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spondylolisthesis is a reliable procedure for the treatment of pain and dusfunction is confirmed by our published and unpublished data.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.
