Back brace spondylolisthesis treatment

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The spine or vertebral column consists of a series of vertebrae stacked upon each other and separated from each other by discs in front and facet joints in the rear. The column is held together with a complex arrangements of ligaments and muscles.

Each vertebra consists of an anterior vertebral body, and a posterior portion that has two facet joints that articulate with the neighboring vertebra on top and two facets that interact with the vertebra on the bottom. These facet joints provide stability to the spine.

In spondylolysis, there is a defect in the pars interarticularis (which means the "piece between the articulations"). So spondylolysis means a defect in the thin connection of bone between the superior and inferior facets. This defect may affect both sides or only one side. Although the defect can be found at any level, the commonest vertebra involved is the 5th lumbar vertebra.

In cases of bilateral spondylolysis, the posterior articulations can no longer provide adequate stability, and slipping of the L5 vertebra forward over the sacrum results. This is spondylolisthesis.

Spondylolysis is the commonest cause of spondylolisthesis.

Spondylolisthesis can be a cause of low back pain.

The forward slip of the vertebra also makes the spinal canal smaller, leaving less room for the nerve roots and spinal cord.

There is usually pain across the low back and into the buttocks. Pain can radiate down the leg to the foot and be associated with numbness and weakness in the foot.

While the diagnosis of spondylolisthesis can be made on x-ray, adequate quantification of the extent of narrowing should be made using either CT or MRI scanning.

Note of caution: the presence of spondylolisthesis doesn't necessarily mean it is the cause of the low back pain.

The first step in the diagnostic evaluation is a history.

• Date of onset
• The location of the pain and what makes it worse. Is there radiation of the pain down the leg?
• Is there any bowel or bladder dysfunction
• Is there weakness in the legs? This could indicate spinal cord compression.
• Is there a history of previous surgery? This can be a cause of degenerative spondylolisthesis>

A physical examination is the next step. During the exam, range of motion, muscle strength, and nerves will be tested.

Usually, after the examination, imaging procedures will be ordered. These may include x-rays, MRI, or CT.

Treatment for spondylolisthesis is not significantly different than for other causes of mechanical back pain. In most cases, surgery will not be necessary. Strengthening the back muscles can help with the mechanical symptoms.

Medications may be used to control pain. Short periods of bed rest may help with acute painful episodes.

For Grades 1 and 2 spondylolisthesis, conservative treatment is usually instituted. This will be similar to treatment for spondylolysis. A rigid lumbosacral orthosis, a type of rigid back brace and intensive physical therapy to strengthen the back and abdominal muscles, as well as stretching exercises for the tight hamstring muscles are standard. A back brace, or corset, may reduce the pain significantly.

X-rays (lateral views only) sometimes are done every few months to check on the severity of the slip. If the patient responds to conservative treatment, the pain gets better, the hamstring tightness improves, and the patient may return to limited activities. The patient should avoid contact sports or other activities that stress the low back.

If the pain does not improve, or if follow-up X-rays demonstrate further slip, surgery may be needed. This is particularly true for grades 3 and grade 4.

Performing a complete laminectomy (removing the lamina) usually frees up trapped nerves. The result is less irritation and inflammation of the nerves. Once the nerves are freed, a spinal fusion is usually performed to control the segmental instability. Fusing L5 to the S1 vertebrae prevenst further slipping.

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