Spondylolisthesis: Causes, Grades and Non-Invasive Management

Spondylolisthesis is the forward slip of one vertebra over the bone below it. It is most common in the lower back, at L4-L5 and L5-S1, and it is graded by how far the bone has moved.

Many cases of spondylolisthesis are small and stable, and many are found by chance on an X-ray taken for another reason. What shapes care is how the slip behaves: whether the bone moves when the spine bends, whether a nerve is pressed, and which positions ease the symptoms. With spondylolisthesis, bending forward often feels easier than leaning back, because bending forward opens the space the nerves pass through.

This guide to spondylolisthesis, its grades and non-invasive care, is published by Chiropractic Specialty Center, Bukit Damansara (KL) main center: WhatsApp+60 17 269 1873 Call+603 2093 1000

Key Takeaways for Spondylolisthesis

Key point	What to know
Types	The two most common types are degenerative, from wear in the disc and joints, and isthmic, from a small stress crack at the back of the vertebra that usually starts in childhood.
Grades	Most slips are grade 1 or 2, and many cause few or no symptoms.
Over time	Long-term studies show that most slips change little over the years, and a slip that grows does not always cause more symptoms.
Positions	Bending forward often feels easier than leaning back, because it opens the space the nerves pass through, while long standing with the back arched tends to load the slip.
Care	Care usually starts without surgery: exercise for the deep trunk muscles, gentle non-rotatory manual care and changes to daily habits.

Spondylolisthesis: Page Guide & Key Sections

• Types of Spondylolisthesis and What Causes Them
• Spondylolisthesis Grades: How Far the Bone Has Slipped
• Spondylolisthesis Assessment at Two KL Centers
• Signs and Symptoms of Spondylolisthesis
• Spondylolisthesis, Spondylolysis and Spondylosis: How They Differ
• How Spondylolisthesis Is Checked: X-Rays, MRI and CT
• Does Spondylolisthesis Get Worse Over Time?
• How Spondylolisthesis Is Managed Without Surgery
• Daily Habits That Ease the Load on a Slipped Vertebra
• When Surgery Is Discussed
• Explore Sciatica, Slipped Disc and Lower Back Pain Topics
• Spondylolisthesis FAQ
• Peer-Reviewed References
• The Author of Spondylolisthesis: Causes & Non-Invasive Management
• Last Updated: Spondylolisthesis: Causes, Grades and Non-Invasive Management

Types of Spondylolisthesis and What Causes Them

The system most doctors use to sort slips by cause was published by Wiltse, Newman and Macnab in 1976. It has five types:

• Degenerative. The disc and the small joints at one level wear down and let the vertebra drift forward. It is about three times more common in women than in men, it becomes more common with each decade after 40, and it is most often found at L4-L5.
• Isthmic. A stress crack, called spondylolysis, forms in the pars interarticularis, a thin bridge of bone at the back of the vertebra. The crack usually starts in childhood, tends to run in families and is most often found at L5-S1. Sports that arch the back again and again, such as gymnastics, add strain to this bridge.
• Dysplastic. The joints at the back of the vertebra formed differently before birth and do not hold the bone in place well. This type is less common.
• Traumatic. A sudden injury breaks a part of the vertebra other than the pars.
• Pathologic. A bone disease or tumor weakens the vertebra.

Degenerative and isthmic slips make up most cases. In a US community study that used CT scans on 188 adults aged 40 to 80, a pars crack was found in 11.5%, and about one in five people with a crack on both sides had no slip at all (Kalichman and colleagues, 2009).

Spondylolisthesis Grades: How Far the Bone Has Slipped

The Meyerding scale grades a slip by how far the upper vertebra has moved forward, measured as a share of the width of the vertebra below it (Koslosky and Gendelberg, 2020).

Grade	How far the bone has slipped	What it usually means
Grade 1	Up to 25%	The most common grade. Symptoms are often mild or absent.
Grade 2	26% to 50%	Still a low-grade slip. Care usually starts without surgery.
Grade 3	51% to 75%	A high-grade slip that is followed more closely.
Grade 4	76% to 100%	A high-grade slip. Surgery is discussed more often at this grade.
Grade 5	More than 100%	Called spondyloptosis: the vertebra has slipped fully off the one below. It is rare.

The grade describes the X-ray, not the person. Two people with the same grade can have very different symptoms, so the examination matters as much as the picture.

Spondylolisthesis Assessment at Two KL Centers

A first visit for spondylolisthesis at Chiropractic Specialty Center looks at how the slip behaves: which movements ease or bring on symptoms, how the hip and trunk muscles work, and whether bending X-rays have been taken. Existing X-rays, MRI reports and scan images are worth bringing. Directions and hours are on the Bukit Damansara contact page and the Bandar Sri Damansara contact page, or you can call or message either center:

• Bukit Damansara (KL, main center): Call +603 2093 1000 or WhatsApp +60 17 269 1873 to see the Bukit Damansara / KL center.
• Bandar Sri Damansara (KL): Call +603 6262 5777 or WhatsApp +60 12 455 6939 to see the Bandar Sri Damansara center.

Signs and Symptoms of Spondylolisthesis

Many people with spondylolisthesis have no symptoms at all. In that CT study, having a slip or a pars crack was not linked with having lower back pain (Kalichman and colleagues, 2009). When symptoms do appear, these are the common ones:

• An ache in the lower back that builds with long standing or leaning back, and eases with sitting or bending forward.
• Tight hamstrings, the muscles at the back of the thighs, mostly in young people with an isthmic slip.
• Pain, tingling or numbness that travels down one leg when a nerve root is pressed, often called sciatica.
• Heavy, tired legs after walking a set distance that ease after sitting or leaning forward. This points to a narrowed spinal canal, called spinal stenosis.
• A change in posture, or a step that can be felt along the lower spine, mostly with high-grade slips.

Leg weakness that keeps getting worse should not be ignored. It calls for a careful assessment by a competent provider, and conservative care can still be a reasonable route for as long as it keeps producing results.

For someone with spondylolisthesis and back or leg pain, new or worsening numbness around the genitals, between the genitals and anus, or around the anus, new difficulty passing urine, or loss of bladder or bowel control needs urgent medical attention: a thorough assessment by a competent clinician the same day. These changes can have several causes. Some may call for an invasive procedure, but being assessed does not mean that surgery is necessarily needed.

Spondylolisthesis, Spondylolysis and Spondylosis: How They Differ

The three names sound alike but describe different things:

• Spondylolisthesis is a slip: one vertebra has moved forward over the one below.
• Spondylolysis is a crack: a stress fracture in the pars, with or without a slip. In a study that followed the same people for 45 years, those with a crack on only one side never developed a slip (Beutler and colleagues, 2003).
• Spondylosis is wear: age-related thinning of the discs, thickening of the joints and bone spurs, without a slip. Our spondylosis guide covers it in detail.

The three can appear together. Wear at L4-L5 can lead to a degenerative slip, and a pars crack at L5-S1 can lead to an isthmic slip.

How Spondylolisthesis Is Checked: X-Rays, MRI and CT

• Standing side-view X-ray. Shows the slip and its grade.
• Bending X-rays. Taken leaning forward and then leaning back, they show whether the vertebra moves between the two positions. A slip that moves is called unstable, and one that stays put is called stable. This split helps guide care (Vanti and colleagues, 2021).
• MRI. Shows the discs, the nerves and ligaments such as the ligamentum flavum. It is used when leg symptoms suggest a pressed nerve or a narrowed canal.
• CT scan. Shows bone in fine detail and can find a pars crack that a plain X-ray misses. In the same study, CT found pars cracks in about twice as many adults as older X-ray studies had.

Does Spondylolisthesis Get Worse Over Time?

For most people, spondylolisthesis changes slowly or not at all. A study that X-rayed 500 first-grade children and followed them into adulthood found pars cracks in 4.4% at age six and in 6% of adults, and a slip rarely grew after the teen years (Fredrickson and colleagues, 1984). When the people with pars cracks were checked again 45 years after the study began, their health scores matched those of the general population, and no one's slip had reached 40% (Beutler and colleagues, 2003).

Degenerative slips follow a similar pattern. A Japanese study followed 145 people with a degenerative slip for 10 to 18 years without surgery. The slip grew in about one in three, but the change did not track with symptoms, and 76% of those who started without nerve problems still had none after 10 years (Matsunaga and colleagues, 2000). People who already had nerve symptoms, such as leg pain on walking, did less well, which is why nerve symptoms that keep getting worse deserve a careful assessment.

How Spondylolisthesis Is Managed Without Surgery

Non-surgical care is the first step for most people with a degenerative slip, with or without nerve symptoms (Kalichman and Hunter, 2008), and it is also the usual starting point for low-grade isthmic slips (Vanti and colleagues, 2021). The aim is to do more of what helps the slipped level and less of what strains it, alone or with help from a chiropractor, physiotherapist or medical doctor. What helps is strength in the deep trunk and hip muscles, free movement in the hips, and positions that keep the lower back from arching for long periods. What strains it is long standing with the back arched, repeated back-bending, and lifting with the back instead of the hips.

Exercise for the deep trunk muscles

In a trial of 44 people with long-term back symptoms and an X-ray showing spondylolysis or spondylolisthesis, one group spent 10 weeks training the deep abdominal muscles together with the multifidus, the small muscles beside the spine, and then used them during the postures and tasks that had been bringing on symptoms. That group reported lower symptom and disability scores, and the change held at 30 months. The group that received usual care showed no real change (O'Sullivan and colleagues, 1997).

Gentle, non-rotatory manual care

Chiropractic care at CSC uses non-rotatory methods, with no twisting of the spine, and the slipped level itself is not pushed into a backward bend. Manual care is aimed at the stiff joints above and below it and at the hips, so that movement is shared more evenly and the slipped level is not doing all the work. Methods include instrument-assisted adjusting with an Activator and sustained positional release.

Physiotherapy

Physiotherapy centers on graded, supervised exercise, stretching of tight hip flexors and hamstrings, and practice in bending and lifting with the hips. Tight hip flexors tilt the pelvis forward and arch the lower back, the position that tends to load a slip.

NSD Therapy®

NSD Therapy® is a non-surgical spine care method invented by Yama Zafer, D.C. It brings together spinal decompression therapy, physiotherapy and non-rotatory chiropractic care, and it is the main approach used for spondylolisthesis at CSC. Which parts are used, and how, is decided after the assessment.

What a plan needs in order to work

For any care of a slip to have a good outcome, four things have to happen. The slip and how it behaves must be diagnosed accurately. The plan must be built around those findings. The plan must be carried out with as few errors as possible. And it must be topped with changes in posture, habits and daily activity. Meeting those conditions takes a provider with in-depth knowledge and experience of slips like this one.

Daily Habits That Ease the Load on a Slipped Vertebra

• Break up long periods of standing. Resting one foot on a low step flattens the arch in the lower back.
• Bend and lift with the hips and knees, and keep the load close to the body.
• Choose low-impact activity such as walking, cycling or swimming, and hold off on deep backward bends until the slip has been assessed.
• Keep a healthy weight, since extra weight adds load to the lower spine.
• Sleep on the side with the knees bent, or on the back with a pillow under the knees.
• Young athletes whose sport arches the back again and again should have back symptoms that keep coming back checked.

When Surgery Is Discussed

Surgery is a last step, not a first one. It is usually considered only when a fair trial of conservative care has not helped, when nerve symptoms keep getting worse, when walking distance stays very short, or when a high-grade slip keeps growing on repeat X-rays. The common operations are decompression, which frees pressed nerves, and fusion, which joins the slipped vertebra to the one below. A slip seen on a scan is not, by itself, a reason for surgery. A keyhole incision is still an incision, and working a camera and tools through it at different angles can disturb the tissue around it.

Planning a visit? You can review the current chiropractic price in Kuala Lumpur and physiotherapy fees in Kuala Lumpur before you come in.

Spondylolisthesis FAQ

What is spondylolisthesis?

Spondylolisthesis is a forward slip of one vertebra over the one below it, most often in the lower back at L4-L5 or L5-S1. The two common causes are wear with age (degenerative) and a stress crack at the back of the vertebra (isthmic). It is graded from 1 to 5 by how far the bone has moved, most slips are grade 1 or 2, and many are found by chance on an X-ray taken for another reason.

What are the symptoms of spondylolisthesis?

Many people have none. When symptoms appear, the common ones are a lower back ache that builds with standing or leaning back, tight hamstrings, leg symptoms from a pressed nerve, and heavy legs after walking that ease with sitting. Bending forward often eases the ache, because it opens the space the nerves pass through. New numbness around the genitals or anus, new difficulty passing urine, or loss of bladder or bowel control needs urgent medical attention the same day.

How is spondylolisthesis diagnosed?

A standing side-view X-ray shows the slip and its grade. Bending X-rays, taken leaning forward and then leaning back, show whether the vertebra moves between the two positions, which separates a stable slip from an unstable one and helps guide care. MRI shows the nerves and discs when leg symptoms suggest a pressed nerve or a narrowed canal, and CT shows fine bone detail such as a pars crack. The images are read together with the examination.

What are the grades of spondylolisthesis?

The Meyerding scale grades a slip by how far the upper vertebra has moved forward, measured as a share of the width of the vertebra below: grade 1 is up to 25%, grade 2 is 26% to 50%, grade 3 is 51% to 75%, grade 4 is 76% to 100%, and grade 5 means the vertebra has slipped fully off the one below. Grades 1 and 2 are the most common. The grade describes the X-ray, not the person, so the examination matters as much.

Can spondylolisthesis be managed without surgery?

In most cases, yes. Non-surgical care is the usual first step, and it centers on exercise for the deep trunk and hip muscles, gentle non-rotatory manual care and changes to daily habits. In a trial of people with a slip or a pars crack, ten weeks of deep trunk muscle training lowered symptom and disability scores, and the change held at 30 months. Surgery is considered when a fair trial of conservative care has not helped or nerve symptoms keep getting worse.

What is the difference between spondylolisthesis, spondylolysis and spondylosis?

Spondylolisthesis is a slip of one vertebra over another. Spondylolysis is a stress crack in the pars, the thin bridge of bone at the back of the vertebra, which may or may not lead to a slip. Spondylosis is age-related wear of the discs and joints, without a slip. The three can appear together: wear at L4-L5 can lead to a degenerative slip, and a pars crack at L5-S1 can lead to an isthmic slip.

Can spondylolisthesis be prevented?

Not every case can be prevented, since isthmic cracks often start in childhood and run in families. Strong trunk and hip muscles, a healthy weight and lifting with the hips all lower the load on the lower spine, while long standing with the back arched and repeated back-bending raise it. Young athletes whose sport arches the back again and again, such as gymnasts, should have back symptoms that keep coming back checked.

Peer-Reviewed References

• Wiltse LL, Newman PH, Macnab I. Classification of spondylolisis and spondylolisthesis. Clin Orthop Relat Res. 1976;(117):23-29.
• Koslosky E, Gendelberg D. Classification in brief: the Meyerding classification system of spondylolisthesis. Clin Orthop Relat Res. 2020;478(5):1125-1130.
• Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am. 1984;66(5):699-707.
• Beutler WJ, Fredrickson BE, Murtland A, et al. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976). 2003;28(10):1027-1035.
• Kalichman L, Kim DH, Li L, et al. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34(2):199-205.
• Matsunaga S, Ijiri K, Hayashi K. Nonsurgically managed patients with degenerative spondylolisthesis: a 10- to 18-year follow-up study. J Neurosurg. 2000;93(2 Suppl):194-198.
• O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976). 1997;22(24):2959-2967.
• Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17(3):327-335.
• Vanti C, Ferrari S, Guccione AA, Pillastrini P. Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment. Arch Physiother. 2021;11(1):19.

These references describe spondylolisthesis and its non-surgical care in general. None of them evaluates care at Chiropractic Specialty Center.

The Author of Spondylolisthesis: Causes & Non-Invasive Management

Spondylolisthesis: Causes & Non-Invasive Management was written by Yama Zafer, D.C., who has 30+ years in chiropractic and physiotherapy and founded Chiropractic Specialty Center in Kuala Lumpur in 2006.

Last Updated: Spondylolisthesis: Causes, Grades and Non-Invasive Management

Spondylolisthesis: Causes, Grades and Non-Invasive Management was last reviewed and updated on October 3, 2026.