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is confirmed by our published and unpublished data.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.
