Lumbar Facet Arthropathy Spondylolysthesis

Keywords; lumbar facet arthropathy spondylolysthesis.

This is a not uncommon condition found at the chiropractic clinic. It's often associated with severe leg pain.

The lumbar facet joints are subject to wear and tear, particularly after a hyperextension injury that was not properly cared for. The ensuing chronic fixation leads invariably to immobilisation arthritis and hyaline cartilage degeneration.

In short, the hyaline cartilage that lines the ends of bones is dependent on movement for correct nutrition. Immobilise or fixate a joint and it rapidly becomes arthritic.


Shall we start by getting this jaw breaker out the way, otherwise you my be tempted to leave this page immediately!

Spondylolysthesis is a spinal condition where one vertebra slides forwards on it's neighbour below. There are two main causes:

1. Trauma which fractures the "pars", usually in childhood, but it's also a stress fracture the sportsmen get. It's very common in cricketers. Fast bowlers get it.

2. Degenerative change (arthropathy) in the facet joints causing the shape and orientation to change, allowing the vertebra to slide forwards. It occurs in the older person.

Lumbar facet syndrome

Lumbar Facet Arthropathy Spondylolysthesis


Mrs G is a 75-year old woman who has had pain in her left buttock for five years. Four months ago she fell down five steps on her buttocks (the staircases in the Nederlands are very steep). A month later the pain started radiating down her the back of her thigh and calf, with tingling on top of her foot.

She couldn't use any power with her left leg without severe pain in the leg. Turning her torso left and right, and straightening up after bending was very painful. The pain in her leg was constant, 24 hours per day. She could never escape it.


  • Looking for a Leg Length Inequality is always tricky. It can't be measured precisely without a special X-ray of the pelvis, which I didn't have, and sometimes it changes after adjusting the pelvis, or even adjusting the foot. However, by eye-balling her pelvis, there was no obvious low side. A mild scoliosis (curvature) however was clearly present. LEG LENGTH INEQUALITY ...
  • There was a marked fixation in the opposite (right) sacroiliac joint, and at the L5-S1 joint (the lumbo-sacral joint). L4 was tender on palpation.
  • Forward bending caused moderate pain in her back and buttock but did not radiate to the leg. Sideways bending, right and left, were mildly uncomfortable.
  • The test of Lasegue for a pinched nerve was very mildly positive at 60 degrees, with pain in the buttock, but not the leg. The Slump test too was mildly positive. SLUMP TEST ... for a pinched nerve.
  • There was no numbness, no muscle weakness and the reflexes were normal.
  • The piriformis muscle was very tender with active trigger points. PIRIFORMIS SYNDROME ...
  • Her right hip shows signs of early hip arthritis. Limited flexion, adduction and internal rotation with pain in the groin. HIP ARTHRITIS ...



The radiological report reads:

"Forward slip of the body of L4 in relation to L5, spondylolisthesis, grade 1.

At L4-5 a canal stenosis is seen with facet arthropathy and hypertrophy (thickening) of the Ligament Flavum. Reduced intervertebral foramena right more than links.

At L5-S1 there is also relative canal stenosis, also on the basis of advanced facet arthropathy and hypertrophy of the Ligament Flavum. There is possibly a small synovial cyst at the left facet joint."

Certainly there is a very small, tight spinal canal, consistent with our case history and findings. Chronic low back pain, buttock pain and radiating pain to the left foot.

Can Chiropractic possibly help? Does chiropractic help have a spinal stenosis explanation and solution...?


Something didn't quite fit. With such severe pain in the leg, I would in the first place have expected pain in the limb when she bent either forwards, or sideways, backwards; and that the tests for a pinched nerve would be strongly positive.

But no, this is not a pinched nerve in the normal sense, but irritated and severely inflamed by the complex toxins exuded by fixated joints.

We had to wait a week, before starting the treatment, for the xrays and scan which brought forth the explanation. Extremely degenerate facet joints at L4 on 5 that had allowed the fourth lumbar vertebra to slide forwards; spondylolysthesis.

Interestingly her symptoms were partly from the S1 nerve root from the fixated L5 joint and partly from the L5 fibre causing tingling on top of her foot from the spondylolysthesis.

The severe fixation in the right sacroiliac joint anatomy was central to the whole problem.

Treatment: lower back and leg pain

The first three treatments involved the sacroiliac joints and L5 using the Thompson drop protocol, and gentle drop treatments on L5 with her in the side-lying posture. The pain increased after the first two treatments. She was dubious, but I assured her that was normal for a chronic condition.

I modified the treatment to include the very degenerate L4-5 joint. From the case notes:

"Flex iets Li bil. Kemp R en L > Links L5. L5R vast. ZSLR L licht in L bil. L4R, L5L roll drops. Steeds pijn, dus: Prone: R sac hard, L si AS hard. Supine R en L Si, ant bekken. Active release therapie aan de linker hamstring, piriformis en Iliotibial band."

Within five treatment she had 50% less pain, and after seven the pain has completely gone.

We are now busy with rehab, still concentrating on the right hip arthritis which is still tender, though also improving, and I'm pondering the need for a heel lift.

Next week we start with a full examination of her neck, which is also stiff and painful.



Mrs G came in today for her seventh treatment. She's smiling and so am I. She played tennis twice this week, with no ill effect. I'm no longer so happy; that wasn't allowed, but it seems with no negative results.

She added a sentence about the loneliness of growing older. The tennis club is her solution. So be it, she's not just a back.

The pain in her left leg has completely stopped and the Slump test is negative. She still has a little discomfort in the right sacroiliac joint, something she has had for years, which is connected to the arthritis in her right hip.

The right groin is still a little painful when she rotates her hip. We're working on it, Rome wasn't built in a day. Nor were Aachen or Cologne as we say in Europe.

They are both worth a visit, by the way. Especially the Dom in Aachen which is where you'll see the remains of Charlemagne; and the Christmas fair in Cologne is generally acknowledged as the best in Europe; and the chocolate museum is to die for.

Managing these complex cases successfully means addressing each and every part of the syndrome. A mixture of symptoms and signs, in this case the

  1. Muscular condition in her left buttock, the Piriformis.
  2. The fixation at L5.
  3. The spondylolysthesis at L4.
  4. The hip arthritis on the other side.
  5. Thinking about the Leg Length Inequality, and would a heel lift help, or hinder.
  6. Convincing the patient of the need to do daily rehab exercises, to start walking more and sitting less. Tennis, mm???
  7. Persuading them to accept that some things belong to the past. Can they still garden, play tennis, golf, work in a bookshop where lifting boxes of books is required...



Lower back and leg pain is an every-day-event in chiropractic clinics. It's our bread and butter. Sometimes it's routine and straightforward, sometimes it can be extremely complex. Occasionally we have to refer patients for surgery. Occasionally!

More often it's we who are trying to cope with very unhappy patients after Failed Back Surgery (FBS) as it's known in the literature, or the complications of surgery. LOWER BACK AND LEG PAIN ...


Today I had a new patient in her upper fifties with a not dissimilar history, but she went for the surgery. Immediately after the operation she developed a severe foot drop, and could only move about with a walker for two months.

And she still has disabling numbness and tingling in her lower leg. The X-ray reveals another LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS ... I wonder what we can do for her, if anything.

My point? These serious cases of degenerative lumbar spines are an every day affair in chiropractic clinics. Each has to be managed carefully, thoroughly, mostly fairly gently though periodically a good "pak sla" is necessary. A good hiding!

Do we chiropractors always win with these difficult cases? No, of course not, but isn't conservative treatment always worth a try before going for surgery?

It's never far from my mind that a favourite relative died (literaly) after her seventh lumbar surgery, aged forty-two. And it all started with a routine, uncomplicated lower back strain. You can do a lot more damage with a knife in your hand, than just a plain hand!

Plus the risk of infection, not to mention Anaesthetic Alzheimers ...


Did you find this page useful? Then perhaps forward it to a suffering friend. Better still, Tweet or Face Book it.

Interesting challenges of the day

1. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks she was 75 percent improved; no longer vomiting or falling. She's not enjoying the Brandt Daroff home exercises.

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?

Interesting questions from visitors

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You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

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Bending and twisting


Short leg?

Lower back and leg pain

Lumbar facet syndrome

Slipped disc

Sacro-Iliac Joint