Isthmic Spondylolisthesis | Slipped Vertebra Due to Fracture

An Overview of Isthmic Spondylolisthesis
(Slipped Vertebra Due to Fracture)

Isthmic spondylolisthesis (slipped vertebra due to a fracture) is a problem that typically occurs with a fracture in the bone that connects the upper and the lower facets, the pars interarticularis (Latin for “area between the joints”). The break normally occurs because of a stress fracture. This bony area when under stress from athletic activity in extension doesn’t have the chance to heal between stressful episodes. Eventually, the stress is greater than the bone can resist and the area fractures. Since this area of the bone is very poorly supplied with blood, healing is impaired and the fracture is quite commonly permanent. The most common area for this to occur is L5-S1.

Fracture Occurrence

These fractures occur in about one of every 20 adolescents. Normally, the age when this break occurs is quite young- about eight to fifteen years. This defect is more common in athletes that participate in sports that require bending backwards (extension) such as gymnastics, diving, volleyball and football (linebackers). Genetics probably plays a substantial role as 50% of the Inuits (Eskimos) have this fracture.

Symptoms of Isthmic Spondylolisthesis

The fracture almost always starts in children and adolescents. Symptoms that occur when the pars first starts to break varies widely. Some kids actually don’t have much pain but only stiffness. If pain does develop, many adolescents will ignore it or won’t report it to their parents. Be suspicious of any child that has back pain as to not miss an acute fracture. If these young patients are identified early, they have a chance to heal in a brace.

The unfortunate hallmark symptoms of isthmic spondylolisthesis is its variability. As the body tries to heal the fracture, it lays down a number of types of tissues including fibrous tissue, cartilage and bone. Free nerve endings grow into this mass. This total compilation of bone, cartilage, nerve and fibrous tissue is called the pannus. This pannus is not as strong as the original pars but can be quite tough and resist tearing for many years. This is why many patients with a spondylolysthesis have no knowledge of this defect and no pain unless the pannus tears.

However, if an abnormally heavy weight or just the right aberrant load stresses the pannus as in a lifting maneuver, the pannus can tear and then become painful. Lower back pain develops. These patients develop symptoms with extension as bending backwards loads the inflamed pannus. Some even have pain with flexion as this may stretch the pannus. As you can see, the patient history may become confusing when developing a diagnosis through the history alone.

The pedicles where the fractures originally occur can grow spurs as all bony fractures do to attempt healing. These spurs can then become large enough to compress the local nerve roots (L5) and leg pain can eventually develop. Leg symptoms normally increase very slowly over time with pain being intermittent and inconsistent in the beginning. As the spur continues to develop and the nerve hole narrows, leg pain can develop into the majority complaint. The leg pain normally occurs with standing (extension) as this narrows the nerve exit hole and disappears with bending forward or sitting.

The vertebral body can slip down the front of the sacrum since the fractured piece of bone is the “door stop” and the vertebra sits on the sacral slope facing downhill. The actual alignment of the spine can change depending upon the amount of slip since the entire spine follows the L5 vertebral slip. The vertebral slip is noted in “grades”. The sacrum is divided into 4 parts. The first 25% is grade I, from 25-50% is grade II, 50-75% is grade III, 75-100% is grade IV and if the vertebra slides off the sacrum into the pelvis, this is a grade V or spondyloptosis. Most spondylolysthesis are grade I or II. The higher grades cause significant deformity with the pelvis and upper spine compensating for the slip.

(Click to Enlarge Image) This is a CT scan of the side view of the lumbar spine in a patient with isthmic spondylolisthesis. The black arrow points to an intact pars (the bony area that connects the upper and lower facets). The white arrow points to the fracture and separation of the upper and lower facets.

(Click to Enlarge Image) This picture illustrates an isthmic spondylolisthesis. The break in the bony pars is demonstrated by the stippled area (arrow) and the nerve root is seen exiting without compression.

(Click to Enlarge Image) This picture illustrates an isthmic spondylolisthesis with a bone spur compressing the exiting nerve. The break in the bony pars is demonstrated by the stippled area and the nerve root is seen being compressed by the bone spur (arrow).

(Click to Enlarge Image) CT scan of patient with a pars fracture of L4.

(Click to Enlarge Image) CT scan of a patient with pars fractures at L5 and L3.

(Click to Enlarge Image) Axial CT image of bilateral pars fractures of L5 (arrows).

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(Please keep reading below for more information on this condition.)

Treatment of Isthmic Spondylolisthesis

Non-Surgical

Most of the time, isthmic spondylolisthesis (slipped vertebra due to a fracture) is not dangerous. Treatment includes physical therapy and a “flat back” program, medications and spinal injections. Education to avoid certain activities and sports that cause extension is important. If there is a significant compression of the L5 that creates weakness or a slip of grade 2 when young or grade 3 when older-surgery is necessary

Surgical

The typical surgery for this disorder is a TLIF but for severe grades, a front and back surgery may be necessary.

For more information on isthmic spondylolisthesis, or to discuss treatment options of a slipped vertebra due to a fracture with a back doctor and spine specialist in the Vail, Aspen, Denver and Grand Junction, Colorado area, please contact Dr. Donald Corenman.

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Isthmic Spondylolisthesis (Slipping of a Vertebra Because of Fracture)

An Overview of Isthmic Spondylolisthesis
(Slipped Vertebra Due to Fracture)

Fracture Occurrence

Symptoms of Isthmic Spondylolisthesis

Are you suffering from symptoms of Isthmic Spondylolisthesis?

Treatment of Isthmic Spondylolisthesis

Non-Surgical

Surgical

Related Content

About the Author: Donald Corenman, MD, DC

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Isthmic Spondylolisthesis (Slipping of a Vertebra Because of Fracture)

An Overview of Isthmic Spondylolisthesis (Slipped Vertebra Due to Fracture)

Fracture Occurrence

Symptoms of Isthmic Spondylolisthesis

Are you suffering from symptoms of Isthmic Spondylolisthesis?

Treatment of Isthmic Spondylolisthesis

Non-Surgical

Surgical

Related Content

About the Author: Donald Corenman, MD, DC

An Overview of Isthmic Spondylolisthesis
(Slipped Vertebra Due to Fracture)