Management of Isthmic Spondylolisthesis in Adults

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Historically pain medications, anti-inflammatory drugs, and physiotherapy were prescribed for symptomatic spondylolisthesis in adult patients. However, a recent clinical study (a prospective randomized trial) pointed out that such a therapeutic approach was ineffective in controlling pain and incapacitation. Further, this study indicated that surgery only brought symptomatic relief in the majority of patients.

Surgical Management
Three main types of surgical approaches may be applicable. Common to all three approaches is the use of internal fixation (screws, rods or plates) and the apposition of local bone graft to enhance a solid bony fusion. The bone graft can be obtained from local bone such as the resected lamina and spinous process and sometimes from the iliac bone (pelvis).

The three surgical procedures are as follows:

1. Posterior decompression with pedicle screw fixation and posterolateral fusion. This operative plan is reserved for patients with mild to moderate slips with marked disc space narrowing (Fig. 8).

pre post op x-rays isthmic spondylolisthesis with instrumentation

Figure 8. Left: Preoperative lateral x-ray illustrating isthmic spondylolisthesis.
Middle/Right: Post-operative lateral and posterior x-rays showing the
pedicle screw fixation (instrumentation) to stabilize the lumbar spine.

2. Posterior decompression and pedicle screw fixation with the addition of lumbar interbody fusion (PLIF or TLIF). This operative strategy is reserved for slips with a relatively preserved disc space and in cases where slip reduction is performed (Fig. 9, 10).

preo post-op x-rays isthmic spondylolisthesis with instrumentation

Figure 9. Left: Pre-operative x-ray indicating spondylolisthesis.
Right: Post-operative x-ray, cage and pedicle screw fixation.

pre-op x-ray mri isthmic spondylolisthesis, post-op x-ray instrumentation

Figure 10. Left/Middle: Lateral x-ray and MRI indicating grade 4 spondylolisthesis.
Right: Post-operative x-ray showing implant and screw fixation following complete slip reduction.

3. Decompression and fixation with sacral transdiscal screw fixation ending in the L5 body. This operative plan is performed in patients with advanced slip accompanied by advanced disc space narrowing.

Management after Surgery
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. Performance of isometric exercises to strengthen the abdominal and paraspinal muscles is recommended. It takes about 3-6 months for a solid bony fusion to mature. Swimming and other non-strenuous sports activities can be performed usually 3-6 months after surgery. Serial post-operative x rays will determine the progress toward a solid bony fusion.

While the outcome of surgery in patients with degenerative disc disease may sometimes be unpredictable and relies among other factors on socioeconomic cofounders, the outcome of surgery in adult isthmic spondylolisthesis is much more predictable and favorable. The combination of mechanical instability and local spinal stenosis make this kind of surgery rewarding.

Updated on: 09/15/15
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Causes of Spondylolisthesis
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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Causes of Spondylolisthesis

There are different types of spondylolisthesis. What type you have all depends on the original cause.
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