Vertebral Spondylolisthesis: Causes and Treatment

Vertebral spondylolisthesis is a condition in which one vertebra slips forward relative to the one below it. It is a frequent pathology in clinical settings, which often generates great concern in patients, especially when they read the radiological report. In reality, in the vast majority of cases spondylolisthesis can be effectively managed with conservative treatment.

Clinical experience and scientific literature confirm that a rehabilitation program aimed at segmental stabilization of the spine offers excellent results in most cases.

Table of Contents

• Types of Spondylolisthesis
• Meyerding Classification (Grades)
• Symptoms
• Diagnosis
• Conservative Treatment
• Exercises for Spondylolisthesis
• Recovery Time
• Physical Activity and Sports
• When is Surgery Needed?
• Frequently Asked Questions (FAQ)
• Related Articles
• Frequently Asked Questions
• Scientific References

Types of Spondylolisthesis

Isthmic Spondylolisthesis

The most common form in young people and adults, caused by a stress fracture of the vertebral isthmus (spondylolysis). The most frequent location is L5-S1.

Degenerative Spondylolisthesis

The most common form in people over 50, caused by degeneration of the articular facets and disc. The most frequent location is L4-L5. Often associated with spinal canal stenosis.

Other Forms

• Dysplastic: congenital, due to malformation of the facet joints
• Traumatic: from acute vertebral fracture
• Pathological: from bone diseases (tumors, Paget’s)

Meyerding Classification (Grades)

Important clinical note: the degree of slippage does not always correlate with symptom severity. We observe patients with grade II who are practically asymptomatic and patients with grade I with significant pain.

Symptoms

• Lumbar pain: worsens with prolonged standing and trunk extension, improves with flexion and rest
• Lumbar stiffness: especially in the morning
• Radiating pain: sciatica or cruralgia if nerve roots are compressed
• Neurogenic claudication: in forms with stenosis, pain in the legs after walking that resolves with rest or flexion
• Hamstring tightness: frequent, especially in juvenile forms
• Palpable “step”: on the spine at the level of the slipped vertebra

Diagnosis

• Lumbar X-ray: identifies the slippage and measures the grade
• Dynamic X-rays (in flexion/extension): assess stability of the slippage
• MRI: evaluates neural structures, discs and any stenosis
• CT scan: for detailed study of bone structures and spondylolysis

Conservative Treatment

Spondylolisthesis is forward slippage of a vertebra causing lumbar pain, stiffness, and radiating leg symptoms, most common at L5-S1 (isthmic) or L4-L5 (degenerative). Conservative treatment is the first approach for grades I-II and includes:

Physiotherapy

• Segmental stabilization: strengthening the transversus abdominis and lumbar multifidus — the natural “muscular corset”
• Flexion exercises: to increase the diameter of the spinal canal
• Stretching: hamstrings, iliopsoas, rectus femoris
• Postural re-education: control of lumbar lordosis
• Manual therapy: mobilization of segments above and below the listhesis (never direct manipulation of the unstable segment)
• Instrumental therapies: TECAR therapy, laser, TENS

Brace

In acute cases or adolescent spondylolysis, a semi-rigid brace for 4-6 weeks can promote healing.

Medications

NSAIDs, muscle relaxants, possibly epidural injections in cases with radicular component.

Exercises for Spondylolisthesis

FUNDAMENTAL PRINCIPLE: in spondylolisthesis, flexion exercises are generally indicated, extension exercises should be avoided. This is the opposite of disc herniation.

Core Stabilization Exercises

Exercise 1: Transversus Abdominis and Multifidus Activation

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Lie supine on a mat with knees bent and feet flat on the floor at hip width. Arms are along the sides or with hands on the abdomen to feel the muscle contraction. The spine should be in neutral position.

Step-by-step execution:

1. Step 1: Inhale deeply through the nose, allowing the abdomen to expand
2. Step 2: While exhaling, “pull the navel toward the spine” as if sucking the belly inward, without moving the pelvis or holding the breath
3. Step 3: Hold the contraction for 10 seconds while continuing to breathe normally, then release slowly

Sets and repetitions: 10 repetitions of 10-second holds — 3 times daily

Common mistakes to avoid:

• Holding breath during contraction
• Moving the pelvis or flattening the back (only work on deep contraction)
• Contracting superficial muscles (rectus abdominis) instead of transversus

How to know you’re doing it correctly:
You feel a slight deep tension under the fingers placed on the abdomen, without the belly “protruding” upward. Breathing remains fluid and the pelvis doesn’t move.

Exercise 2: Pelvic Tilt

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Lie supine with knees bent and feet on the floor at hip width. Arms are along the sides. Notice a natural space between the lumbar area and the floor.

Step-by-step execution:

1. Step 1: Gently contract the abdominal muscles and glutes
2. Step 2: Flatten the lumbar area against the floor, rotating the pelvis backward (the pubic bone slightly lifts toward the ceiling)
3. Step 3: Hold the position for 10 seconds breathing normally, then release slowly returning to neutral position

Sets and repetitions: 15-20 repetitions of 10-second holds — 5-second rest between repetitions

Common mistakes to avoid:

• Lifting the pelvis off the ground (it’s not a bridge, but a rotation)
• Pushing with feet to force the movement
• Holding breath during the hold

How to know you’re doing it correctly:
The space between the lumbar area and the floor completely disappears. You feel simultaneous contraction of lower abdominals and glutes, without tension in the upper back.

Exercise 3: Dead Bug

Difficulty: Intermediate | Equipment: Mat | Duration: 8 minutes

Starting position:
Lie supine with arms extended toward the ceiling (perpendicular to the floor) and knees bent at 90 degrees with hips flexed at 90 degrees (inverted table position). The lumbar area should be well adhered to the floor.

Step-by-step execution:

1. Step 1: Activate the transversus abdominis by flattening the lumbar area against the floor
2. Step 2: While exhaling, slowly extend the right arm overhead and the left leg forward, bringing them toward the floor without touching it
3. Step 3: While inhaling, return to starting position and repeat with left arm and right leg, always keeping the back flat on the ground

Sets and repetitions: 3 sets x 8-10 repetitions per side — 45-second rest between sets

Common mistakes to avoid:

• Arching the lumbar area when extending arm and leg (sign that you’re going too low)
• Performing the movement too quickly losing control
• Forgetting to coordinate breathing with movement

How to know you’re doing it correctly:
The lumbar area stays glued to the floor throughout the movement. You feel deep abdominal work without tension in the neck or back. The movement is slow and controlled.

Exercise 4: Bridge with Pelvic Tilt

Difficulty: Intermediate | Equipment: Mat | Duration: 7 minutes

Starting position:
Lie supine with knees bent and feet on the ground at hip width. Arms are along the sides with palms facing down.

Step-by-step execution:

1. Step 1: First perform pelvic tilt, flattening the lumbar area against the floor
2. Step 2: Maintaining the tilt, slowly lift the pelvis from the ground vertebra by vertebra, until knees-pelvis-shoulders are aligned
3. Step 3: Hold for 5 seconds at the top, then descend slowly one vertebra at a time, returning to starting position

Sets and repetitions: 3 sets x 10-12 repetitions — 30-second rest between sets

Common mistakes to avoid:

• Hyperextending the lumbar area in the high phase of the bridge (particularly harmful error in spondylolisthesis)
• Losing pelvic tilt during ascent
• Pushing the pelvis too high, exceeding the knee-shoulder line

How to know you’re doing it correctly:
You feel intense work of glutes and abdominals, without tension or pain in the lumbar area. The body forms a straight line from knees to shoulders, without a “peak” in the lumbar area.

Exercise 5: Front Plank with Pelvic Tilt

Difficulty: Intermediate | Equipment: Mat | Duration: 5 minutes

Starting position:
Prone position, supported on forearms (elbows under shoulders) and toes. The body should form a straight line from head to heels.

Step-by-step execution:

1. Step 1: Position yourself on forearms and toes, activating the transversus abdominis
2. Step 2: Bring the pelvis into slight posterior tilt (contract glutes and lower abdominals) to avoid any lumbar extension
3. Step 3: Hold the position for 15-30 seconds (progress gradually up to 60 seconds), breathing normally

Sets and repetitions: 3-5 repetitions with 15-60 second holds — 30-second rest between repetitions

Common mistakes to avoid:

• Letting the pelvis “drop” downward creating hyperlordosis (very risky in spondylolisthesis)
• Raising the pelvis excessively in a “tent” position
• Holding breath during the hold

How to know you’re doing it correctly:
The body forms a straight line without depressions in the lumbar area. You feel uniform work of abdominals, glutes and shoulders. A side observer should not see any curve in the lumbar area.

Flexion Exercises

Exercise 6: Knees to Chest

Difficulty: Easy | Equipment: Mat | Duration: 4 minutes

Starting position:
Lie supine on a mat with legs extended and arms at your sides. Head is resting on the ground.

Step-by-step execution:

1. Step 1: Slowly bend both knees bringing them toward the chest
2. Step 2: Hug the knees with both hands, gently drawing them closer to the chest until feeling a comfortable stretch in the lumbar area
3. Step 3: Hold the position for 20-30 seconds breathing deeply, then slowly release the legs

Sets and repetitions: 5 repetitions of 20-30 second holds — 10-second rest between repetitions

Common mistakes to avoid:

• Pulling the knees too forcefully, causing pain
• Lifting the head off the ground creating cervical tension
• Performing the movement with jerky motions instead of smoothly

How to know you’re doing it correctly:
You feel a pleasant stretch and decompression in the lumbar area. The sensation is one of relief and relaxation, not pain. Breathing becomes deeper and more relaxed.

Exercise 7: Cat Stretch (Flexion Phase Only)

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Quadruped position with hands under shoulders and knees under hips. The back is in neutral position.

Step-by-step execution:

1. Step 1: While exhaling, slowly round the back upward (like a cat stretching), bringing the chin toward the chest
2. Step 2: Contract the abdominals and bring the pelvis into posterior tilt, pushing the lumbar area toward the ceiling
3. Step 3: Hold for 5 seconds, then slowly return to neutral position (NEVER go into extension/lordosis)

Sets and repetitions: 10-15 slow repetitions — 5-second pause in neutral position between repetitions

Common mistakes to avoid:

• Also performing the extension phase (lordosis) which is contraindicated in spondylolisthesis
• Moving only the neck without involving the lumbar tract
• Performing the movement too quickly

How to know you’re doing it correctly:
You feel a stretch along the entire spine, particularly in the lumbar area. The sensation is one of “opening” between the vertebrae. The movement starts from the pelvis and propagates toward the head.

Exercise 8: Child’s Pose

Difficulty: Easy | Equipment: Mat | Duration: 3 minutes

Starting position:
Kneeling on the mat, sitting on your heels, with knees together or slightly apart.

Step-by-step execution:

1. Step 1: Slowly bend the torso forward, extending the arms in front of you on the floor
2. Step 2: Rest the forehead on the ground (or on a cushion if you can’t reach) and completely relax the lumbar area
3. Step 3: Breathe deeply with the diaphragm, allowing the torso to relax a bit more downward with each exhalation. Hold for 30-60 seconds

Sets and repetitions: 3-5 repetitions of 30-60 seconds — 15-second rest in upright position between repetitions

Common mistakes to avoid:

• Lifting the glutes off the heels during the stretch
• Holding breath or breathing superficially
• Forcing the position if you feel knee pain

How to know you’re doing it correctly:
You feel a comfortable stretch along the entire lumbar spine and a sensation of deep relaxation. Breathing is slow and diaphragmatic. Lumbar tension decreases progressively.

Stretching

Exercise 9: Hamstring Stretch

Difficulty: Easy | Equipment: Mat, towel or elastic band | Duration: 5 minutes

Starting position:
Lie supine with both legs extended. Pass a towel or elastic band under the sole of the foot to be stretched.

Step-by-step execution:

1. Step 1: Holding both ends of the towel, slowly lift the leg upward keeping the knee as extended as possible
2. Step 2: Gently pull the towel until feeling a stretch in the back of the thigh (not pain)
3. Step 3: Hold the position for 30 seconds breathing normally, then slowly lower the leg and repeat on the other side

Sets and repetitions: 3 repetitions of 30 seconds per leg — 10-second rest between repetitions

Common mistakes to avoid:

• Lifting the head or shoulders off the ground during stretching
• Excessively bending the knee of the raised leg
• Pulling forcefully until causing acute pain (stretching should be moderate tension)

How to know you’re doing it correctly:
You feel a stretch in the back of the thigh, from the glute area to the popliteal fossa. The sensation is one of moderate tension, not pain. The lumbar area stays resting on the ground.

Exercise 10: Iliopsoas Stretch

Difficulty: Intermediate | Equipment: Mat, cushion (optional) | Duration: 5 minutes

Starting position:
Lunge position with the back knee resting on the ground (on a cushion for greater comfort). The front foot is firmly planted on the ground with the knee bent at 90 degrees. The torso is upright.

Step-by-step execution:

1. Step 1: Contract the glutes and bring the pelvis into posterior tilt (rotate the pubic bone upward), flattening the lumbar area
2. Step 2: Maintaining the tilt, slowly advance body weight forward until feeling a stretch in the front of the hip and back thigh
3. Step 3: Hold the position for 30 seconds breathing deeply, then return to starting position and repeat on the other side

Sets and repetitions: 3 repetitions of 30 seconds per side — 15-second rest between repetitions

• Arching the back during the lunge (serious error in spondylolisthesis, nullifies the stretching effect and overloads the unstable segment)
• Losing pelvic tilt when advancing too far
• Leaning the torso forward instead of keeping it upright

How to know you’re doing it correctly:
You feel a stretch in the front of the hip and thigh on the side with the knee on the ground. The lumbar area remains flat and stable. There is no tension or pain in the lower back.

Exercises to AVOID

• Superman, cobra, McKenzie press-ups (extension)
• Overhead weight lifting
• Heavy squats and deadlifts (in initial phases)
• Sports with hyperextension: gymnastics, diving, butterfly swimming

Recovery Time

In clinical practice, most patients with grade I-II achieve good symptom control in 2-4 months with consistent exercises.

Physical Activity and Sports

Recommended: swimming (no butterfly), walking, stationary bike, pilates, yoga (avoiding extensions)

To avoid: artistic gymnastics, heavy weight lifting, contact sports, long-distance running

When is Surgery Needed?

Surgery (arthrodesis/spinal fusion) is indicated in 10-20% of cases:

• Intractable pain after 3-6 months of conservative treatment
• Progressive neurological deficits
• Documented progressive slippage
• Symptomatic grades III-V with neurological compromise

Frequently Asked Questions (FAQ)

Frequently Asked Questions

What is vertebral spondylolisthesis?

Vertebral spondylolisthesis is a condition where one vertebra slips forward over the vertebra below it. While this diagnosis can often cause concern, it is a frequent pathology that is effectively managed with conservative treatment in the vast majority of cases.

How is spondylolisthesis typically managed conservatively?

Conservative management for spondylolisthesis primarily involves a rehabilitation program focused on segmental stabilization of the spine. This approach aims to strengthen the ‘muscular corset’ to improve spinal stability and alleviate pain.

What is the significance of the degree of vertebral slippage?

It is important to note that the degree of vertebral slippage does not always correspond to the severity of perceived symptoms. Clinical experience and scientific literature confirm that many individuals with varying degrees of slippage can achieve excellent results with a targeted rehabilitation program.

What is the role of a physical therapist in treating spondylolisthesis?

A physical therapist is central to implementing the conservative treatment plan, particularly through a specialized rehabilitation program. This program focuses on strengthening core muscles to stabilize the spine, reduce pain, and improve functional movement.

For a broader overview of related conditions, see our back pain guide.

Scientific References

1. Kalichman L, et al. Spondylolysis and spondylolisthesis: prevalence and association with low back pain. Spine. 2009;34(2):199-205.
2. O’Sullivan PB, et al. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22(24):2959-2967.
3. Weinstein JN, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007;356(22):2257-2270.
4. Meyerding HW. Spondylolisthesis; surgical fusion. Surg Gynecol Obstet. 1932;54:371-377.
5. Sys J, et al. Nonoperative treatment of active spondylolysis in elite athletes. Eur Spine J. 2001;10(6):498-504.
6. Steiger F, et al. Surgery in lumbar degenerative spondilolisthesis. Eur J Radiol. 2015;84(5):765-774.
7. Ferrari S, et al. Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic spondylolisthesis. J Chiropr Med. 2012;11(2):125-133.
8. Kreiner DS, et al. Guideline summary review: diagnosis and treatment of adult isthmic spondylolisthesis. Spine J. 2016;16(12):1478-1485.
9. Bydon M, et al. Degenerative lumbar spondylolisthesis. Neurosurg Clin N Am. 2019;30(3):299-304.
10. Noonan KJ, et al. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis. J Pediatr Orthop. 1997;17(6):712-717.

Sources and Scientific References

1. Lurie J et al. (2016). Management of lumbar spinal stenosis. BMJ. 352:h6234. DOI | PubMed
2. García-Ramos CL et al. (2020). Degenerative spondylolisthesis I: general principles. Acta Ortop Mex. 34:324-328. PubMed
3. Kalichman L et al. (2008). Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 17:327-335. DOI | PubMed
4. Petersen T et al. (2017). Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskelet Disord. 18:188. DOI | PubMed
5. Cohen SP et al. (2007). Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 106:591-614. DOI | PubMed