MRI annular tear

Why do annular tears hurt so much?

Annular tears are seen on MRI scans of the lumbar spine.  They appear as tiny white dots in the back of the disk.  The radiologist will call annular tears “posterior high intensity zone lesions.”  In addition to severe low back pain, they are a source of confusion, concern, and unanswered questions about their significance and treatment.

Here is a short video where I review the MRI scan of someone with an annular tear of the L5-S1 disc

Here is a short description of his symptoms in his own words:

  • prior to August 2016 I was doing a lot of recreational running

  • At the end of July 2016 I fell while biking, felt a sharp pain immediate after fall but everything seemed OK after two days.

  • early Dec 2016, moved a piece of furniture and felt sharp pain in back – obviously this caused severe injury of the disc

  • mid Dec 2016 – got my MRI scan

  • end Dec 2016 – new sharp pain bottom of pelvis. Obviously I re-injured the disk again and made things worse. Back pain lasted for 2-3 weeks before slowly improving.

  • Jan 2017 – back pain started to improve and I was able to do some back pain excercises

  • beginning Feb 2017 – started to feel numbness (I assume it was because I took a business trip, more sitting, traveling with bag, airports… that caused things worse)

  • last 7 days I was very careful and things have improved slowly.  my tensor latae fasciae spasm continues.  I cannot run.

  • Through all this time I felt almost no leg pain. I had some occasional pain in the toes which I was not sure if originates from spine (not severe, one day episodes). Numbness scared me but it was not very severe.

What I ask myself all the time is:

  • I can hear popping in my back with certain moves (for example changing position while sleeping from one hip to another or with some leg movements). Does this come from the disc tear or herniation? It is painless.  I have feeling it comes from the back.

  • What is my prognosis? As most people would, I would like to avoid surgery but do not want to make things worse. I have no problems with pain at the moment but would like to return to some sport activities in the future. I learned that healing should take at least 6 months. Is this possible without surgery in my case?

  • What would be your recommendation in my case?

And here is his MRI scan

In this patient’s case, I recommend that he continue with non-operative care.  His pain has already started to decrease and he is still active.  We would reasonably expect that with time this should heald and he should feel like he has a normal spine.

Here are some other examples of MRI scans of the spine with an annular tear

In this first example of an annular tear in the L4-5 disk in a 22 year old female, there is a tiny white dot in the back of the disk where the fibers of the annulus are torn.

annular tear L4.5

In this second example, in the L5/S1 disk, the annular tear is centrally located and is more apparent on the axial view.  These are T2 sequences, and the computer algorithm that creates the T2 images from the raw MRI scan data makes fluid look bright white.  You will notice that the cerebrospinal fluid appears bright white.  CSF is a filtrate of plasma.  Since the CSF appears white, we conclude that the annular tear is probably a gap in the fibers of the annulus fibrosis that is fluid filled.

Most patients with annular tears have similar histories.  They report that they were lifting a heavy object, moving awkwardly, or twisting at the same time.  Suddenly they felt like they were shot or stabbed in the back.  They are often in a tremendous amount of pain.  Since they do not have a large disk herniation on the MRI scan, these patients are often described as having “pain out of proportion to expectations”.  This is a little unfair because in my experience, annular tears seem to be very slow to heal and they can be a cause of long lasting and disabling back pain.


I believe that annular tears represent a partial disk herniation.  The annulus fibrosis that surrounds the intervertebral disk is made up of many layers.  When an annular tear occurs, the central portion of the disk, the nucleus pulposus, herniates through most, but not all of the layers of the annulus.  A fragment of disk material is stuck in the middle of the tear and it is surrounded by fluid and inflammation.

The nucleus of the intervertebral disk is made of a protein core consisting of proteoglycans.  These long, branched proteins are relatively acidic, viscous, and naturally slippery.  As such, they are designed to prevent adhesions and scar tissue formation since they are natural shock absorbers.  When they get trapped in between the fibers of the annulus, they prevent the collagen fibers in the annulus from healing.  As a result, there is a permanent weak spot in the fibers of the annulus which is a constant source of pain.

Whats the best treatment for annular tears?

A number of times in my surgical career I have operated on patients with broad based disk bulges, an annular tear, and both back and leg pain.  When I make a small incision in the outer covering of the disk, a fragment of disk material squeezes out as if it were under pressure.  Typically, there is a small cavity where the annular tear is located that is filled with fragments of disk material.  The patient’s leg pain gets better after the operation because of the microsurgical decompression.  Interestingly, the patient’s back pain improves rapidly after the operation because without the fragment of the disk stuck in the tear the annulus can finally heal.

I’ve arrived at the conclusion that for some patients with relentless back pain related to an annular tear it makes more sense to have a microsurgical decompression with an exploration of the annular tear and a removal of the fragment of the disk that is just underneath the surface.  This seems to kick start the healing process and let them get on with their lives faster. My favorite technique for treating annular tears is now an endoscopic technique. Here is a video of how I do that operation:

Other patients, however, will get better with non-operative treatment.  With time, and and a gradual return to normal activities, their back starts to settle down and they have less and less pain.

The other option is an injection into the disk space of either platelet rich plasma or adipose derived stem cells.  There is good evidence to suggest that PRP injections are effective in shortening the time that annular tears hurt.  Stem cell injections are also a really exciting area of active clinical research and there is some early evidence to suggest that stem cells injected directly into the disc may help.  At the moment, the best evidence suggests that either a microscopic decompression with a removal of the trapped fragments or a platelet rich plasma injection is the best treatment if non operative treatment simply isn’t working.

What kind of options do you have if you have an annular tear?

Many annular tears will get better with non operative treatment, but some don’t.  If you’ve had pain for more then 6 weeks and you have already had an MRI scan of the spine, I can review your MRI scan for you and tell you what options you have.   To get started with this process click here: MRI review service

reverse hyper

Spondylolisthesis: can it be reversed?

What is spondylolisthesis?

Spondylolisthesis is a common cause of back and leg pain.  The most common question that I get asked immediately after I tell someone that they have a “spondy”, is a variation of….

  • “Can it be fixed without surgery?”
  • “Will it go back into place if I do a lot of back bends?”
  • “Can I reverse my spondylolisthesis with physical therapy?”

Let’s look deeper into questions surrounding the idea of reversing spondylolisthesis.  The word spondylolisthesis has two words with Latin roots.  “Spondy” is latin for spine, and “listhesis” is latin for slipping.  In this condition one vertebral body slips forward with respect to the one immediately underneath it.  The two most common locations of a spondylolisthesis are L4-5 and L5-S1.

Case Examples

Here is an X-ray of the spine with a spondylolisthesis at the L4-5 level.  In this case, this a grade 1 slip — L4 has slipped about 20% of the length of the L5 vertebral body.


L4.5 grade 1 spondy lateral preop

This condition has a couple of different causes.  The most common cause of a spondylolisthesis is degenerative disk disease caused by the normal aging process.

The other most common cause is repeated hyperextension during sports as an adolescent when the spine can develop a stress fracture called a “spondylolysis”.  This typically causes back pain during adolescence and may later progress to a spondylolisthesis.

Why do some people develop a spondylolisthesis?

The risk factors for developing a spondylolisthesis include:

  • female sex
  • hyper flexibility
  • increased lumbar lordosis
  • according to, sports such as football and gymnastics that involve hyperextensions of the spine.

I’ve written a more detailed article about there natural history and treatment of spondylolisthesis here:

Reversing Spondylolisthesis: is it possible?

Since the surgical treatment for fixing a spondylolisthesis typically involves a single level fusion of the spine, most people want to know about their alternatives.  Their two most common concerns / desires are as follows:

1. They are reluctant to jump right into a fusion

2. They are very interested in alternatives.

I’m a cross fitter.  I love to surf.  If I had a spondy, I’d want to wait for as long as I could before I got a fusion.  I’d also do all the PT and non-operative treatment that I could.  I checked the crossfit boards and found this thread on spondylolisthesis:

“I am an active duty Army officer diagnosed with Spondylolisthesis, L5 shifted approx 30-35% forward (anterior) over S1. I most likely incurred my injury during my early years in the military. To my knowledge, the degree of shift has not changed over the years. I have been crossfitting for 4 years, and my back issues have fluctuated over the years in terms of severity and impact to my workouts. However, it has not impacted my ability to do my job or deploy. At this time, I am mid way through my 8th deployment, and I’m trying to proactively minimze my syptoms as much as possible on a daily basis.

I avoid heavy deadlifts and GHDs, but pretty much do every thing else as Rx’d. My symptoms sometimes include back soreness, which gets too severe to exercise about 1-2 times a year for a few days. I do my best to listen to my body and reduce my activity when this happens.”

The recommendations that follow this post include an excellent discussion about the pros and cons of reverse hyper-extension exercises with the lumbar spine, inversion therapy, and avoiding certain heavy lifts — like deadlift and squats.  If you want to read the entire thread, follow this link —

This is a picture of rogue’s reverse hyper extension machine for the lumbar spine:

reversing spondylolisthesis

What should you do next?

Here’s my opinion.  FORM is critically important if you have a spondylolisthesis.  If you think about it, a spondylolisthesis is probably a normal response to an abnormal movement pattern.  Most of these patients trend towards the hyper flexible part of the athletic spectrum.  Their joint laxity and movement patterns probably put increased stress on the intervertebral disk during physical exercise.  Most likely, this is a shear type of force where the trunk is trying to slide anteriorly with respect to the pelvis.  If the core is strong and the trunk is solidly anchored to the pelvis, this shear force should be offset by the stabilizing strength of the glutes and spina erecta musculature.

If you workout with PERFECT FORM, you should theoretically neutralize the forces trying to push your slipping vertebral body anteriorly.  If you strengthen the muscles that neutralize these forces, you should be able to work out with risking progression while also stabilizing your core.   Do this for long enough and you’ll have a bullet proof core and less pain.

My favorite book on this subject is Kelly Starrett’s Becoming a Supple Leopard, but you can always start with

Neutral Spine.  Neutral Spine.  Neutral Spine.  That’s the mantra you should be repeating to yourself every time you lace up your shoes if you have a spondylolisthesis.

What about surgery?

Finally, a word about surgical treatment.  As the field of microscopic spine surgery has evolved, I have become much more willing to perform an microscopic decompression of the nerve roots affected by the spondylolisthesis, especially if someone has leg pain on only one side.

In my opinion, correct body mechanics has just as much ability to stabilize a spondylolisthesis as a fusion does, and if I needed an operation because I had relentless leg pain due to a spongy, I’d have a microscopic decompression and be absolutely meticulous about my rehab.

If you’ve got questions about what to do about your spondylolisthesis and you’d like us to review your MRI scan, we’d be happy to just visit this page here to get started.


Back pain and strength training…. are free weights an answer?

Back pain and free weights?

I practice spine surgery in Monterey, California, which is home to the Naval Post Graduate School and the Defense Language Institute.  In the years that I’ve been in practice I’ve seen a lot of active duty soldiers rotate through Monterey for advanced degrees or language proficiency training.  They share similar histories.  They are fit, strong, and all of them have a lot of “mileage” on their backs.  Running around the desert with a heavy rucksack on, or jumping in and out of helicopters in the middle of the night is certain to cause back pain at some point.  Most of these soldiers report that they were fine while they were with their units in Afghanistan or Iraq and their back pain was manageable.  If anything, it was made better by staying active.  However, once they are crammed into a desk learning 40+ words of a foreign language a day, their backs start to ache.

Back pain and military service

Not surprisingly, all of their MRI scans are abnormal with degenerative changes typical of someone who is used to carrying a heavy rucksack and jumping in and out of a helicopter for a living.  I’ve help enough of them rehabilitate themselves that I know they are able to return to active duty, including paratrooper and flight duty, in spite of relatively significant degenerative changes and disk bulges.  I have also performed enough microscopic decompression surgery on active duty soldiers to know that after a well done microdiscectomy they will pass their fit for duty physicals and can return to service.  However, if they have a fusion, their military careers are basically over.

Since this is a patient population that prides itself on strength, endurance, and toughness, I get asked a lot of questions about strength training for both non-operative and post-operative rehabilitation.  My response is always encouraging, with a caveat.  Just like your mother said, POSTURE is IMPORTANT.  In my opinion, the following article does a great job of summarizing the arguments in favor of strength training as a way of avoiding back pain — especially the counter-intuitive exercises like deadlifting and squatting.


I caution these patients that this is one of those times where form truly is more important than function.  It’s better to lift correctly than to lift heavily, especially if your back is already injured.  I also believe that Kelly Starrett — of mobilityWOD and Becoming a Supple Leopard fame — is probably the most articulate advocate for proper form.

Is weight lifting safe if you have back pain?

The clear answer is Yes.  As long as it is done correctly.  If you are getting back into the gym after an episode of low back pain, or if you are rehabilitating after surgery, get some help.  Find someone who is really knowledgeable, like a strength and conditioning coach or a really good physical therapist.  Make sure your form is perfect.  Start light, and work your way up.  Done properly, even deadlifts and squats can help reduce back pain.

anterior microforaminotomy opening

Cervical microforaminotomy versus anterior cervical discectomy and fusion

Why we do Microforaminotomy surgery instead of fusions for neck and arm pain

My neurosurgical partner, Dr. Dimitrov, and I got interested in cervical microforaminotomies in 2010.  Our very first patient was a local big wave surfer who had arthritis and disk herniations at three levels in the cervical spine.  With 3 level cervical disk disease, and occasional episodes of severe neck pain, he had been told over and over again that #1 he needed a 3 level fusion, and #2 after the fusion, he wasn’t going to be able to surf big waves again.  I know him socially, and he asked me for a second opinion.

When I had the chance to examine him, it was clear that he only had pain in his left C6 nerve root distribution.  When I gave him a pain diagram to complete, he circled this image.

His MRI scan showed that he while he did have 3 level degenerative disk disease in his cervical spine, he had a large extruded disk fragment and a bone spur compressing the nerve root on the left side.  We discussed his options and because he was adamant that he would rather live with the pain and the muscle weakness than have a fusion and have to give up surfing, we discussed performing an anterior cervical foraminotomy.  I gave him a number of articles from the literature to read and he agreed that this seemed like a very reasonable approach.  We did his operation, his pain disappeared, and his strength came back.  Understandly, he was delighted.  Even better, he was convinced that he’d avoided a big operation that would have left him partially disabled.  I agreed.  He sent his friends, and they sent their friends, and now this is an operation that we perform frequently.  Happy surfers make for happy surgeons.

Here’s an explanation of the anterior cervical microforaminotomy as an alternative to a cervical fusion.

Medical definitions that you need to know

First, a couple of simple definitions.  The medical term for neck and arm pain caused by a herniated disk is “cervical radiculopathy”.

The word radiculopathy is composed to two words with latin origins.  The word “radix” means root and the word “opathy” means a disease of.  A herniated disk puts pressure on the root of the nerve and causes pain every where the nerve travels.

A herniated disk usually squeezes the nerve root as it tries to leave the spinal canal through a small bony tunnel called the neuroforamen.  The word neuroforamen also has latin origins.   “neuro” is the latin word for nerve and “foramen” is the latin word for an opening.

MRI findings that cause cervical radiculopathy

Ok, now that we understand those two terms, let’s look at an MRI scan of the cervical spine.  This view is called the saggital view and there are 7 vertebrae in the cervical spine, C1 through C7.  Between each of these bones are the intervertebral disks.  Here at the C5-6 level there is a disk herniation.  On this view we can see how the disk is bulging out towards the spinal cord and the nerve roots and when we switch to a cross-section, called the axial view, we can see how the disk bulge is off to one side and putting pressure on the nerve root as it travels through the neuroforamen.

The location of the pain is a clue as to which nerve root is being affected.  The cervical nerve roots travel to particular parts of the arm and the hand.  We have our patients complete a pain diagram and a pain journal and this helps us confirm which nerve root is irritated and inflamed by the herniated disk.

Non-operative treament and fusion surgery

When the symptoms of a cervical radiculopathy do not get better with non-operative treatment that includes physical therapy and anti-inflammatory medications, most patients realize that they may need a surgical solution for their pain.  They need the pressure to be taken off the nerve root so that the pain will stop.

The standard operation for a herniated cervical disk is something called an anterior cervical discectomy and fusion.  This is a surgical procedure that removes the damaged intervertebral disk and replaces it with a spacer and titanium plate, stabilizing that level.  This operation reliably alleviates the pain from a herniated disk, but unfortunately, fusing one level in the cervical spine increases the mechanical stress on the adjacent levels in the cervical spine and accelerates the natural degenerative process that occurs with age.  This can lead to a loss of range of motion, more pain, and more surgery in the future.

The results of cervical fusion surgery can be very good, but many younger patients who are athletically active would really like to avoid a fusion.

Cervical microforaminotomy — an alternative to fusion surgery
There is an excellent operation for this problem that completely avoids a fusion.  This operation is called an anterior cervical microforaminotomy.  It has an excellent track record in the medical literature.

In fact, the former head of neurosurgery at the University of California in Los Angeles remarked in one of his papers that “Patients treated with the anterior cervical neural foraminotomy procedure have equivalent or better outcomes than those who undergo current cervical procedures. It appears to be a good procedure for carefully selected patients with one sided cervical radiculopathy and avoids a fusion of the disc space.”

In this operation, a small incision about 1 inch long is made in the front of the neck and the damaged disk is exposed with the help of a microscope.  A tiny tunnel is created in the disk and the surgeon works all the way back to the nerve root, lifting the herniated fragments of disk off the nerve root.  Because the operation requires removing less than 20% of the disk, a fusion is not necessary.

In these still images from an operating microscope we can see the surgeon using a special neurosurgical tool called a kerrison rongeur to clean the herniated disk off the nerve root.  The surgeon is working through a small channel in the disk that measures 1/8 of an inch by 1/4 of an inch.

Here are the before and after MRI images of the spine demonstrating removal of the herniated disk with an increase in the size of the neuroforamen.

After this procedure the patient can return to normal activities within two weeks.  We advise patients to avoid sports such as mountain biking, horseback riding, and surfing for 6 weeks, but after everything has healed we expect all of our patients to have normal range of motion of the neck and no activity restrictions.

At the minimus institute in Monterey, California, we specialize in motion preserving procedures for cervical disk disease.  We want to see all of our patients free from pain and able to return to the activities that they love.

If you are interested in a cervical microforamiotomy or alternatives to fusion surgery, contact our concierge and we will arrange to have your MRI scan reviewed by one of our surgeons.

MRI review to see if you are a candidate for a microforaminotomy


Spondylolisthesis: Everything you ever wanted to know, and more…..

The History of Spondylolisthesis

Spondylolisthesis is a medical term that describes an abnormal anatomic alignment between two bones in the spine.  This anatomic abnormality has been around since antiquity.  It was first described in the modern medical literature by a Belgian obstetrician named Dr. Herbinaux.   In 1782, Dr. Herbinaux noticed that the abnormal alignment of the lumbar spine and pelvis in very severe cases made natural childbirth difficult.  He was the first one to name this condition in which one vertebral body is slipped forward with respect to the one underneath it.

The term spondylolisthesis comes from two greek words: “spondy” (σπονδυλος) which means “vertebra” and “listhesis” (ὁλισθος) which means “a slip”.

How common is spondylolisthesis?

Spondylolisthesis most commonly affects the lower lumbar spine, typically at the L4/5 or L5/S1 levels.  Spondylolisthesis is a very common condition, occurring in about 5% of the population.  The most common type of spondylolisthesis is a degenerative slip that occurs at the L4/5 level.  This type of slip is caused by degeneration of the intervertebral disk and the facet joints.  Natural aging results in an increase in the “sloppiness” of the joint, much like a worn bushing in a car.  Here are two images that depict the changes that occur as the disk degenerates.  The gel-like substance inside the disk shrinks, the edges of the disk become irregular, and bone spurs develop.

normal anatomy of the lumbar spine

mechanical wear and tear on the spine creates a spondylolisthesis  degenerative disk disease

In this series of images, I use a CV joint from a car to illustrate how the spine is a mechanical joint and many years of “wear and tear” will cause the joint to become sloppy.



The Medical Definition of a degenerative spondylolisthesis

A recent clinical consensus paper was produced by the North American Spine Society will be referenced throughout this guide.  Their version of the “best working definition” of a degenerative lumbar spondylolisthesis is as follows: an acquired anterior displacement of one vertebra over the subjacent vertebrae, associated with degenerative changes, without an associated disruption or defect in the vertebral ring.

The key elements in this definition — anterior slip, degenerative change, and no disruption of the vertebral ring are easy to demonstrate in a typical case of spondylolisthesis.  As the disk deteriorates it becomes less capable of absorbing all of the forces of normal human movement.  Because the joint has increased “play” or “sloppiness” L4 starts to slip forward with respect to L5.  Here are X-rays and an MRI scan of a typical case of a grade 1 spondylolisthesis.  Flexion and extension X-rays are often used to evaluate how much abnormal motion occurs at the level of the spondylolisthesis.

  spondylolisthesis AP xray grade 1  lateral xray grade 1 L4.5 spondylolisthesis   lateral xray grade 1 L4.5 spondylolisthesis flexion view  lateral xray grade 1 L4.5 spondylolisthesis extension view

The second most common type of spondylolisthesis that we see occurs at L5/S1.  This condition is especially common in people who have repetitively extended their spine during athletics in adolescence.  The theory is that repetitive hyperextension of the spine during athletics results in a stress fracture.  This stress fracture called a spondylolysis.  The stress fracture occurs in a part of the vertebral body called the pars inter-articularis which disrupts the continuity of the vertebral ring.  The lack of a connection between the posterior and anterior parts of the L5 vertebral body allows the L5 vertebral body to slip forwards with respect to S1.  The association between adolescent athletics and this condition is very strong.  About 95% of competitive gymnasts and about 35% of competitive football players have X-ray evidence of the stress fracture that may result in a spondylolisthesis later on in life.

hyperextension of the spine results in spondylolysis hyperextension of the spine during gymnastics spondylolysis  spondylolysis fracture of the pars inter-articularis high grade spondylolisthesis with spondylolysis

This condition usually develops in two stages.  First, the patient has an episode of low back pain during their adolescence which is when the stress fracture of the pars interarticularis occurs.  Then as the disk starts to degenerate later in life, they begin to complain of low back and leg pain.  In contrast to a degenerative spondylolisthesis, this type of slip does involve a disruption of the vertebral ring, so this is often called an “isthmic” spondylolisthesis

Symptoms of spondylolisthesis 

Patients with spondylolisthesis complain of low back pain and pain along the course of the nerves that are pinched by the spondylolisthesis.  The narrowing of the normal space available for the nerve roots in the spinal canal is called stenosis.  The back pain typically occurs in the area of the lower lumbar spine and often radiates around the abdomen and into the buttocks.  The location of the nerve root pain depends upon where the slip is occurring and where the nerve roots are compressed.

Nerve root compression due to stenosis is called a radiculopathy: radix is the greek word for “root” and pathos a word for “a disease of”.   Pain and numbness in the legs as the result of a spondylolisthesis occurs in patterns called a radiculopathy that are very characteristic.  The human body is divided into a series of dermatomes which can be visualized as a map of where the nerves travel after the leave the spinal canal.  When the root of the nerve is affected, the entire course of the nerve is typically painful, numb, or the skin in this area is unusually sensitive.  For example, here is a map of the normal dermatomes of the body, and then three diagrams of an L4, L5, and S1 radiculopathy.  Patients with a spondylolisthesis at L4/5 usually have L5 nerve root pain due to compression of the L5 nerve root in the neural foramen.  Patients with a slip at L5/S1 usually have both L5 nerve and S1 root pain due to tension on the nerve roots.  For example, a patient with an L4/5 spondylolisthesis will usually describe low back pain at the base of the spine, radiating into the buttocks.  There is usually also pain and numbness along the sides of the legs, down the front and sides of the calves, with numbness and tingling in the feet.

If your major problem is pain and numbness in the legs, and especially if it is only affecting one leg, you may be a good candidate for a microscopic decompression instead of a fusion.  If you are interested in exploring this option, I may be able to review your MRI scan for you.

L4 radiculopathy

L4 nerve root pain

L5 radiculopathy

L5 nerve root pain

S1 radiculopathy

S1 nerve root pain


The pain that is associated with spondylolisthesis is variable.  It is often worse with standing.  Many patients find that the length of time they can walk comfortably gets shorter and shorter as the disease progresses.  We call this finding “limited walking endurance”.   This is often an indicator of how severely the patient is affected and how much nerve root compression they have.  Patients who are able to walk for more than an hour rarely need operative treatment.   Those who can only walk for a few hundred yards before they are limited by back and leg pain are more likely to require surgery.  These patients will often experience substantial relief once their spondylolisthesis is corrected.  While the pain associated with a spondylolisthesis is usually worse when the patient is on their feet, many patients have a hard time sleeping at night because the nerve root pain keeps them awake.


Xray and MRI findings in spondylolisthesis.

The best test for diagnosing a spondylolisthesis is a lateral Xray of the lumbar spine with the patient standing.  It is important that the patient is standing because there are some slips that return to their normal position when the patient lies down.  This is why some cases of spondylolisthesis are not apparent on supine X-rays or an MRI scan.  The best test for evaluating the degree of nerve root compression and spinal stenosis caused by spondylolisthesis is an MRI scan of the lumbar spine.

Here are a series of X-rays and MRI scans showing the relevant anatomic finding in a typical L4/5 degenerative spondylolisthesis.  Click on these images to enlarge them to full size

And here are the X-rays and MRI scans of a patient with an L5/S1 spondylolisthesis with bilateral pars defects.

L5/S1 spondylolisthesis

Non-operative treatment of spondylolisthesis

Physical Therapy: While it may not be possible to reverse the degenerative changes that occur with aging, it is possible to strengthen the muscles that surround the spine.  I have written a blog post about this particular point, which can be read here: reversing spondylolisthesis

PT helps to stabilize the lumbar spine and will often result in a decrease in symptoms of low back and leg pain to the point where surgery becomes unnecessary.  This type of therapy MUST emphasize active rehabilitation, which means that the patient must work actively to strengthen the muscles of the abdomen, low back, and core.  Massage, hot pack treatments, and electrical stimulation may feel good at the time, but their effects are usually temporary.  While massage feels great, it usually does NOT result in sustained relief.  The type of therapy that we employ emphasizes core conditioning and strengthening and our therapists will instruct you on how to do these exercises properly.  If your symptoms are relatively mild and you are still able to exercise, hike, and play some sports, then often a Pilates or a Yoga program may be very beneficial, less costly, and more convenient than going to a physical therapist.

physical therapy for spinal instability  core exercises for spinal instability  

Medical Management

Non-steroidal pain relievers like Aspirin, Tylenol, Motrin, and Ibuprofen are very helpful in the management of spondylolisthesis.  The medications can calm down the inflammation that accompanies degenerative disk disease.  This often makes it possible to participate in physical therapy with less pain.  If you can do PT,  it makes it possible to work harder to strengthen the muscles of the low back and abdomen.

NSAIDs for spondylolisthesis

Selective Nerve Root Blocks:  In our clinic we have specialists who perform selective nerve root blocks with injectable medications like Cortisone and Kenalog.  These are much stronger than the anti-inflammatories you can take by mouth.  These injections are performed in the surgical center and are done using an intra-operative X-ray machine to make sure that the medication is injected in the same area where the nerve root compression is occurring.  In our experience, nerve root blocks are very helpful for patients.  They will often result in a sufficient reduction in pain so that physical therapy is tolerable.  The block may also interrupt the “cycle of inflammation” to the point where the symptoms are manageable and surgery can be avoided indefinitely.


Why you should avoid narcotics

In our experience, using narcotic pain medications on a daily basis for the treatment of the pain associated with a spondylolisthesis is a bad idea.  Because spondylolisthesis is a condition that tends to worsen with time, most people who start taking narcotics find it very difficult to stop.  The use of narcotic pain medications for an open-ended diagnosis is dangerous.  This is because there is not a defined point in the future when we know that the pain will spontaneously resolve.  For example, if a patient has a fracture, we know that the pain will subside once the fracture heals.  However, with a spondylolisthesis, because there is not a possibility of spontaneous correction, the patient will continue to perceive a need for narcotics on a regular basis.  This quickly leads to tolerance as the medications become less effective with time and their routine use becomes habit forming.  For more information on my philosophy about the use of narcotic pain medications, click here.

What the establishment says about non-operative care for spondylolisthesis

The North American Spine Society’s consensus statement on non-operative care for spondylolisthesis is a follows: The majority of patients with symptomatic degenerative lumbar spondylolisthesis and an absence of neurologic deficits will do well with conservative care. Patients who present with sensory changes, muscle weakness, [or a short walking endurance] are more likely to develop progressive functional decline without surgery. Progression of slip correlates with jobs that require repetitive anterior flexion of the spine. Slip progression is less likely to occur when the disc has lost over 80% of its native height and intervertebral osteophytes have formed. Progression of clinical symptoms does not correlate with progression of the slip.

Surgery for spondylolisthesis: do you need it?

Here is what the North American Spine Society has to say: Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical and interventional treatment.  In our clinic we agree with this statement.

What this means to us is that patients who have symptoms that can be clearly attributed to their spondylolisthesis should first be educated about their condition.  Next they should consider physical therapy and lifestyle changes that we believe are associated with improvements in back pain.  If they continue to have pain they should consider a selective nerve root block to temporarily reduce the inflammation in the nerve roots — as long as this is seen as a bridge to making physical therapy more tolerable.  Surgery should only be considered when the patient has continued symptoms that do not improve with physical therapy or medical management.

Our technique for the surgical correction of spondylolisthesis is designed to achieve four goals

1. relieve the nerve root compression that is causing pain and numbness in the legs

2. stabilize the unstable spinal segment that is slipping, only if necessary

3. improve the alignment of the spinal canal

4. provide the patient with a durable solution that will improve their quality of life for years to come.

While there is a great deal of debate about the best surgical technique for the treatment of spondylolisthesis, the NASS clinical guidelines do state that surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis…and that …decompression and fusion is recommended as a means to provide satisfactory long-term (greater than 4+ years) results for the patient.  For example, on a recent Spine Surgery Board Certification Examination administered by the American Academy of Neurological Surgeons, the following question was asked: A 47 year old dentist presents with a 5 year history of intractable low back pain refractory to several courses of physical therapy and numerous medications.  He has recently developed bilateral L5 radiculopathy.  MR imaging demonstrates grade II anterolisthesis of L4 on L5 with resulting L4-5 central canal stenosis and bilateral neuroforaminal stenosis. The BEST treatment option is:

  1. dorsal column stimulator
  2. anterior lumbar interbody cage fusion
  3. laminectomy and pedicle screw fusion
  4. epidural steroid injection
  5. laminectomy with facetectomy

The correct answer, according to the AANS, is #3.  Here is their explanation: This patient has failed reasonable attempts at non-operative management and has an anatomical abnormality that corresponds to his clinical symptomatology.  Surgical correction is the best option.  Decompression alone in the presence of spondylolisthesis in a relatively young patient is associated with a high incidence of progressive listhesis and worsening pain.

Here’s where I disagree.  I think that it in carefully selected patients, a microscopic decompression with meticulous physical therapy and rehabilitation can result is excellent clinical results.  When I am able to alleviate someone’s leg pain so that they can go back to working out and keep their core strong, they are happy.

I’d be happy to give you second opinion if you are interested in whether or not a fusion is necessary in your case

In the meantime, here is a series of pictures from our operating room during correction of a spondylolisthesis of the spine using a traditional approach…

surgery for spondylolisthesis  intraoperative image spondylolisthesis  decompression for spondylolisthesis  size of incision spondylolisthesis surgery  drain connected to reservoir  rolling the patient back into a supine position

Here are a series of x-rays that demonstrate the correction of spondylolisthesis with a decompression and fusion of the slip performed in our clinic in Monterey, California.  You can click on each of these Xrays to enlarge them to full size.

L4.5 degenerative spondylolisthesis repaired with an L4.5 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L4.5 grade 1 spondy AP preop  L4.5 grade 1 spondy lateral preop  L4.5 spondy postop AP  L4.5 spondy postop lat


L5/S1 isthmic spondylolisthesis repaired with an L5/S1 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L5.S1 Grade 2 spondylolisthesis AP  L5.S1 Grade 2 spondylolisthesis lateral  L5.S1 Grade 2 spondylolisthesis extension  L5.S1 Grade 2 spondylolisthesis extension  L5.S1 grade 2 spondylolisthesis post op AP  L5.S1 grade 2 spondylolisthesis postop lateral


I’ve also got a large number of patients that haven’t needed  a stabilization.  Instead, I’ve done a microscopic decompression for them, especially if they only have pain and numbness in one leg.  If they are able to decrease the chance of future progression of the spondylolisthesis with lumbar spine strengthening exercises, they are delighted with the opportunity to live without a fusion every day.

If you’ve already had an MRI scan and are intrested in discussing your options, I will review your MRI scan for and tell you whether or not I think a microscopic decompression rather than a fusion will work in your case.

To learn more about your options for non-fusion treatment of spondylolisthesis, click here: MRI review.

axial plane for MRI scan

MRI Scans: Where Abnormal Findings Are Normal

An Introduction to MRI scans

The very first MRI scan of the human body was performed in 1977. Prior to this, we were basically making educated guesses about what was wrong with the spine. Today, the modern practice of spine surgery relies heavily on the interpretation of MRI scans.

MRI scans slice the human body into thin sections

Magnetic Resonance Imaging creates thin section images of the inside of the human body. This technique allows us to visualize anatomic structures from any angle and direction. The two most common slices that we look at on MRI scans of the spine are the sagittal and coronal slices. The saggital plane sections the human body lengthwise. The axial plane creates a cross section of the human body.

MRI axial planeMRI sagittal plane

An MRI image looks like a photograph, but it is actually a computerized image of the nuclear magnetic resonance of molecules inside the human body. These images are superior to CT scans and X-rays. The resolution and clarity of the images is better, we can see more fine detail, and this test uses harmless radio waves instead of ionizing radiation.

MRI scans as a medical tool

Magnetic Resonance Imaging is an amazing tool that allows us to see deep inside the human body with a degree of clarity that is absolutely amazing. We can visualize the tiny details of normal and abnormal human anatomy. We can clearly see the intervertebral discs, spinal cord and nerve roots. In addition to normal anatomy, we have also learned to identify a number of findings that may cause neck and arm pain or back and leg pain. The list of abnormal findings that we can see on an MRI scan include the following:

disc desiccation

disc degeneration

disc bulging

disc herniations

annular tears

spinal stenosis

neuroforaminal narrowing

We are going to look at examples of each of these conditions. However, before we do, it is important that you understand that after the age of 30, essentially every MRI scan of the human body is abnormal.

Every MRI scan after the age of 30 is “abnormal”

These two pictures explain why. The natural aging process causes changes to every structure of the human body. The spine is no different. If we were to look at the skin of the gentlemen on the right with a microscope, we would see evidence of degeneration, loss of elasticity (which is called elastosis), noncancerous skin growths (called keratoacanthomas), pigment changes such as liver spots, and thickening of the skin. These findings would all be described as “abnormal”.

MRI scans reveal a natural aging process

However, we could describe the skin on the right as “normal for age”. We only describe it as abnormal when we compare it to the image of the baby on the left.  Most people, even if they don’t have any back pain, will still have evidence of abnormalities on MRI scans.  Disc degeneration, bulging disks, and herniated discs occur very commonly and they may not be causing symptoms of pain. For example, in a paper published in the journal radiology, the researches found that approximately 90% of people WITHOUT any history of back pain in the last 6 months still have evidence of annular tears, disc degeneration, and disc bulging at one or multiple levels.

Therefore, the critical task when it comes to interpreting MRI scan is CORRELATING the findings on the MRI scan with the patient’s complaints and with the physical exam.

What a normal MRI scan looks like.

This is an MRI scan of a 40 year old male. There are 5 intervertebral discs in the lumbar spine. We are going to start with a normal level which has a normal intervertebral disc. Each disc separates two bones called vertebrae in the spine. In this case, this is the L3-4 disc. Above the disc is the L3 vertebral body and below the disc is the L4 vertebral body. The center of the disc, the annulus pulpous is relatively white. The front and back of the disc, the annulus fibrosis is dark black, thick, and is not bulging into the spinal canal. The spinal canal is filled with white fluid, called cerebrospinal fluid (CSF).  Inside the CSF is the spinal cord and the nerve root that go down to the legs.

normal saggital MRI scan lumbar spine

On the axial image, the neuroforamen are wide open and there is plenty of space available for the nerve roots.

normal axial slice MRI lumbar spine

Disc dessication

Using the same MRI scan, let’s look at a dessicated disc. Desiccation is the state of dryness, or the process of drying. The theory here is that when we are young, and our discs are young, our discs have a high water content.

MRI scan lumbar disc dessicationWhen we are young, the center of the disc, called the annulus fibrosis, has an electrical charge that holds onto water very well. The disc is viscous, elastic, and is a good shock absorber. With time, the center of the disk loses water content and the disk starts to “dry out”. I tell patients that all of our intervertebral discs start out as fat plump grapes and eventually end up like raisins. Just like us.

MRI reveals disc dessicationDisc Degeneration

Disc degeneration is a more advanced form of disc dessication. In addition to the nucleus pulposus drying out, the disc starts to collapse.  Bone spurs form around the edges of the intervertebral disc. Disc degeneration is the same thing as degenerative arthritis. This condition is inevitable. It’s just as certain as death and taxes, and it will happen to everyone if they live long enough. The one thing that predicts whether or not you will have degeneration of your discs is the number of birthdays you have had. The more birthdays, the more evidence you are certain to have of disc degeneration.

MRI scan shows disc space degeneration

Disc bulging and herniations

Disc bulges and herniations come in all sorts of sizes and shapes. As the disc starts to degenerate, it can bulge out towards the spinal canal and the nerve roots. This first example is described by the radiologist as a “herniation”.  This herniation is still contained by the annulus.  As such, it is probably more accurate to describe this as a disc bulge.

MRI scans focal disk herniation

In contrast, this example shows a really large disc herniation.  In this case, the nucleus pulposus has herniated completely through the annulus and there is a large free fragment of disc material filling the neural foramen and completely obstructing the normal path for the exiting and traversing nerve roots.

 MRI scan large disc herniationAnnular tears on MRI scan

Annular tears are a particularly interesting finding on MRI scans. They represent a partial disc herniation where only a few of the fibers of the annulus fibrosis remain. Here is a short video illustrating the typical findings in an annular tear.


Spinal Stenosis and neuroforaminal narrowing: what that looks like on the MRI scan

The end result of all of these changes is spinal stenosis. Stenosis mean “narrowing”.  The process of disc bulging, degenerative disc disease, and the development of arthritis of the spine all cause narrowing of the space available for the nerve roots. Here is a short video where I review the MRI scan of someone with two level severe spinal stenosis and illustrates this process.

Making Sense of your MRI scan

Recently, it has become much more common to give the patient a copy of the MRI and report from the radiologist.  Unfortunately, this often creates a lot of confusion and concern.

I have been practicing spine surgery in Monterey, California for more than 12 years.  About 4 or 5 years ago, ObamaCare mandated that patients be given a health care summary document when they finished seeing the doctor.  This applied to MRI scanners as well.  Now, it is very common for the patient to see the radiologists report, usually before they see the doctor who ordered the scan.

By the time that a patient sees me, they usually have had the opportunity to read their own MRI report which typically sounds something like:

  • “disc dessication is prominent at L5/S1.”
  • “There is broad based disk bulging at L4/5 and L5/S1 and degenerative disk disease at these two levels.”
  • “Complete disc space collapse with prominent osteophytosis is noted at L5-S1”

Patients love Google.  After an hour or two of typing the words they don’t recognize on their MRI report into the Google search bar they are scared.  They arrive in my office CONVINCED that there is something dramatically wrong with their back.

I begin by explaining that these findings can be considered a normal part of aging and that they frequently occur in patients without back pain or sciatica.

While there is a healthy debate about what constitutes an abnormal versus a normal MRI scan of the spine, there are a few key findings that reveal a problem that we know will require surgery.

If your MRI scan does not show evidence of severe stenosis, spondylolisthesis, neuroforaminal narrowing, or a large extruded disk hernation, chances are that you can probably get better without surgical treatment.

However, the opposite is also true.  If you MRI scan shows that you have a large disk herniation, a free fragment, severe neuroforaminal narrowing, severe spinal stenosis, or a severe spondylolisthesis, chances are, you may need to have an operation after all.  The important thing to do is make sure that you have the right operation.

I specialize in non-fusion, outpatient, microscopic surgery for herniated disks, spinal stenosis, spondylolisthesis, and sciatica. If you think you may be a candidate, I will review your MRI scan to see if we can help you.

If you are interested in having me review your MRI scan, you can follow this link:

[button url=”” target=”_blank” color=”blue” size=”large” border=”true” icon=”MRI review”]MRI review[/button]

I have also prepared a short video explaining some of your options so that you can make the right decision about spine surgery.


Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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    Phone: +1-831-648-7200

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