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Lumbar Spondylolisthesis

What is lumbar spondylolisthesis.

Lumbar spondylolisthesis occurs when a vertebra in the lower spine shifts out of place and onto the bone below it, often because of weakness or a stress fracture. It is more common in young athletes and older adults who suffer from arthritis. It can cause pain, stiffness, and muscle spasms.

Non-surgical options are often successful in relieving the symptoms, but sometimes surgery is needed. Spinal fusion is one of the more common options to relieve lumbar spondylolisthesis.

What You Can Expect at UTHealth Neurosciences

The UTHealth Neurosciences Spine Center brings together a multidisciplinary team of board-certified, fellowship-trained neurosurgeons, neurologists, researchers, and pain management specialists who work together to help provide relief for even the most complex problems. Your team will share insights, leading to better treatment decisions and outcomes.

We first investigate nonsurgical treatment options, including medical management, pain management, physical therapy, rehabilitation, and watchful waiting. When surgery is needed, our neurosurgeons routinely employ innovative minimally invasive techniques. Throughout the treatment process, we will work closely with the doctor who referred you to ensure a smooth transition back to your regular care. While you are with us, you will receive expert care, excellent communication, and genuine compassion.

Causes of Lumbar Spondylolisthesis

Usually lumbar spondylolisthesis results from spondylolysis, a crack or stress fracture in the pars interarticularis, the thin portion of the vertebra that connects the upper and lower facet joints.

In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. The injury is most commonly seen in children and adolescents who participate in sports that involve repeated stress on the lower back, including football, weightlifting, and gymnastics. Repetitive stress can cause a fracture on one or both sides of the vertebra. It also may be caused by a birth defect in the lumbar spine or an acute injury.

In adults, the most common cause is abnormal wear on the cartilage and bones, such as through arthritis. The condition affects people over the age of 50 and is more common in women than in men. Bone disease and fractures also can cause lumbar spondylolisthesis. Genetics may play a role, as some people are born with thinner-than-normal vertebral bone.

Early Signs of Lumbar Spondylolisthesis and Diagnosis

Symptoms of spondylolisthesis may vary from none to mild to severe. The most common symptom is low back pain.

The condition can cause lordosis (swayback). In later stages it may result in kyphosis (roundback) as the upper spine falls off the lower spine. General symptoms are lower back pain; muscle tightness in the hamstrings; pain, numbness, or tingling in the thighs and buttocks; tenderness in the area of the vertebra that is out of place; weakness in the legs; and difficulty standing and walking.

Our spine specialists diagnose spondylolisthesis by taking a thorough medical history, conducting a physical exam, and asking you to undergo imaging studies that may include X-ray, CT scan, or MRI scan.

Treatments for Lumbar Spondylolisthesis

Your doctor may use X-rays, CT scans, or an MRI, as well as a physical exam, to determine the severity of your condition. Initial treatment may include rest, physical therapy, nonsteroidal anti-inflammatory drugs, oral corticosteroids, and/or bracing that limits movement of the spine and allows the fracture to heal.

Surgery may be recommended for patients who have severe or high-grade slippage of the vertebra, such as when more than 50% of the fractured vertebra slips forward on the vertebra below it. The procedures most often recommended for people with lumbar spondylolisthesis are spinal fusion or a laminectomy to decompress the nerves.

Anatomy of the neck and spine

The spine is divided into the following regions:

  • The cervical region (vertebrae C1-C7) encompasses the first seven vertebrae under the skull. Their main function is to support the weight of the head, which averages 10 pounds. The cervical vertebrae are more mobile than other areas, with the atlas and axis vertebra facilitating a wide range of motion in the neck. Openings in these vertebrae allow arteries to carry blood to the brain and permit the spinal cord to pass through. They are the thinnest and most delicate vertebrae.
  • The thoracic region (vertebrae T1-T12) is composed of 12 small bones in the upper chest. Thoracic vertebrae are the only ones that support the ribs. Muscle tension from poor posture, arthritis, and osteoporosis are common sources of pain in this region.
  • The lumbar region (vertebrae L1-L5) features vertebrae that are much larger to absorb the stress of lifting and carrying heavy objects. Injuries to the lumbar region can result in some loss of function in the hips, legs, and bladder control.
  • The sacral region (vertebrae S1-S5) includes a large bone at the bottom of the spine. The sacrum is triangular-shaped and consists of five fused bones that protect the pelvic organs.

Spine Disease and Back Pain

Arthrodesis Artificial Disc Replacement Cauda Equina Syndrome  Cervical corpectomy Cervical disc disease Cervical discectomy and fusion Cervical herniated disc Cervical laminectomy Cervical laminoforaminotomy Cervical radiculopathy Cervical spondylosis (degeneration) Cervical stenosis Cervical spinal cord injury Degenerative Disc Disease Foraminectomy Foraminotomy Herniated discs Injections for Pain Kyphoplasty Laminoplasty Lumbar herniated disc Lumbar laminectomy Lumbar laminotomy Lumbar radiculopathy Lumbar spondylolisthesis Lumbar spondylosis (degeneration) Lumbar stenosis

Neck Pain Peripheral Nerve Disorders Radiofrequency Ablation Scoliosis Spinal cord syrinxes Spinal deformities Spinal injuries Spinal fractures and instability Spinal Cord Stimulator Trial and Implantation Spinal Fusion Spinal Radiosurgery Spine and spinal cord tumors Spondylolisthesis Stenosis Tethered spinal cord Thoracic herniated disc Thoracic spinal cord injury Transforaminal Lumbar Interbody Fusion Vertebroplasty

At UTHealth Neurosciences, we offer patients access to specialized neurological care at clinics across the greater Houston area. To ask us a question, schedule an appointment, or learn more about us, please call (713) 486-8100, or click below to send us a message. In the event of an emergency, call 911 or go to the nearest Emergency Room.

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Lumbar spondylosis: clinical presentation and treatment approaches

  • Open access
  • Published: 25 March 2009
  • Volume 2 , pages 94–104, ( 2009 )

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  • Kimberley Middleton 1 &
  • David E. Fish 2  

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Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as “an illness in search of a disease.” Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

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Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives [ 1 – 3 ]. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks [ 4 ]. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population [ 5 , 6 ]. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable [ 7 ].

Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country [ 8 ]. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine [ 9 ]. Back pain has been termed as “an illness in search of a disease” [ 10 ]. Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative [ 11 , 12 ].

We will elaborate on these degenerative processes and their clinical implications. We will further discuss the diagnostic approaches and the efficacy of existing treatment options.

Tackling the terminology

The terms lumbar osteoarthritis , disk degeneration , degenerative disk disease , and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.

Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation [ 13 , 14 ]. Osteophytes included within this definition fall into one of the two primary clinical categories [ 14 ]. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels [ 15 ]. These osteophytes have minimal effect on intervertebral disk height [ 16 ] and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine [ 15 ].

By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes, associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes [ 16 ]. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues [ 14 ]. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.

Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses [ 16 ]. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.

Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks) [ 17 ]. Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine [ 17 , 18 ]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.


Degenerative spine changes are remarkably common in population studies. Symmons’ et al. [ 19 ] study of individuals aged 45–64 years identified 85.5% of participants to demonstrate osteophytes within the lumbar spine. O’Neill et al. [ 20 ] explored osteophytosis within a UK adult population over age 50 years, finding 84% of men and 74% of women to demonstrate at least one vertebral osteophyte, with increased incidence among individuals with more physical activity, self reported back pain, or higher BMI scores. Despite marked variability within the population, men appear to have more significant degenerative changes than women, both with regard to number and severity of osteophyte formation [ 20 ].

Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% [ 21 ] and degenerative spinal stenosis in 20% [ 11 ]. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups [ 22 ].

Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence [ 23 ] found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study [ 15 ]. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.


The high incidence of simultaneous degenerative changes to the intervertebral disk, vertebral body, and associated joints suggests a progressive and dynamic mechanism, with interdependent changes occurring secondary to disk space narrowing [ 17 ].

Intervertebral disks are believed to undergo what Kirkaldy Willis and Bernard [ 24 ] first coined a “degenerative cascade” (Fig.  1 ) of three overlapping phases that may occur over the course of decades. Phase I (Dysfunction Phase) describes the initial effects of repetitive microtrauma with the development of circumferential painful tears of the outer, innervated anulus, and associated end-plate separation that may compromise disk nutritional supply and waste removal. Such tears may coalesce to become radial tears, more prone to protrusion, and impact the disk’s capacity to maintain water, resulting in desiccation and reduced disk height. Fissures may become ingrown by vascular tissue and nerve endings, increasing innervation and the disk’s capacity for pain signal transmission [ 25 ]. Phase II (Instability Phase) is characterized by the loss of mechanical integrity, with progressive disk changes of resorption, internal disruption, and additional annular tears, combined with further facet degeneration that may induce subluxation and instability. During Phase III (Stabilization Phase), continued disk space narrowing and fibrosis occurs along with the formation of osteophytes and transdiscal bridging [ 26 ].

The spectrum of pathological changes in facial joints and the disk and the interaction of these changes. The upper light horizontal bar represents dysfunction, the middle darker bar instability, and the lower dark bar stabilization

Schneck presents a further mechanical progression, building upon this degenerative cascade of the intervertebral disk, to explain other degenerative changes of the axial spine. He proposes several implications of disk space narrowing. Adjacent pedicles approximate with a narrowing of the superior–inferior dimension of the intervertebral canal. Laxity due to modest redundancy of the longitudinal ligaments enables bulging of the ligamentum flavum and potential for spine instability. Increased spine movement permits subluxation of the superior articular process (SAP), causing a narrowed anteroposterior dimension of the intervertebral and upper nerve root canals. Laxity may also translate into altered weight mechanisms and pressure relationships on vertebral bone and joint spaces believed to influence osteophyte formation and facet hypertrophy to both inferior and superior articular processes with risks for projection into the intervertebral canal and central canal, respectively. Oblique orientations of the articular processes may further cause retrospondylolisthesis, with resulting anterior encroachment of the spinal canal, nerve root canal, and intervertebral canal [ 17 ].

Biochemical research exploring osteophyte formation supports the above process. Osteophyte lipping is believed to form at periosteum [ 27 ] through the proliferation of peripheral articular cartilage which subsequently undergoes endochondral calcification and ossification [ 28 ]. Changing weight mechanics and pressure forces as well as alterations in oxygen tension and dynamic fluid pressure appear to be influential factors in osteophyte formation [ 14 ]. Mesenchymal stem cells of the synovium or periostium are likely precursors, with synovial macrophages and a milieu of growth factors and extracellular matrix molecules acting as probable mediators in this process [ 29 ].

Clinical presentation

Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine [ 9 ].

These degenerative anatomical changes may culminate in a clinical presentation of spinal stenosis, or narrowing within the spinal canal [ 30 ] through progressive ingrowth of osteophytes, hypertrophy of the inferior articular process [ 31 ], disk herniation, bulging of the ligamentum flavum [ 17 ], or spondylolisthesis. The clinical result: a constellation of pain symptoms encompassed in the term neurogenic claudication (NC). NC may include (to varying extents) lower back pain, leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning [ 30 ].

Clinical presentations of radiculopathy may emanate from many sources, all of which can be explained by the degenerative process. Disk bulging may affect descending rootlets of the cauda equina, nerve roots exiting at the next lower intervertebral canal, or the spinal nerve within its ventral ramus, if protruding centrally, posterolaterally, or laterally, respectively [ 32 ]. Osteophyte lipping along the posterior aspect of vertebral bodies, along upper or lower margins, may similarly impinge upon the same neural structures as the bulging disk just described [ 17 , 33 ]. Hypertrophic changes to the superior articular process may intrude upon nerve roots within the upper nerve root canal, dural sac, or prior to exiting from next lower intervertebral canal, depending on their projection [ 34 ]. These theoretical forms of impingement have been substantiated through cadaver studies. A 70% reduction or 30% residual diameter of neuroforminal space is cited as the critical amount of occlusion to induce neural compromise [ 15 ]. Moreover, compression of the posterior disk to less than 4 mm height, or foraminal height to less than 15 mm has also been determined as critical dimensions for foraminal stenosis and nerve impingement [ 35 ].

Etiology/risk factors

What factors mediate this degenerative progression? What leads a large portion of the population to manifest spondylosis, even early on in their lives? Given the substantial variability in the number and degree of spine changes observed in individuals and the wide range of clinical presentations, answers to these questions hold promise to broaden treatment options.

The influence of age

Large studies of osteoarthritis have long recognized the aging process to be the strongest risk factor for bony degeneration, particularly within the spine [ 36 ]. An extensive autopsy study in 1926 reported evidence of spondylitis deformans to increase in a linear fashion from 0% to 72% between the ages of 39 and 70 years [ 37 ]. A subsequent autopsy study by Miller et al. [ 38 ] similarly noted an increase in disk degeneration from 16% at age 20 to about 98% at age 70 years based on macroscopic disk degeneration grades of 600 specimens. Other studies corroborate this finding [ 20 , 39 ].

The associations are nevertheless imperfect. Kramer [ 40 ] found increasing age to be significantly associated with osteophyte formation but not predictive of the degree of disk space narrowing observed in a retrospective review of radiographs of women. She observed significant variability, noting “although few younger women have high average scores, some older women have no radiographic sign of OA, while others are severely affected.” Multiple studies have also demonstrated the presence of significant lumbar degeneration to be evident even within the first two decades [ 38 , 39 ]. Such variability within members of the same age category suggests the influence of other contributing factors.

The impact of activity and occupation

Disk generation has long been associated with certain activities. Retrospective studies cite Body Mass Index (BMI), incident back trauma, daily spine loading (twisting, lifting, bending, and sustained nonneutral postures), and whole body vibration (such as vehicular driving) to be factors which increase both the likelihood and severity of spondylosis [ 20 , 41 ]. While these correlations exist, a study following progressive radiographic changes in lumber DDD did not find significant associations with the extent of physical activity, noting only age, back pain, and associated hip OA to be predictive of DDD and osteophyte changes [ 42 ].

The role of heredity

Genetic factors likely influence the formation of osteophytes and disk degeneration. Spector and MacGregor [ 43 ] proposed that 50% of the variability found in osteoarthritis can be attributed to heritable factors. Similarly, twin studies evaluating the progression of degenerative changes in lumbar MRI imaging suggest that approximately half (47–66%) of the variance could be explained by genetic and environmental factors, attributing only 2–10% of variance to physical loading and resistance training [ 44 ]. Another twin study revealed a high degree of similarity in signal intensity, disk height narrowing, disk bulging, and end-plate changes [ 45 ]. A search for these underlying genetic factors has identified polymorphisms in genes regulating inflammatory pathways and a Vitamin D Receptor allele to correspond to radiographic progression of lumbar disk degeneration [ 46 ].

A functional adaptation?

Is osteophyte formation inherently pathological? van der Kraan and van den Berg question if osteophyte formation may represent a remodeling process, functionally adapting to the instability or the changes in the demands of the spine [ 14 ]. Likewise, Humzah and Soames [ 47 ] emphasize the dynamic and reparative qualities of the intervertebral disk, responding to variations in mechanical loading and influencing vertebral kinematics to extend this argument. Osteophytes may form in the absence of other degenerative processes, and cartilaginous damage may exist without corresponding osteophytes [ 14 ]. Although there remains a strong association between the presence of osteophytes and other degenerative spine changes, isolated instances of one without the other occur, in the absence of overt symptoms.

A diagnostic approach

The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.

Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit [ 25 ]. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes [ 18 ]. While correlations between the number and severity of osteophytes and back pain exist [ 20 , 22 ], the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.

Nerve compression symptoms by clinical history may also be confirmed by electromyographic studies demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam. Diagnostic injections can facilitate localization by isolating and anesthetizing irritated nerve roots (via epidural), or by blocking suspected pain generators within facet joints, sacroiliac joints, or the disk space itself (via discography) [ 48 ].

Intervention and treatment options

Given our limited ability to isolate causative sources of chronic lower back pain, there is a little consensus with regard to a definitive treatment approach. Substantial variation in management by conservative and invasive approaches exists between practitioners throughout the country [ 8 ]. We will briefly describe these treatment options for the management of chronic low back pain syndromes within each of the four primary categories: physical therapy (and associated modalities and behavioral techniques), pharmacotherapy, injection therapy, and surgical intervention.

Exercise-based and behavioral interventions

Exercise therapy.

Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises [ 49 ]. Significant variation in regimen, intensity, and frequency of prescribed programs presents challenges to assessing efficacy among patients [ 50 ]. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in subacute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement [ 49 ]. The optimal approach to exercise therapy in chronic low back pain sufferers appears to be those regimens involving an individually-designed exercise program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. Such results are complemented by other conservative approaches, including NSAIDS, manual therapies, and daily physical activity [ 50 ].

Transcutaneous electrical nerve stimulation (TENS)

A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively. Such devices are frequently available in outpatient exercise therapy settings, with up to a third of patients experiencing mild skin irritation following treatment [ 51 ]. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion [ 52 , 53 ].

Back school

Back School was introduced first in Sweden with the purpose of minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises [ 54 ]. Two meta-analyses concluded that there is moderate evidence for improvement in both pain and functional status for chronic low back pain within short and intermediate time courses, when measured against other modalities such as exercise, joint manipulation, myofascial therapy, and/or other educational therapy [ 52 , 54 ].

Lumbar supports

Lumbar back supports may provide benefit to patients suffering chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity, and reduce mechanical forces. They may further have effects by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work [ 52 ].

Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis, are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are theorized to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression, and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals [ 52 ]. Nonetheless, patients with chronic symptoms and radicular pain have not found traction to provide significant improvement in pain nor daily functioning [ 55 – 57 ]. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning [ 52 ].

Spine manipulation

Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: “(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) disruption of articular or periarticular adhesion, (4) unbuckling of motion segments that have undergone disproportionate displacement, (5) reduction of disk bulge, (6) repositioning of miniscule structures within the articular surface, (7) mechanical stimulation of nociceptive joint fibers, (8) change in neurophysiological function, and (9) reduction of muscle spasm” [ 58 ].

Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement [ 52 ]. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school, and NSAID prescription, spinal manipulation appears comparable in its effectiveness both in short- and long-term benefits [ 52 , 59 ]. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk herniation or cauda equina syndrome occurring in fewer than 1/3.7 million [ 60 ].

Massage therapy

Massage therapy for chronic LBP appears to provide some beneficial relief. Weighed against other interventions, it proved less efficacious than TENS and manipulation, comparable with corsets and exercise regimens, and superior to acupuncture and other relaxation therapies, when followed over a 1-year course. Such preliminary results need confirmation, and evaluation for cost-effectiveness, but nevertheless suggest a potential role in certain, interested patients [ 61 ].

Multidisciplinary back therapy: the bio-psychosocial approach

Psychopathology is well recognized for its association with chronic spinal pain, and, when untreated, its ability to compromise management efforts [ 25 ]. For this reason, patients may find relief through learned cognitive strategies, termed “behavioral”, or “bio-psychosocial” therapy. Strategies involving reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. To date, evidence is limited with regard to the efficacy of operant, cognitive, and respondent treatment approaches [ 52 ].


Treatment efforts to control pain and swelling, minimize disability, and improve the quality of life with lumbar spondylosis often require medication to complement nonpharmacologic interventions. Extensive research efforts have explored the efficacy of different oral medications in the management of low back pain secondary to degenerative processes. Nonetheless, there remains no clear consensus regarding the gold-standard approach to pharmacologic management [ 62 ].

NSAIDS are widely regarded as an appropriate first step in management, providing analgesic and anti-inflammatory effects. There is adequate data demonstrating efficacy in pain reduction in the context of chronic low back pain [ 63 – 66 ], with use most commonly limited by gastrointestinal (GI) complaints. COX2 inhibitors offer modest relief in chronic LBP and improved function in the long-term setting. While they elicit fewer GI complications, their utilization has been curbed due to evidence for increased cardiovascular risk with prolonged use [ 52 ].

Opioid medications

Opioid medications may be considered as an alternative or augmentive therapy for patients suffering from gastrointestinal effects or poor pain control on NSAID management. The practice of prescribing narcotics for chronic low back pain sufferers is extremely variable within practitioners, with a range of 3–66% of chronic LBP patients taking some form of opioid in various literature studies [ 67 ]. These patients tend to report greater distress/suffering and higher functional disability scores [ 68 , 69 ]. Two meta-analyses suggest a modest short-term benefit of opioid use for treatment of chronic LBP while issuing a warning regarding the limited quality of available studies and the high rate of tolerance and abuse associated with long-term narcotic use within this patient population [ 62 , 67 ].


The use of antidepressants for treatment of LBP symptoms has also been explored considerably given their proposed analgesic value at low doses, and dual role in treatment of commonly comorbid depression that accompanies LBP and may negatively impact both sleep and pain tolerance [ 52 ]. Two separate reviews of available literature found evidence for pain relief with antidepressants, but no significant impact on functioning [ 70 , 71 ].

Muscle relaxants

Muscle relaxants, taking the form of either antispasmodic or antispasticity medications, may provide benefit in chronic low back pain attributed to degenerative conditions. There remains moderate to strong evidence through several trials comparing either a benzodiazepine, or non-benzodiazepine with placebo that muscle relaxants provide benefit with regard to short-term pain relief and overall functioning [ 52 , 62 , 72 ].

Injection therapy

Epidural steroid injections.

Epidural steroid injections (ESI) have become a common interventional strategy in the management of chronic axial and radicular pain due to degeneration of the lumbar spine. These injections may be performed through interlaminar, transforaminal, or caudal approaches. Usually by way of needles guided under fluoroscopy, contrast, then local anesthetic and steroid are infused into the epidural space at the target vertebral level and bathe exiting nerve roots. Symptomatic relief is theorized to occur through complementary mechanisms. Local anesthetics provide quick diagnostic confirmation, and therapeutically may short circuit the “pain spasm cycle” and block pain signal transmission [ 73 ]. Corticosteroids are well recognized for their capacity to reduce inflammation through blockade of pro-inflammatory mediators.

Within the span of less than one decade (1998–2005), the number of ESI procedures performed has increased by 121% [ 73 ]. Despite this widespread utilization, controversy remains regarding the efficacy of these injections, fueled by the expense and the infrequent but potential risks related to needle placement and adverse medication reactions. Available published data cites wide ranges in reported success rates due to variation in study designs, distinct procedural techniques, small cohorts, and imperfect control groups [ 74 ]. For example, prior to the year 2000, few efficacy studies of lumbar ESI utilized fluoroscopy to establish appropriate needle position. Research suggests that without fluoroscopic guidance confirmation, needle position may be inappropriate in as frequently as 25% of cases, even with experienced providers [ 75 ]. Review articles and practicing clinicians alike must interpret such methodological differences between studies to assemble opinions on efficacy and utility of ESI for LBP treatment.

One such review exploring efficacy of interlaminar lumbar injections concluded strong evidence for short-term pain relief and limited benefit for long-term benefit [ 73 ] citing, among many, randomized controlled trials (RCT) by Arden and Carette of unilateral sciatic pain, finding statistically significant improvement in up to 75% of patients with steroid/anesthesia versus saline injections at 3 weeks, with benefit waning by 6 weeks and 3 months, respectively [ 76 , 77 ].

The same review evaluating the transforaminal injection approach to unilateral sciatica found strong evidence for short-term, and moderate evidence for long-term symptom and functional improvement, based on the findings from several RCT. Vad et al. [ 78 ] studied 48 patients with herniated nucleus pulposus or radicular pain, treated with transforaminal ESI versus trigger point injections, citing an 84% improvement in functional scoring compared with 48% in the control group, extending for a follow-up period of 1 year. Lutz et al. [ 79 ] treated and followed a different cohort of 69 patients with the same underlying diagnoses, with transforaminal ESI for 80 weeks demonstrating 75% of patients with a successful long-term outcome, defined as >50% reduction in pain scores. In spinal stenosis, transforaminal ESI has achieved >50% pain reduction, improved walking, and improved standing tolerance in symptomatic patients extending through 1 year follow-up [ 80 ]. Furthermore, prospective trials by Yang and Riew found patients with severe lumbar radiculopathies and spinal stenosis treated with transforaminal injections experienced such sustained functional and symptomatic benefits so as to avoid intended surgical intervention [ 81 – 83 ].

Facet injections

Facet joints, also termed zygapophysial joints, are paired diarthrodial articulations between adjacent vertebrae. These joints are innervated from the medial branches of the dorsal rami and, through anatomical studies, possess free and encapsulated nerve endings, mechanoreceptors, and nociceptors. Inflammation to the joint creates pain signals which are implicated in 15–45% of patients with low back pain [ 25 ].

Diagnostic blocks of the joint inject anesthesia directly into the joint space or associated medial branch (MBB). Systematic reviews of both retrospective and prospective trials reveal single diagnostic facet blocks carry a false-positive rate of 22% to 47% [ 84 ] and medial branch blocks of 17–47% in the lumbar spine [ 85 ].

Subsequent therapeutic injections are similarly performed through either approach, with systematic reviews concluding moderate evidence available for short-term and long-term pain relief with facet blocks [ 86 ]. This evidence stems from studies such as Fuch’s RCT showing significant pain relief, functional improvement, and quality of life enhancement at 3 and 6 month intervals [ 87 ]. By contrast, Carette et al. [ 88 ] found no meaningful difference in perceived benefit between patients treated with steroid versus saline (control) injection at 3 and 6 month intervals. Available literature of MBB similarly show moderate evidence for short- and long-term relief [ 86 ] based on RCT of MBB under fluoroscopy, showing significant relief (by means of pain relief, physical health, psychological benefit, reduced narcotic intake, and employment status), with 1–3 injections in 100% patients at 3 months, 75–88% at 6 months, and 17–25% at 1 year [ 89 ].

SI joint injections

The sacroiliac joint space is a diarthrodial synovial joint with debated innervation patterns that involve both myelinated and unmyelinated axons. Injury or inflammation at the joint creates pain signals which are implicated in 10–27% of patients with low back pain [ 25 ] and may also refer to the buttocks, groin, thigh, and lower extremities.

There is moderate evidence to support the use of both diagnostic and therapeutic blocks of the SI joint [ 25 ]. Pereira treated 10 patients with MRI-guided bilateral SI joint injections of steroid, eight of whom reported “good to excellent” pain relief persisting through 13 months follow-up [ 90 ]. Maugers compared corticosteroid versus placebo injections under fluoroscopic guidance in SI joints of 10 symptomatic patients, reporting patient benefit only in the corticosteroid group. That benefit waned slowly over time, from 70% of patients at 1 month, to 62% at 3 months, and 58% at 6 months [ 91 ]. At this point, there is limited evidence to support radiofrequency neurotomy (ablation procedure) of the SI joint [ 92 ].

A recent meta-analysis provided the following guiding principles with regard to the frequency these procedures should be implemented in clinical practice. In cases of ESI, facet, and sacroiliac injections, diagnostic injections should be considered at intervals of no sooner than 1–2 weeks apart. Therapeutic injections may be performed at most every 2–3 months, provided the patient experiences greater than 50% relief within 6 weeks. Injections should be performed only as they are medically necessary given their associated risks and significant costs [ 25 ].

Intradiscal nonoperative therapies for discogenic pain

Discogenic pain has been identified as the source in 39% of patients with chronic low back pain. As described above, a cascade of effects induces the changes in the disk which generate pain. Discography seeks, when noninvasive imaging has failed, to identify damaged disks through injection of fluid into disk levels, in an attempt to reproduce patient symptoms. The technique’s utility remains controversial given significant potential for false positives. Provoked pain may be alternatively represent central hyperalgesia, reflect the patient’s chronic pain or psychological state, or result from technical difficulty due to the procedure itself [ 93 ].

If a diseased disk is identified, several treatment options exist. In addition to surgical correction, there are minimally invasive options. Both Intradiscal electrothermal therapy (IDET) and Radiofrequency posterior annuloplasty (RPA) involve electrode placement into the disk. Heat and electrical current coagulate the posterior anulus, and in doing so, strengthen collagen fibers, seal figures, denature inflammatory exudates, and coagulate nociceptors [ 25 ]. Current evidence provides moderate support for IDET in discogenic pain sufferers. Preliminary studies of RPA provide limited support for short term relief, with indeterminate long-term value. Both procedures have associated complications, including catheter malfunction, nerve root injuries, post-procedure disk herniation, and infection risk [ 25 ].

Surgical options

Surgical interventions are generally reserved for patients who have failed conservative options. Patients must be considered as appropriate “surgical candidates,” taking into consideration medical comorbidities as well as age, socioeconomic status, and projected activity level following a procedure [ 18 ]. Many surgical approaches have been developed to achieve one of the two primary goals: spinal fusion or spine decompression (or both).

Spinal fusion is considered in patients with malalignment or excessive motion of the spine, as seen with DDD and spondylolisthesis. Several surgical fusion approaches exist, all involving the addition of a bone graft to grow between vertebral elements to limit associated motion. Decompression surgery is indicated for patients with clear evidence of neural impingement, correcting the intrusion of bone or disk as might be seen in spinal or foraminal stenosis, disk herniation, osteophytosis, or degenerative spondylolisthesis. Despite dramatic increases in the number of procedures performed over the last several decades, there remains controversy as to the efficacy of these procedures in resolving chronic low back unresponsive to conservative management.

Controversy arises, in part, due to the inherent challenges of comparing the available research. Systematic reviews cite the heterogeneity of current trials which evaluate different surgical techniques with differing comparison groups and limited follow-up, frequently without patient-centered or pain outcomes included [ 18 ]. Some case series reveal promising results [ 94 ]. Nonetheless, a recent meta-analysis of 31 randomized controlled trials, concluded, “[there is] no clear evidence about the most effective technique of decompression for spinal stenosis or the extent of that decompression. There is limited evidence that adjunct fusion to supplement decompression for degenerative spondylolisthesis produces less progressive slip and better clinical outcomes than decompression alone.” Another review, noting no statistically significant improvement in patients undergoing fusion compared with nonsurgical interventions commented, “surgeons should recommend spinal fusion cautiously to patients with chronic low back pain. Further long-term follow-ups of the studies reviewed in this meta-analysis are required to provide more conclusive evidence in favor of either treatment” [ 95 ].

Lumbar spondylosis is a complicated diagnosis. We chose to define it broadly as degenerative conditions of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically, its pervasiveness throughout all patient populations makes the exact diagnosis of symptomatic cases extremely difficult. Moreover, there is no current concrete, gold-standard treatment approach to the diverse range of patient presentations despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be a critical research focus. Important clues are in place, from genetic studies, risk factor analysis, and explorative treatment approaches. These efforts, and future endeavors will no doubt fine-tune and present means to tackle not only symptoms, but confront progression, and ultimately prevention of disease in years to come.

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Middleton, K., Fish, D.E. Lumbar spondylosis: clinical presentation and treatment approaches. Curr Rev Musculoskelet Med 2 , 94–104 (2009).

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  • Grade I – Less than 25 percent slippage
  • Grade II – Between 25 and 50 percent slippage
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  • Grade IV – More than 75 percent slippage
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Spondylolisthesis is where one of the bones in your spine, called a vertebra, slips forward. It can be painful, but there are treatments that can help.

It may happen anywhere along the spine, but is most common in the lower back.

Check if you have spondylolisthesis

The main symptoms of spondylolisthesis include:

  • pain in your lower back, often worse when standing or walking and relieved when sitting or bending forward
  • pain spreading to your bottom or thighs
  • tight hamstrings (the muscles in the back of your thighs)
  • pain, numbness or tingling spreading from your lower back down 1 leg ( sciatica )

Spondylolisthesis does not always cause symptoms.

Spondylolisthesis is not the same as a slipped disc . This is when the tissue between the bones in your spine pushes out.

Non-urgent advice: See a GP if:

  • you have lower back pain that does not go away after 3 to 4 weeks
  • you have pain in your thighs or bottom that does not go away after 3 to 4 weeks
  • you're finding it difficult to walk or stand up straight
  • you're worried about the pain or you're struggling to cope
  • you have pain, numbness and tingling down 1 leg for more than 3 or 4 weeks

What happens at your GP appointment

If you have symptoms of spondylolisthesis, the GP may examine your back.

They may also ask you to lie down and raise 1 leg straight up in the air. This is painful if you have tight hamstrings or sciatica caused by spondylolisthesis.

The GP may arrange an X-ray to see if a bone in your spine has slipped forward.

You may have other scans, such as an MRI scan , if you have pain, numbness or weakness in your legs.

Treatments for spondylolisthesis

Treatments for spondylolisthesis depend on the symptoms you have and how severe they are.

Common treatments include:

  • avoiding activities that make symptoms worse, such as bending, lifting, athletics and gymnastics
  • taking anti-inflammatory painkillers such as ibuprofen or stronger painkillers on prescription
  • steroid injections in your back to relieve pain, numbness and tingling in your leg
  • physiotherapy to strengthen and stretch the muscles in your lower back, tummy and legs

The GP may refer you to a physiotherapist, or you can refer yourself in some areas.

Waiting times for physiotherapy on the NHS can be long. You can also get it privately.

Surgery for spondylolisthesis

The GP may refer you to a specialist for back surgery if other treatments do not work.

Types of surgery include:

  • spinal fusion – the slipped bone (vertebra) is joined to the bone below with metal rods, screws and a bone graft
  • lumbar decompression – a procedure to relieve pressure on the compressed spinal nerves

The operation is done under general anaesthetic , which means you will not be awake.

Recovery from surgery can take several weeks, but if often improves many of the symptoms of spondylolisthesis.

Talk to your surgeon about the risks and benefits of spinal surgery.

Causes of spondylolisthesis

Spondylolisthesis can:

  • happen as you get older – the bones of the spine can weaken with age
  • run in families
  • be caused by a tiny crack in a bone (stress fracture) – this is more common in athletes and gymnasts

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Spondylolisthesis and Spondylolysis

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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Cervical Spondylosis article more useful, or one of our other health articles .

Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

In this article

What is spondylolisthesis, spondylolisthesis vs spondylolysis.

  • Who gets spondylolisthesis and spondylolysis? (Epidemiology)

Spondylolisthesis causes (aetiology)

  • Types of spondylolisthesis
  • Presentation

Differential diagnosis


  • Spondylolisthesis treatment and management

Complications of surgical repair

Spondylolisthesis prognosis.

Spondylolisthesis is the movement of one vertebra relative to the others in either the anterior or posterior direction due to instability. Degenerative spondylolisthesis is a common pathology, often causing lumbar canal stenosis [ 1 ] .

Anatomy of the vertebrae

The vertebrae can be divided into three portions:

  • Centrum - involved in weight bearing. This is the body of the vertebra and is formed of cancellous bone.
  • Dorsal arch - surrounds and protects the spinal cord. It carries the upper and lower facet joints of each vertebra which articulate with the facet joints of the vertebra above and below, respectively. The part of the vertebral arch between them is the thinnest part and is called the pars interarticularis, or the isthmus.
  • Posterior aspect - protrudes and can be palpated on the lower back.

Lumbar vertebra 1 inferior surface

Lumbar vertebra 1 inferior surface

Lumbar vertebra 1 anterior surface

Lumbar vertebra 1 anterior surface

Images by Anatomography, via Wikimedia Commons . Click here to see a lumbar vertebra 1 close-up superior surface animation.

Spondylolysis and spondylolisthesis are separate conditions, although spondylolysis often precedes spondylolisthesis.

  • Spondylolysis is a bony defect (commonly due to a stress fracture but it may be a congenital defect) in the pars interarticularis of the vertebral arch, separating the dorsum of the vertebra from the centrum. It may occur unilaterally or bilaterally. It most commonly affects the fifth lumbar vertebra and may cause back pain.
  • Spondylolisthesis refers to the anterior slippage of one vertebra over another (or the fifth vertebra over the sacrum). There are five forms:
  • Isthmic : the most common form, usually acquired in adolescence as a consequence of spondylolysis but often unnoticed until adulthood.
  • Degenerative : developing in older adults as a result of facet joint osteoarthritis and bone remodelling.
  • Traumatic (rare): resulting from fractures of the neural arch.
  • Pathologic : from metastases or metabolic bone disease.
  • Dysplastic : (rare): congenital, resulting from malformation of the pars.
  • Spondylosis is a general term for degenerative osteoarthritic changes in the spine. It involves dehydration of the intervertebral discs with consequent narrowing of the intervertebral spaces. There may be changes in the facet joints with osteophyte formation and this may put pressure on the nerve roots, causing motor and sensory disturbance.

Who gets spondylolisthesis and spondylolysis? (Epidemiology) [ 2 ]

  • Spondylolysis is a common diagnosis with a high prevalence in children and adolescents complaining of low back pain.
  • There is an increased risk of spondylolysis in young athletes like gymnasts, presumably due to impact-related stress fractures . However most cases are low-grade. At-risk activities include gymnastics, diving, tennis, cricket, weightlifting, football and rugby.
  • Isthmic spondylolisthesis affects around 5% of the population but is more common in young athletes. 60-80% of people with spondylolysis have associated spondylolisthesis [ 3 , 4 ] .
  • The majority of cases of spondylolysis and spondylolisthesis affect L5 and most of the remainder affect L4.
  • Degenerative spondylolisthesis is more common in older people, particularly women.
  • Traumatic, metastatic and dysplastic spondylolistheses are relatively rare.
  • Many cases of spondylolisthesis are asymptomatic.

Spondylolisthesis commonly occurs due to a fracture or defect in the pars interarticularis, the narrowest part of the posterior vertebral arch between the upper and lower facet joints. When this is breached, the upper facet joint may no longer be able to hold the vertebra in place against the downward force of body weight and forward/downward slippage occurs.

Risk factors that increase the risk of spondylolysis developing into spondylolisthesis include [ 5 ] :

  • Female gender.
  • Presence of spina bifida or spina bifida occulta .
  • Vertebral wedging.
  • Hyperlordosis.
  • Positive family history.
  • Certain high-impact sports, as evidenced by increased rates in athletes and gymnasts [ 3 ] .

Types of spondylolisthesis [ 2 ]

  • Stable or unstable.
  • Asymptomatic or symptomatic.
  • Graded according to degree of slippage; the Meyerding classification is based on the ratio of the overhanging part of the superior vertical body to the anterio-posterior length of the inferior vertebral body:
  • Grade I: 0-25%.
  • Grade II: 26-50%.
  • Grade III: 51-75%.
  • Grade IV: 76-100%.
  • Grade V (spondyloptosis): >100%.
  • Graded according to type; the Wiltse classification (1976):
  • Type I: dysplastic (congenital).
  • Type II: isthmic: secondary to a lesion involving the pars interarticularis:
  • Subtype A: secondary to stress fracture.
  • Subtype B: result of multiple healed stress fractures resulting in an elongated pars.
  • Subtype C: acute pars fracture (rare).
  • Type III: degenerative.
  • Type IV: post-traumatic: fracture in a region other than the pars.
  • Type V: pathological: diffuse or local disease.
  • Type VI: iatrogenic.

Presentation [ 4 ]

Spondylolysis symptoms.

  • Most cases of spondylolysis are asymptomatic and identified incidentally.
  • It may present with low back pain provoked by lumbar extension, paraspinal spasm and tight hamstrings.
  • It frequently does not show on X-ray. It is important to consider it in the differential diagnosis of back pain, as its identification can prevent progression and avoid the potential need for aggressive intervention.

Spondylolisthesis symptoms

Presentation varies slightly by type although common spondylolisthesis symptoms include exercise-related back pain, radiating to the lower thighs, which tends to be eased by rest, particularly in positions of spinal flexion.

Isthmic spondylolisthesis

  • Most patients are asymptomatic, even with progressing slippage.
  • Symptoms often begin around the adolescent growth spurt.
  • Back pain - worse with activity (particularly back extension) - this may come on acutely or insidiously.
  • Pain may flare with sudden or trivial activities and is relieved by resting.
  • Pain is worse with higher grades of disease.
  • Pain may radiate to buttocks or thighs
  • There are usually no neurological features with lower grades of slippage but radicular pain becomes common with larger slips. Pain below the knee due to nerve root compression or disc herniation would suggest more severe slippage. High degrees of spondylolisthesis may present with neurogenic claudication or even cauda equina impingement.
  • Tightened hamstrings are very common
  • There may be enhanced lordosis and a waddling gait with shortened step length.
  • There may be gluteal muscular wasting.

Degenerative spondylolisthesis

  • Pain is aching in nature and insidious in onset.
  • Pain is in the low back and posterior thighs.
  • Neurogenic claudication may be present with lower-extremity symptoms worsening with exercise.
  • Symptoms are often chronic and progressive, sometimes with periods of remission.
  • If lumbar stenosis is also present, reflexes may be diminished.

Dysplastic spondylolisthesis

  • Presentation and physical findings are similar to isthmic spondylolisthesis but with a greater likelihood of neurological compromise.

Traumatic spondylolisthesis

  • Patients will have experienced acute trauma and are likely to have significant pain.
  • Severe slips may cause cauda equina compression with bladder and bowel dysfunction, radicular symptoms or neurogenic claudication.
  • Physical findings are as for the other types.

Pathological spondylolisthesis

  • Symptoms may be insidious in onset and associated with radicular pain.

Other causes of back pain need to be ruled out - eg:

  • Osteoarthritis .
  • Ankylosing spondylitis .
  • Mechanical lower back pain .
  • Spinal cord lesion.
  • Multiple myeloma .
  • Vertebral compression fracture .
  • Lumbar disc prolapse.
  • Discitis/other spinal disc problems .
  • Blood tests - looking for infection, myeloma, hypercalcaemia/hypocalcaemia.
  • Lateral spinal X-rays - will show spondylolisthesis. These are best performed in the position of maximal pain.
  • Oblique spinal X-rays - may (but will often not) detect spondylolysis.
  • Radionuclide scintigraphy and CT may help in cases of spondylolysis in distinguishing progressing lesions of the pars from stable lesions.
  • MRI is often performed perioperatively to look at relationships between the bony and neurological structures in the compromised area.

Spondylolisthesis treatment and management [ 1 , 2 , 4 ]

The goal of treatment is to relieve pain, stabilise the spinal segment and stop or reverse the slippage. Patients need to be evaluated for the presence of instability, as if there is an unstable segment early surgery will be needed.

Depending on the severity of the spondylolysis and symptoms associated it may be treated either conservatively or surgically, both of which have shown significant success.

Conservative treatments such as bracing and decreased activity have been shown to be most effective with patients who have early diagnosis and treatment. Low-intensity pulsed ultrasound in addition to conservative treatment appears to achieve a higher rate of bony union. Surgery may be required if conservative treatment, for at least six months, failed to give sustained pain relief for the activities of daily living.

For degenerative spondylolisthesis, surgery is indicated mainly for perceived functional impairment. Improvement in neurological symptoms is one of the main treatment objectives. For this, it is useful to perform radicular decompression. The most frequent technique is direct posterior decompression.

Conservative treatment

  • Complete bed rest for 2-3 days can be helpful in relieving pain, particularly in spondylolysis, although longer periods are likely to be counterproductive. Patients should try to sleep on their side as much as possible, with a pillow between the knees.
  • Activity modification to prevent further injury. This may mean avoidance of activities if there is >25% slippage.
  • Analgesia - eg, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), codeine phosphate.
  • Steroid and local anaesthetic injections are sometimes used around compressed nerve roots or even into the fracture area of the pars for diagnostic purposes.
  • Bracing: a brace or corset may be recommended for a pars interarticularis fracture which is likely to heal. Bracing with exercise may be beneficial for patients with mild or even more severe degrees of slippage.
  • Physiotherapy: this includes massage, ultrasound, bracing, mobilisation, biomechanical correction, hydrotherapy, exercises for flexibility, strength and core stability and a gradual return to activity programme.
  • More than 80% of children treated non-surgically will have full resolution of symptoms.
  • A meta-analysis of observation studies suggested that around 80% of all patients treated non-operatively would have a successful clinical outcome after one year. Lesions diagnosed at the acute stage and unilateral lesions were the best subgroups [ 6 ] .

Surgical treatment

  • If there is evidence of progression or if conservative measures are ineffective then surgical therapy may be offered. This depends also on degree and aetiology.
  • Surgical intervention involves a prolonged rehabilitation period so it is generally not considered until conservative treatments have failed. An exception would be in the case of significant instability or neurological compromise and in high-grade slips.
  • Surgical therapy involves fusing the affected vertebra with a neighbouring normally aligned vertebra (both anteriorly and posteriorly). The intervertebral disc is usually also removed, as it is inevitably damaged. The slipped vertebra may be realigned.
  • Whilst most surgeons agree that decompression of the nerves is of benefit to patients, the benefit of realigning slipped vertebrae is uncertain. For example, when the spondylolisthesis is very gradual in onset, or in cases of congenital spondylolisthesis, compensatory changes in the spine and musculature occur so that realignment may increase the possibility of further injury.
  • There is good evidence that surgical treatment of symptomatic spondylolisthesis is significantly superior to non-surgical management in the presence of [ 7 ] :
  • Significant neurological deficit.
  • Failed response to conservative therapy.
  • Instability with neurological symptoms.
  • Degree of subluxation of III or more.
  • Unremitting pain affecting quality of life.
  • A large systematic review concluded that reduction of displacement carried benefits over fusion alone, although a large retrospective review showed high complication rates, particularly for older patients with more severe disease [ 8 , 9 , 10 , 11 ] .
  • Fusion techniques can be associated with neurological complications in older patients with degenerative spondylolisthesis, but in adolescent patients outcomes are good [ 9 ] .
  • Surgery is commonly complicated by pseudoarthrosis (non-union) which may result in chronic pain years down the line.
  • In the case of spondylolysis, if surgery is offered it would involve pinning the defect. However, most cases are managed conservatively.
  • Implant failure.
  • Pseudoarthrosis (failure of bone healing leading to a 'false joint').
  • Poor alignment of the fusion.
  • Neurological damage: foot drop, spinal cord compression . Chronic nerve injury/inflammation: neuropathic pain can persist in the face of apparent surgical success, possibly due to permanent changes in the nerves or a deregulation of pain control mechanisms.

Spondylolisthesis is generally a benign condition; however, it runs a chronic course and is therefore a cause of much morbidity and disability. In degenerative spondylolisthesis this will relate in part to the progress and prognosis of the underlying changes.

Dr Mary Lowth is an author or the original author of this leaflet.

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Further reading and references

Guigui P, Ferrero E ; Surgical treatment of degenerative spondylolisthesis. Orthop Traumatol Surg Res. 2017 Feb103(1S):S11-S20. doi: 10.1016/j.otsr.2016.06.022. Epub 2016 Dec 30.

Gagnet P, Kern K, Andrews K, et al ; Spondylolysis and spondylolisthesis: A review of the literature. J Orthop. 2018 Mar 1715(2):404-407. doi: 10.1016/j.jor.2018.03.008. eCollection 2018 Jun.

Toueg CW, Mac-Thiong JM, Grimard G, et al ; Prevalence of spondylolisthesis in a population of gymnasts. Stud Health Technol Inform. 2010158:132-7.

Syrmou E, Tsitsopoulos PP, Marinopoulos D, et al ; Spondylolysis: a review and reappraisal. Hippokratia. 2010 Jan14(1):17-21.

Sadiq S, Meir A, Hughes SP ; Surgical management of spondylolisthesis overview of literature. Neurol India. 2005 Dec53(4):506-11.

Klein G, Mehlman CT, McCarty M ; Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop. 2009 Mar29(2):146-56. doi: 10.1097/BPO.0b013e3181977fc5.

Alfieri A, Gazzeri R, Prell J, et al ; The current management of lumbar spondylolisthesis. J Neurosurg Sci. 2013 Jun57(2):103-13.

Weinstein JN, Lurie JD, Tosteson TD, et al ; Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun91(6):1295-304. doi: 10.2106/JBJS.H.00913.

Sansur CA, Reames DL, Smith JS, et al ; Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis. J Neurosurg Spine. 2010 Nov13(5):589-93. doi: 10.3171/2010.5.SPINE09529.

Kasliwal MK, Smith JS, Kanter A, et al ; Management of high-grade spondylolisthesis. Neurosurg Clin N Am. 2013 Apr24(2):275-91. doi: 10.1016/ Epub 2013 Feb 21.

Longo UG, Loppini M, Romeo G, et al ; Evidence-based surgical management of spondylolisthesis: reduction or arthrodesis in situ. J Bone Joint Surg Am. 2014 Jan 196(1):53-8. doi: 10.2106/JBJS.L.01012.

Related Information

  • Cervical Spondylosis
  • Orthopaedic Problems in Childhood
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  • Continuing Education Activity

Spondylolysis is a unilateral or bilateral defect in the region of the pars interarticularis, (isthmus or bone bridge between the inferior and superior articular surfaces of a single vertebra) is most commonly the result of repetitive trauma to the growing immature skeleton of a genetically susceptible individual. The prevalence of this condition is 4% by age 6 and 6% by age 14. Spondylolysis usually is asymptomatic, but approximately 10% of affected individuals present with symptoms including insidious onset, low back pain that is exacerbated with activity or lumbar hyperextension, and may or may not be associated with a radicular component. This activity outlines the evaluation and treatment of spondylolysis and highlights the role of the interprofessional team in managing patients with this condition.

  • Describe the causes of spondylolysis.
  • Review the presentation of a patient with spondylolysis.
  • Summarize the treatment options for spondylolysis.
  • Outline the importance of cooperation among the interprofessional team on the proper biomechanics to optimize comfort, decrease stress, and promote healing in those with spondylolysis.
  • Introduction

Spondylolysis is a unilateral or bilateral defect in the region of the pars interarticularis, which may or may not be accompanied by the vertebral body slippage. It is most commonly the sequelae of repetitive trauma to the growing immature skeletal architecture among a genetically susceptible individuals. [1] [2] [3]  The pars interarticularis is considered the isthmus or bone bridge between the inferior and superior articular surfaces of a single vertebra.  [4] [5] [6]

Spondylolysis may be congenital or acquired. Although the exact pathogenesis remains unknown in all cases, it is most commonly secondary to a fatigue or stress fracture of the pars interarticularis that persists as a non-union. It typically develops in genetically susceptible children and adolescents with faulty biomechanics, and who also experience repetitive microtrauma on the pars interarticularis from repeated activities involving lumbar hyperextension with rotation. [3] [4] [5] [6]

  • Epidemiology

The prevalence of spondylolysis is 4% by age 6 and 6% by age 14 and thereafter remains constant throughout adulthood.

There is a genetic predisposition with an increased incidence seen in:

  • Males (male to female ratio of 2:1)
  • Alaskan Eskimo descendants
  • First-degree offspring of patients with the condition
  • Concurrent pathologies such as spina bifida occulta, Marfan syndrome, osteogenesis imperfecta, and osteopetrosis.

Adolescents involved in sports have a higher prevalence compared to those not involved in sports. The mean age of diagnosis is 15 years of age.

There is an increased incidence among participants of certain higher-risk sports which involve repeated axial loading and/or lumbar hyperextension with rotation. These sports include gymnastics, dance, football (particularly linemen), rugby, wrestling, martial arts, soccer, basketball, cheerleading, pitching, golf, tennis, volleyball servers, weightlifting, and butterfly and breaststroke swimming. [3] [4] [7] [8]

  • Pathophysiology

Ninety percent of the cases of spondylolysis occur at the L5 vertebra with decreasing incidence at progressively higher lumbar levels. Excessive lumbar lordosis is a risk factor for spondylolysis development. Most commonly, pars interarticularis defects occur bilaterally as opposed to unilaterally. Unhealed pars interarticularis defects may progress to lytic (isthmic) spondylolisthesis, which is an anterior displacement of the vertebral body in relation to the vertebra below. It is important to note unilateral lesions never progress to spondylolisthesis. However, in patients with bilateral spondylolysis, at the time of diagnosis, 50% to 75% will already have accompanying spondylolisthesis. Slip progression is more common in adolescents compared to adults, and although the incidence of spondylolysis is more common in males, the slip progression of spondylolisthesis occurs more frequently in females.

Additionally, multifidi muscles of the back attach to the mamillary process of the vertebra thereby stabilizing vertebral joints and providing stability at each segmental level. The mammillary process is not completely formed until 25 years of age. Full ossification of the neural arch is also not completed until the same age limit. These 2 factors play a pivotal role in the development of the condition during adolescence. [8] [5] [3]

  • History and Physical

Spondylolysis mostly remains asymptomatic, but approximately 10% of affected individuals manifest symptoms constituting of insidious onset, recurrent axial low back pain that increases with activity, is exacerbated by lumbar hyperextension, and may or may not be associated with a radicular component. The pain can range from mild to severe in intensity and is described as a dull, aching pain in the lower back, buttocks, and posterior thigh regions. If neurologic symptoms/signs are present, it is likely secondary to spondylolysis with spondylolisthesis or associated degenerative processes resulting in narrowing of the neuroforamina and the spinal nerve impingements. Since spondylolysis most commonly affects L5 on S1, the corresponding dermatomal and myotomal pattern clinical manifestations usually occur. It is important to note that if the patient’s spondylolysis has progressed to spondylolisthesis and they are presenting with pain, the degree of pain does not correlate with the degree of slippage, and this presents a diagnostic challenge and explains why the condition is often advanced at the time of diagnosis.

The neurological examination would specifically show increased lumbar lordosis, tight hamstrings, reduced trunk range of motion (particularly with extension), tenderness to palpation overlying the pars fracture site, a positive stork test (single leg hyperextension and rotation of the spine which reproduces the patient pain and is diagnostic of spondylolysis until proven otherwise), with the characteristic absence of any radiculopathy. Again, radicular symptoms can occur, but they are uncommon. [9] [7] [3]

As a general consensus rule, a patient's neurologic examination, as well as all laboratory evaluations including inflammatory markers, will be largely unremarkable.

There are no universally accepted guidelines for an imaging protocol, but the initial imaging studies of choice when the condition is suspected are plain radiographs in the posteroanterior, lateral, and oblique views of the lumbosacral region in the standing position. When present, the lesion is most typically visible in the oblique view which shows the classic "collar on the Scotty dog" and represents the bony defect between the inferior articular surface and the superior articular surface of a single vertebra. As with any stress fracture, plain films may miss the lesion within the first 2 weeks of the injury. Additionally, it has been reported that plain radiographs only have a sensitivity of 33% in detecting spondylolysis. Some authorities advocate axial CT-imaging as the test of choice for spondylolysis; however, due to the high prevalence of spondylolysis in the pediatric population and concerns regarding unnecessary radiation exposure, the next advanced imaging modality is typically chosen, if plain films are negative, is the MRI. MRI is excellent at detecting bone marrow edema associated with acute pars interarticularis stress injury as well as detailing neural and soft tissue pathologies. The SPECT scan is a suitable alternative to MRI for detecting acute stress fractures and is also useful in determining the acuity of a fracture. It however carries the risk of concurrent radiation hazards, which is therefore preferably avoided in the pediatric population. [7] [10] [8] [9]

  • Treatment / Management

Most patients with spondylolysis, including athletes, can be managed conservatively. In fact, patients who are asymptomatic and their condition is discovered incidentally on imaging may maintain their current level of physical activity without any activity restrictions. However, if the patient presents with acute symptomatic spondylolysis as confirmed by SPECT-scan or MRI, conservative treatments are warranted and would include:

  • Relative 6 to 12 weeks of spinal bracing (Corset versus TLSO), thus, limiting spinal mobilization and stress on the pars interarticularis. However, a recent meta-analysis found that 83% of patients treated non-operatively improved clinically regardless of any spinal bracing.
  • Activity modifications including cessation of activities, especially those involving a hyperextension of the spine. Athletic activities may be gradually resumed as the pain subsides.
  • Physical therapy emphasizing spinal stabilization through stretching of the hip flexors, hamstrings, quadriceps, gastrocnemius-soleus complex, and strengthening of the abdominal and back muscles utilizing a pain-free range of motion with the application of the progressive resistance training protocol such as William’s flexion exercises is generally advised.

Adjunctive treatments including ice/heat therapy, NSAIDS, epidural steroid injections, massage, osteopathic or chiropractic manipulation, and cognitive-behavioral therapy (CBT) are generally well-tolerated, are of benefits, and should be considered.

With conservative treatment protocol, 75% of adolescents will improve, and invariably their lytic defects heal. Unilateral defects are more likely to heal than bilateral defects. In cases of spondylolysis with concomitant spondylolisthesis, the bony defects are unlikely to heal but the implementation of the same conservative treatment principles typically results in an abatement of the patients’ symptomatology and return to their previous level of activity. A recent randomized control trial found no difference in the clinical outcomes among patients with spondylolisthesis among cohorts treated conservatively with those managed surgically; which is clinically significant considering the cost and the potential complications associated with surgical treatments. Additionally, there is currently no clinical evidence favoring spinal bracing in preventing vertebral slippage among patients with spondylolysis and spondylolisthesis.

Surgical intervention is only warranted if the patient fails a conservative management trial of at least 6 months or has progressive neurologic symptoms with saddle anesthesia, bowel/bladder dysfunction, refractory pain, or develops spondylolisthesis of grade 3 or higher. The most commonly performed surgical treatments of spondylolysis include a direct repair of the defect in the pars interarticularis at L1 to L4 levels and an inter-transverse fusion for defects at the L5 level. [7] [11]

  • Differential Diagnosis
  • Muscular strains and sprains
  • Lumbar radiculopathy secondary to degenerative disc disease and resultant disc bulge and/or herniation
  • Spinal canal stenosis
  • Epidural abscess
  • Fracture of other components of the posterior vertebral arch
  • Osteoid sarcoma or other primary bone tumors
  • Pathologic fracture secondary to osteoporosis, malignancy, infections, or additional intrinsic bone-weakening etiologies
  • Degenerative spondylolisthesis of adulthood
  • Ankylosing spondylitis [7] [4]

The prognosis in patients with spondylolysis is usually excellent. Asymptomatic individuals require no specific treatments or any modifications to activities of daily living or athletic activities. Even patients who present with symptomatic spondylolysis usually have a very favorable prognosis as validated by a recent meta-analysis which demonstrated that the  92% of the adolescent athletes were able to return to competitions when they are treated conservatively, and 90% of the time when managed surgically. [11] [1] [3] [4]

  • Complications

In the majority of patients with spondylolysis, the condition is occult and remains asymptomatic throughout their lifetimes. However, degenerative disc disease and resultant spondylosis, which typically occurs as a sequela of the aging process, have a propensity to be accelerated in patients with spondylolysis. This may lead to spinal stenosis and lumbar radiculopathies. These deleterious effects may also occur secondary to vertebral body slippage in almost 50% to 75% of patients with bilateral spondylolysis. Potential surgical complications would include a failed fusion, infections, chronic persistent pain, neurological deteriorations, and the failed back surgery syndrome. [11] [1] [4]

  • Postoperative and Rehabilitation Care

The need for surgical correction of spondylolysis is uncommon. However, if surgical correction is justified, the postoperative rehabilitative processes should include stringent protection of the surgical site until wound closure (bracing is typically surgeon dependent), proper analgesia, graded physical therapy, and education on proper biomechanics with an emphasis on maintaining corrective postures and sleeping positionings. [9] [11] [1]

  • Consultations

Orthopedic and neurosurgical consultations as indicated. [4] [7]

  • Deterrence and Patient Education

Asymptomatic individuals, whose condition is discovered incidentally on imaging, should be reassured of the generally benign course of the disease throughout their lifetime, without any need for activity restrictions. However, symptomatic individuals with a pars interarticularis defect that is actively undergoing treatment, regardless of whether the treatment is conservative or surgical, need to have an education and understanding on proper biomechanics to optimize their comfort as well as to decrease stress and promote healing of the involved structures. Techniques that should be taught and implemented include:

  • Log-rolling while getting in and out of bed and limiting truncal movement in only one plane at a time (in other words, sagittal, coronal, transverse) during transfers and ambulation
  • Utilizing a lumbar roll while sitting, pillow under the knees when supine, and between the knees when side-lying helps to maintain the neutrality of the spine thereby decreasing stress on the concerned vertebra, promoting healing, as well as maximizing patient comfort. [4] [7] [3]
  • Enhancing Healthcare Team Outcomes

Spondylolysis is best managed by an interprofessional team that includes a surgeon, primary care provider, physical therapist, nurse, and sports physician. The majority of patients are managed conservatively.

Surgical correction of spondylolysis is uncommon. However, if surgical correction is necessary the postoperative rehabilitative care should include protection of the surgical site until wound closure (bracing is typically surgeon dependent), proper analgesia, physical therapy, and education on proper biomechanics with an emphasis on posture and sleeping positioning. An integral part of the postoperative rehabilitative care of athletes constitutes a graded return to sports protocol, comprising of education on maintaining proper biomechanics at first, and gradually progressing to sport-specific activities as tolerated. [9] [11] [1]

For those who remain compliant with physical therapy, the prognosis is good. Those who continue to lead a sedentary lifestyle usually develop chronic refractory pain and the resultant poor quality of life. [12]  

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Spondylolysis with Spondylolisthesis, showing spino pelvic parameters, slip, dysplasia of upper endplate of S1, Slip angle (SA = angle between inferior endplate of L5 and line perpendicular to the S1 posterior wall) and lumbo sacral angle (LSA = angle (more...)

Lateral X-ray of the pelvis and lower lumbar spine showing spondylolysis and spondylolisthesis. Contributed by George Ampat FRCS

Disclosure: Brandon McDonald declares no relevant financial relationships with ineligible companies.

Disclosure: Andrew Hanna declares no relevant financial relationships with ineligible companies.

Disclosure: John Lucas declares no relevant financial relationships with ineligible companies.

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  • Cite this Page McDonald BT, Hanna A, Lucas JA. Spondylolysis. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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  • Review Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management. [J Sports Med (Hindawi Publ Cor...] Review Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management. Goetzinger S, Courtney S, Yee K, Welz M, Kalani M, Neal M. J Sports Med (Hindawi Publ Corp). 2020; 2020:9235958. Epub 2020 Jan 21.
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A Study on the Effectiveness of Dermoneuromodulation on Neck Pain and Disability among Patients with Cervical Spondylosis

Nishar Basha, K A (2019) A Study on the Effectiveness of Dermoneuromodulation on Neck Pain and Disability among Patients with Cervical Spondylosis. Masters thesis, RVS College of Physiotherapy, Coimbatore.

INTRODUCTION: Cervical Spondylosis is defined as a chronic degenerative process affects the intervertebral discs and facet joints, and may progress to disk herniation, osteophyte formation, vertebral body degeneration, compression of the spinal cord, or cervical spondylotic myelopathy. OBJECTIVES: 1. To find out the effectiveness of Dermoneuromodulation in the management of neck pain among patients with Cervical Spondylosis. 2. To find out the effectiveness of Dermoneuromodulation in the management of disability among patients with Cervical Spondylosis. METHODOLOGY: Study Setting: The study was conducted in R.V.S Physiotherapy Outpatient Department, Sulur and Ideal Physiotherapy Centre, Coimbatore. Selection of subjects: 10 patients were selected who fulfilled the inclusion and exclusion criteria. Study Design: The study design was a pre and post-test experimental study. Inclusion criteria: 1. Clinically diagnosed cervical spondylosis patients. 2. Age 55 to 65 years. 3. Symptoms for at least three months. 4. Both male and female. 5. Patient who are willing to participate. Exclusion criteria: 1. Patients having psychosocial problems. 2. Diabetes mellitus, Uncontrolled Hypertension, Rheumatoid arthritis. 3. Any surgeries in cervical region. 4. Thoracic kyphoscoliosis. 5. Skin infections in the neck region. 6. Pregnancy. 7. Acute Urticaria. 8. Congenital deformities of the nervous system. RESULTS: Total number of 10 clinically diagnosed cervical spondylosis patients were chosen and DNM was given for a period of four weeks. Pain and Disability were assessed by VAS and Neck disability index before and after Interventions. Both male and female were included. Analysis of Dependent Variable pain in the experiment: The Calculated Paired ‘t’ value for pain is 10.9 and the table ‘t’ value is 3.250 at 0.005 level of significance. Hence, the calculated ‘t’ value is greater than the table ‘t’ value there is significant difference in pain following DNM among cervical spondylosis patients. Analysis of Dependent Variable disability in the experiment: The Calculated Paired ‘t’ value for disability is 8.86 and the table ‘t’ value is 3.250 at 0.005 level of significance. Hence, the calculated ‘t’ value is greater than the table ‘t’ value there is significant difference in disability following DNM among cervical spondylosis patients. CONCLUSION: An experimental study was done to find out the effectiveness of DNM in pain and disability among patients with cervical spondylosis. 10 clinically diagnosed cervical spondylosis patients were included in this study and DNM was given for a period of four weeks, pain and disability were assessed by VAS and NDI before and after the interventions respectively. From the statistical results, it can be concluded that there is reduction in pain and disability. Therefore, Dermoneuromodulation is more effective in reducing pain and disability among patients with Cervical Spondylosis.

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