SECTION
Spondylolisthesis
CHAPTER
57
Spondylolisthesis: Introduction
Derived from the Greek (spondylo spine, olisthesis slip),
spondylolisthesis describes a spectrum of conditions that share
the common ingredient of one vertebra having shifted forward
relative to its neighbor. Consistent with its varied etiologies,
spondylolisthesis may manifest with symptoms ranging from
back discomfort to cauda equina syndrome. For those with
mild symptoms with minimal deformity, observation is often
all that is necessary. For others with neurologic impairment
and progressive deformity, spinal decompression, deformity
correction, and fusion may be advisable. In recent years, an
improved understanding of the different forms of spondylolis-
thesis has helped to guide treatment. Despite these efforts,
many common misconceptions regarding this common spinal
deformity remain. The goal of this section is to differentiate
the unique forms of spondylolisthesis, discuss the natural his-
tory, highlight well-established treatment methods, and pro-
vide surgical guidance to maximize the outcomes of operative
intervention.
Gravity and longitudinal muscle contraction on the lordotic
lumbar spine and pelvis apply force to lower lumbar vertebrae
with a caudalventral vector. Left unchecked, these forces
would cause the lower lumbar vertebrae to slip and rotate for-
ward relative to the sacrum. Such forces are normally counter-
acted by several anatomic structures: the superior and inferior
facets, the posterior arch, pedicles, and disc. It is the failure of
one or more of these structures that leads to the forward slip-
page of the vertebra over timethe condition of spondylolis-
thesis. As the vertebra shifts forward, it carries the cephalad
levels of the spine with it. This pathologic spinal malalignment
can lead to the development of axial back pain; spinal stenosis;
compensatory changes to other regions of the spine, pelvis, and
lower extremities; and, in severe cases, regional or global sagit-
tal malalignment.
LWBK836_Ch57_p553-555.indd 553
VI
Charles Edwards II
Mark Weidenbaum
ETIOLOGY AND CLASSIFICATION
Several pathologic conditions can lead to the radiographic
finding of spondylolisthesis (Chap. 58). Five etiologies of spon-
dylolisthesis are defined by the broadly adopted classification
of Wiltse et al (Table 57.1).6 Recognition of the potential for
surgical decompression to destabilize the spine led to the addi-
tion of a sixth type: iatrogenic. Most spondylolisthesis cases are
of the dysplastic, isthmic, and degenerative types. These are the
highlighted in the chapters to follow. The evaluation and treat-
ment of spondylolisthesis caused by acute trauma, neoplastic/
metabolic processes, or excessive surgical decompression are
discussed in other sections of the text.
DYSPLASTIC AND ISTHMIC SPONDYLOLISTHESIS
Congenital anomalies of the posterior elements can significantly
compromise their normal buttressing function. Spina bifida
and elongation of the facets are common findings. While such
anomalies are present at birth, a listhesis does not develop until
after the child becomes ambulatory. With standing, the caudad
ventral force vector applied to the lumbar spine goes unchecked
at the site of posterior element failure. As the disc and growth
plates are unable to independently restrain the caudadventral
force, they begin to fail. Precocious degeneration of the disc
and focal failure of the lumbosacral vertebral growth plates
leads to further progression of the spondylolisthesis. As L5 shifts
forward relative to the sacrum, stenosis at the lumbosacral junc-
tion can occur. Even in low-grade slips (50%) severe stenosis
can occur with cauda equina compression.
Recognition of the broad range of spondylolisthesis defor-
mities arising from dysplastic changes led Marchetti and
Bartolozzi2 to further subdivide this category into high and low
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 554 Section VI Spondylolisthesis

Classification of
TABLE 57.1 Spondylolisthesis by Wiltse,
Newman, and MacNab6
Type IDysplastic: The deformity arises from congenital
anomalies of the posterior elements.
Type IIIsthmic: This type is due to deficient or elongated pars
interarticularis.
Type IIIDegenerative: Aging of the disc and facets leads to
translational laxity within the motion segment.
Type IVTraumatic: Acute fracture of the pedicles, facet, or
lamina (except pars).
Type VPathologic: A neoplastic or metabolic process results in
failure of the facet complex and the resultant spondylolisthesis
deformity.
Type VIIatrogenic: Excessive resection of the posterior elements
or disc leads to segmental instability.

dysplasia. In cases of low dysplasia, L5 maintains its rectangular

shape, the superior end plate of the sacrum remains flat, and
lumbar lordosis remains in the normal range. In contrast, cases
with high dysplasia have primary features of severe posterior
element malformation and secondary effects of sacral end plate
rounding and a trapezoidal L5. The distinction between high
and low dysplasia is useful for prognostic value. Low-grade slips
have a low risk for significant translation and rarely lead to lum-
bosacral kyphosis. In contrast, high-grade dysplasia has a dis-
tinct likelihood for progressive deformity and worsening of
symptoms over time.
ISTHMIC SPONDYLOLISTHESIS
Failure of the pars interarticularis in the child is termed spon-
dylolysis (Fig. 57.1). The pars can fail by three mechanisms:
1. Fatigue fracture (most common),
2. Elongated pars due to repetitive healed fractures, and
3. Acute traumatic fracture of the pars.
In many cases of spondylolysis, the fibrous tissue surround-
ing the pars defect, the ligamentous restraints, and the disc are
sufficient to maintain the alignment of the affected vertebra.
However, when such structures are overpowered by gravita-
tional forces and normal muscle contraction, isthmic spon-
dylolisthesis results. Spondylolysis develops during childhood
with an incidence of 0% at birth, 5% at age 7 years, and 7% by
age 18 years. 5
Although dysplastic and spondylolytic types of spondylolis-
thesis are often treated as separate entities, distinctions between
them are blurred. In a longitudinal study of 500 first-grade chil-
dren with spondylolysis, Fredrickson et al noted 70% to have
spina bifida occultaa dysplastic finding.1 This is further sug-
gested by the consistent finding of spondylolysis to be more
prevalent among individuals with a family history of spondylolis-
thesis. Longitudinal studies reveal that most children with
spondylolysis develop a mild slip over time, but development of
a severe spondylolisthesis deformity is extremely rare. Several
studies have sought to define risk factors for progression of
spondylolisthesis (Chap. 60). Spinopelvic balance (Chap. 59),
pelvic incidence, increased slip angle, and disc degeneration
have been identified as having prognostic value. It remains
unclear, however, as to whether each of these factors actually
cause slip progression or result from it.
Figure 57.1. Standing lateral radiograph demonstrating the pres-
ence of a pars fracture (spondylolysis) of L5. Note the discontinuity of
the posterior elements of L5 with the bony defect at the posterior
inferior aspect of the pedicles where they would normally adjoin the
lamina.
Most patients with spondylolysis and low-grade spondylolis-
thesis remain asymptomatic. When symptoms arise, they typi-
cally include axial back pain, tight hamstrings, and L5 radiculi-
tis. Treatment options range from observation, activity
restriction, bracing, physical therapy, and medications to surgi-
cal repair of the pars defect, arthrodesis, and reduction of the
slip. Symptomatic patients are successfully managed with non-
operative measures in a most cases. For adolescent spondylolysis
patients with persistent symptoms despite appropriate nonop-
erative measures, pars repair (Chap. 61) or segmental arthrod-
esis (Chap. 62) yields satisfactory results. Adults with continued
back discomfort and/or radiculopathy may be treated effectively
with a decompression and fusion procedure.
High-grade spondylolisthesis (defined as 50% slip) is an
uncommon clinical entity (Fig. 57.2). In such cases, it seems
that a continuum exists between the extremes of those with low
dysplastic features and a well-balanced spine versus those with
high dysplastic features and poor spinopelvic balance. For those
with a well-balanced spine and low dysplastic features, a bias
toward nonoperative treatment or fusion with minimal efforts
at reduction seems reasonable. On the other hand, for those
patients with high dysplastic features and poor spinopelvic bal-
ance, decompression, reduction, and arthrodesis should be
considered. Reduction techniques for high-grade spondylolis-
thesis are known to carry an increased risk of complications.
Distorted anatomy, stretched nerve roots, lengthy surgery, and
a most challenging biomechanical environment increase the
potential for lumbar nerve root injury, nonunion and other

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Figure 57.2. Standing lateral radiograph demonstrating high-
grade spondylolisthesis (spondyloptosis). L5 has translated forward
off the sacrum and has rotated into marked lumbosacral kyphosis.
Typical features are demonstrated, including a rounded sacral end
plate, trapezoidal body of L5, narrow L5 pedicles, L5 inferior end
plate traction osteophyte, a vertical sacrum, compensatory hyperlor-
dosis (L1-5), and L4-5 retrolisthesis.
perioperative risks. Chapters 64 through 69 describe the pearls
and pitfalls of several surgical techniques advocated for these
challenging deformities. A growing consensus has emerged
that the priority of high-grade spondylolisthesis reduction is
restoration of lumbosacral lordosis, not complete correction of
translation. While anatomic correction of translation offers the
benefits of superior biomechanics and improved surface area
for fusion, this comes at the expense of increased lumbar nerve
root stretch and a greater potential for nerve root injury.
DEGENERATIVE SPONDYLOLISTHESIS
Degenerative spondylolisthesis is the end product of the cas-
cade of disc degeneration and facet complex osteoarthritis. As
the disc height narrows, the vertebra subluxes forward (anter-
olisthesis) or backward (retrolisthesis) relative to its neighbor
below. Dynamic translation of the vertebra in combination with
spinal stenosis produces the typical symptoms of axial back pain,
radiculopathy, and neurogenic claudication. It predominantly
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Chapter 57 Spondylolisthesis: Introduction 555
affects individuals older than 40 years, women, individuals of
African descent, and the L4-5 level. The slip rarely progresses
beyond grade II (50%). Initial nonoperative treatment is appro-
priate and includes anti-inflammatory medications, physical
therapy, and occasionally an epidural steroid injection. For
patients with persistent or progressive symptoms, surgical inter-
vention provides a high rate of improvement. The benefits of
surgery were highlighted in a 2009 report by Weinstein et al4 in
the multicenter prospective (SPORT) comparison of surgical
and nonoperative treatment for degenerative spondylolisthesis.
Analysis of the as-treated groups showed superior functional
outcomes with surgery at all early postoperative time points
with maintenance of superior results with surgery at 4-year
follow-up.
Many forms of surgical intervention are proposed for degen-
erative spondylolisthesis (Chap. 63). Decompression alone is
reserved strictly for those patients with a very stiff and degen-
erative disc at the level to be decompressed. In general, con-
comitant arthrodesis is recommended to minimize the risk of
progressive slip and recurrence of symptoms after decompres-
sion. While noninstrumented fusion has a role in select cases,
most surgeons prefer the concomitant use of instrumentation
to reduce nonunion rates and to improve functional outcomes.3
In recent years, many surgeons have utilized interbody fusion
techniques in their treatment of degenerative spondylolisthe-
sis. Theoretical benefits of interbody fusion are increased sur-
face area for fusion, restoration of foraminal height, augmenta-
tion of lordosis, and reduced risk for screw loosening due to
partial stress shielding by the interbody support. Popular inter-
body techniques are the TLIF (transforaminal lumbar inter-
body fusion), PLIF (posterior lumbar interbody fusion), XLIF
(extreme lateral interbody fusion), and ALIF (anterior lumbar
interbody fusion). Unfortunately, studies comparing the out-
comes of these techniques with each other and posterior instru-
mented fusion are rather limited and lack long-term follow-up.
Additional studies are very much needed to clarify the optimal
approach for degenerative spondylolisthesis.
REFERENCES
1. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural history of spon-
dylolysis and spondylolisthesis. J Bone Joint Surg 1984;64(A):699707.
2. Marchetti PC, Bartolozzi P. Classification of spondylolisthesis as a guideline for treatment.
In Bridwell KH, DeWald RL (eds). The textbook of spinal surgery, 2nd ed. Philadelphia:
Lippincott-Raven, 1997:12111254.
3. Thomasen K, Christenses FB, Eiskjaer SP, et al. The effect of pedicle screw instrumentation
on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospec-
tive, randomized clinical study. Spine 1997;22:28132822.
4. Weinstein J, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment
for lumbar degenerative spondylolisthesis: four-year results in the Spine Patient Outcomes
Research Trial (SPORT) randomized and observational cohorts, J Bone Joint Surg Am
2009;91:12951304.
5. Wiltse LL. Spondylolisthesis in children. Clin Orthop Relat Res 1961;21:156.
6. Wiltse LL, Newman PH, MacNab W. Classification of spondylolysis and spondylolisthesis.
Clin Orthop Relat Res 1976;117:23.
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