Diagnosis of Spondylolisthesis

Signs and Symptoms of Spondylolisthesis

Many individuals with spondylolysis and spondylolisthesis have no symptoms. When symptoms are present, they do not always correlate with the degree of defect (i.e. they may be much worse or milder than the severity of the slip indicated by imaging studies). Young people often develop symptoms during the preadolescent growth spurt. If symptoms are present, back and leg pain are the most common.

Symptoms of Spondylolysis

  • Low-back pain during hyperextension of the spine
  • Pain appearing initially during sports and progressing to pain during daily activities which may eventually interfere with sleep
  • Pain when bending backward
  • Hyperlordosis - increased "inward" curvature of the lower back, also called 'swayback'
  • Tightness in the hamstring muscle Acute spondylolysis is usually painful with any activity involving pressure on the back (e.g., running and jumping). Symptoms are usually not problematic when sitting. The individual may experience spinal spasms, pain with lumbar extension, and/or tight hamstring muscles.

Symptoms of Low-Grade Spondylolisthesis

  • Back pain during lumbar hyperextension and/or flexion; may be constant or intermittent, aggravated by strenuous activity, and relieved with rest
  • Hamstring tightness or weakness
  • Pain aggravated with lifting or bending
  • Knee-flexed, hip-flexed gait (Phalen-Dickson sign)
  • Leg pain that is worse with activity and relieved by rest
  • Tenderness and irregularities in bony alignment that may be felt or palpated
  • Shortened appearance of the trunk and lumbar hyperlordosis (inward curvature of the spine)

Back pain is the most common symptom of spondylolisthesis. Children are typically symptomatic during a growth spurt when parents will bring in a child to the doctor complaining of:

  • Poor posture
  • Irregular gait such as walking with knees bent and short stride
  • Muscle spasms making the lower back stiff and painful
  • Tight hamstrings

Pain in the back and buttocks is present in up to 80% of individuals with spondylolisthesis. It is usually exacerbated by standing, walking, and intense sports or other physical activities. Initially pain may be felt only at extremes of lumbar range of motion and may progress to less extreme movements over time. Relief usually comes with resting.

Hamstring tightness is almost always present even with low grade slippage. If the hamstring tightness is severe enough to shorten the length of each step, a waddling gait may be noted. Neurological symptoms related to nerve compression (e.g., radiculopathy) may be unilateral or bilateral, intermittent or chronic, and are associated with higher grades of slippage.

Symptoms of High-Grade Isthmic Spondylolisthesis

With high-grade slippage (Grade III/IV) changes occur at the L5-S1 level including, acceleration of degeneration of the L5-S1 disk, bone erosion, and compression of the L5 nerve root, all of which lead to compensatory postural changes such as hyperlordosis ('swayback') but continued slippage of the vertebra increases the tilt producing a 'slip angle' that can lead to kyphosis ('roundback'). Although lower back pain is often present it may not be severe. The most common neurological deficit is entrapment of the L5 nerve root leading to frequent complaints of radiculopathy and/or claudication (pain in the thighs or lower legs).

Unilateral pain is more common than bilateral. In addition, the trunk of the body often sits in a forward position over the pelvis and the individual may adopt certain compensatory strategies to correct the imbalance (e.g., walking with flexed knees and hips). Scoliosis ('S' shaped curvature of the spine), may also be noted secondary to the misalignment of the spinal segments. In pediatric patients, the L5-S1 facet joints are often dysplastic (improperly formed) and subclinical signs of spina bifida may also be present at the L5 and sacrum level.

Some clinical signs that are often recognizable in individuals with high-grade spondylolisthesis include:

  • Shortening of the trunk
  • Protruding abdomen
  • Flattened buttocks
  • Limited flexion
  • Restricted spinal mobility
  • Tight hamstring muscles
  • Waddling gait
  • Hip and knee flexion
  • Bladder and bowel dysfunction - may occur with severe degrees of slippage and stretching of L5-S1 nerve roots

Symptoms of Degenerative Spondylolisthesis

Degenerative spondylolisthesis usually develops gradually and is described as more of an 'ache' than the more defined 'pain' associated with isthmic spondylolisthesis. The aching sensation occurs in the lower back and posterior thighs. Symptoms are often chronic and progressive although some patients may experience remission. Neurogenic claudication (weakness or heaviness in the legs) rather than radiculopathy may be the presenting pain pattern. Claudication occurs in approximately 15-20% of individuals and is usually mild. Depending on the degree of spinal stenosis, reflexes in legs may be affected. In degenerative spondylolisthesis, the slip most often occurs between L4-L5 and the nerve that is compressed is usually the L5 nerve root but the L4 nerve roots can be affected as well.

Some patients with degenerative spondylolisthesis present with low back pain and arthritic changes, while others present with signs of spinal stenosis, (e.g., buttock and leg pain in addition to low back pain). They experience relief from pain when they rest their spine or lean on something (e.g., supermarket wagon). Pain is mostly related to activity (e.g., walking). Degenerative spondylolisthesis is not caused by spondylolysis.