)

In surgery, the slipped vertebrae are stabilised with screws and gradually unite (fusion). The primary aim is to immobilise the two unstable vertebrae so the bones permanently join; 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, colloquially 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 (Minimally Invasive 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 that these treatments do nothing more than postpone the condition. 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 depends on the degree of slippage and symptoms. Excessive backward bending that increases pain, contact sports and heavy loading should be restricted.

Is Swimming Good for Spondylolisthesis?

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 in Spondylolisthesis?

No, a mobile slip alone does not determine the need for screws. Symptom severity, neurological findings, nerve compression and the degree of slippage are assessed together. Screw-and-rod systems, colloquially known as metal implants, 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 Spondylolisthesis 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 to Diagnose Spondylolisthesis?

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 Spondylolisthesis 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 Doctor Treats Spondylolisthesis?

Neurosurgery and physical medicine and rehabilitation specialists treat spondylolisthesis.

Which Specialist Treats Spondylolisthesis in Istanbul?

One of the physicians treating spondylolisthesis in Istanbul is M. Levent Deniz, MD, a specialist in neurosurgery.

How Much Does Spondylolisthesis 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 – Neurosurgery Specialist
• ⚠️ Medical Disclaimer: This page is for information only; consult your doctor for diagnosis and treatment.