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Key points
- Degenerative spondylolisthesis means one lumbar vertebra has slipped forward on the one below because the small joints at the back of the spine have worn.
- It is a common cause of lumbar spinal stenosis: leg pain or heaviness on walking or standing that eases when you sit or lean forward.
- Many people manage with activity changes, physiotherapy and pain relief, but persistent nerve symptoms often need surgery to free the nerves.
- The British Association of Spine Surgeons (BASS) patient information reports good leg-pain relief in about 70 to 80% of people after decompression surgery. Back pain responds less reliably.
- Loss of bladder or bowel control or saddle numbness is an emergency.
What is degenerative spondylolisthesis?
‘Spondylo’ means vertebra and ‘listhesis’ means slipping. In degenerative spondylolisthesis, one bone in the lower back has moved forward relative to the bone beneath it. It most often affects the L4/L5 level and is generally a condition of later life, seen particularly in women.
Each vertebra is linked to its neighbours by a disc at the front and a pair of small facet joints at the back. Like any joint, the facets can develop arthritis. When that wear becomes advanced, the joints can no longer hold the vertebra firmly in line and it gradually creeps forward. The slip can be slight or more marked.
It is different from the slip that follows a stress fracture in the back of the vertebra, which tends to affect younger people. That condition is covered in our guide to spondylolysis and spondylolytic spondylolisthesis.
How does it cause symptoms?
The slipped segment can be painful in itself, giving low back ache, stiffness, muscle tightness and tenderness, sometimes with pain into the buttocks and thighs.
More troublesome for many people is the effect on the nerves. As the bone shifts, the space for the nerves shrinks. Worn discs lose height, arthritic joints swell and grow bony spurs (osteophytes), and the elastic ligament lining the back of the canal (the ligamentum flavum) buckles inwards. Together these can squeeze the nerve roots and the bundle of nerves in the lower canal, called the cauda equina. This narrowing is known as lumbar spinal stenosis.
Typical symptoms of nerve compression include:
- Aching, heaviness, tingling or numbness in the buttocks and legs, often both sides
- Symptoms that build up with standing or walking and ease when you sit down or bend forward (leaning on a shopping trolley often helps)
- Sciatica-type pain running down one leg if a single nerve root is pinched
- Less commonly, real weakness, so that the legs feel as though they will not work properly
Diagnosis
Your specialist will ask about your symptoms and walking distance and examine your back and legs. Standing X-rays show the slip and whether it moves when you bend. An MRI scan shows how much pressure there is on the nerves.
Treatment options
Non-surgical treatment
If your symptoms are mild or manageable, a sensible starting point includes physiotherapy, pain relief, pacing your activities, weight management and, for some, nerve root injections to settle a flare. Cycling and walking with a slight forward lean are often more comfortable than standing.
It is worth knowing, however, that BASS patient information notes these approaches rarely give lasting relief once nerves are significantly compressed, because they cannot remove the narrowing or correct the instability. If your walking is becoming more limited, it is reasonable to discuss surgery.
Surgery
The main goal of surgery is to give the trapped nerves more room. This is called decompression. Through a cut in the middle of the lower back, the surgeon removes part or all of the bony roof of the canal (laminotomy or laminectomy), along with the thickened ligament, and trims the overgrown facet joints. In some cases this is done through a narrow tube to limit muscle disturbance. Our guide to lumbar decompression explains this in more detail.
Because removing bone can make an already slipped segment less stable, your surgeon may also recommend a fusion. Screws placed into each vertebra are joined by rods to hold the segment still, and bone graft is laid alongside so the bones knit together; BASS describes this as taking about 3 to 6 months. Sometimes the disc is also replaced with a cage from the back (PLIF or TLIF) or the side (XLIF), restoring height and widening the nerve exits. See our guide to lumbar spinal fusion. The final extent of surgery is sometimes only decided during the operation.
Surgery cannot halt the natural ageing of the spine. Its main purpose is to ease leg symptoms. BASS patient information reports good relief of leg pain in about 70 to 80% of people (up to 8 in 10), often building over several months. Back pain, which is largely due to arthritis and muscle spasm, improves less predictably. Long-standing numbness or weakness may persist.
If a fusion is planned, stopping smoking matters. BASS advises stopping all nicotine ideally 2 to 3 months beforehand, as it hampers bone healing more than any other factor. Please also tell your team if you take blood thinners, anti-inflammatories or oestrogen-containing medicines such as the combined pill or HRT.
Risks and complications
The figures below are from BASS patient information on surgery for degenerative spondylolisthesis. They are approximate and your surgeon will discuss your own level of risk.
| Risk | Approximate frequency (BASS) |
|---|---|
| Nerve root injury | Under 1 in 100 for a first operation; up to 10 in 100 for repeat surgery |
| Tear in the dura (the lining around the nerves) | Fewer than 5 in 100 |
| Further operation to repair a persistent fluid leak | Less than 0.05% |
| Superficial wound infection | Up to 4 in 100 |
| Deep wound infection | Fewer than 1 in 100 |
| Blood clot in the leg or lung (DVT or PE) | Fewer than 1 in 700 |
| Bones fail to fuse (non-union), if fused | Up to 5 in 100 |
| Death from injury to major blood vessels or organs | About 1 in 10,000 |
| Fatal complication of general anaesthetic | About 1 in 250,000 |
Other possible problems include bleeding, recurring leg pain from scar tissue, difficulty placing screws (which can injure a nerve) or later screw breakage, pressure injuries from positioning (very rarely affecting eyesight) and, rarely, symptoms that end up worse. In extremely rare cases, bleeding into the canal or reduced blood flow to the nerves can cause paralysis. Side-approach (XLIF) surgery can also cause thigh pain, numbness or weakness in hip bending, which may or may not be permanent.
Recovery
BASS guidance suggests most people go home 1 to 3 days after surgery. Removable stitches or clips are usually taken out by the practice nurse at 10 to 14 days. Expect to avoid driving for about four weeks, take around four weeks off work (up to eight for heavy jobs), avoid heavy lifting for up to three months and avoid flying for six weeks, or up to three months for long-haul. Leg pain may take eight weeks or more to settle, and sensation and strength can keep improving for a year or so.
Seek urgent medical help (A&E or 999) if you have:
- Numbness or altered feeling around the genitals, back passage or inner thighs (the ‘saddle’ area)
- New difficulty passing urine, losing control of your bladder, or not being aware that your bladder is full
- Loss of bowel control
- A change in sexual sensation or function
- Weakness in one or both legs that is quickly getting worse
These can be warning signs of cauda equina syndrome, which needs emergency assessment. Please do not wait for a routine appointment.
Further reading
- BASS patient booklet: Degenerative Spondylolisthesis of the Lumbar Spine
- NHS: Spinal stenosis
- Spinemathema: Lumbar spinal stenosis
- Spinemathema: Lumbar spinal fusion (TLIF and ALIF)
This guide is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.
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