What Is Spondylolisthesis, the Spine Condition Reported to Plague Luigi Mangione?

This is a story from MedPage Today.

Luigi Mangione, the person accused of murdering United Healthcare CEO Brian Thompson, reportedly underwent spinal surgery for chronic back pain caused by spondylolisthesis.

Spondylolisthesis occurs when one vertebra slips forward on the vertebra below it, explained Jessica Stark, MD, a spine surgeon at UTHealth Houston. This slippage, a sequela of arthritis, most often occurs in the lumbar spine and can put pressure on the nerves around the spine.

“Really arthritic backs can have varying degrees of spondylolisthesis throughout the spine, simply because the joints have become overgrown and slipped in different places,” Stark said. Page Med today.

Pain levels depend on the degree of slippage and how the spondylolisthesis occurred. When patients come in with this illness, Stark begins by assessing the severity and extent to which the illness is affecting the patient’s life. Many report pain or numbness in their back and legs.

“I always tell patients that pain is sort of a warning sign of nerve compression, but numbness and weakness are true nerve damage,” Stark said. “When we get to weakness, that’s really when we start to worry, because that’s when that nerve gets severely damaged and sometimes, especially with certain nerves, once they’re under so much pressure, you become so weak that the nerve can’t heal itself.”

She noted that people can develop spondylolisthesis for a variety of reasons.

Degenerative spondylolisthesis, the most common form, results from worn bones rubbing against each other over time. Most of the time this happens at age 50 or older. Some people, such as those who do manual labor or play impact sports, experience greater wear and tear on their bodies from these high-impact activities and are more likely to suffer arthritis or herniated discs earlier as well as develop spondylolisthesis. Women and African Americans are also more likely to develop degenerative spondylolisthesis, according to the American Academy of Orthopedic Surgeons.

People born with birth defects or fractures — defects in the part of the bone at the back of the spine that holds joints in place — may see their bones slip earlier, perhaps even in adolescence. Traumatic pars fractures, most commonly resulting from vehicle accidents or falls, can also lead to spondylolisthesis.

“Acute injuries, like trauma, obviously result in more nerve damage because it happens all at once, and their nerves haven’t been stretched for a long time, so they don’t have that kind of protective healing of the nerve roots that goes on slowly,” Stark explained.

Treatment often begins with core-strengthening physical therapy to reduce pressure on the spine, long-acting anti-inflammatories like celecoxib (Celebrex) or meloxicam, and possibly muscle relaxants or nerve pain relievers like gabapentin (Neurontin). For some, this level of intervention is sufficient.

But if the condition does not improve or worsens after 6 weeks, the next step is to give injections every few months. Stark said this usually involves a lumbar epidural steroid injection that has anti-inflammatory effects along with lidocaine for short-term numbing pain relief. Like other similar injections, lumbar epidural steroid injection works best the first time and becomes less effective with each injection.

Surgical stabilization of the spine with four screws and two rods is the last resort and definitive treatment. Stark said most surgeons also clean the disc and install “some type of interbody, which is a cage, into the disc space to allow for anterior fusion as well, because that puts a lot of pressure on those screws, on the rods, and that can fail over time.” This gives the procedure a better chance of sticking, she explained.

Once the vertebrae are stabilized, the first point of movement of the spine is at a higher level, which slightly increases the risk of arthritis at that level. About 20 years after surgery, some people need a second operation on top of the first.

The positive side of a difficult disease, Stark said, is that some of the most effective treatments are relatively new.

“I can fix this with a small incision less than an inch,” she said. “I think it’s great that we can do this – and that wasn’t an option 10 years ago.”