Expertise · Diagnosis & treatment
Spondylolisthesis
In spondylolisthesis, one vertebral body slips forward relative to the one beneath it. This causes back pain that typically increases with standing and walking, as well as leg pain from nerve compression. In competitive athletes, spondylolysis is a common cause; in older patients, the degenerative form predominates.
What is spondylolisthesis?
Spondylolisthesis describes the forward slippage of one vertebral body over the one below it. Severity is classified according to Meyerding into four grades (I = up to 25% slippage, IV = complete dislocation). In adults, grades I and II are by far the most common.
Degenerative spondylolisthesis (usually L4/L5) occurs through wear of the facet joints in older patients and is the most common form. Isthmic spondylolisthesis (L5/S1) results from a defect in the vertebral arch (spondylolysis) and is common in young competitive athletes – particularly with repetitive hyperextension (gymnastics, weightlifting, American football).
Symptoms
- Lumbar back pain – typically load-dependent, worsened by standing and walking, improved when lying down
- Leg pain and weakness – when nerve compression from stenosis is also present
- Stiffness after prolonged sitting or standing
- Low back pain with hyperlordosis – hyperextension often worsens symptoms
- Young athletes: deep low back pain without radiation, typically after intensive training – rule out spondylolysis
Causes and forms
- Degenerative – wear of the facet joints in older patients, most common form
- Isthmic (spondylolysis) – stress fracture of the vertebral arch, typical in competitive athletes under 30
- Congenital – constitutional malformation of the vertebral arch, rare
- Iatrogenic – destabilisation following prior surgery
Diagnosis
- Standing lumbar spine X-ray (AP and lateral, flexion-extension views if needed) – gold standard for grading and stability assessment
- MRI – assessment of nerve compression, disc status and surrounding soft tissue
- CT with oblique reformats (for spondylolysis) – demonstrates the vertebral arch defect
- SPECT/CT – in athletes, to demonstrate acute, healable stress fractures
Treatment
Conservative therapy
For stable, low-grade spondylolisthesis without severe neurological deficits, conservative treatment is the first choice:
- Physiotherapy – core muscle strengthening, movement training
- Weight reduction – substantially reduces mechanical load
- Periradicular therapy (PRT) or facet joint injections – for painful nerve root compression
- Athletes: load reduction, targeted stabilisation therapy, SPECT-CT follow-up
When is surgery indicated?
- Progression of slippage (radiological follow-up)
- Treatment-resistant pain despite conservative management
- Relevant neurological deficits or increasing walking limitation
Surgical procedures
Decompression ± fusion
For concomitant stenosis: decompression of the nerve roots, supplemented by fusion when instability is confirmed. Whether fusion is necessary depends on the grade of slippage, stability and clinical picture – not on the diagnosis alone.
Percutaneous instrumentation
Minimally invasive stabilisation with pedicle screws and rods through small incisions, under image-intensifier guidance. Tissue-sparing, rapid rehabilitation – particularly suited to purely dynamic instability without severe deformity.
My approach
The decision to fuse is the central question in spondylolisthesis. I base this on proven instability on flexion-extension radiographs and the clinical picture – not on the diagnosis as a reflex indication for fusion. Current evidence (SPORT spondylolisthesis trial, NORDSTEN) shows that many patients benefit from decompression alone.
Where fusion is necessary, I perform the instrumentation minimally invasively and under image-intensifier guidance. In young athletes with spondylolysis, conservative management with a targeted return-to-sport protocol is the treatment of choice – surgery is rarely necessary.
More on spine care in competitive sport →What does the research say?
SPORT trial spondylolisthesis: surgery vs. conservative treatment (NEJM 2007)
In the SPORT trial, patients treated surgically for degenerative spondylolisthesis performed significantly better over 4 years compared with the conservative group – in terms of pain, function and quality of life. The study design has limitations (high crossover rate), but remains the most important randomised evidence. Weinstein JN et al., NEJM 2007, PMID 17538085 →
Decompression with or without fusion for spondylolisthesis (NEJM 2016)
Försth et al. (SWESPINE) found no significant differences in 2-year outcomes between decompression alone and decompression plus fusion – including in patients with degenerative spondylolisthesis. The fusion group had longer procedures and more bleeding without clinical benefit. Försth P et al., NEJM 2016, PMID 27276561 →
NORDSTEN trial: decompression alone vs. with fusion (NEJM 2021)
Austevoll et al. (NORDSTEN) randomised 267 patients with stenosis and degenerative slippage. At 2 years, no significant difference in the primary endpoint (leg pain). The fusion group had significantly more complications and longer operating times. The results support a selective approach to the fusion indication. Austevoll IM et al., NEJM 2021, PMID 34879207 →
Questions about your situation?
Describe your symptoms to me. I take the time to review findings, perform an examination and provide a clear, written assessment.