Lumbar spondylolisthesis: what it is, symptoms, and conservative, tubular, and endoscopic treatment options

Lumbar listhesis, also known as lumbar spondylolisthesis, occurs when a vertebra of the spine slips forward or backward relative to the vertebra below it. This displacement can be mild and cause no symptoms, or it can produce low back pain, leg pain, tingling, weakness, or difficulty walking.

Although the diagnosis may worry the patient, not all cases require surgery. Many patients improve with conservative treatment. In other cases, when there is nerve compression, persistent pain, or instability, surgical treatments may be considered, including minimally invasive techniques such as tubular surgery and endoscopic surgery.

What is lumbar spondylolisthesis?

The lumbar spine is made up of vertebrae, discs, ligaments, joints, and nerves. These structures work together to provide support, movement, and protection for the nerve roots that travel toward the legs.

Listhesis appears when a vertebra loses part of its normal alignment and slips over another. This can narrow the lumbar canal or the foramina, which are the spaces through which the nerves exit. When these spaces are reduced, the nerves can become compressed and produce symptoms.

Frequent types of lumbar spondylolisthesis

Different types of listhesis exist. The most common are:

1. Degenerative listhesis. It is common in adults and older adults. It is related to progressive wear of the discs, facet joints, and ligaments. It usually occurs at the L4-L5 level. It can be accompanied by a narrow lumbar canal, low back pain, and leg pain when walking.
2. Isthmic listhesis. It is related to an injury or defect in a part of the vertebra called the pars interarticularis. It can occur in young people, athletes, or adults who had the defect years earlier. It is common at L5-S1.
3. Retrolisthesis. In this case, the vertebra slips backward. It can also be associated with disc wear, low back pain, or nerve compression.
4. Traumatic or pathological listhesis. It is less frequent. It can be due to fractures, tumors, infections, or diseases that weaken the spine.

What symptoms can it cause?

Some people have listhesis and have no symptoms. In other cases, it can cause progressive discomfort. The most frequent symptoms are:

• Low back pain.
• Pain radiating to the buttock, thigh, leg, or foot.
• Tingling or numbness in the legs.
• A sensation of tiredness or heaviness when walking.
• Pain that improves when sitting or bending forward.
• Difficulty walking long distances.
• Lumbar stiffness.
• Muscle spasm.
• Weakness in one or both legs.
• Pain that worsens when standing or walking.
• In advanced cases, problems urinating or having bowel movements.

When the pain radiates to the leg, it may be due to compression of a nerve root. When the patient needs to stop while walking because of pain, weakness, or numbness, an associated narrow lumbar canal may be present.

How is it diagnosed?

The diagnosis is made with a combination of clinical history, physical examination, and imaging studies. The most commonly used studies are:

• Lumbar X-rays. They allow the degree of vertebral displacement to be observed. Dynamic X-rays, in flexion and extension, help assess whether there is abnormal mobility or instability.
• MRI. It is one of the most important studies because it shows the discs, nerves, lumbar canal, nerve roots, ligaments, and the presence of compression.
• CT. It helps better evaluate the bone, joints, fractures, pars interarticularis, and surgical anatomy.
• Electromyography. It may be requested in some cases to study nerve function, especially when there is doubt between lumbar radiculopathy and peripheral neuropathies.

What does the grade of listhesis mean?

Listhesis is usually classified according to the percentage of displacement of one vertebra over another. In general, grade I corresponds to mild displacement; grade II, to moderate; grade III, to significant; grade IV, to severe; and grade V, to complete displacement or spondyloptosis.

Most patients have low-grade listhesis. Treatment does not depend solely on the percentage of displacement, but on the symptoms, nerve compression, spinal stability, age, physical activity, associated illnesses, and the response to conservative treatment.

Conservative treatment of lumbar spondylolisthesis

Conservative treatment is usually the first option when there is no progressive neurological deficit or warning signs. Its goal is to reduce pain, improve mobility, strengthen the musculature, and reduce nerve irritation.

1. Patient education. Understanding the problem helps control fear and make better decisions. Having listhesis does not mean the spine “is going to break” or that surgery is always needed. Many cases are managed with exercise, physical therapy, weight control, postural hygiene, and medical treatment.
2. Activity modification. During periods of intense pain, it is recommended to avoid activities that increase symptoms, such as lifting heavy objects, making efforts with poor posture, standing for long periods if it increases the pain, repeated spinal extensions, high-impact exercise during a flare-up, and abrupt flexion or rotation movements. This does not mean absolute rest: walking in a controlled way and staying active is usually better than staying in bed for prolonged periods.
3. Physical therapy. It is a fundamental part of treatment. It should focus on lumbar stabilization and progressive strengthening. It can include deep abdominal and gluteal strengthening, pelvic control exercises, stretching of the hamstrings and hip flexors, lumbar stability exercises, postural re-education, gait work, manual therapy in selected cases, and low-impact aerobic exercise. The goal is not to “put the vertebra back in place,” but to improve the functional stability of the spine and reduce the load on the nerves.
4. Medications. The doctor may prescribe medications to control pain and inflammation, such as analgesics, anti-inflammatories, or neuropathic pain medications. The choice depends on each patient; not everyone can take anti-inflammatories, especially if they have severe gastritis, kidney disease, uncontrolled hypertension, anticoagulation, or a history of gastrointestinal bleeding. Self-medication is not recommended.
5. Injections or blocks. In patients with radicular pain or inflammation of a nerve root, epidural injections or selective blocks may be considered. These procedures can help reduce pain and facilitate rehabilitation. They do not correct the listhesis, but they can control symptoms in well-selected patients.
6. Weight control and strengthening. Excess weight increases the mechanical load on the lumbar spine. Losing weight, improving trunk strength, and increasing muscle endurance can reduce pain and improve function.
7. Lumbar brace. In some cases, a brace may be used temporarily to provide support during a painful flare-up. It should not replace physical therapy or be used permanently without medical guidance, since excessive use can promote muscle weakness.

When is surgery considered?

Surgery may be considered when conservative treatment fails to control the symptoms or when there is neurological risk. Some indications are:

• Persistent low back pain or leg pain.
• Pain that limits walking, working, or sleeping.
• Clear compression of nerve roots on MRI.
• Progressive weakness.
• An associated narrow lumbar canal.
• Instability on dynamic X-rays.
• Significant loss of quality of life.
• Failure of well-performed conservative treatment.
• Cauda equina syndrome, which is an emergency.

The decision to operate must be individualized. We do not operate on an X-ray or an MRI alone; we treat the whole patient.

Minimally invasive treatments for lumbar spondylolisthesis

Minimally invasive surgery aims to treat nerve compression and, when necessary, stabilize the spine with less muscle damage than traditional open surgery. The options include lumbar decompression by tubular technique, endoscopic decompression, minimally invasive lumbar fusion, percutaneous screw placement, and hybrid techniques depending on the case.

Not all patients are candidates. The choice depends on the type of listhesis, the degree of instability, the affected level, the compression, the deformity, the predominant pain, and the general condition.

Tubular technique: what does it involve?

Tubular surgery uses dilators and a tubular retractor to reach the spine through a small incision. Instead of widely detaching the muscles, they are progressively separated using tubes. This allows work at the affected site with a microscope or magnified vision.

It can be used for decompression of a narrow lumbar canal, freeing of nerve roots, narrow lateral recesses, foraminal stenosis, associated herniations, some cases of fixed listhesis, and minimally invasive lumbar fusion when stabilization is required.

In selected patients, it can offer smaller incisions, less muscle injury, less bleeding, less postoperative pain, faster functional recovery, a shorter hospital stay, decompression directed at the site of compression, and the possibility of being combined with percutaneous screws if fusion is required. These advantages depend on the diagnosis, the technique, surgical experience, and the patient’s condition.

Spinal endoscopy: what is it?

Spinal endoscopy uses a high-definition camera and fine instruments to treat compressed structures through small incisions. It can be performed through different approaches, depending on the site of compression: interlaminar, transforaminal, biportal, or uniportal. In selected cases, it can help free a nerve root, remove disc fragments, enlarge narrow spaces, or treat localized stenosis.

Does endoscopy work for all cases of listhesis?

No. Endoscopy can be useful in patients with localized compression and stable low-grade listhesis. However, if there is significant instability, deformity, severe displacement, or mechanical pain from abnormal movement, a stabilization or fusion procedure may be necessary. Endoscopy should not be seen as a universal solution; it is a useful tool when the anatomical problem and the symptoms match its indications.

When is lumbar fusion needed?

Lumbar fusion aims to join two or more vertebrae to provide stability. It may be necessary when listhesis is accompanied by instability, significant mechanical pain, or when the required decompression may increase instability. Fusion can be performed with open or minimally invasive techniques; in the latter, screws can be placed through small incisions and decompression can be performed with less muscle damage.

It may be considered when there is unstable listhesis, abnormal movement on dynamic X-rays, significant mechanical low back pain, nerve compression associated with instability, recurrence of symptoms after prior treatments, a need to remove structures that stabilize the spine, or higher-grade listhesis.

Difference between decompression and fusion

Decompression consists of freeing the nerves. It can include removing part of the bone, ligamentum flavum, hypertrophic tissue, or disc compressing the nerve root. Its main goal is to improve leg pain, tingling, numbness, or claudication.

Fusion aims to stabilize the segment. It can include screws, rods, bone grafts, and interbody cages. Its goal is to reduce abnormal movement, improve stability, and prevent the spine from continuing to slip in selected cases.

In some patients, decompression is enough. In others, decompression plus fusion is required.

Expected benefits of minimally invasive surgical treatment

The benefits may include improvement of leg pain, better walking ability, reduction of tingling or numbness, improvement in daily function, less postoperative muscle pain compared with more extensive approaches, faster recovery in selected patients, less bleeding, shorter hospital time, and preservation of healthy structures when possible.

The symptom that usually improves fastest is pain radiating into the leg. Strength and sensation may take longer, especially if the nerve was compressed for a long time.

Risks and possible complications

Every surgery carries risks. In lumbar surgery, they may include bleeding, infection, persistent pain, recurrence of symptoms, nerve root injury, cerebrospinal fluid leak, hematoma, instability, the need for another surgery, failure or loosening of implants if screws are placed, nonunion of the fusion, residual low back pain, anesthetic complications, and thrombosis or general medical problems.

The risk depends on age, associated illnesses, smoking, osteoporosis, weight, the type of listhesis, the degree of compression, the technique used, and the experience of the surgical team.

Recovery after minimally invasive surgery

Recovery varies depending on the procedure. An isolated decompression usually has a faster recovery than a fusion. In general, the patient may need to walk early, control pain, care for the wound, avoid lifting weight at first, avoid abrupt bending and twisting, perform physical therapy when the surgeon authorizes it, attend periodic medical check-ups, undergo follow-up studies if implants were placed, and progressively return to activities.

The return to work depends on the type of job, the patient’s progress, pain, strength, and the type of surgery performed.

Warning signs

You should seek immediate medical attention if you have progressive loss of strength in a leg, loss of bladder or bowel control, numbness in the genital area or “saddle” distribution, unbearable pain that does not improve, fever, unexplained weight loss, intense nighttime pain, a history of cancer with new low back pain, a recent infection associated with back pain, a fall or significant trauma, or, after surgery, pus drainage, fever, a red wound, or pain that worsens.

Loss of sphincter control, numbness in the genital area, or progressive weakness may indicate severe nerve compression and requires urgent evaluation.

Frequently asked questions

Does lumbar spondylolisthesis always require surgery?

No. Many patients can improve with physical therapy, medications, weight control, activity modification, and injections.

Can the vertebra be repositioned with physical therapy?

Generally, physical therapy does not “put the vertebra back” in place, but it can improve muscle stability, reduce pain, and improve function.

Does endoscopy correct the listhesis?

Endoscopy can help free compressed nerves in selected cases, but it does not correct significant instability. If the spine moves abnormally, stabilization may be required.

Is the tubular technique the same as endoscopy?

No. Both are minimally invasive, but they are not identical. The tubular technique uses a tubular retractor and generally a microscope or magnified vision. Endoscopy uses a camera and specific instruments through a small incision.

When is it necessary to place screws?

Screws may be necessary when there is instability, significant listhesis, significant mechanical pain, or when decompression may leave the segment unstable.

Does leg pain improve after surgery?

In many patients, pain radiating into the leg improves faster than low back pain. Sensation and strength may take longer to recover.

Can I exercise if I have listhesis?

Yes, but it should be appropriate and supervised exercise. Low-impact exercises, deep abdominal and gluteal strengthening, controlled mobility, and lumbar stability are preferred. Exercises that increase pain or generate excessive lumbar hyperextension should be avoided.

Conclusion

Lumbar spondylolisthesis is the displacement of one vertebra over another. It can be mild and asymptomatic, or it can cause low back pain, sciatica, tingling, weakness, and difficulty walking.

Treatment must be individualized. In many patients, conservative management with physical therapy, medications, weight control, activity modification, and injections may be sufficient. When there is nerve compression, persistent pain, weakness, or instability, surgical treatments may be considered. Minimally invasive techniques, such as tubular surgery and endoscopy, allow certain cases to be treated with small incisions and less muscle damage. However, not all patients are candidates; in some cases, lumbar fusion is required to stabilize the spine.

The best decision is made by assessing symptoms, physical examination, MRI, dynamic X-rays, and the patient’s needs.

Final message for the patient

Having lumbar spondylolisthesis does not necessarily mean needing surgery. The most important thing is to identify whether there is nerve compression, instability, or neurological damage. With an appropriate evaluation, it is possible to choose between conservative treatment, minimally invasive decompression, endoscopy, or lumbar fusion, depending on each case.

This text is informational and does not replace a personalized medical consultation. If you have low back pain with leg pain, weakness, tingling, or difficulty walking, see a neurosurgery and spine specialist.