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Isthmic Spondylolisthesis: Adult Slip Progression

Part 3: Isthmic Lumbosacral Spondylolisthesis in Adults

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Adult Slip Progression
In contrast to the well-documented slip progression (increase in the extent of anterior vertebral slippage) that may occur in children and adolescence, late progression of isthmic spondylolisthesis in adults is rarely discussed or described in spine literature. In the last decade, adult onset slip progression was recognized and described in the medical literature as a distinct clinical entity causing severe incapacitating back and leg pain (1). Moreover, it was found that slip progression is not at all rare. It is always accompanied by disc degeneration at the slip level. As the disc loses it structural and functional integrity, the lumbosacral junction (L5-S1) becomes unstable and the slip progresses.

The following figures exemplify isthmic slip progression in adults (Fig. 5a, 5b, 5c). These serial lumbar spine radiographs (x-rays) demonstrate the progressive nature of the slip. The increased spondylolisthesis always coincides with disc degeneration at the slip level.

x-rays lumbar slip progression

Figure 5a. Serial radiographs (x-rays) demonstrating progression
of vertebral slippage in the lumbar spine at age 34, 40, and 47.

x-rays isthmic spondylolisthesis

Figure 5b. Lateral x-rays indicating isthmic spondylolisthesis.

x-rays isthmic spondylolisthesis

Figure 5c. Additional lateral x-rays indicating isthmic spondylolisthesis.

Slip progression occurs in about 20% of adults with isthmic spondylolisthesis. Slip progression starts usually after the third decade of life and coincides with marked disc degeneration at the olisthetic (downward slipping) level. Slip progression is associated with clinical signs of mechanical instability and spinal stenosis manifested by incapacitating low back pain and significant sciatica. The concurrent occurrence of disc degeneration at the slip level and adult slip progression explains how an asymptomatic developmental lesion, present for at least two or three decades, may become symptomatic.

Reference
1. Floman Y. Spine 25:342, 2000.

Updated on: 02/01/10
David S. Bradford, MD
Isthmic spondylolisthesis is an important cause of back pain and disability in children, adolescents, and adults. The natural history and clinical presentation of isthmic spondylolisthesis is distinct from other etiologies of spondylolisthesis. Dr. Floman has made an important contribution to our understanding of isthmic spondylolisthesis in adults by demonstrating a significant incidence of deformity progression in adulthood, and suggesting a mechanism to explain the variable onset of pain associated with spondylolisthesis in adults. (1) Operative management in the patient with symptomatic isthmic spondylolisthesis is clearly superior to non-operative care. (2) However, there remains significant variation in surgical strategies, and limited evidence to guide decision-making.

In low-grade isthmic spondylolisthesis, the role of anterior column support has not been well-defined, and there is little consensus on circumferential arthrodesis compared with posterolateral fusion alone. In fact, a beneficial effect of instrumentation has not been clearly established in these cases. (3) In contrast, in grade 3 and 4 spondylolisthesis, there is strong evidence to suggest improved rates of arthrodesis and better clinical outcome with structural support of the anterior column. (4) In high-grade spondylolisthesis, partial reduction and transosseous fixation has resulted in reliably good clinical outcomes. (5) The role of complete reduction and restoration of lumbopelvic relationships remains to be established.

Dr. Floman's observation that the surgical treatment of symptomatic isthmic spondylolisthesis is a reliable procedure for the treatment of pain and dusfunction is confirmed by our published and unpublished data. (5,6,7) Further investigations including multicenter prospectve clinical studies are required to establish an evidence-based consensus approach regarding the role of interbody arthrodesis in low-grade spondylolisthesis, the role of reduction of slippage and restoration of lumbosacral lordosis in high-grade spondylolisthesis, and the role of in-situ arthrodesis in adults.

1. Floman, Y. Spine. 2000;25(3):342-7.
2. Moller H, Hedland R. Spine. 2000;25(13):1711-5.
3. Moller H, Hedland R. Spine. 2000;25(13):1716-21.
4. Molinari RW, et al. Spine. 1999;24(16):1701-11.
5. Smith JA, et al. Spine. 2001;26(20):2227-34.
6. Bradford, DS. J Bone Joint Surg Am. 1990;72(7):1060-6.
7. Butterman GR, et al. Spine. 1998;23(1):116-27.

 

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Isthmic Spondylolisthesis: Symptoms and Diagnosis

Serial x-rays (radiographs) of the lumbar spine may be helpful to establish a diagnosis of isthmic spondylolisthesis. These x-rays are taken over a period of several years.
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