Did you know that back pain and leg pain will cause about 80% of our population to see a physician each year? Although most back pain is minor and will usually resolve on its own, there are many different diagnoses that can cause lingering lower back pain. About 10% of the patients that see an orthopaedic spine specialist for their back pain are diagnosed with a condition where the bones in the spine have slipped or changed position slightly. In medical terminology, this is called spondylolisthesis.
There are several different reasons that the bones may slide or change position. The most common is degenerative disease of the discs that cause the bones of the spine to sit more loosely on each other and allows shifting to occur. Children may also have a failure to form a complete connection in the spine. This lack of connection allows the bones to slip on each other.
In adolescents, back pain may start as the bones start to shift and become irritated due to the abnormal connection in the spine. As children become more active in sports and use their backs for athletic activities, the instability related to the lack of connection in the back bones will start to become painful. X-rays, taken at this time, may show a break in the bones; however, there are a significant number of these kids with back pain who will have normal looking x-rays. These children may need to have a further evaluation with a CT scan to help visualize the bones of the spine more specifically. There a large portion of these individuals that may live their entire lives with a break in their vertebrae and not experience back pain until their discs start to degenerate.
The largest group of patients with spondylolisthesisis is the middle age population, as they have degeneration in the discs that leads to back pain and doctor visits. As the discs degenerate, they are not able to support the weight of the spine, which allows the bones to shift. Due to the change in the position of the bones, the discs will have to bear the brunt of the patient’s body weight and movement, which in turn, applies more stress to the discs and forces them to degenerate faster.
Most patients with a mild slippage of the bones will not have any worse back or leg pain than most people their age. There are no particular restrictions in activities that need to be considered in mild spondylolisthesis. However, as patients get older, the discs that are between the slipped bones will continue to degenerate. Disc cartilage degeneration can be painful and can lead to an increase in the slippage of the bones. As the spine continues to degenerate and slip, the nerves that are protected by the bones will begin to receive pressure from the discs and bones. Pinching the nerves in the back will cause pain in the distribution of the nerve roots. This pain is felt in the back of the legs and down to the foot, called sciatica. The nerve pain is usually the most painful and many patients will wonder why the doctor is checking their back when it is their leg that is hurting them.
The initial treatments for low back and leg pain related to spondylolisthesis are a physical therapy program and anti-inflammatory medications. Exercise, stretching, traction, as well as manual therapies, can be very helpful in relieving the pain. The goal is to try to relieve the pressure on the nerve and mobilize the bones and discs to allow for a more fluid motion of the back without irritating the muscle, tendon or nerves. Most patients will respond well to this treatment and can manage with a home exercise program.
If this treatment is not successful, injections of steroids around the nerves and joints may be helpful in relieving some of the acute pain. After pain reduction, the exercise program may be more effective. If all of these treatments don’t work, surgery should be considered to relieve the back and leg pain. Although some patients are reluctant to have back surgery, with the improved surgical techniques I use, spondylolisthesis is one of the conditions of the spine that responds very successfully to surgery.