SpineUniverse Case Study Library

Adolescent High-Grade Isthmic Spondylolisthesis


The patient is a 14-year-old healthy, high-level gymnast who presented with one-year history of insidious low back pain. The pain was associated with physical activities and worsened with impact activities. She described recent (past few months) onset of pain and tingling down her left leg to the dorsum of the left foot.


  • 5'-3", 140-pound female
  • Limited range of motion in the lumbar spine
  • Pain with >40 degrees of forward flexion and >10 degrees of extension
  • 5/5 strength throughout lower & upper extremities
  • Sensation intact to pin prick from C4-T1 and L2-S1
  • Patellar and achilles deep tendon reflexes: 2+
  • No upper motor neuron signs

Prior Treatment

She had undergone multiple trials of physical therapy and chiropractic modalities, experiencing no improvement in symptoms.

Pretreatment Imaging

Anteroposterior (AP) and lateral standing lumbar radiographs reveal a Grade III spondylolisthesis of L5 on S1 (Figures 1A and 1B, below).

AP and lateral standing lumbar radiographs reveal Grade III spondylolisthesis of L5 on S1

Figures 1A and 1B (above)

Figures 2A and 2B (below) show axial and sagittal T2-weighted MRI sequences reveal:

  • Exaggerated lumbar lordosis
  • Grade III spondylolisthesis, L5-S1
  • Bilateral spondylolysis, L5
  • Mild posterior wedging of L5 and mild deformity of the superior S1 endplate
  • Severe stenosis at L5-S1 of the spinal canal and neural foramina

axial and sagittal T-2 weighted MRI lumbar spine

Figures 2A and 2B (above)

Left and right paraspinal T2-weighted MRI sequences (Figures 3A and 3B, below) reveal severe stenosis at L5-S1, neural foramina.

parasagittal T2-weighted MRIs, severe stenosis L5-S1

Figures 3A and 3B (above)


High-grade (Myerding Grade III) isthmic spondylolisthesis

Suggest Treatment

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Selected Treatment

In-situ circumferential L4-S1 fusion.

  • L4-L5 posterior spinal decompression, laminectomy
  • L5-S1 bilateral lateral recess and foraminal decompression
  • Sacral dome osteotomy
  • Transforaminal lumbar interbody fusion (TLIF) L5-S1
  • Posterior segmental pedicle screw instrumentation with rod placement L4-S1
  • Posterior spinal fusion autograft and allograft L4-S1

Intra-operative findings:

  • Right L5 nerve root appeared significantly stretched
  • Left L5 nerve root compressed by hypertrophic ligament and capsule -> impingement of the exiting nerve root

Post-Treatment Imaging

Postoperative standing AP (Figure 4A), lateral radiographs of the lumbar spine (Figure 4B) and lumbo-sacral junction (Figure 4C). Successful fusion observed with cage in adequate position at the L5-S1 junction with instrumentation intact from L4 to sacrum.

postoperative standing AP, lateral x-ray lumbar spine

Figures 4A and 4B (above)

postoperative x-ray of the lumbosacral junction

Figure 4C (above)


At 2-years following surgery, the patient has returned to gymnastics and cheerleading with no back or leg pain. She is even able to run one-mile in nine minutes without any problems.

Case Discussion

This is a challenging case of high grade lumbosacral spondylolisthesis in a teenager with symptomatic radiculopathy and failed conservative therapy. The authors are to be congratulated on their outcome. Points to note are the interbody fusions at L5-S1, increasing potential fusion bed mass, and taking the stress off their sacral instrumentation. Extension to L4 would also facilitate reduction.

Of note as well, is partial but not complete reduction. This was probably obviated intraoperatively by finding the nerve roots already stretched. This is often the case despite complete bilateral facetectomy and disc space mobilization, and it is preferable to bilateral L5 deficits. This would be a challenging case from an anterior approach, and the authors impart many thoughtful and appropriate messages with this case. The enemy of good is better.

Authors' Response

The concept of a partial reduction is crucial here. We did not attempt a full reduction to avoid L5 deficit, particularly the right L5 nerve root. Functionally, this is important, as dysfunction from an aggressive reduction attempt could affect the patient's ability to drive.

If there is some overlap between L5 and S1 nerve root compression symptoms, in a patient who presents with a spondylolisthesis less severe than a Meyerding Grade IV, a transformational lumbar inter body fusion (TLIF) can be performed. The listhesis is too severe (Meyerding Grade IV), trans-sacral fixation can be performed.

All posterior fixation is preferred by the authors as it is less invasive than a combined anterior and posterior approach. Also, iliac fixation is recommended in many cases if the S1 screws are not deemed rigid intraoperatively. Consideration of BMP for posterolateral fusion should be given to enhance fusion.

Community Case Discussion (1 comment)

SpineUniverse invites spine professionals to share their thoughts on this case.

while what was done is conventional, there needs to be a change in thinking
my treatment is; 1/ ALIF with lordotic cage and BMP2 . (usually just the discectomy and cage insertion reduces the kyphosis and the listhesis 75 percent)
2/posterior fusion and instrumentation CONFINED to L5-S1 . NO decompression. Leave the "rattler ' in place for grafting. nerves are affected by elogation. restoring lordosis shortens the middle column and avoids stretching the L5 nerve root.
there is absolutely no reason to incorporate a healthy L4-L5 disc into the fusion
interbody is necessary, but very hard to do a TLIF in grades three and above. It is much easier to do an ALIF, and easier to correct the kyphosis
I have a series of 15 treated above with no nerve root palsy and no revisions


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