[stupidback]

#24107

Hello Dr. Corenman,

First off, thank you very much for taking the time to read questions from myself and other people.

I was diagnosed with spinal instability at L4/L5 and L5/S1, with grade 1 retrolisthesis at both levels (most apparent on flexion/extension). Also have <2 mm disc bulges and mild canal/foraminal stenosis as a result of these conditions. Minimal disc height loss from L5/S1. My spine has started to curve a bit and I’ve lost some lordosis too. Also relevant, an orthopedic doctor has revealed to me that I have ligamentous laxity in several joints, though I am not to the extent of being double-jointed. 29 years old.

I used to have a lot of trouble sleeping due to sciatica (main complaint), but now it has resolved after a few epidurals and courses of physical therapy. I am mostly okay day-to-day but afraid to do anything that requires long amounts of sitting, which will cause the sciatica to return. I have adjusted by sleeping on the floor (bed caused sciatica), doing home exercises, stretching, and using standing desks for work/home.

Overall, things are better than they were when this started about 3 years ago, but I am anxious/distressed about the future. My first spine doctor warned if things didn’t get better he would fuse both levels. After reading about activity limitations and the likelihood of adjacent disc levels degenerating after a fusion, this pretty much seems like a “death” sentence. I try to stay as active as I can safely, and maintain a healthy weight (I am 145 lbs and 5′-8″), but I don’t know much about this condition or what to expect for the future. I have had a few massages too which have helped some.

I know every patient is different so you can’t really speak in absolutes, but in general:
1. Is fusion the only solution for my condition? For example, let’s say if my foraminal stenosis got worse to the point where I needed surgery. Would I be able to have a foraminotomy instead? From what I have read, it seems like instability basically cancels out the possibility for anything but a fusion…
2. Does the slippage of retrolisthesis arrest after a while? Or can I expect the slippage to just get worse as I age?
3. Knowing that I have ligamentous laxity, I have seen a lot about prolotherapy but it sounds like a snake oil type thing, do you have an opinion?
4. Any suggestions?

Thanks!

[Donald Corenman, MD, DC]

#24113

Instability has to do with the abnormal motion of one segment on another. Are you sure these are retrolisthesis and not anterolisthesis (spondylolisthesis)? Retrolisthesis is a much more stable condition than an anterolisthesis as an anterolisthesis involves fracture or severe wear of the facets with disc wear and a retrolisthesis involves disc degeneration only.

How much motion do you have on the flexion/extension X-rays?

Instability with mainly leg pain can be caused by lateral recess or foraminal stenosis. Both could be addressed with a decompression only but foraminal stenosis cannot be decompressed if there is an anterolisthesis.

A retrolisthesis will become more stable with severe disc degeneration but an “in-between phase” can occur where the low back pain becomes worse before it becomes better.

I am not a fan of prolotherapy for anything else than SI joint syndrome. The wrong location for injection can be injurious.

For you, neutral spine and core strengthening would be the best therapy.

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[stupidback]

#24146

Thanks Dr. Corenman for your comments and time!

If retrolisthesis is where the vertebrae above the other slips back, e.g. L4 is shifted backwards relative to L5, then yes that’s what I have. There is no scale on the x-rays and I don’t have a good way of taking a clear picture of them (films, not digital), so I used a ruler to measure the upper vertebrae front to back length, and then the distance between the rear tips of the adjacent vertebrae on the midplane of each disc. % I’m giving is the 2nd distance divided by the 1st.

On flexion it looks like S1 rotates so that the tailbone raises in the air, so then L5 is shifted back relative to S1 about 13%. On extension it looks roughly the same (maybe a tad less), but L4 decides to shift back on L5 as well by about ~10%. Standing up straight it looks “normal” except that I have lost a bit of lordosis and the spine has decided to curve around a bit. This was in 2015, 1 year after initial diagnosis.

I can no longer extend back that far (and don’t try since that makes it slip). I try to remember to clench my glutes when bending in any direction since that seems to keep the sacrum from moving about too much. I have had several courses of PT and do the home exercises every other day, as well as several stretches.

Thanks again for your time/expertise; it’s encouraging to hear that retrolisthesis is a more stable condition and that a foraminotomy could be a possibility if needed. There is not a lot of information out there about retrolisthesis vs. the more common forward-slip.

P.S. As one last question, I see that you are a DC — would chiropractic help or hurt someone in my position? I had a few weeks of treatments but stopped after reading that people with slippage shouldn’t have this done.

[Donald Corenman, MD, DC]

#24186

Your pattern of slip is unusual but does occur occasionally. There is a disorder called Scheuermann’s disease where the thoracic spine develops a large curve (hyperkyphosis) and the lumbar spine develops retrolisthesis due to this abnormal stress. I will assume you don’t have a large mid-back curve.

Your retrolisthesis at L5-S1 sounds stable (no motion) and your L4-5 has abnormal motion (shifting forward and back). This is a common pattern when the lower vertebra becomes more degenerative over time (stiffer) and the one above develops hypermobility.

You have to be careful as you are only 29 years old and have a tendency to develop this instability. If you had a fusion of L4-S1, what do you think will happen to L3-4? The chance of instability would somewhat increase. If you can manage this disorder and avoid surgery, you might be ahead. If however, you have nerve compression at a degenerative but stable level, the chance of developing instability is limited. That is, if L5-S1 doesn’t move much but any spur that forms does compress a nerve root, you might be relatively safe with surgery at that level. If L4-5 moves like you notice, surgery could increase instability.

Core strength (Pilates) and occasional injections would be a good plan.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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