LUMBAR

SPONDYLOLISTHESIS

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INTRODUCTION

Spondylolisthesis is the displacement of

one vertebra over the subjacent vertebra. This
slippage, which can occur at anytime from
infancy through adulthood, has several different
causes.

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EPIDEMIOLOGY
The various types of spondylolisthesis have
different fundamental causes.

Isthmic spondylolisthesis is caused by a defect

in the pars interarticularis, which is called a
spondylolysis, pars defect, or pars fracture.

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 Cont...
Along with the degenerative type, the isthmic
type is one of the two most common forms of
spondylolisthesis. Lumbar spondylolysis and
isthmic spondylolisthesis occur in approximately
6% of the general population, and occur most
commonly at the L5-S1 level.

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 The incidence of lumbar
spondylolysis
Causian
Males (6,4%)

African-
American
Males (2,3%)

Caucasian
The highest incidence females (2,3%)
reported is 54% in
native resident of African-
greenland Amercan
Females (1,1%)

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 Cont...
Degenerative spondylolisthesis has a 3:1 prevalence
in women, with African-American women affected
three times more frequently than Caucasian women.
The most commonly involved level is L4-L5, followed
by L3-L4. Unlike isthmic spondylolisthesis, the L5-S1
level is rarely affected by degenerative
spondylolisthesis .

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 Cont...
As the name implies, degenerative spondylolisthesis is
caused by degenerative changes in the disk and facet
complex, which lead to instability at the affected level.

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 Cont...

In congenital and dysplastic spondylolisthesis, the

pars interarticularis is intact but the L5-S1 facet
joints are abnormally developed. This deficiency
in the facet joints leads to instability and the
resultant anterior translation of the L5 vertebral
body.
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 Cont...
Because the posterior arch is not fractured, as in
isthmic spondylolisthesis, the L5 lamina translates
anteriorly with the vertebral body and can cause
central spinal canal stenosis, with symptoms of stenosis
occurring with slippages of more than 35%.

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 Cont...
Traumatic spondylolisthesis is characterized by a
dislocated or subluxated lumbar spine, which has
moved anterior to the sacrum because of bilateral
dislocations or fractures of the L5-S1 facet joints,
pedicles, pars interarticularis, or a fracture line
crossing the sacrum.

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 Cont...
This lesion is caused by high-energy trauma and is
rarely isolated. Most instances of traumatic
spondylolisthesis are accompanied by multiple
traumatic injuries and visceral, vascular, and neurologic
symptoms.

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Pathogenesis
The pathogenesis of isthmic spondylolisthesis following
spondylolysis also has been extensively studied. By
definition, isthmic spondylolisthesis is slippage
associated with a spondylolysis of the cephalad
involved vertebra; however, spondylolysis does not
develop in all patients with this type of anterior
slippage.
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 Cont
Degenerative spondylolisthesis is a disorder that
affects older patients. Chronic degenerative changes
that occur in the facet joint and disk space result in
the loss of normal segmental stability. Certain
anatomic variants, including hyperlordosis, sagittal
orientation of the facet joints, and sacralization of
the L5 vertebral body can predispose a patient to the
development of degenerative spondylolisthesis.

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 Cont
In congenital and dysplastic spondylolisthesis,
abnormalities of the vertebral arch or facet joints lead
to spondylolisthesis at the lumbosacral junction.
Abnormalities include failure of formation of the facet
joint or sagittal alignment of the L5-S1 facet complex.

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 Traumatic spondylolisthesis involves a bony or
ligamentous injury that results in acute instability of
the involved level. This type of injury can include
high-energy trauma resulting in ligamentous rupture,
facet complex fracture, and possible facet
subluxation and dislocation.

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Clinical Presentation

Chronic isthmic spondylolisthesis frequently causes

low back pain in adult patients. Radiculopathy may
eventually develop in the lower extremities because
of the fibrocartilaginous proliferation around the
pars defect.

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 Cont
The typical symptoms of chronic sthmic
spondylolisthesis are low back pain caused by spinal
instability and radiating leg pain caused by
compression of the exiting nerve root.

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 Cont
In degenerative spondylolisthesis, lateral recess and
foraminal stenosis result in radiculopathy caused by
compression of the traversing nerve root.
Hypertrophy and subluxation of the involved facet
complex, combined with the common degenerative
changes of disk bulging and ligamentum flavum
redundancy, cause compression on the exiting nerve
root at that level.

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Treatment
Isthmic Spondylolisthesis and Spondylolysis
Nonsurgical Treatment
Early diagnosis may be extremely
important in attaining bony healing of the pars.

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 Cont
Nonsurgical treatments include nonsteroidal anti-
inflammatory drugs, brace therapy, sports activity
restrictions, and, occasionally, short-term bed rest.
Regardless of whether the pars defect heals, most
symptoms resolve over time with conservative
treatment.

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 Cont
Physical therapy, home-based strengthening programs,
weight reduction, activity modification, and possible
injection therapy, including epidural injections, facet
blocks, and pars injections, may be beneficial in certain
patients.

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Direct Repair of Spondylolysis
Various techniques to directly repair a pars
defect have been described. These techniques
include bone grafting with the placement of wires,
screws, or hook-screw constructs to stabilize the
fractured pars. The goal of these procedures is to
restore the normal anatomy and save a spinal
motion segment to retain the associated spinal
mobility.

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 Cont
For these procedures to be successful, the pain
source must be the pars defect itself. The pain
generator can be preoperatively verified by injecting
the defect with a local anesthetic. In patients who do
not respond to the local anesthetic injection, direct
repair of the pars defect is not recommended; other
causes of low back pain should be evaluated.

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Decompression of Lumbar Nerve Roots
Affected by Spondylolysis
Decompressive laminectomy (the Gill
procedure) has been described for patients with
lumbar spondylolysis and associated radiculopathy.

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 Cont
Less invasive techniques to decompress the involved
nerve root in patients with spondylolysis have been
developed. These decompression-only procedures are
indicated in patients older than 40 years and in those
with radiculopathy without low back pain and no
evidence of spinal instability on dynamic radiographs.

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 Cont
The advantage of these minimally invasive
techniques is the feasibility of excising the edge of the
spondylolysis site and associated scar tissue, with
possibly less damage to the posterior elements,
paravertebral muscles, and posterior ligamentous
structures. Patients treated with a decompression-only
procedure.
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 Low-Grade Isthmic Spondylolisthesis
Noninstrumented Fusion
Because of the risk of increased spondylolisthesis
following posterior decompression alone, spinal
stabilization in addition to decompression has been
recommended in adult patients with symptomatic
isthmic spondylolisthesis.

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 In one prospective randomized study comparing
instrumented and noninstrumented lumbar posterolateral
fusion for adult isthmic spondylolisthesis, posterolateral
fusion performed without instrumentation relieved pain
and improved function; the use of supplementary
transpedicular instrumentation did not improve the fusion
rate or the clinical outcomes.

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Instrumented Fusion
Numerous surgical procedures have been
described for isthmic spondylolisthesis, including
decompression with or without posterolateral lumbar
fusion and (possibly) with instrumentation and the
addition of an interbody fusion.

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 Cont
In a systematic review of the radiographic and clinical
outcomes of adult patients who were surgically treated
for low-grade isthmic spondylolisthesis, the authors
concluded that a combined anterior and posterior
procedure most reliably achieves fusion and a
successful clinical outcome.

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 Cont

In a prospective study to compare the

outcomes of posterior lumbar interbody fusion
and posterolateral fusion in patients with adult
isthmic spondylolisthesis, the type of fusion did
not affect the 2-year outcome.

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 In another prospective study, 164 adult patients
with isthmic spondylolisthesis were evaluated to
determine predicative factors for outcomes of spinal
fusion.30 Patients who worked prior to surgery, males,
and those who exercised regularly had better outcomes
after fusion.

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 Cont
The results of a systematic review of 29 selected
high-quality studies on lumbar fusion showed no
difference in outcomes between different fusion
techniques. Overall, the optimal type of surgery for
low-grade adult isthmic spondylolisthesis remains
controversial.

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 High-Grade Spondylolisthesis
Although high-grade isthmic spondylolisthesis
(grade III, IV, or V) accounts for a distinct minority of all
patients with spondylolisthesis, the treatment of high-
grade spondylolisthesis can be complex and difficult.
The optimal treatment of this pathology remains
controversial.
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 Cont
Most patients with high-grade spondylolisthesis
or spondyloptosis (complete subluxation of the
cephalad vertebra off the lower vertebra; grade V
spondylolisthesis) become symptomatic during
adolescence. A recent literature review evaluated the
surgical treatment of high-grade spondylolisthesis in
the pediatric population.

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 Degenerative Spondylolisthesis
Nonsurgical Treatment
As in many spinal disorders, the preferred initial
treatment of patients with degenerative
spondylolisthesis is nonsurgical. Nonsurgical treatment
includes antiinflammatory medications, physical
therapy, activity modification, and home-based exercise
programs.

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Surgical Treatment
The primary surgical treatments for degenerative
spondylolisthesis are decompression alone,
decompression with noninstrumented fusion, and
decompression with instrumented fusion.

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 Cont
Surgical indications include back pain or leg
symptoms that are recalcitrant to nonsurgical
treatment, lead to a significant impairment in quality of
life, and have associated significant or progressive
neurologic deficits or neurogenic bowel or bladder
symptoms.

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Decompression Alone
The goal of surgical decompression is the relief of
symptomatic neurologic compression. The treatment of
degenerative spondylolisthesis frequently includes
central and lateral recess decompression because of
the combined central spinal stenosis and facet joint
changes that lead to lateral recess stenosis.
Laminectomy is commonly performed in this setting.

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Decompression With Noninstrumented Fusion
Because of the risk of worsening instability and
vertebral body translation following decompression of
a lumbar spondylolisthesis, a fusion has been
advocated in conjunction with the decompressive
procedure. Noninstrumented posterolateral lumbar
fusion was among the first types of lumbar fusions
advocated for this use.

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Decompression With Instrumented Fusion
With the widespread acceptance of lumbar
pedicle screws, instrumented lumbar fusions have
become both technically feasible and
commonplace. The success rates of instrumented
posterolateral lumbar fusions in association with
decompression for degenerative spondylolisthesis
have been evaluated.

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 Cont..
At 4-year follow-up in randomized and
observational cohorts, patients with degenerative
spondylolisthesis who were treated surgically had
greater pain relief and improvement in function
throughout that time frame when compared with
patients treated nonsurgically.

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 Cont..
Because various surgical treatments were used in the
study, conclusions regarding the optimal surgical
approach require further data analysis.

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 Congenital and Dysplastic Spondylolisthesis
Patients with congenital or dysplastic
spondylolisthesis often become symptomatic in early
adolescence as the slippage increases. Back pain,
hamstring tightness, and spinal canal stenosis are
caused by the intact posterior elements.

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 Cont..
After these symptoms develop, conservative
treatment is rarely useful. Surgical treatment consists
of stabilizing the motion segment with neural
decompression if necessary. Various techniques have
been used, but no high-quality studies comparing these
techniques have been performed.

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 Traumatic Spondylolisthesis
Traumatic spondylolisthesis injuries are
high-energy, unstable injuries that are
frequently accompanied by other multisystem
trauma. The initial treatment of these patients
includes stabilization of the associated
traumatic injuries and appropriate evaluation
and diagnosis of the spondylolisthesis.

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 Cont..
The treatment of the traumatic spondylolisthesis
requires stabilization of the subluxation or dislocation,

usually with an instrumented fusion. Instrumentation

to the pelvis or proximal to the involved motion
segment may be needed to provide appropriate
fixation.

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Pelvic fixation may be required if there is an associated
pelvic fracture or ligamentous injury. Significant
neurologic injury can occur because of the rapid
neurologic compression that occurs with these injuries,
and decompression of compressed nerve roots or the
central canal may be required.

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