Read 7.7.

19

Review Article

Adult Isthmic Spondylolisthesis

Abstract
Thomas R. Jones, MD, PhD Isthmic spondylolisthesis is present in a small subset of the adult
Raj D. Rao, MD population. Although the incidence of low back pain in these
Downloaded from https://journals.lww.com/jaaos by Lc+LFovvA8movljADFsdzG2mBs/4i0r4TBOsxvw+icYXHWiUdgzoFumxgq4L9NIFNt74nHqaktzc/CSlWu8CEwGq4Fi9B0CxiiCZljXSUiPnYBSEWtnc278NwyOMfNxe/AvXFiWwb60= on 11/12/2018

persons is similar to that of the general population, both pars

interarticularis defect and forward slip can serve as unique pain
generators. Neurologic symptoms may result from nerve root
impingement related to the pars defect or degenerative changes
associated with the deformity. Most symptomatic cases are
successfully managed nonsurgically, but patients with intractable
pain or neurologic symptoms may benefit from surgical
decompression and stabilization. Surgical intervention has shown
>80% success in appropriately selected patients, with a low
incidence of complications. Surgical techniques include
decompression, posterolateral fusion, anterior lumbosacral
interbody fusion, and circumferential fusion methods.
Circumferential fusion results in improved fusion rates and, in some
studies, superior clinical outcomes. The choice of procedure is
generally guided by the patient’s radiographic and clinical findings
as well as risk-benefit considerations.

Dr. Jones is Resident, Department

of Orthopaedic Surgery, Medical
College of Wisconsin, Milwaukee,
WI. Dr. Rao is Professor,
Department of Orthopaedic Surgery,
Medical College of Wisconsin.
Dr. Rao or a member of his
immediate family serves as a board
member, owner, officer, or
committee member of the North
American Spine Society and the
Lumbar Spine Research Society.
Neither Dr. Jones nor a member of
his immediate family has received
anything of value from or owns
stock in a commercial company or
institution related directly or
indirectly to the subject of this
article.
Reprint requests: Dr. Rao,
Department of Orthopaedic Surgery,
Medical College of Wisconsin, 9200
West Wisconsin Avenue, Milwaukee,
WI 53226-0099.
J Am Acad Orthop Surg 2009;17:
609-617
Copyright 2009 by the American
Academy of Orthopaedic Surgeons.
T
he pars interarticularis, some-
times referred to as the “isth-
mus,” is a thin bicortical region of
the posterior arch of the lumbar ver-
tebra, where the lamina and the infe-
rior articular process intersect with
the pedicle and superior articular
process. A fibrocartilaginous cleft in
this region is referred to as a spondy-
lolysis or a pars defect; this finding is
present in 6% of the North Ameri-
can adult population.1 Dissociation
of the anterior and posterior verte-
bral arch in these persons can result
in isthmic spondylolisthesis, or ante-
rior translation of the vertebra. This
occurs in 50% to 75% of persons
with spondylolysis.1 Isthmic spondy-
lolisthesis can also result from elon-
gation or fractures of the pars inter-
articularis (Table 1).
Spondylolisthesis of L5 on S1 was
first described by the Belgian obste-
trician Herbiniaux3 in 1782, when he
noted obstruction of the pelvic outlet
during delivery caused by what he
termed a lumbosacral dislocation.
Killian4 coined the term “spondy-
lolisthesis” (from the Greek spondyl
[vertebra] and olisthesis [to slip]) in
1854. In 1855, it was observed that
a defect in the pars was required for
slip to occur.5 In 1888, Neugebauer6
expanded on these observations,
publishing his own data on 26 clini-
cal cases and 17 cadaver specimens.
He postulated that an intact neural
arch prevented the slippage and that
pars elongation or failure permitted
listhesis.
Incidence and
Pathogenesis
Spondylolysis may result from a ge-
netic predisposition to a dysplastic

October 2009, Vol 17, No 10 609

Adult Isthmic Spondylolisthesis
Table 1
Wiltse Classification of
Spondylolisthesis
Type Description
I Dysplastic: congenital abnor-
malities of the upper
sacrum or the arch of L5
II Isthmic: lesion in the pars
interarticularis
A. Lytic: fatigue fracture of
the pars
B. Elongated but intact
pars
C. Acute fracture
III Degenerative: resulting from
long-standing intersegmen-
tal disease
IV Traumatic: fractures in re-
gions other than the pars
V Pathologic: generalized or
local bone disease
cartilaginous region in the develop-
ing posterior arch, with superim-
posed biomechanical stressors.2,7,8 In
a population-based study of 500 ele-
mentary school students, Fredrick-
son et al1 reported an incidence of
lumbar spondylolysis of 4.4% in pa-
tients aged 6 years. An additional
eight subjects developed spondyloly-
sis between the ages of 12 and 25
years, for an adult incidence of 6%.
Ninety percent of the lytic defects oc-
curred at the L5-S1 level, with two
thirds of the defects in males,
whether children or adults. Bilateral
pars defects were present in 22 pa-
tients, with unilateral pars defects
present in 8. Slippage was identified
in 74% of subjects with pars defects
at L5-S1 but was not seen in subjects
with pars defects at other lumbar
levels or with unilateral pars defects.
In a 45-year natural history study
of 30 subjects with pars defects,
Beutler et al9 showed that adults
with unilateral pars defects tend not
to develop listhesis of the vertebral
body. Subjects with bilateral pars de-
fects who did not have listhesis at the
time of diagnosis had variable prog-
610
nosis in terms of progression of slip,
with half showing no listhesis over
45 years and the other half slipping a
mean of 24%. Subjects with slippage
at the time of diagnosis went on to
additional slippage of 7% to 20%.
Listhesis at the L4-L5 level consti-
tutes approximately 10% of all slips
and is associated with greater pro-
gression and symptoms.10,11
The incidence of slip progression in
asymptomatic adults with bilateral
defects at L5 is estimated to be 5%,
with the overall likelihood of pro-
gression decreasing with age.9 MRI
studies show that disk degeneration
occurs infrequently in persons with
unilateral pars defects but frequently
in patients with bilateral defects at
L5-S1, with greater levels of disk de-
generation being associated with
higher levels of slip.9,12 Slip progres-
sion is estimated to occur in 20% of
symptomatic adults, with disk degen-
eration at the slip level in all.12 Pro-
gression tends to be greater in adults
than in adolescents, is more frequent
in subjects with bilateral L4 spondy-
lolysis, and correlates with disk de-
generation at the slip level. Progres-
sion >10 mm occurs in <5% of
subjects.10
Mechanical factors play a role in
adults with spondylolysis. In adult
high-level athletes, the overall inci-
dence of spondylolysis (8%) is simi-
lar to that in the general popula-
tion.13 However, higher incidences
are found in athletes who participate
in throwing sports (27%), artistic
gymnastics (17%), rowing (17%),
weight lifting (13%), and swimming
(10%). A prospective MRI study of
adolescent cricket players demon-
strated unilateral fatigue failure of
the pars on the opposite side of the
bowler’s dominant hand, with most
defects occurring at L4.14 The defects
showed imaging characteristics con-
sistent with stress fracture. Another
study showed that nonambulatory
patients with cerebral palsy did not
Journal of the American Academy of Orthopaedic Surgeons
develop spondylolysis or spondy-
lolisthesis.15 Stress fractures of the
pars have been found in 15% of
American college football players16
and were detected in 12 of the 51
cricket bowlers reported on by Eng-
strom and Walker.14
In the person with bilateral failure
of the pars interarticularis, micromo-
tion can occur at this site as the re-
sult of the posterior pull of the
paraspinal musculature on the loose
posterior elements and anteriorly di-
rected shear at the intervertebral
disk. Shear generated by sacral incli-
nation, lumbar lordosis, and bipedal
gait are all important mechanical
factors in the pathogenesis of
spondylolisthesis. The discontinuity
between the inferior articular process
and the vertebral body results in in-
creased stress on the intervertebral
disk, which becomes the primary re-
straint to listhesis.
Clinical Presentation
Low back pain and related disability
in adults with spondylolysis or
spondylolisthesis is similar to that in
the general population. Back pain is
rare during childhood and adoles-
cence and increases with age.
Women with a pars defect do not
have an increased incidence of low
back pain during pregnancy.9 Some
studies show an increased likelihood
of low back pain with listhesis >10
mm, slip at the L4-L5 level or low
lumbar index, and an increased like-
lihood of both low back and leg pain
with disk degeneration at the slip
level.10,17
Given the high incidence of asymp-
tomatic spondylolysis and spondy-
lolisthesis, other causes of back pain
must be considered in all patients. A
thorough description of the pain
should be obtained, including the ex-
act location, chronicity, severity, and
quality as well as alleviating and ex-

acerbating factors. Neurologic in-
continence of the bladder or bowel is
unusual, but occasionally patients re-
port subtle changes in urinary fre-
quency or emptying that correspond
temporally with their back and/or
radicular symptoms. Precipitating
occupational and recreational risk
factors must be explored.
On physical examination, the patient
with spondylolisthesis may have a pal-
pable step-off at the spinous process
above the slip level. The trunk is short-
ened, and lumbar hyperlordosis is
present in persons with increased sa-
cral inclination. Affected patients fre-
quently have limited lumbar spine range
of motion, with worsening pain on ex-
tension, and tight hamstrings.
In a series of 255 patients, Saraste10
reported that neurologic findings
were rare at initial presentation in
both adolescents and adults (2%)
but increased to 18% at 29-year
follow-up. Pain radiating into the
buttocks and posterior thighs is com-
mon in the adult with back pain.
This may represent referred pain
from stimulation of the strained anu-
lus fibrosus, degenerative disks, or
degenerative facet joints. Radicular
pain or paresthesia that travels in a
dermatomal pattern below the knee
is more specific for nerve root im-
pingement and may be accompanied
by corresponding neurologic deficits.
Neurologic symptoms and signs in
spondylolisthesis result from im-
pingement on the exiting nerve root
by hypertrophic fibrocartilaginous or
bony tissue at the site of the pars in-
terarticularis defect, vertebral end
plate osteophytes, or nerve root trac-
tion from static or dynamic listhe-
sis.18,19 Disk bulges or herniations
can result in nerve root impinge-
ment. Rarely, impingement of the L5
nerve root has been reported to oc-
cur between the L5 transverse pro-
cess and the sacral ala in cases of
isthmic spondylolisthesis >20% and
large transverse process diameter.20
October 2009, Vol 17, No 10
Thomas R. Jones, MD, PhD, and Raj D. Rao, MD
As opposed to degenerative spondy-
lolisthesis, with the isthmic form, the
vertebral body and posterior ele-
ments are dissociated; thus, forward
slip of the vertebral body itself does
not typically result in foraminal or
central stenosis. Similarly, complete
occlusion of the cauda equina is un-
likely in patients who have bilateral
defects of the pars interarticularis
and a loose posterior neural arch.
However, it can occur occasionally in
patients with an elongated pars inter-
articularis and high-grade listhesis,
as the thecal sac gets stretched over
the posterosuperior border of the
sacrum. Axial low back pain in isth-
mic spondylolisthesis is most fre-
quently caused by chronic lumbar
muscle strain secondary to lumbar
hyperlordosis and sagittal malalign-
ment. Other causes of axial low back
pain include referred pain from the
degenerative disk, facet joints, and fi-
brocartilaginous pars defect as well
as from increased stress on the anu-
lus fibrosus at the slip level.9,10
The presence of radicular symptoms
or findings that anatomically corre-
spond to the level of the pars defect are
useful in verifying that the pars defect
is indeed the pain generator. In persons
with axial back pain alone, careful as-
sessment of the history and clinical ex-
amination is required to diagnose the
source of pain. We have found the fol-
lowing factors to be generally reliable
in determining that the pars defect may
be a source of axial back pain: neuro-
logic pain correlating to the level of the
pars defect, a history of adolescent back
pain, the absence of other spinal pathol-
ogy, pathologic motion as demonstrated
on dynamic radiographs, and the ab-
sence of secondary gain.
Imaging
A pars interarticularis defect may be
seen on a lateral lumbosacral spine
radiograph. This view allows grad-
ing of the degree of slip as well as
measurement of the slip angle, which
is a measure of kyphosis at the lis-
thetic level (Figure 1). The lumbar
index, a measure of deformity of the
listhetic vertebral body (frequently
referred to as a trapezoidal shape),
and pelvic incidence, a measure of
lumbosacral-pelvic orientation that
is related to spinal sagittal alignment,
can also be determined with this
view (Figures 2 and 3). If the lateral
radiograph fails to show the pars de-
fect and clinical suspicion remains, a
30° oblique lateral view of the lum-
bar spine should be obtained. AP
and 30° caudal-tilt AP radiographs
may show associated scoliosis or
spina bifida occulta. The physician
should note dysplastic features such
as a trapezoidal L5 vertebra, sacral
doming, and deficient inferior articu-
lar process as well as degenerative
changes, such as loss of disk height
and osteophyte formation. Flexion
and extension lateral radiographs
may be useful in visualizing dynamic
mobility at the listhetic segment and
subtle spondylolisthesis in a patient
with a known pars defect.
Long-term studies have shown no
correlation between lumbar index,
spondylolysis level, or percentage of slip
and progression of slip during adult-
hood. Loss of radiographic disk height
at L5-S1 has been shown to be statis-
tically correlated to greater percentage
of slip at this level.9 A low lumbar
index, a measure of vertebral body
wedging, correlates with high-grade
slips. Saraste10 reported that a lum-
bar index below 75 was associated
with a higher degree of slip at pre-
sentation but did not correlate with
progression of slip at a mean 29-year
follow-up. Mean pelvic incidence in
adults has been shown to be 57°;
normal range is 53.2° ± 7.0° in men
and 48.7° ± 7.0° in women. Pelvic
incidence >68.5° correlates strongly
with the degree of slip (P = 0.03).21
CT provides the best detail of bony
architecture, and it is highly sensitive
611
Adult Isthmic Spondylolisthesis

Figure 1

Illustration showing measurements used in radiographic diagnosis of spondylolisthesis. A, With the Meyerding method
of classifying the severity of slip, the superior end plate of the subjacent vertebra is divided into quarters, and the loca-
tion of the posterior margin of the listhetic vertebra within these divisions is determined. A grade 5 slip, spondyloptosis,
is complete (>100%) slippage of one vertebra on the other. The lytic defect is indicated with an arrow. Inset, Grade III
L5-S1 slip. B, The slip angle (A) is a measure of kyphosis at the listhetic level. It is calculated by determining the angle
between a line perpendicular to the posterior margin of the subjacent vertebral body and a line parallel to the superior
end plate of the olisthetic vertebra. (Panel B adapted with permission from Herman MJ, Pizzutillo PD, Cavalier R:
Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am 2003;34:461-467.
http://www.sciencedirect.com/science/journal/00305898.)

Figure 2
The lumbar index is calculated by
dividing the height of the posterior
cortex (P) of the olisthetic vertebral
body by the height of the anterior
cortex (A) of the vertebral body.
The value is expressed as a
percentage (P/A × 100%).
for spondylolysis. CT is also useful
in monitoring healing of the pars in-
terarticularis in patients treated with
immobilization or repair of a defect.
CT following myelography is used
for neuroimaging in patients with a
pacemaker and in those with exten-
sive instrumentation or marked coro-
nal plane deformity, for whom MRI
is less effective. MRI is less useful for
evaluating pars defects, but it allows
evaluation of associated degenerative
or herniated disks. Assessment of
central or foraminal stenosis at the
level of the slip can be correlated to
nerve root impingement and is help-
ful in identifying specific pain gener-
ators in conjunction with the history
and physical examination (Figure 4).
Particularly in adolescent patients,
bone scans can be helpful in diagnos-
ing stress reactions at the pars inter-
articularis that are not visualized on
plain radiographs or CT scans. Sub-
stantial uptake at the pars may indi-
cate healing potential of an acute
stress fracture. It also may be helpful
in distinguishing an acute pars frac-
ture from a chronic defect. Single-
photon emission CT has been shown
to be more sensitive than and supe-
rior to MRI and standard technetium
Tc-99m bone scanning in detecting
spondylolysis and can be used as a
tool to monitor healing of spondy-
lolytic defects treated with brac-
ing.22,23
Treatment
Nonsurgical
Most adults with axial or radicular pain
related to lumbar spondylolisthesis will

612 Journal of the American Academy of Orthopaedic Surgeons


improve with nonsurgical treatment.
The mainstay of early treatment of these
symptomatic patients is the judicious
use of nonsteroidal anti-inflammatory
drugs, along with modification of pain-
provoking activities and relative rest for
1 to 2 weeks. Muscle relaxants are help-
ful in some patients with greater pain.
Narcotic analgesics should be used spar-
ingly and for short durations in cases
of severe pain.
Flexion-based physical therapy ex-
ercise regimens are generally supe-
rior to extension-based programs
in achieving symptomatic relief.24,25
Low-impact aerobic activity (eg, cy-
cling) is encouraged. In a prospective
randomized study, patients with isth-
mic spondylolisthesis and severe low
back or radicular pain lasting for 1
year who were treated with an ex-
ercise regimen had more pain and
disability than did those who under-
went in situ fusion with no postoper-
ative physical therapy.26 There is no
clear evidence that physical therapy
modalities such as heat, ultrasound,
and massage are beneficial in the
management of isthmic spondylolis-
thesis.
More than 75% of adults with back
and leg pain resulting from a pars de-
fect and grade I to II spondylolisthesis
will have successful outcomes using an-
tilordotic bracing and activity modifi-
cation for 3 to 6 months.27-29 Epidu-
ral steroid injections may provide some
relief of radicular symptoms, but they
are unlikely to help patients with axial
pain. Patients with persistent symptoms
typically remain active and neurolog-
ically stable, even in the presence of
high-grade spondylolisthesis.30
Surgical
No guidelines have been established
for surgical intervention in adults
with isthmic spondylolisthesis spe-
cific to the degree or progression of
slip. The adult who fails to respond
to 6 months of nonsurgical treatment
October 2009, Vol 17, No 10
Thomas R. Jones, MD, PhD, and Raj D. Rao, MD
Figure 3
Pelvic incidence (PI) is calculated
by drawing a reference line (SE)
along the superior end plate of S1.
The measure originates from the
midpoint of the end plate. A line (P)
is drawn perpendicular to the
reference line from the midpoint of
the S1 superior end plate. A
second line is drawn from the
midpoint to the center of the
femoral heads (SF). PI is the angle
between these lines.
and who continues to have back
and/or radicular pain, has progres-
sive neurologic deficit, or has neuro-
genic claudication causing significant
disability is a candidate for surgery.
Indications for surgical stabilization
in young adults and adolescents in-
clude symptomatic grade III or
greater slip and progressive deformi-
ty.31,32 Development of cauda equina
syndrome is an absolute indication
for surgery. However, this rarely oc-
curs other than in high-energy
trauma cases.
Decompression
Posterior decompression of the the-
cal sac and nerve roots at the level of
the pars defect was initially described
by Gill et al33 in 1955. The loose
posterior element is removed along
with any hypertrophic fibrous tissue
at the pars defect. Partial facetec-
Figure 4
Sagittal T2-weighted MRI scan
demonstrating hypertrophic bony
and fibrocartilaginous tissue (arrow)
on the ventral aspect of an L5 pars
defect. The defect along with the
slip and posterior disk protrusion,
contributes to foraminal
impingement of the L5 nerve root.
tomy and resection of any compress-
ing bone from the pedicle complete
the decompression of the nerve root.
In the original description of the pro-
cedure, disk exploration was per-
formed, and protruding fragments
were débrided. Long-term follow-up
by Gill34 on a cohort of patients was
encouraging, with 90% satisfactory
outcomes at an average of 71
months. However, subsequent stud-
ies have failed to produce similar
outcomes.
Decompression alone is now rarely
used and is restricted to older pa-
tients with stabilizing anterior osteo-
phytes who present with primarily
radicular symptoms. Decompression
alone has been associated with poor
outcomes, up to a 27% slip progres-
sion rate, and accelerated disk de-
generation at long-term follow-up.35
Contraindications to decompression
alone include predominant low back
pain and high-grade mobile slips.
613
Adult Isthmic Spondylolisthesis
Posterior and Posterolateral
Lumbar Arthrodesis
In 1943, Meyerding36 reported pos-
terior fusion of the laminae and
spinous processes using autograft in
patients with back pain and spondy-
lolisthesis. Good or improved clini-
cal outcomes were obtained in >88%
of patients regardless of initial grade
of slip. Unilateral posterolateral fu-
sion (PLF) between the transverse
processes was initially described by
Watkins37 in 1953 and was later re-
vised to include fusion of bilateral
transverse processes, or the modern
PLF.
A broad range of outcomes of PLF in
isthmic spondylolisthesis has been re-
ported. In a systematic review of the lit-
erature, Jacobs et al38 reported an
81% to 100% fusion rate and 60%
to 98% clinical success with PLF
alone. A meta-analysis of published
studies through the year 2003 dem-
onstrated an overall 83% fusion rate
and a 75% clinical success rate in
patients undergoing posterior fusion
for isthmic spondylolisthesis.39 No
statistically significant difference in
clinical outcomes or incidence of fu-
sion was found in patients who un-
derwent PLF either with or without
decompression.
The role of instrumentation in the
treatment of isthmic spondylolisthe-
sis is unclear. Some studies, including
the only randomized, controlled trial
comparing instrumented with nonin-
strumented fusion,40 have failed to
show either improved fusion rates or
clinical outcomes with the use of in-
strumentation.41 However, a meta-
analysis of published studies demon-
strated clear benefit in fusion rates
(90% versus 77%) and clinical suc-
cess (85% versus 64%) with the in-
clusion of instrumentation.39 Neu-
rologic complications are more
common with pedicle screw instru-
mentation. This outcome is largely
attributable to screw misplacement.
614
Circumferential Fusion
Some surgeons combine posterior de-
compression of the neural elements
and posterior instrumented fusion
with an interbody fusion, using a
separate anterior lumbar interbody
fusion (ALIF), posterior lumbar in-
terbody fusion (PLIF), or transfo-
raminal lumbar interbody fusion
(TLIF). The large vertebral end-plate
surfaces theoretically increase the
likelihood of a successful fusion, and
the combined release and distraction
of the disk space allows improved
deformity correction.
ALIF involves complete disk re-
moval under direct visualization
through an abdominal approach, fol-
lowed by insertion of a structural
bone graft or synthetic cage. The
published clinical success and fusion
rates for isolated use of ALIF for
isthmic spondylolisthesis have been
comparable to those with PLF.38,42
PLIF is performed following decom-
pressive laminectomy at the level of
the spondylolisthesis. Access to the
disk space is obtained through the
interlaminar window by retraction
of the thecal sac and traversing nerve
root. Short-term clinical outcomes
are largely equivalent to those of PLF
alone, but correction of sagittal
alignment and maintenance of reduc-
tion is better with PLIF.43-45 In one
study, a higher proportion of unsatis-
factory outcomes was found in the
PLIF group compared with the PLF
group, despite superior radiographic
results with PLIF.44
The TLIF technique includes lami-
nectomy and unilateral facetectomy,
after which the disk space is ap-
proached through the unroofed fo-
raminal zone. The lateralized portal
allows for reduced manipulation of
the thecal sac and nerve roots com-
pared with PLIF while enabling the
surgeon to simultaneously decom-
press both exiting and traversing
nerve roots. In patients with grade I
and II isthmic spondylolisthesis,
Journal of the American Academy of Orthopaedic Surgeons
TLIF has shown a fusion rate of
94.8% and significant improvement
in Oswestry Disability Index score (P
< 0.01).46 Complications with both
PLIF and TLIF include postoperative
radiculopathy from injury to the
nerve root during exposure of the
disk space, incidental durotomy, mi-
gration of the interbody implant, and
epidural bleeding.
A meta-analysis of outcomes from 35
studies of low-grade adult isthmic
spondylolisthesis revealed a statistically
significant difference in fusion rate of
98% for circumferential stabilization
versus 83% for PLF and 74% for an-
terior fusion alone (P < 0.0001).39
Clinical outcomes were best in pa-
tients who underwent anterior fusion
alone (90%), followed by circumfer-
ential fusion (86%) and PLF (75%).
More recent comparative studies, in-
cluding short- and long-term follow-
up, have shown statistically signifi-
cant improvement in clinical scores
for circumferential fusion using PLF
combined with either ALIF or PLIF
over PLF alone, with nonsignificant
trends toward improved fusion
rates.42,47
Reduction
Reduction of high-grade slips and cor-
rection of slip angle theoretically pro-
vide an improved mechanical environ-
ment for fusion, allow for fewer
segments to be fused, and provide im-
proved sagittal alignment and correc-
tion of cosmetic deformity. A degree of
passive slip reduction is obtained intra-
operatively by muscle relaxation dur-
ing anesthesia, patient positioning, and
intraoperative release during decom-
pression and diskectomy. The benefits
of further active attempts at improve-
ment in sagittal alignment need to be
weighed against the potential risks of
neurologic injury.
Active reduction of slip is at-
tempted via pedicle screw instrumen-
tation under neurologic monitoring
(ie, somatosensory-evoked poten-
 Thomas R. Jones, MD, PhD, and Raj D. Rao, MD

tials, electromyography, direct nerve Figure 5

stimulation) and fluoroscopic guid-
ance. Interbody fusion is performed
concurrently or as a separate proce-
dure. Direct comparisons with in situ
fusion techniques have shown im-
proved rates of fusion and improved
radiographic parameters of align-
ment, although no differences in
clinical outcomes have been ob-
served.48,49
Injury to the cauda and exiting nerve
roots can occur as the listhetic segment
is reduced, although frank cauda equina
syndrome is rare. The L5 root in par-
ticular is subject to significant strain
during reduction.50 Catastrophic in-
juries with permanent paralysis,
bowel and bladder dysfunction, and Pseudarthrosis and implant failure following attempted posterolateral fusion
sexual dysfunction have been re- in a young, active patient. AP (A) and lateral (B) radiographs demonstrating
ported. Recent studies examining revision instrumentation carried out through a posterior approach, followed by
a second-stage anterior interbody diskectomy and arthrodesis performed with
partial active posterior distractional
a synthetic spacer. Successful bony union of the L5 and S1 vertebral bodies
reduction with neurologic mon- was achieved, along with improvement of deformity.
itoring and circumferential fusion
through either anterior or posterior
Figure 6
approaches have shown excellent re-
sults, with minimal complications
and no catastrophic events.51,52

High-grade Spondylolisthesis
High-grade slips (ie, >50%) present
unique challenges. Posterior fusion
alone in affected patients results in a
greater likelihood of pseudarthrosis,
slip progression, neurologic deficit,
and implant failure.31,49,53 The evi-
dence suggests that circumferential
fusion techniques in these patients al-
low for improved correction of slip
angle and degree of slip, provide sta-
ble fixation, maintain deformity cor-
rection, and carry a low risk of ma-
jor complications (Figure 5).
Transsacral fixation is an alterna-
Transsacral fibular strut graft following L4-S2 laminectomy in an adolescent
tive technique specific to high-grade girl with high-grade spondylolisthesis and neurologic deficit. AP (A) and
slips.54 Following lumbosacral lami- lateral (B) radiographs show passage of a fibular strut from posterior to
nectomy, a fibular strut is passed anterior, followed by bilateral alo-transverse fusion and L4-S1 pedicle screw
fixation.
from posterior to anterior through
the body of S1 into the body of L5
(Figure 6). Bilateral posterolateral In patients with a fixed spondylopto- L5 through separate anterior and pos-
fusion from L4 to the sacrum is per- sis of L5 on S1, complete resection of terior approaches has been de-
formed in routine fashion. the anterior and posterior elements of scribed.55 This is followed by fusion

October 2009, Vol 17, No 10 615

Adult Isthmic Spondylolisthesis
and pedicle screw instrumentation of
L4 to S1. Gaines55 reported long-
term outcomes of 30 patients, aged
12 to 50 years, who underwent the
procedure. Only two cases of pseud-
arthrosis were noted, and all 30 pa-
tients reported satisfaction with the
procedure, even though 23 experi-
enced transient postoperative L5
neurapraxia, with 2 patients having
permanent deficits requiring ankle-
foot arthroses. Long-term correction
of sagittal alignment was achieved,
and no bowel, bladder, or sexual
dysfunction occurred.
Summary
Isthmic spondylolisthesis is present in
6% of adults, most of whom are
asymptomatic. In persons who present
with axial back pain or radicular find-
ings and show evidence on imaging of
a pars defect, careful assessment is re-
quired to ensure that the pars defect is
in fact the source of pain. Nonsurgical
management, including nonsteroidal
anti-inflammatory drugs, specific phys-
ical therapy regimens, and bracing, are
generally successful in controlling symp-
toms. Several surgical options are avail-
able for patients with intractable symp-
toms despite nonsurgical management
and include decompression, PLF, ALIF,
and circumferential fusion. The specific
surgical technique selected for any given
patient depends on the patient’s clini-
cal and imaging findings as well as in-
dividualized consideration of patient-
specific risks and benefits.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 26
and 40 are level I studies. References
1, 9, 11, 14, 16, 19, 21-23, 25, and
47-49 are level II studies. References
616
13, 15, 17, 24, 29, 30, 38, 39, and
42-46 are level III studies. Most of
the remaining references are level IV
studies.
Citation numbers printed in bold
type represent references published
within the past 5 years.
1. Fredrickson BE, Baker D, McHolick WJ,
Yuan HA, Lubicky JP: The natural
history of spondylolysis and
spondylolisthesis. J Bone Joint Surg Am
1984;66:699-707.
2. Wiltse LL: The etiology of
spondylolisthesis. J Bone Joint Surg Am
1962;44:539-560.
3. Herbiniaux G: Traité sur divers
accouchements laborieux, et sur les
polypes de la matrice. Brussels, Belgium,
JL Boubers, 1782.
4. Killian HF: Schilderungen neuer becken
formen und ihres verhaltens im leben.
Mannheim, Germany, Verlag von
Bosserman, 1854.
5. Robert zu Coblenz: Eine eigenthümliche
angeborene Lordose, wahrscheinlich
bedingt durch eine Verschiebung des
Körpers des Lendenwirbels auf die
vordere Fläche des ersten
Kreuzbeinwirbel (Spondylolisthesis
Kilian), nebst Bermerkungen über die
Mechanik dieser Beckenformation.
Monatsschr Geuburts Frauenkr (Berlin)
1855;5:81-94.
6. Neugebauer FI: The classic: A new
contribution to the history and etiology
of spondyl-olisthesis by F. L.
Neugebauer. Clin Orthop Relat Res
1976;117:4-22.
7. Wynne-Davies R, Scott JH: Inheritance
and spondylolisthesis: A radiographic
family survey. J Bone Joint Surg Br 1979;
61:301-305.
8. Stewart TD: The age incidence of neural-
arch defects in Alaskan natives,
considered from the standpoint of
etiology. J Bone Joint Surg Am 1953;35:
937-950.
9. Beutler WJ, Fredrickson BE, Murtland
A, Sweeney CA, Grant WD, Baker D:
The natural history of spondylolysis and
spondylolisthesis: 45-year follow-up
evaluation. Spine (Phila Pa 1976) 2003;
28:1027-1035.
10. Saraste H: Long-term clinical and
radiological follow-up of spondylolysis
and spondylolisthesis. J Pediatr Orthop
1987;7:631-638.
11. Grobler LJ, Novotny JE, Wilder DG,
Frymoyer JW, Pope MH: L4-5 isthmic
spondylolisthesis: A biomechanical
analysis comparing stability in L4-5 and
L5-S1 isthmic spondylolisthesis. Spine
Journal of the American Academy of Orthopaedic Surgeons
(Phila Pa 1976) 1994;19:222-227.
12. Floman Y: Progression of lumbosacral
isthmic spondylolisthesis in adults. Spine
(Phila Pa 1976) 2000;25:342-347.
13. Soler T, Calderón C: The prevalence of
spondylolysis in the Spanish elite athlete.
Am J Sports Med 2000;28:57-62.
14. Engstrom CM, Walker DG: Pars
interarticularis stress lesions in the
lumbar spine of cricket fast bowlers.
Med Sci Sports Exerc 2007;39:28-33.
15. Rosenberg NJ, Bargar WL, Friedman B:
The incidence of spondylolysis and
spondylolisthesis in nonambulatory
patients. Spine (Phila Pa 1976) 1981;6:
35-38.
16. McCarroll JR, Miller JM, Ritter MA:
Lumbar spondylolysis and
spondylolisthesis in college football
players: A prospective study. Am J Sports
Med 1986;14:404-406.
17. Saraste H: Symptoms in relation to the
level of spondylolysis. Int Orthop 1986;
10:183-185.
18. Edelson JG, Nathan H: Nerve root
compression in spondylolysis and
spondylolisthesis. J Bone Joint Surg Br
1986;68:596-599.
19. Jinkins JR, Rauch A: Magnetic
resonance imaging of entrapment of
lumbar nerve roots in spondylolytic
spondylolisthesis. J Bone Joint Surg Am
1994;76:1643-1648.
20. Wiltse LL, Guyer RD, Spencer CW,
Glenn WV, Porter IS: Alar transverse
process impingement of the L5 spinal
nerve: The far-out syndrome. Spine
(Phila Pa 1976) 1984;9:31-41.
21. Hanson DS, Bridwell KH, Rhee JM,
Lenke LG: Correlation of pelvic
incidence with low- and high-grade
isthmic spondylolisthesis. Spine (Phila Pa
1976) 2002;27:2026-2029.
22. Masci L, Pike J, Malara F, Phillips B,
Bennell K, Brukner P: Use of the one-
legged hyperextension test and magnetic
resonance imaging in the diagnosis of
active spondylolysis. Br J Sports Med
2006;40:940-946.
23. Saifuddin A, Burnett SJ: The value of
lumbar spine MRI in the assessment of
the pars interarticularis. Clin Radiol
1997;52:666-671.
24. Sinaki M, Lutness MP, Ilstrup DM, Chu
CP, Gramse RR: Lumbar
spondylolisthesis: Retrospective
comparison and three-year follow-up of
two conservative treatment programs.
Arch Phys Med Rehabil 1989;70:594-
598.
25. O’Sullivan PB, Phyty GD, Twomey LT,
Allison GT: Evaluation of specific
stabilizing exercise in the treatment of

chronic low back pain with radiologic
diagnosis of spondylolysis or
spondylolisthesis. Spine (Phila Pa 1976)
1997;22:2959-2967.
26. Möller H, Hedlund R: Surgery versus
conservative management in adult
isthmic spondylolisthesis: A prospective
randomized study. Part 1. Spine (Phila
Pa 1976) 2000;25:1711-1715.
27. Steiner ME, Micheli LJ: Treatment of
symptomatic spondylolysis and
spondylolisthesis with the modified
Boston brace. Spine (Phila Pa 1976)
1985;10:937-943.
28. d’Hemecourt PA, Zurakowski D,
Kriemler S, Micheli LJ: Spondylolysis:
Returning the athlete to sports
participation with brace treatment.
Orthopedics 2002;25:653-657.
29. Sys J, Michielsen J, Bracke P, Martens
M, Verstreken J: Nonoperative treatment
of active spondylolysis in elite athletes
with normal X-ray findings: Literature
review and results of conservative
treatment. Eur Spine J 2001;10:498-504.
30. Harris IE, Weinstein SL: Long-term
follow-up of patients with grade-III and
IV spondylolisthesis: Treatment with and
without posterior fusion. J Bone Joint
Surg Am 1987;69:960-969.
31. Boxall D, Bradford DS, Winter RB, Moe
JH: Management of severe
spondylolisthesis in children and
adolescents. J Bone Joint Surg Am 1979;
61:479-495.
32. Pizzutillo PD, Hummer CD III:
Nonoperative treatment for painful
adolescent spondylolysis or
spondylolisthesis. J Pediatr Orthop
1989;9:538-540.
33. Gill GG, Manning JG, White HL:
Surgical treatment of spondylolisthesis
without spine fusion: Excision of the
loose lamina with decompression of the
nerve roots. J Bone Joint Surg Am 1955;
37:493-520.
34. Gill GG: Long-term follow-up evaluation
of a few patients with spondylolisthesis
treated by excision of the loose lamina
with decompression of the nerve roots
without spinal fusion. Clin Orthop Relat
Res 1984;182:215-219.
35. Amuso SJ, Neff RS, Coulson DB, Laing
PG: The surgical treatment of
spondylolisthesis by posterior element
resection. J Bone Joint Surg Am 1970;
52:529-536.
October 2009, Vol 17, No 10
Thomas R. Jones, MD, PhD, and Raj D. Rao, MD
36. Meyerding HW: Spondylolisthesis:
Surgical treatment and results. J Bone
Joint Surg Am 1943;25:65.
37. Watkins MB: Posterolateral fusion of the
lumbar and lumbosacral spine. J Bone
Joint Surg Am 1953;35:1014-1018.
38. Jacobs WC, Vreeling A, De Kleuver M:
Fusion for low-grade adult isthmic
spondylolisthesis: A systematic review of
the literature. Eur Spine J 2006;15:391-
402.
39. Kwon BK, Hilibrand AS, Malloy K, et al:
A critical analysis of the literature
regarding surgical approach and
outcome for adult low-grade isthmic
spondylolisthesis. J Spinal Disord Tech
2005;18(suppl):S30-S40.
40. Möller H, Hedlund R: Instrumented and
noninstrumented posterolateral fusion in
adult spondylolisthesis: A prospective
randomized study. Part 2. Spine (Phila
Pa 1976) 2000;25:1716-1721.
41. McGuire RA, Amundson GM: The use
of primary internal fixation in
spondylolisthesis. Spine (Phila Pa 1976)
1993;18:1662-1672.
42. Remes V, Lamberg T, Tervahartiala P,
et al: Long-term outcome after
posterolateral, anterior, and
circumferential fusion for high-grade
isthmic spondylolisthesis in children and
adolescents: Magnetic resonance imaging
findings after average of 17-year follow-
up. Spine (Phila Pa 1976) 2006;31:2491-
2499.
43. Ekman P, Moller H, Tullberg T,
Neumann P, Hedlund R: Posterior
lumbar interbody fusion versus
posterolateral fusion in adult isthmic
spondylolisthesis. Spine (Phila Pa 1976)
2007;32:2178-2183.
44. Madan S, Boeree NR: Outcome of
posterior lumbar interbody fusion versus
posterolateral fusion for spondylolytic
spondylolisthesis. Spine (Phila Pa 1976)
2002;27:1536-1542.
45. Suk SI, Lee CK, Kim WJ, Lee JH, Cho
KJ, Kim HG: Adding posterior lumbar
interbody fusion to pedicle screw
fixation and posterolateral fusion after
decompression in spondylolytic
spondylolisthesis. Spine (Phila Pa 1976)
1997;22:210-219.
46. Lauber S, Schulte TL, Liljenqvist U,
Halm H, Hackenberg L: Clinical and
radiologic 2-4-year results of
transforaminal lumbar interbody fusion
in degenerative and isthmic
spondylolisthesis grades 1 and 2. Spine
(Phila Pa 1976) 2006;31:1693-1698.
47. Swan J, Hurwitz E, Malek F, et al:
Surgical treatment for unstable low-
grade isthmic spondylolisthesis in adults:
A prospective controlled study of
posterior instrumented fusion compared
with combined anterior-posterior fusion.
Spine J 2006;6:606-614.
48. Muschik M, Zippel H, Perka C: Surgical
management of severe spondylolisthesis
in children and adolescents: Anterior
fusion in situ versus anterior
spondylodesis with posterior
transpedicular instrumentation and
reduction. Spine (Phila Pa 1976) 1997;
22:2036-2042.
49. Molinari RW, Bridwell KH, Lenke LG,
Ungacta FF, Riew KD: Complications in
the surgical treatment of pediatric high-
grade, isthmic dysplastic
spondylolisthesis: A comparison of three
surgical approaches. Spine (Phila Pa
1976) 1999;24:1701-1711.
50. Petraco DM, Spivak JM, Cappadona JG,
Kummer FJ, Neuwirth MG: An
anatomic evaluation of L5 nerve stretch
in spondylolisthesis reduction. Spine
(Phila 1976) 1996;21:1133-1138.
51. Spruit M, van Jonbergen JP, de Kleuver
M: A concise follow-up of a previous
report: Posterior reduction and anterior
lumbar interbody fusion in symptomatic
low-grade adult isthmic
spondylolisthesis. Eur Spine J 2005;14:
828-832.
52. Shufflebarger HL, Geck MJ: High-grade
isthmic dysplastic spondylolisthesis:
Monosegmental surgical treatment.
Spine (Phila Pa 1976) 2005;30(6 suppl):
S42-S48.
53. Schoenecker PL, Cole HO, Herring JA,
Capelli AM, Bradford DS: Cauda equina
syndrome after in situ arthrodesis for
severe spondylolisthesis at the
lumbosacral junction. J Bone Joint Surg
Am 1990;72:369-377.
54. Bohlman HH, Cook SS: One-stage
decompression and posterolateral and
interbody fusion for lumbosacral
spondyloptosis through a posterior
approach: Report of two cases. J Bone
Joint Surg Am 1982;64:415-418.
55. Gaines RW: L5 vertebrectomy for the
surgical treatment of spondyloptosis:
Thirty cases in 25 years. Spine (Phila
1976) 2005;30(6 suppl):S66-S70.
617