LUMBAR SPONDYLOLISTHESIS

The spine is a structure consisting of the structures called the vertebrae, which are regularly arranged on one another. There are 30 vertebrae in our body, 24 of which are moving structures. Five of the vertebrae are in the lumbar region. When we look at the anatomical structures of the vertebrae, 3 main structures attract our attention. These are the vertebral body, the vertebral arch called ‘lamina’ that protects the spinal cord canal, and the facet joints connecting the vertebrae to one another. As described in detail in the section about lumbar disc herniation, there are also structures called ‘discs’ between the vertebrae, which ensure an even distribution of the vertebrae and provide flexibility to the spine.

In its simplest definition, lumbar spondylolisthesis is a condition in which a vertebra slides over the vertebra below it, and as a result they squeeze the spinal cord as well as the nerve roots arising from it, and consequently cause symptoms in the patient. This slippage occurs sometimes with the progression of an advancing fracture between the lower lumbar spine and sacrum, and constitutes a typical adult lumbar spondylolisthesis (isthmic spondylolisthesis) when one of the vertebrae slides over the vertebra below it. Besides this kind of lumbar spondylolisthesis, there is also a degenerative type of spondylolisthesis, which is caused by intervertebral arthritis and impairment of the intervertebral disc structure.

Symptoms

In general, patients mostly complain of lumbar pain. Patients also suffer from unilateral or bilateral hip pain, leg pain, tingling in the legs, gait disturbance and shortened walking distance, and weakness in the legs at advanced stages of the disease. Symptoms usually decrease with rest, but standing on feet, brisk walking and increased activity cause the emergence of the symptoms.

Diagnosis

In medicine, diagnosis always starts with listening to the patient and examining him/her. After that, it is necessary to evaluate the patient by using auxiliary diagnostic methods. In spondylolisthesis, having a direct x-ray from 4 directions would give significant information for diagnosis. Sometimes stress fracture (spondylosis) is not seen on such x-ray images; and in such cases, scintigraphy or computed tomography should be requested from the patient. Magnetic resonance imaging can also be performed to evaluate soft tissues. Magnetic resonance gives us detailed information about the structures of intervertebral discs, spinal cord, thecal sac and nerve roots extending from it, joints connecting the vertebrae to one another, and muscle tissues surrounding the spine. As a result of these tests, the patient is diagnosed with stress fracture (spondylosis) and spinal slippage (isthmic type spondylolisthesis). Direct x-ray and magnetic resonance imaging would give adequate information in cases of degenerative spinal slippage. Slippage degree in isthmic type spondylolisthesis is calculated as the slippage percentage of a vertebra that slides over another vertebra, and it is classified as the1st, 2nd, 3rd and 4th degree.

Treatment

The treatment is classified in 2 categories as non-surgical treatment procedures and surgical procedures. In cases where there is only lumbar pain and there is no nerve root compression, no loss of strength in the legs or feet, and no motility observed in the direct x-ray images of the lumbar vertebrae, non-surgical treatment procedures should be performed. Non-surgical procedures cannot repair mechanically impaired structures (cracked and/ or slipped vertebrae), but enhance the ability of patients to return to their daily and business lives by means of pain control. These procedures involve rest-cure, analgesics and anti-inflammatory drugs, movement restriction program, corset and physiotherapy practices. Disease symptoms can be controlled with non-surgical treatment procedures if patients do not gain weight in the future, learn how to do their daily vital activities without difficulty, and adopt these as a life style. If the pain cannot be controlled with the methods described above without loss of strength, consultation can be requested from physicians engaged in physiotherapy, rehabilitation and algology.

Surgical treatment should be considered for the patients suffering from symptoms such as pain, loss of strength in the legs and/or feet, and urinary and fecal incontinence. In such cases, bone pressure on the nerve root should be eliminated with the procedure called ‘decompression’ (intended for relieving the nerve root compression), then the vertebrae should be fixed with the procedure called ‘fusion’ in medicine (colloquially known as platinum placement). Those working at a desk job can return to work after 1 month. However, manual workers should wait for a period of 2 months. Some patients may need physiotherapy and a rehabilitation program in the postoperative period.