SPINE Volume 28, Number 10, pp 10271035
2003, Lippincott Williams & Wilkins, Inc.
The Natural History of Spondylolysis
and Spondylolisthesis
45-Year Follow-up Evaluation
William J. Beutler, MD,* Bruce E. Fredrickson, MD,* Albert Murtland, MD,
Colleen A. Sweeney, MA,* William D. Grant, EdD,* and Daniel Baker, MD
Study Design. A prospective study of spondylolysis
and spondylolisthesis was initiated in 1955 with a radio-
graphic and clinical study of 500 first-grade children.
Objective. To determine the natural history of spon-
dylolysis and spondylolisthesis.
Summary of Background Data. Most studies on the
natural history of spondylolysis and spondylolisthesis are
based on patient populations presenting with pain. Criti-
cal to any natural history investigation is the study of a
population of affected individuals, whether symptomatic
or not, from onset of the condition through their lives.
Methods. By study of a population from the age of 6
years to adulthood, 30 individuals were identified to have
pars lesions. Data collection at a 45-year follow-up as-
sessment included magnetic resonance imaging, a back
pain questionnaire, and the SF-36 Survey.
Results. No subject with a pars defect was lost to
follow-up evaluation once a lesion was identified. Sub-
jects with unilateral defects never experienced slippage
over the course of the study. Progression of spondylolis-
thesis slowed with each decade. There was no associa-
tion of slip progression and low back pain. There was no
statistically significant difference between the study pop-
ulation SF-36 scores and those of the general population
the same age.
Conclusions. This report is the only prospective study
to document the natural history of spondylolysis and
spondylolisthesis from onset through more than 45 years
of life in a population unselected for pain. Subjects with
pars defects follow a clinical course similar to that of the
general population. There appears to be a marked slow-
ing of slip progression with each decade, and no subject
has reached a 40% slip. [Key words: natural history, spon-
dylolisthesis, spondylolysis] Spine 2003;28:10271035
The natural history of spondylolysis and spondylolisthe-
sis has been studied and debated for years.15 The fetal
incidence has been shown conclusively to be zero.2,3,6 9
The 6% incidence at adulthood has been verified in ad-
ditional studies, with some ethnic variation.3,10 There
From the *State University of New York Upstate Medical University,
Syracuse, New York, and Guthrie Clinic, Sayre, Pennsylvania.
Funded by a research grant from the North American Spine Society.
Acknowledgment date: April 18, 2002. First revision date: October 2,
2002.
Acceptance date: October 7, 2002.
Device status/drug statement: The submitted manuscript does not con-
tain information about medical devices or drugs.
Conflict of interest: Professional organizational funds were received in
support of this work. No benefits in any form have been or will be
received from a commercial party related directly or indirectly to the
subject of this article.
Address correspondence and reprint requests to Bruce E. Fredrickson,
MD, SUNY Upstate Medical University, Orthopedic Surgery, 550 Har-
rison Center, Suite 130, Syracuse, NY; E-mail: fredricb@upstate.edu
has not been a prospective study to delineate the course
of individuals with a spondylolytic defect, whether
symptomatic or not, through their lives. The purpose of
this investigation was to delineate the natural history of
spondylolysis and spondylolisthesis in a study popula-
tion of 30 individuals.
In the early 1950s, Dr. Daniel Baker initiated a pro-
spective study to determine the incidence and natural
history of spondylolysis and spondylolisthesis.2 From
1955 to 1957, radiographs were taken of all first-grade
children in a northern Pennsylvania town, a study pop-
ulation of 500 children. A total of 22 subjects 6 years of
age were determined to have a lytic defect of the pars
interarticularis, giving a rate of 4.4%. By adulthood,
lumbar lytic lesions had developed in an additional eight
subjects, bringing the total to 30 subjects and establish-
ing an incidence of 6%. Four decades of follow-up eval-
uation in this prospective study have now been
concluded.
The study population currently is older than 50 years.
The 30 subjects were located, and detailed clinical and
radiographic follow-up data were obtained. Initial find-
ings were reported in 1984, with the study population in
their third decade of life. In 1988, follow-up assessment
included lumbar radiographs and a back pain question-
naire. In 1999, similar studies were conducted with the
addition of MRI and the SF-36 questionnaire. Specifi-
cally, the authors continue to examine the rate of slip
progression, any symptoms presenting over a subjects
lifetime, and any clinical or radiographic findings corre-
lating with spondylolisthesis progression.
Materials and Methods
The only inclusion criterion for the study population required
that the child had attended one of the local elementary schools
in the years 1954 to 1957. Parental permission was obtained
for each child in the study. The small size of the first-grade
classes made it necessary to conduct the study over three con-
secutive years. Children with a lumbar spine lesion initially
were followed yearly. Lesions were identified by consensus
with a radiologist. Questionable lesions were studied with sup-
plemental oblique radiographs and tomography. The fol-
low-up evaluation to the age of 29 years is detailed in the
authors 1984 report.2
During the adult phase of the study, consent was obtained
for each contact. Institutional review board approval was
maintained throughout the adult phase of the study. In the
early phase of the study, permission was obtained through the
existing hospital committees of the era. In 1988 and in 1999,
1027
1028 Spine Volume 28 Number 10 2003

Figure 2. The method of measuring lumbar index.

to allow simplified grading of disc and foraminal changes from

MRI images from various centers around the United States.
The sagittal image in Figure 4 exemplifies each grade of disc
Figure 1. The method of measuring percentage of slip (%slip degeneration. The axial image of Figure 5 demonstrates mod-
A/B 100%). erate foraminal stenosis on the right and severe stenosis on the
left. Figure 6 provides an example of mild foraminal stenosis at
the slipped level.
anteroposterior, oblique, and lateral radiographs were ob- An independent reviewer provided statistical analysis. Sta-
tained. In 1988, both supine and erect radiographs were com- tistical analysis included the application of 2, analysis of vari-
pleted for comparison of the two study techniques. Magnetic ance for repeated measures, and logistic regression. All data
resonance imaging was included in the 1999 studies.
Clinical follow-up assessment in 1988 involved completion
of a back pain questionnaire. Questions presented to the sub-
jects sought information on severity, frequency, and duration
of any back and leg symptoms. Time off work, medication use,
and disability information also were obtained. In 1999, a sim-
ilar questionnaire was used, but was supplemented with the
SF-36 questionnaire.
Isthmic spondylolisthesis was measured by a modification
of Taillards method. Lumbar index and slip angle were mea-
sured on lateral radiographs (Figures 13). Disc height was
determined at both the defect level and the level above, and
reported as an average height of anterior, posterior, and middle
disc measurements.
Magnetic resonance imaging availability in the 1999 fol-
low-up assessment allowed evaluation of disc degeneration,
disc herniation, and foraminal narrowing. Disc degeneration
for each of the lumbar discs was graded on a scale from no
degeneration to mild, moderate, or severe degeneration. Disc
herniation at any lumbar level was recorded. Foraminal steno-
sis at the level of listhesis was graded from no stenosis to mild,
moderate, or severe foraminal stenosis. The grading system
used for disc degeneration and foraminal stenosis was devised Figure 3. The method of measuring slip angle.
 Natural History of Spondylolysis and Spondylolisthesis Beutler et al 1029

Figure 4. No disc degenerative changes are demonstrated at

L1L2 and L3L4, and mild change is shown at L4 L5. Moderate
changes are seen at L2L3, and severe disc degeneration is
evident at L5S1.

analysis was completed using SAS-SPC for Windows, Version

8.01.

Results
Of the 500 children in the study population, 22 subjects
(4.4%) were found to have unilateral or bilateral pars
interarticularis defects of the lumbar spine at the age of 6
years. Defects developed in an additional eight subjects
between the ages of 12 and 25 years. This group of 30
subjects with identified pars lesions consisted of 10 fe-
males and 20 males. Of the 30 subjects, 22 had bilateral
L5 pars defects and 8 subjects had unilateral defects (1 at
L1, 1 at L2, 1 at L4, and 5 at L5). No subject with a pars
interarticularis defect was lost to follow-up evaluation
once the lesion was identified.
Healing of a pars defect was seen in three subjects, and Figure 5. A, Severe foraminal stenosis is noted on the left. B, The
only with unilateral defects. Oblique lumbar radiograph right foramen is graded as moderate stenosis.
was used to confirm the healing. Tomography was used
to clarify questionable cases. Healing at the age of 31
years was noted in one male subject with a unilateral L5 graphs. Four subjects consented to clinical but not radio-
defect found at the age of 16 years. Another male with a graphic follow-up assessment. Magnetic resonance im-
unilateral L5 defect found at the age of 14 years was aging was obtained for 21 subjects. Lumbar radiographs
healed at the age of 31 years. The third subject to expe- were obtained for 22 subjects. All of the three deceased
rience healing of a pars lesion was a female with a uni- subjects had completed the 1988 clinical and radio-
lateral L5 defect found at the age of 8 years. Healing was graphic follow-up assessment. One deceased male with a
noted at the age of 28 years. bilateral L5 pars defect found at the age of 25 years had
In 1988, 24 subjects consented to follow-up evalua- an 18% slip in the 1988 studies. He died of congestive
tion. In 1999, all 30 subjects were located. Three subjects heart failure at the age of 46 years. A second male died of
had died after the 1988 follow-up. In 1999, of the re- a myocardial infarction at the age of 44 years. He had a
maining 27 subjects, all but one completed the SF-36 and bilateral L5 pars defect found at the age of 6 years with
back pain questionnaire. This one subject refused to no initial slip. He had progressed to a 24% slip at the
complete any follow-up evaluation, including radio- 1988 follow-up assessment. The third deceased subject
1030 Spine Volume 28 Number 10 2003
Figure 6. Mild foraminal stenosis is demonstrated at the slipped
level.
died of prostate carcinoma at the age of 45 years. He had
a unilateral L2 defect found at the age of 6 years.
Unilateral Defects
The eight subjects with unilateral defects never experi-
enced slippage over the course of the study. This group
consisted of five men and three women. Three subjects
had healing of the unilateral defect (one by the age of 12
years, and the others by the age of 31 years). The slip
angle for subjects with unilateral defects went from 28
in 1960 to 18 in 1988. The lumbar index was 74 in
1955 and 85 in 1988. The disc height at L5S1 was
maintained at 92% of the L4 L5 disc height over the
course of the study. The back pain questionnaire in 1988
noted that no subject with unilateral pars defect ever had
more than mild low back pain, and four of the subjects
reported only rare back pain lasting less than 1 day.
The SF-36 data in 1999 noted that two of the subjects
scored lower than 80 on the bodily pain scale (moderate
pain). One of these subjects was a female with an L4 pars
defect who had a sedentary job. The second subject with
moderate reported pain was a male with a unilateral L5
defect and a history of discectomy at L4 L5. He worked
a heavy duty lifting position as a machinist. He was
the only subject with a unilateral defect ever to use nar-
cotic analgesic medication.
The MRI data on the unilateral defect group noted
that only two of the eight subjects had any disc degener-
ation. One subject had degeneration at the L5S1 disc
space only (with a L1 pars defect). The other subject had
a unilateral L5 defect, with disc degeneration noted at all
lumbar levels except L1L2. In the 1999 follow-up, there
were no disc herniations in the unilateral group. Fora-
mens were maintained with no significant narrowing at
any level.
Bilateral Defects
There were 22 subjects with bilateral pars defects. All
bilateral pars defects were at L5. Initial examination at
the age of 6 years found 15 bilateral L5 pars defects. One
bilateral defect was found a year later. These subjects
were termed the early defect group. Six subjects were
grouped into a late defect group with bilateral L5 le-
sions developing between the ages of 12 and 25 years.
Both groups had a male:female ratio of 2:1.
Over the course of the study, spondylolisthesis never
developed in 4 of the 22 subjects with bilateral L5 le-
sions. There also was no documented healing of the pars
interarticularis defects.
Initial slip at the lumbosacral level was noted in 10 of
the 16 bilateral L5 defects discovered in subjects at the
age of 6 years. Of the five female subjects with early
defects, all but one presented with a slip in addition to
the defect. The average slip was 11% for all subjects with
initial spondylolisthesis. Slip progression was slow. The
average slip in the 1999 studies for this group was 18%.
Of the six subjects with early bilateral L5 pars defects,
but without spondylolisthesis at the initial 1956 study,
three never experienced slippage, and the other three
progressed to an average slip of 24%. One subject in this
group had the largest slip of the study population (39%).
Six subjects were in the late bilateral defect group.
Bilateral L5 lesions developed in these subjects between
the ages of 12 and 25 years. The ratio of men to women
was again 2:1 for this group. Again, there was diversity
in this group with respect to slip progression. At the final
follow-up assessment, one had never slipped, one had
slipped up to 10%, two had slipped up to 20%, and two
had slipped up to 30%.
In 1988, both supine and erect lateral lumbar radio-
graphs were obtained. The purpose for both views was to
evaluate in the study population any difference in the
percentage of slip and the other evaluated indexes with
each radiographic view. In the studies of the 1950s and
1960s, only the supine lateral view had been obtained. In
1988, 18 of the subjects had consented to both sets of
radiographs. The average slip for those with spondylolis-
thesis in 1988 was 9% on the supine radiographs and
10% on the erect views. There was no statistically signif-
icant difference in the percentage of slip between the two
radiographic techniques, similar to findings in other
studies of adult spondylolisthesis.3
Lumbar index was evaluated in 1956, 1970, and
1988. The average lumbar index for all subjects was 78
in 1956 and 80 in 1988. There was no statistical associ-
ation between lumbar index, spondylolysis level, early
versus late slip, percentage of slip, or progression of slip
for most years of follow-up evaluation. An associated
lower lumbar index with a greater percentage of slip was
noted in the 1988 data (P 0.0089). The lumbar index
in childhood offered no predictive value for later slip.
Slip angle was evaluated in the 1960 follow-up eval-
uation and in 1988. The slip angle ranged from 29 to
12 for all subjects in 1988. There was an association
 Natural History of Spondylolysis and Spondylolisthesis Beutler et al 1031
between percentage of slip and more positive slip angle in
1988 (P 0.0079). There was no predictive value in the
slip angle and ultimate slip on late follow-up assessment.
Disc height was measured on the initial 1950s radio-
graphs and on the 1988 and 1999 studies. There was an
inverse relation with decreasing L5S1 disc height, as a
ratio to the L4 L5 disc height, with greater percentage of
slip, but it was not statistically significant. Concomitant
degeneration of the L4 L5 disc, although mild as com-
pared with that of L5S1, may weaken the statistical
relation. There was a statistically significant inverse re-
lation between the absolute height of the lumbosacral
disc and the percentage of slip (P 0.0062). There was
no association between the percentage of slip at L5S1
and degeneration of the L4 L5 disc.
There were 10 subjects (6 males and 4 females) with
early segmental laxity. These subjects presented at the
age of 6 years with bilateral pars defects and initial spon-
dylolisthesis. Initial slip in this subgroup ranged from
7% to 17%. There was a wide variability in progression
of slip. Five subjects (3 males and 2 females) had no
progression of slip over the next 45 years. Five subjects (3
males and 2 females) had progression of the slip, with
increases of 7% to 20% from the initial slip.
Three subjects, all males, had late segmental laxity.
These subjects presented with bilateral pars defects at the
age of 6 years, but no documented spondylolisthesis.
Spondylolisthesis developed in each over the following
decade. Again, there was wide variability in any progres-
sion of slip noted in early adulthood. The first subject
had no progression of his 11% slip. The slip of a second
subject went from 14% to 24%, and the slip of the third
subject had gone from 22% to 36% at the last follow-up
assessment.
Slip progression was greatest early in life, regardless of
early or late defects, or whether the subject demonstrated
early segmental laxity or late segmental laxity. In the first
decade of follow-up evaluation, the average slip progres-
sion was 7% for those that did progress. Progression in
the second and third decades was an average of 4%. In
the fourth decade of follow-up evaluation, average pro-
gression was 2%.
MRI Data
Magnetic resonance imaging data at the 1999 follow-up
demonstrated that most subjects had some disc degener-
ation at some level. Only two subjects, both with unilat-
eral pars defects, had no degenerative changes at any
level. Only two subjects with bilateral L5 defects had no
degeneration of the lumbosacral disc. Both of these sub-
jects had no spondylolisthesis. A slip exceeding 15% al-
ways was associated with moderate or severe degenera-
tion of the lumbosacral disc.
There was an association between a greater degree of
disc degeneration at L5S1 and percentage of slip (P
0.0006). There was no association between disc degen-
eration at L4 L5 and percentage of slip. Only two disc
herniations were noted in the 1999 studies, and none
were at L5S1. There was a relation between percentage
of slip and the severity of foraminal stenosis at L5S1.
Clinical Follow-up Evaluation
Three study subjects underwent lumbar spine surgery as
adults. The first subject, who had a unilateral L5 defect,
had a L4 L5 discectomy for acute disc rupture. The sec-
ond subject underwent a discectomy at L3L4 for acute
disc rupture. This subject had bilateral L5 defects and a
slip of 18% at L5S1 at the time of his surgery. The third
subject, with a history of lumbar surgery, had bilateral
L5 defects and a slip of 9% at L5S1 at the time of his
fusion without instrumentation. Follow-up evaluation of
this subject in 1999 radiographs noted appearance of slip
progression to 18% with pseudarthrosis. The subject re-
ported that a work-related injury had precipitated the
onset of his pain before his surgery. He denied pain on
the 1999 SF-36 questionnaire.
There was no association of low back pain with preg-
nancy in the six female subjects that carried a pregnancy
to term. Each of these had between two and four chil-
dren. All but one denied any pain with pregnancy. The
one who had experienced pain reported that it was dur-
ing a twin pregnancy with complications unrelated to her
lumbar spine while she was on bed rest for the last tri-
mester. She had experienced no pain with a later single
birth. Of the remaining four female subjects, one had
miscarriages, one refused the survey, and two were never
pregnant. After the childbearing years, no female patient
had a documented increase in percentage of slip.
Three subjects, all males, died between the 1988 and
1999 follow-up assessments. All had completed both the
clinical and radiographic 1988 follow-up evaluation.
The 10% death rate (3/30) of the current subject group is
similar to the 6.2% rate reported in 1990 for subjects
born in 1950 in the United States.11
During childhood and adolescence, only one pain ep-
isode was noted in any of the study subjects. A female
subject, in whom a bilateral L5 defect had developed at
12 years of age, had experienced low back pain at the age
of 16 years. It resolved with conservative therapy. She
had experienced no further pain until the age of 28 years,
when she again had an episode of back pain. In 1988, 12
subjects denied any pain, 11 subjects reported mild in-
termittent low back pain, and 1 subject, who had initial
spondylolisthesis and a slip of 10% in 1988, reported
moderate low back pain. No subject reported any severe
low back pain episodes.
In 1999, all but one of the living subjects indepen-
dently completed the SF-36 questionnaire. For each of
the function and pain indexes, there was no significant
difference between the subject population and the SF-36
Health Manual Survey for subjects 45 to 55 years of age
(Figure 7).12,13 There was no statistically significant dif-
ference in the pain or physical functioning scores be-
1032 Spine Volume 28 Number 10 2003
Figure 7. The SF-36 data for the
study group (n 26), ages 45 to
54 years, and the SF-36 mean
values from the SF-36 Health Sur-
vey Manual. GH, general health;
PF, physical functioning; RP, role
limitation from physical health; RE,
role limitation from emotional
problems; SF, social functioning;
MH, mental health; BP, bodily pain;
VT, energy/fatigue.
tween the subject group as a whole or those with a slip
and the SF-36 norms.
No subject ever filed a disability claim related to low
back pain. In 1999, 14 subjects reported episodes of back
pain lasting longer than 5 days over their lifetime (9
subjects with a slip and 5 subjects without a slip). Eight
subjects reported a day of lost work over their lifetime
because of low back pain (5 with a slip and 3 without a
slip). Only three subjects had any narcotic analgesic use
for low back pain over their lifetime.
Discussion
Clinicians understanding of the natural history of spon-
dylolysis and spondylolisthesis remains incomplete.
Most current studies involve review of a symptomatic
patient group seen at a spine center and maintained un-
der observation.1,3,5,14,15 The current study provides the
natural history of these disorders in a group of asymp-
tomatic subjects from the time of onset until the age of 50
years.
The authors report in 1984 noted a 4.4% incidence
of spondylolysis in 6-year-old children.2 This increased
to an incidence of 6% in adulthood. These findings are
similar to those in other studies. The male:female ratio of
2:1 in the current study also is similar to that reported in
population studies.9,16 18
The prognosis for a 6-year-old child with a pars inter-
articularis defect in terms of disability and pain appears
to follow that of the general population. Pain with these
lesions is rare in childhood and adolescence. It is inter-
esting that this time of life also is associated with the
greatest slip progression for the subjects that do experi-
ence slip.
Pain did increase as the study population aged. In the
study group, only one subject had a brief episode of pain
in the first two decades. By the fifth decade, the authors
noted seven subjects with a score of lower than 50 (mod-
erate pain) on the SF-36 pain assessment. However, in
the general population, the incidence of low back pain
increases with age. Santos-Eggimann et al19 reported in a
recent study that low back pain lasting longer than 7
days was reported by 20.2% of men ages 25 to 34 years,
with an increase to 28.5% in 65-to 74-year-olds. The
proportion of women the same age reporting low back
pain went from 31.1% to 38.8%. Population studies
also have noted a greater incidence of disc degeneration
with age.20
Pain was not prominent in the current study popula-
tion. A number of studies have reported the prominence
of pain with spondylolisthesis, but the populations stud-
ied had presented initially with symptoms. The current
findings show no difference in pain or function indexes
with the degree or progression of slip. There was no
significant difference in the SF-36 scores for unilateral or
bilateral pars defects and the norms for the general pop-
ulation. The onset of slip, whether in childhood or ado-
lescence, did not occur with pain in those years, nor was
it associated with pain in adulthood.
In 1990, the authors reported a relation between slip
progression and disc degeneration.21 Other authors have
reported similar findings since that time.4,5,15 This rela-
tion of both the height of the L5S1 disc and the severity
of disc degeneration with the overall percentage of slip
continued at the 45-year follow-up assessment.
The etiology of the initial slip in the authors 6- and
7-year-old subjects is more problematic. Ten of their
subjects presented at this age with bilateral pars defects
and initial spondylolisthesis. They categorized this group
as having early segmental laxity. A degree of initial slip is
determined by individual disc laxity idiopathic to each
person. This laxity occurs within the disc complex.
Farfan et al22 postulated that the prevalence of isthmic
spondylolisthesis in childhood is explained by a slip of
the epiphyseal plate. These authors noted that in the
young spine, the bond between the disc and the epiphy-
seal plate is strong and the epiphyseal line does not close
until the late teenage years. Whether the laxity was
within the disc or the growth plate in the current subjects
with early segmental laxity could not be determined by
this study.
There does not yet appear to be an increased risk of
slip progression in the adult decades of the current study.
This finding has been confirmed in other studies investi-
 Natural History of Spondylolysis and Spondylolisthesis Beutler et al 1033
gating the natural history of spondylolisthesis.5,14,23
Some spondylolisthesis studies have reported adult slip
progression, but in a pain-selected study population. Flo-
man15 reported on 18 patients presenting to a spine cen-
ter with incapacitating low back pain. These patients
were retrospectively found to have a 9% to 30% slip
progression after the third decade of life. A review of
radiographs noted the concurrent observation of disc de-
generation at the slipped level. Floman15 concluded that
disc degeneration explained how an asymptomatic lesion
would become symptomatic and lead to increased slip in
adulthood. The author estimated that his study patients
represented 20% of his clinic population, and reported
this as an incidence of adult slip progression in patients
with spondylolisthesis. This incidence of adult slip pro-
gression compares the 23% incidence of slip progression
reported by Seitsalo et al.24
The current authors agree that disc degeneration can
lead to increased slip and possible low back pain.5 Their
unselected study population had only a small increase in
slip as adults, and no relation of progression to painful
symptoms or disability was noted. Their data support
the findings of the pain-selected studies if only the symp-
tomatic subjects are observed. When the five subjects
with at least moderate pain in the 1999 follow-up assess-
ment were examined, the authors noted only one subject
with slip progression in the forth and fifth decades. This
would result in a 20% incidence (1 in 5 subjects) of adult
progression of 10% or more slip associated with low
back pain. Only with selection of symptomatic subjects
does the current incidence of progression compare with
that of the pain-selected patient population studies.
However, the incidence of symptomatic slip progression
in adulthood among the current unselected study popu-
lation presenting with bilateral L5 lesions in childhood
or adolescence would be 5% (1/22). This 5% incidence
of progression in adulthood appears to be an appropriate
estimate to use for counseling of a child or adolescent
presenting with bilateral L5 pars lesions.
Some spondylolisthesis studies have noted a 1:1 ratio
of men to women.14,24 These studies use a symptomatic
patient population. The current asymptomatic study
population ratio was 2:1 (20 men and 10 women). This
ratio becomes 1:1 (3 men and 2 women) if only the symp-
tomatic spondylolisthesis subjects in the 1999 follow-up
assessment are included. A higher female percentage is
reported in symptomatic study populations and may cor-
relate with female reporting of more intense pain or
other factors not identified.1
The inclusion of MRI data in the current study is
unique to a study reporting on the natural history of
spondylolysis and spondylolisthesis. Osterman et al4 re-
ported looking at 15 patients with mild olisthesis and
finding disc degeneration in all of them, but offered no
correlation with percentage of slip or progression. Stud-
ies so far have relied on radiographs to document col-
lapse of the disc, indirectly assessing evidence of degen-
eration. The finding of some disc degeneration in most of
the current subjects is consistent with studies investigat-
ing the asymptomatic general population of the same
age. Boden et al25 noted a 51% incidence of lumbar disc
degeneration in 40- to 59-year-olds, and Jarvik et al20
noted a 49% incidence of lumbar disc degeneration in
asymptomatic 45- to 55-year-olds.
The current MRI data show a greater degree of disc
degeneration and foraminal stenosis with greater overall
percentage of slip. There was no association of spon-
dylolisthesis with disc herniation. Any disc herniation
was noted at levels other than the slip, and usually at
L4 L5 level. Classic teaching has maintained that herni-
ation occurs at the level above the listhesis. The current
data show an increased percentage of subjects with de-
generation at L4 L5 and L5-S1, as compared with the
higher lumbar levels. There was no association between
the degree or incidence of degenerative change at L4 L5
and the percentage of slip at L5S1.
Much effort has been expended to determine indica-
tors for future slip.1,5,14,24 This determination is of par-
ticular interest to parents who have a child or adolescent
with the finding of a pars defect or spondylolisthesis. In a
study population of symptomatic patients, Seitsalo et
al24 did find a predictive value in the percentage of slip
observed on presentation. Saraste5 noted a lower lumbar
index in young patients with spondylolysis, and a lower
lumbar index in patients with spondylolisthesis, as com-
pared with a control group. She did not find a predictive
value of the lumbar index for slip progression. In a nat-
ural history study with a 7-year follow-up period, Fen-
nered et al1 retrospectively studied 47 symptomatic pa-
tients with spondylolysis or spondylolisthesis. No
prognostic factor for progression of slip or need for fu-
ture operative treatment was found. In the current study,
only the presence of a bilateral pars defect versus a uni-
lateral defect was associated with a greater probability of
slip later in adult life. There was no predictive value in
the percentage of slip, age of the subject at the time of the
slip, lumbar index, or slip angle at the time of presenta-
tion for the final slip.
The degree of initial slip in a child or adolescent pre-
senting with bilateral pars interarticularis defects is de-
pendent on an individuals disc laxity. The authors found
subjects with early segmental laxity and subjects with
late segmental laxity (slip in adolescence or later, but
bilateral defects at the age of 6 years). They also found
that 18% (4/22) of their subjects with bilateral L5 pars
defects never experienced slippage over the 45 years of
follow-up evaluation.
Early or late development of pars defects was not as-
sociated with early or late segmental laxity. Later slip
progression could not be predicted by the age of the
subject at time of the initial slip. The current study and
others have found disc height reduction at the level of
slip. Specifically, the current authors found disc height
reduction associated with the degree of slip in adulthood
follow-up evaluation. However, in childhood and ado-
lescence, the presence of spondylolisthesis was not asso-
1034 Spine Volume 28 Number 10 2003
ciated with the disc height, and disc height offered no
predictive value for later slip.
There was an association between disc degenera-
tion on MRI and degree of slip in the 1999 follow-up
assessment. The degree of slip was associated with the
loss of disc height noted on plain radiographs, and
with the degree of degenerative findings on MRI. It
may be that future study of MRI findings in a child-
hood spondylolysis population will lead to a clinical
indicator of individual segmental laxity and a predic-
tor of future slip.
The current death rate was similar to national sta-
tistics for the age group.11 The lumbar surgical history
of the current subjects appeared to have no relation to
presence of spondylolisthesis at the lumbosacral level.
Only one subject had surgery directed at the slipped
level, but this subject went on to further asymptomatic
slip.
Which comes first, significant disc degeneration or
slip? The degree of degenerative change at the lumbosa-
cral level in the adult MRI studies did not correlate with
pain, but was associated in the subjects with greater
overall slip. However, the degenerative changes on MRI
did not correlate with any progression of slip in the pre-
ceding decade. It is possible that the current subjects will
increase their current slow progression of slip over the
next decade as the lumbar degenerative process becomes
more prominent.
What advice then can be given to the parents of a child
with a lumbar pars lesion or low-grade spondylolisthe-
sis? The current findings indicate a benign course for the
first 50 years of life. Only a small percentage of subjects
develop symptomatic slip progression in long-term fol-
low-up studies. These subjects cannot be predicted on
initial childhood studies. The authors also agree with the
findings of their earlier study and those of others, con-
cluding that there is no justification for generally advis-
ing children and adolescents with spondylolysis and low-
grade spondylolisthesis not to participate in competitive
sports.10,16,26
Conclusions
Clinical decisions made with patients presenting with
spondylolysis and spondylolisthesis principally include
concern for future progression of the spondylolisthesis
and issues concerning pain. This report describes the
only prospective study to document the natural history
of these entities through more than 45 years of life in a
population unselected for pain. The current study dem-
onstrated that a unilateral pars defect is not associated
with further slip or disability. It showed that subjects
with bilateral L5 pars defects follow a clinical course
similar to that of the general population. There appears
to be a marked slowing of slip progression in the adult
decades to the age of 50 years, and no subject has
reached a 40% slip. It remains to be seen whether adult
disc degeneration will accelerate the current minimal slip
progression.
Key Points
Unilateral pars defects were not associated with
spondylolisthesis or disability.
Bilateral pars defects followed a clinical course
similar to that of the general population.
The natural history of spondylolysis and spon-
dylolisthesis shows a slowing of slip progression
with each decade to the age of 50 years.
Bilateral pars defects will develop symptomatic
progression in only a small percentage of subjects
in long-term follow-up studies.
Acknowledgments
A study over 50 years cannot be completed without the
input of many people. The authors thank the North
American Spine Society for their support of this work
through a research grant. This report is given in memory
of Drs. Dan Baker and Albert Murtland, who had the
foresight to initiate this study and tirelessly continue it
over its many decades.
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Point of View
Stuart L. Weinstein, MD
University of Iowa
Iowa City, Iowa
The literature on spondylolysis and spondylolisthesis has
many shortcomings. Minimal natural history is available.
Most of the reported studies are retrospect reviews, with
children and adolescents combined. Type 1 (dysplastic) and
Type 2 (isthmic) spondylolisthesis often are combined as
well, as are patients with lysis and listhesis. Radiographic
parameters vary from study to study. Radiographic posi-
tioning often is not standardized, and different outcome
measures are used. As with most retrospective reviews, in-
ter- and intrarater reliability issues surface.
This article by Beutler and colleagues reports a long-
term follow-up evaluation of the only population study
on spondylolysis available in the literature. The study
represents the conclusion of a four-decade prospective
23. McPhee IB, OBrien JP, McCall IW, et al. Progression of lumbosacral spon-
dylolisthesis. Aust Radiol 1981;25:915.
24. Seitsalo S, Osterman K, Hyvarinen H, et al. Progression of spondylolisthesis
in children and adolescents: a long-term follow-up of 272 patients. Spine
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25. Boden SD, Davis, DO, Dina TS, et al. Abnormal magnetic-resonance scans of
the lumbar spine in asymptomatic subjects. J Bone Joint Surg [Am] 1990;72:
403 8.
26. Herring SA, Standaert CJ. Reevaluating the diagnostic assessment and treat-
ment of spondylolysis is the young athlete. SpineLine 2001;1:16 9.
investigation begun in the 1950s. Although the study
numbers are small, this report adds valuable information
on the natural history of this condition. Although the
varying methodologies used in the sequential studies
could be criticized, the report provides very valuable
long-term information about spondylolysis. It confirms
the generally benign nature of the condition. It demon-
strates that unilateral pars defects are not associated with
further slip, and that those with bilateral defects follow a
clinical course similar to that of the general population.
Although further slippage may occur in adulthood, most
patients live active, pain-free, fully functional lives. The
study highlights the generally benign nature of the spon-
dylolysis affecting the majority of patients.