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Spondylolisthesis

Last updated: May 17, 2021

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Spondylolisthesis is a condition in which a vertebral body slips anteriorly in relation to the subjacent vertebrae. The condition affects up to 10% of the population. The two most common forms of spondylolisthesis are isthmic and degenerative. Isthmic spondylolisthesis is associated with a disruption of the vertebral ring and most commonly occurs at L5–S1. This form is most prevalent in children and adolescents and is often associated with repetitive hyperextension of the spine (e.g., in gymnasts). Degenerative spondylolisthesis occurs at L4–L5 and most commonly affects individuals over 50 years of age. Other forms of spondylolisthesis may be associated with congenital disease, trauma or bone fractures, and underlying bone pathology (e.g., Paget disease). Spondylolisthesis may be asymptomatic or cause lumbar pain on exertion, gait problems, radiculopathic pain, or urinary incontinence. Some patients have a palpable step-off sign at the lumbosacral area. Diagnosis is established with imaging. Most patients achieve good symptomatic control with conservative treatment (e.g., physical therapy). Surgical treatment (e.g., vertebral fusion, decompression laminectomy) is reserved for patients with refractory symptoms and/or neurological deficits. Overall, children and adolescents have better outcomes than adults and elderly patients.

  • Spondylolisthesis: anterior slippage of a vertebral body over the subjacent vertebra
  • Isthmic spondylolisthesis (spondylolytic form): spondylolisthesis resulting from an abnormality in the pars interarticularis [1]
  • Degenerative spondylolisthesis: spondylolisthesis resulting from degenerative changes, without an associated disruption or defect in the vertebral ring [2]
  • Congenital spondylolisthesis: spondylolisthesis secondary to congenital anomalies (e.g., hypoplastic facets, sacral deficits, poorly developed pars interarticularis).

References:[1][4][5][6][7][8][9]

Epidemiological data refers to the US, unless otherwise specified.

Risk factors include:

References:[4]

The severity of symptoms often correlates with the degree of vertebral slippage. [1][2][3][10][11]

  • Consider in patients with characteristic clinical features; in asymptomatic patients, the diagnosis may be incidental.
  • Imaging studies confirm the diagnosis, help monitor progression, and are needed to guide the treatment.

Spondylolisthesis is often an incidental finding.

X-ray lumbosacral spine [2][8]

Meyerding classification [9]

Grade Slippage
I

< 25%

II 25–50%
III

51–75%

IV 76–100%
V > 100%, referred to as spondyloptosis
  • Low-grade slippage: grades I and II
  • High-grade slippage: grades ≥ III

Additional imaging studies [1][2][8]

Order to assess for spinal stenosis and impingement of nerve roots in patients with signs of neurological involvement.

See also “Differential diagnosis of lower back pain.”

References:[4]

The differential diagnoses listed here are not exhaustive.

General principles

  • Treatment goals are to reduce pain, restore mobility, and prevent disease progression.
  • Conservative treatment can be attempted initially in most patients.
  • Surgical treatment is usually reserved for patients with high-grade slippage or persistent symptoms.

Immediate surgery consultation is required for patients with motor deficit or cauda equina syndrome to evaluate the need for emergency surgical decompression. [16]

Conservative treatment [2][8][17][18]

  • Indications
    • Initial treatment for patients with low-grade slippage and no significant neurological involvement
    • Consider as initial treatment for high-grade degenerative spondylolisthesis with no significant neurological involvement. [8][11]
  • General recommendations [8][17]
    • Physical therapy: e.g., bracing, back-strengthening exercises [8]
    • Physical activity restriction: e.g., 1–2 days of rest during acute symptoms, stopping sports that contribute to spondylolisthesis
    • Management of comorbidities that might contribute to symptoms and disease progression: e.g., osteoporosis or obesity [8]
  • Pain management

Surgical treatment [1][2][11][17][18]

The best surgical approach and indications should be discussed in consultation with a specialist.

  • Conservative treatment gives satisfactory results in 80% of cases.
  • The rate of success from surgical treatment is higher in children than in adults.

References:[19][20][21][22]

  1. Kreiner DS, Baisden J, Mazanec DJ, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis. The Spine Journal. 2016; 16 (12): p.1478-1485. doi: 10.1016/j.spinee.2016.08.034 . | Open in Read by QxMD
  2. Matz PG, Meagher RJ, Lamer T, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. The Spine Journal. 2016; 16 (3): p.439-448. doi: 10.1016/j.spinee.2015.11.055 . | Open in Read by QxMD
  3. KUNZE KN, LILLY DT, KHAN JM, et al. High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management. International Journal of Spine Surgery. 2020; 14 (3): p.327-340. doi: 10.14444/7044 . | Open in Read by QxMD
  4. Vokshoor A. Spondylolisthesis, Spondylolysis, and Spondylosis. Spondylolisthesis, Spondylolysis, and Spondylosis. New York, NY: WebMD. http://emedicine.medscape.com/article/1266860-overview#a11. Updated: February 3, 2017. Accessed: February 16, 2017.
  5. Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population.. Spine (Phila Pa 1976). 2009; 34 (2): p.199-205. doi: 10.1097/BRS.0b013e31818edcfd . | Open in Read by QxMD
  6. Tebet MA . Current concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia. 2014; 49 (1). doi: 10.1016/j.rbo.2013.04.011 . | Open in Read by QxMD
  7. Perrin AE. Lumbosacral Spondylolisthesis. Lumbosacral Spondylolisthesis. New York, NY: WebMD. http://emedicine.medscape.com/article/2179163-overview#a6. Updated: February 1, 2016. Accessed: February 28, 2017.
  8. Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. European Spine Journal. 2007; 17 (3): p.327-335. doi: 10.1007/s00586-007-0543-3 . | Open in Read by QxMD
  9. Koslosky E, Gendelberg D. Classification in Brief: The Meyerding Classification System of Spondylolisthesis. Clin Orthop Relat Res. 2020; 478 (5): p.1125-1130. doi: 10.1097/corr.0000000000001153 . | Open in Read by QxMD
  10. Will JS, Bury DC, Miller JA. Mechanical Low Back Pain. Am Fam Physician. 2018; 98 (7): p.421-428.
  11. Tebet MA. Current concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Rev Bras Ortop. 2014; 49 (1): p.3-12. doi: 10.1016/j.rboe.2014.02.003 . | Open in Read by QxMD
  12. Osterman K, Schlenzka D, Poussa M, Seitsalo S, Virta L. Isthmic spondylolisthesis in symptomatic and asymptomatic subjects, epidemiology, and natural history with special reference to disk abnormality and mode of treatment.. Clin Orthop Relat Res. 1993 : p.65-70.
  13. Andrew ST, Porter DO. Spondylolisthesis. In: Giangarra CE, Manske RC, eds. Clinical Orthopaedic Rehabilitation. Elsevier ; 2017.
  14. Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016; 13 (9): p.1069-1078. doi: 10.1016/j.jacr.2016.06.008 . | Open in Read by QxMD
  15. Roth CJ, Angevine PD, Aulino JM, et al. ACR Appropriateness Criteria Myelopathy. J Am Coll Radiol. 2016; 13 (1): p.38-44. doi: 10.1016/j.jacr.2015.10.004 . | Open in Read by QxMD
  16. Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda equina syndrome. BMJ. 2009; 338 (mar31 1): p.b936-b936. doi: 10.1136/bmj.b936 . | Open in Read by QxMD
  17. Samuel AM, Moore HG, Cunningham ME. Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence. Current Reviews in Musculoskeletal Medicine. 2017; 10 (4): p.521-529. doi: 10.1007/s12178-017-9442-3 . | Open in Read by QxMD
  18. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis. The Journal of Bone and Joint Surgery-American Volume. 2009; 91 (6): p.1295-1304. doi: 10.2106/jbjs.h.00913 . | Open in Read by QxMD
  19. Frennered AK, Danielson BI, Nachemson AL.. Natural history of symptomatic isthmic low-grade spondylolisthesis in children and adolescents: a seven-year follow-up study.. J Pediatr Orthop. 1991; 11 (2): p.209-13.
  20. Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. J Pediatr Orthop. 1987; 7 (6): p.631-8.
  21. Seitsalo S, Osterman K, Hyvãrinen H, Tallroth K, Schlenzka D, Poussa M.. Progression of spondylolisthesis in children and adolescents. A long-term follow-up of 272 patients. Spine (Phila Pa 1976). 1991; 16 (4): p.417-21.
  22. Floman Y. Progression of lumbosacral isthmic spondylolisthesis in adults. Spine (Phila Pa 1976). 2000; 25 (3): p.342-7.