Isthmic Spondylolisthesis: Symptoms and Diagnosis

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Patient complaints include low back pain with/without buttock or thigh pain. Symptoms are "mechanical" in nature, meaning that the pain is aggravated by standing and walking and relieved by lying down. In addition, symptoms of spinal stenosis (narrowed spinal canal and intervertebral foramina) are also common. Complaints such as tired legs, numbness and tingling after walking a certain distance are common. Symptoms are partially or completely relieved by leaning forward or sitting down for a couple of minutes (Fig. 6).
Woman experiencing low back painPatient complaints include low back pain with/without buttock or thigh pain.

  • Low back pain
  • Buttock pain
  • Thigh pain
  • Walking and standing aggravates pain
  • Tired legs
  • Numbness, tingling sensations

x-rays lumbar vertebral slip, post-op instrumentation

Figure 6. Lateral x-ray illustrating lumbar vertebral slippage
and instrumentation to stabilize the lumbosacral segment (L5-S1).

How Adult Slip Progression is Diagnosed
Serial x-rays (radiographs) of the lumbar spine may be helpful to establish the diagnosis. Serial radiographs are x-rays taken over a period of several years. Simple standing x-rays of the lumbar spine may suffice in patients with a sole complaint of back pain. However, in cases with accompanying sciatica (leg pain), these may not suffice. Further, computed tomography (CT) and magnetic resonance imaging (MRI) are important diagnostic tools used to assess spondylolisthesis (Fig. 7). In addition, electromyography (nerve testing) may further help to evaluate symptoms but, it is not a mandatory diagnostic procedure in every case.

mri isthmic spondylolisthesis

Figure 7. MRI, lateral view of lumbosacral
level indicating isthmic spondylolisthesis.

Commentary by 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.

Updated on: 04/24/18
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Management of Isthmic Spondylolisthesis in Adults
David S. Bradford, MD
Professor and Chair Emeritus
UC San Francisco
Department of Orthopaedic Surgery
San Francisco, CA
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Management of Isthmic Spondylolisthesis in Adults

The use of modern spinal instrumentation eliminates the need for post-operative bracing. Soon after surgery, the patient can get on his feet and walk, as tolerated.
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