Spondylolisthesis
Spondylolisthesis is a condition in which one vertebra slips forward relative to the vertebra below it, altering the mechanics of the spine and potentially compressing spinal nerves. It can occur in young athletes following a stress fracture of the posterior vertebral arch or, far more commonly, in older adults as a result of progressive degenerative changes in the discs and facet joints. At Maryland Orthopedic Specialists, most patients with Grade I or Grade II spondylolisthesis are managed successfully without surgery through targeted physical therapy, core stabilization, and epidural steroid injections when neurogenic symptoms are present.
Ready to get started?
Schedule an appointment with a specialist experienced in treating spondylolisthesis.
In-network with most major insurance plans. Same-day appointments available for acute injuries.
What is spondylolisthesis?
Types of spondylolisthesis: - Isthmic spondylolisthesis results from a defect in the pars interarticularis — the narrow bony bridge connecting the superior and inferior facets at each vertebral level. Pars defects (spondylolysis) are most common at L5–S1 and are associated with repetitive hyperextension activities: gymnastics, football linemen, weightlifting, and ballet.
Types of spondylolisthesis:
- Isthmic spondylolisthesis results from a defect in the pars interarticularis — the narrow bony bridge connecting the superior and inferior facets at each vertebral level. Pars defects (spondylolysis) are most common at L5–S1 and are associated with repetitive hyperextension activities: gymnastics, football linemen, weightlifting, and ballet. When bilateral pars defects allow the vertebral body to slip forward, the result is isthmic spondylolisthesis. This is the predominant type in patients under 30.
- Degenerative spondylolisthesis occurs when progressive facet joint arthropathy and disc height loss lead to instability at a motion segment, most commonly L4–L5. The incompetent facet joints no longer resist anterior shear forces, and the upper vertebra gradually translates forward. This is the predominant type in adults over 50 and is more common in women and in patients with diabetes.
- Less common types include traumatic, dysplastic, iatrogenic (post-laminectomy instability), and pathologic spondylolisthesis.
Meyerding grading system classifies the degree of forward slip as a percentage of the vertebral body width:
- Grade I (0–25% slip): Usually managed non-operatively
- Grade II (26–50% slip): Non-operative first; surgical referral if refractory
- Grade III (51–75% slip): Surgical consultation generally recommended
- Grade IV (76–100% slip): Surgical consultation generally recommended
- Grade V — Spondyloptosis (>100% slip): Surgical management
MOS primarily manages Grade I and II spondylolisthesis non-operatively and coordinates surgical referral for Grade III–IV or cases with progressive neurological deficit.
Treatment options
Grade I–II spondylolisthesis responds well to non-operative management for the vast majority of patients.
Physical Therapy
Core and gluteal strengthening stabilizes the slipped vertebra and is the most important long-term treatment for spondylolisthesis. Lumbar stabilization exercises address the dynamic shear forces on the affected segment, reducing pain and preventing worsening. A structured PT program is recommended as the first step before any injections or procedures are considered.
Activity Modification
Avoiding high-impact loading, heavy lifting, and repetitive hyperextension reduces stress on the unstable segment and allows symptoms to settle. Low-impact activities like cycling and swimming keep patients active without aggravating the slip. Even during a flare, staying gently active is better than complete rest.
Medications and Injections
NSAIDs manage day-to-day pain and help patients stay engaged in their rehab program. Epidural steroid injections address associated nerve root compression and neurogenic claudication when leg symptoms are a significant part of the picture. Facet injections are an option when posterior element pain is the dominant complaint.
Surgical Referral
Grade III–IV slippage, progressive neurological deficit, or failure of 6 months of conservative care are indications for surgical evaluation, which MOS coordinates with a spine surgery specialist. Outcomes of decompression and fusion for these cases are excellent.
Frequently Asked Questions
Can spondylolisthesis get worse?
Is spondylolisthesis the same as spondylolysis?
Can my young athlete return to sports?
Will I need surgery?
How long is recovery after spinal fusion for spondylolisthesis, and when can I return to normal activities?
Meet the specialists
John J. Christoforetti, MD
Orthopedic Surgery · Sports Medicine · Hip Preservation Surgery
Meet Dr. Christoforetti →
Related conditions
References
- Meyerding HW. "Spondylolisthesis." Journal of Bone and Joint Surgery 1931;13:39–48. (Foundational classification paper)
- Kalichman L, Hunter DJ. "Diagnosis and conservative management of degenerative lumbar spondylolisthesis." European Spine Journal 2008;17(3):327–335. https://doi.org/10.1007/s00586-007-0543-3
- Hresko MT. "Isthmic spondylolisthesis." Journal of the American Academy of Orthopaedic Surgeons 2013;21(10):609–616. https://doi.org/10.5435/JAAOS-21-10-609
- Watters WC 3rd, Bono CM, Gilbert TJ, et al. "An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis." Spine Journal 2009;9(7):609–614. https://doi.org/10.1016/j.spinee.2009.03.016
- OrthoInfo / AAOS. "Spondylolysis and Spondylolisthesis." https://orthoinfo.aaos.org/en/diseases--conditions/spondylolysis-and-spondylolisthesis/