NARRATIVE REVIEW
Degenerative Spondylolisthesis
Theodore D. Koreckij, MD*w and Jeffrey S. Fischgrund, MDz
Abstract: Degenerative spondylolisthesis (DS) is one of the more
commonly encountered spine conditions. The diagnosis of DS has
changed little in the last 30 years. However, there has been an
evolution in the treatment of this disease entity. There have been
several landmark papers that helped govern our treatment. These
helped serve as the basis for the treatment arms of the Spine
Patient Outcomes Research Trial (SPORT), which offers the
highest quality evidence to date. Although few would argue that
the fusion of the diseased segment appears to offer the best and
most durable results, treatment of this disease is best tailored to
the individual. Fusion may offer the best results in the young
active patient, but the same results may never become evident in
the medically infirm patient. Laminectomy or unilateral lam-
inoforaminotomy still plays a role in disease treatment. This re-
view will focus on the diagnosis and the treatment of DS as well as
discuss the author’s preferred treatment of this disease.
Key Words: degenerative spondylolisthesis, laminectomy, fu-
sion, treatment
(J Spinal Disord Tech 2015;28:236–241)
D egenerative spondylolisthesis (DS) is one of the most
commonly encountered spine conditions and few
topics in spine surgery have received more intense debate
and been the subject of more research investigations. The
term was first utilized in the 1960s by Newman and Stone,1
although it appears to be described in the literature decades
earlier. It is derived from the root Greek terms “spondylos”
meaning vertebra and “olisthesis” meaning to slip forward.
Spondylolisthesis can be caused by several mecha-
nisms, and a classification system developed by Marchetti
and Bartlozzi has been described.2 This review will focus
on primary DS, whereby degenerative processes lead to
the forward slippage of a vertebral body, with an intact
neural arch, which in turn results in spinal stenosis and a
classic presentation of neurogenic claudication, with or
without low back pain.
Received for publication April 30, 2015; accepted May 19, 2015.
From the *Dickson-Diveley Midwest Orthopaedic Clinic, Leawood, KS;
wDepartment of Orthopaedics, University of Missouri—Kansas
City, Kansas City, MO; and zWilliam Beaumont Hospital, Royal
Oak, MI.
The authors declare no conflict of interest.
Reprints: Theodore D. Koreckij, MD, Dickson-Diveley Midwest Or-
thopaedic Clinic, 3651 College Blvd, Leawood, KS 66211 (e-mail:
tkoreckij@gmail.com).
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236 | www.jspinaldisorders.com
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EPIDEMIOLOGY AND NATURAL HISTORY
DS is a disease of aging. Although more commonly
found in women (2–3:1, female:male), its incidence in-
creases in both sexes with age.3,4 Its predilection for
women is thought to be due to an increase in ligamentous
laxity and hormonal effects.5 There is also evidence to
support that baseline lumbar and pelvic parameters may
lead to the development of DS. Aono and colleagues
followed 142 women without baseline deformity over a
mean of 14 years and found an incidence of newly de-
veloped DS of 12.7%. The authors reported that in-
creased pelvic incidence, L4 vertebral inclination, an
adjusted vertebral size, and facet orientation in the sag-
ittal plane were all independent predictors of the devel-
opment of DS.6 The development of DS is likely a
multifactorial process taken together with the above
causes as well as degenerative processes of aging affecting
both the intervertebral disk and facet joints.
There is little known about the natural history of
DS. Matsunaga and colleagues reported 145 non-
surgically managed patients with a minimum of 10 years’
follow-up evaluation. The authors reported slip pro-
gression in 49 patients (34%). Intervertebral disk heights
of the diseased segment decreased significantly through-
out the length of the study with a concomitant decrease in
low back pain. They also concluded that this narrowing
of the intervertebral disk as well as spur formation, sub-
cartilaginous sclerosis, and/or ossification of ligaments
may prevent the progression of the disease in a process
they call spinal restabilization. More than three quarters
of their patient population failed to develop any neuro-
logical sequelae after >10 years of follow-up. However,
the authors report that the patients who presented with
neurological symptoms, but refused surgical treatment,
portended the worst prognosis at the final follow-up.7 The
remainder of what we know is based on conservative
treatment arms, which will be discussed in detail with the
Spine Patient Outcomes Research Trial (SPORT).
CLINICAL PRESENTATION AND DIAGNOSIS
Symptom-related DS can be related to either spinal
stenosis or mechanical low back pain. Spinal stenosis
typically produces leg symptoms. The term used to de-
scribe the classic pattern of legs symptoms associated with
spinal stenosis is neurological claudication. Verbeist was
the first to describe these features of neurogenic claudi-
cation, and it has been subsequently proven in cadaveric
and in vivo imaging studies.8,9 This pattern typically
includes lower extremity pain, paresthesia, a sense of
J Spinal Disord Tech  Volume 28, Number 7, August 2015
J Spinal Disord Tech  Volume 28, Number 7, August 2015
FIGURE 1. A standing lateral radiograph showed L4/L5 de-
generative spondylolisthesis.
heaviness or weakness associated with walking or stand-
ing. Positions placing the spine in extension are in par-
ticular troublesome for patients suffering from spinal
stenosis, and symptoms are relieved rapidly upon posi-
tions of spinal flexion (ie, sitting). It may be differentiated
from vascular claudication, which is not affected by the
position of the spine. Patients may also present with a
more radicular pattern as a result of foraminal or lateral
recess stenosis.
The diagnosis of DS is best detected on standing
lateral radiographs (Fig. 1). DS can frequently have a
dynamic component to it and can be missed on supine
radiographs as the diseased segment reduces to an ana-
tomic position. This scenario is commonly encountered
when MRI is used to evaluate lower extremity com-
plaints. Segebarth and colleagues highlighted this fact in a
recent retrospective analysis. In their series of 416 pa-
tients, 109 were found to have DS on standing lateral
radiographs. Of these, only 78 were found to have a
corresponding spondylolisthesis on MRI, leaving 31
(28%) of the DS levels undiagnosed on MRI.10
The most commonly utilized radiographic classi-
fication was proposed by Meyerding.11 Under this clas-
sification scheme, the degree of forward translation is
determined as the percentage of the whole vertebral body
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Degenerative Spondylolisthesis
FIGURE 2. Axial T2 image demonstrating facet effusion (red
arrow) in a patient with degenerative spondylolisthesis.
divided into quartiles. Grade I represents a slip of <25%
of the vertebral body, grade II represents a slip of between
25% and 50%, etc. until grade V, which represents a
spondyloptosis or the entire vertebral body being slipped
forward. The majority of DS will represent grade I or II.
The controversy arises when deciding how much static or
dynamic translation is considered abnormal. The study
by Boden and Wiesel12 is frequently quoted in the liter-
ature and places 4 mm as the dividing line between nor-
mal and abnormal translation. There are also MRI
findings associated with dynamic instability. Several
studies have shown that the presence of a facet effusion or
interspinous process fluid was indicative of a dynamic
spondylolisthesis demonstrated by flexion/extension ra-
diographs, which are being increasingly utilized in the
decision-making process (Fig. 2).13,14
SURGICAL TREATMENT OPTIONS AND RESULTS
There is a large body of literature regarding the sur-
gical treatment of DS. Unfortunately, as with much of the
literature in spine surgery, the evidence supporting many of
treatments is of poor quality. In addition, the outcomes
utilized by the published results are different, making
comparisons difficult. The SPORT was a multicenter,
prospective, randomized control trial for which we have 4-
year data on DS that represents our highest level evidence
to date and will be discussed in detail later. However, to
understand how the treatment arms of that study were
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Koreckij and Fischgrund J Spinal Disord Tech  Volume 28, Number 7, August 2015

developed requires an understanding of the literature that

was undertaken before its inception. For the purposes of
this review, an effort was made by the authors to include
only those studies of prospective randomized nature when
discussing the treatment techniques in an attempt to discuss
the highest quality evidence available.
These treatment options have evolved from de-
compression alone to the utilization of a decompression
with an instrumented 360-degree fusion. The Herkowitz
and Kurz study was the first prospective, randomized trial
comparing decompression with and without postero-
lateral in situ fusion with an average follow-up of 3 years
in 50 patients. They reported significant improvement in
outcomes when the decompression was combined with a
posterolateral fusion over decompression alone. Ninety-
six percent of the fusion patients reported a satisfactory
outcome compared with only 44% in the decompression
alone group, 44% of the fusion patients reporting
excellent outcomes compared with only 8% of the decom-
pression alone patients. Scores for back and leg symp-
toms were also significantly better in the fusion cohort of
patients. This study reported a pseudoarthrosis rate of
36%, although it did not appear to have a deleterious
effect on the outcome with all patients reported to have
good results. Seven of the 25 patients demonstrated slip
progression despite attempted arthrodesis. All 7 of these FIGURE 3. Anteroposterior radiograph of pedicle screw in-
patients went on to excellent or good results. In the strumentation with posterolateral fusion.
nonfusion patients, 24 out of 25 patients developed slip
progression with only 11 of those 24 reporting excellent or VAS scores for back and leg pain in patients who ach-
good results and 13 reporting a fair or poor result.15 The ieved solid fusion. They specifically highlight that no
authors concluded that a fibrous union may add enough differences were seen between the groups until 5 years
stability to provide for improved clinical outcomes. postoperatively.19
Mardjetko and colleagues reported on a meta- The literature is fairly supportive that fusion is nec-
analysis of studies published between 1970 and 1993, essary to achieve the best and most durable clinical out-
demonstrating improved outcomes with noninstrumented comes. However, now the debate seems to have centered on
fusion over decompression alone. In this review, 6 papers the best way to achieve fusion. Zdeblick and colleagues
with a total of 71 patients of short-term to mid-term compared noninstrumented posterolateral fusion and 2
follow-up revealed 90% satisfactory results with fusion different types of instrumentation. These results revealed a
compared with 67% of the patients with decompression 65% fusion rate seen with noninstrumented fusions, a 77%
alone.16 In 2004, Ghogawala and colleagues published a fusion rate with the use of semirigid instrumentation, and
prospective, nonrandomized, multi-institutional study 95% with the use of rigid fixation.20 Fischgrund et al21
comparing decompression alone (n = 14) with decom- published a prospective, randomized study of 68 patients
pression with instrumented fusion (n = 20). Again, fusion with DS comparing decompression and noninstrumented
patients reported significantly greater improvements over posterolateral fusion with decompression and an in-
decompression alone patients. However, a major weak- strumented fusion with pedicle screw fixation at the 2-year
ness of many of these studies mentioned thus far is their follow-up (Fig. 3). The addition of instrumentation in-
short-term to mid-term follow-up.17 creased fusion rates to 83% compared with 45% for non-
The importance of long-term follow-up is demon- instrumented patients. As expected with the relatively short
strated by a study published by Kornblum and col- follow-up, clinical outcomes were not significantly different
leagues. This study was a follow-up of that original study between the 2 groups.
by Herkowitz and Kurz. In 47 patients with 5–14 years of A meta-analysis published in 2007 analyzed random-
follow-up (average, 7 y 8 mo), they reported that 86% of ized control trials and comparative observation studies be-
the patients who attained a solid fusion reported good/ tween 1966 and 2005. Six studies were included in the review,
excellent outcomes with regard to the pain and the ac- including 3 observational and 3 randomized studies. The use
tivity level versus 56% of the patients who developed of instrumentation significantly improved the relative risk of
pseudoarthrosis.18 Tsutsumimoto and colleagues reported achieving a solid fusion over noninstrumented fusions. The
42 patients who underwent a posterolateral fusion with- randomized studies demonstrated a greater relative risk of
out instrumentation at a mean follow-up of 9.5 years. The achieving solid fusion than the observational studies (1.96 vs.
data demonstrated improved clinical outcome scores and 1.20), highlighting the importance of randomized control

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J Spinal Disord Tech  Volume 28, Number 7, August 2015
studies. The authors went on to conclude that although clear
evidence exists that fusion rates are improved by the addition
of instrumentation, however, the current literature has been
unable to show a definitive clinical improvement using an
instrumented fusion over a noninstrumented fusion.22
More recently, at the forefront of discussions re-
garding the treatment DS is the SPORT trial. This was a
large prospective multicenter study involving surgical
candidates from 13 centers in 11 states. Collectively, it
focused on the treatment of disk herniation, spinal
stenosis, and DS. In the DS cohort, patients who received
surgery underwent a decompression with or without fu-
sion and with or without instrumentation. The non-
operative treatment arm included today’s standard
therapeutic interventions (ie, NSAIDS, physical therapy,
epidural injections). It also used validated outcome
measures, setting it apart from most of the other studies
discussed in this chapter. A total of 607 patients were
enrolled in the DS arm of the study, making it the largest
study to date. Within the study design, 2 trial method-
ologies were utilized; of the 607 patients enrolled, 304
were placed into the randomized cohort and 303 into an
observation cohort that declined randomization.23
The 2- and 4-year results have been published and
revealed significant improvements in all primary and
secondary outcome measures in the surgically treated
groups. This treatment effect was seen as early as 6 weeks
after surgery and was maintained throughout the 4-year
follow-up time period. However, it should be noted that
nonsurgical treatment resulted in modest improvements
in most patients.24 One criticism of the SPORT trial is the
significant crossover seen in both treatment arms. In
other words, a large percentage of patients who either
chose or were randomized to nonoperative treatment ul-
timately were treated operatively and vice versa. Thus,
when the data are analyzed from an intent-to-treat per-
spective, there is no treatment difference. It is only when
as-treated analyses are performed that a treatment effect
in favor of surgery is realized. This represents one of the
largest confounders in that patients who want to have
surgery appear to do better with surgery.25
The SPORT trial has also led to a number of pub-
lications that have performed subgroup analyses to try to
aid in our understanding of which patients derive the best
benefit with surgery. Some of the results are more intuitive
such as the findings by Freedman et al,26 which highlight
that diabetic patients do not have as much improvement in
pain and function with surgery as their nondiabetic coun-
terparts (although showing greater improvement with sur-
gery than with nonoperative management). Pearson et al27
reported that patients with predominantly leg pain had
greater improvements with surgery than predominantly
back pain patients, although surgery did result in significant
improvement in back pain patients. Others’ findings are less
intuitive, such as those published by Rihn and colleagues
with regard to obesity. They found no significant difference
in the treatment effect on comparing nonobese and obese
patients. Interestingly, obese patients faired far worse with
nonoperative treatment, leading to a significant treatment
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Degenerative Spondylolisthesis
effect in favor of surgery in obese patients. However, cau-
tion should be utilized when treating obese patients surgi-
cally as these patients have a significantly higher infection
rate and double the rate of reoperation at 4 years.28
Additional studies through the SPORT database
have looked at perennially argued debates such as iliac crest
bone grafting. Although less popular today due to the
concern of increased morbidity and availability of bone
graft substitutes, Radcliff et al29 showed that outcome
scores in patients who underwent iliac crest bone graft were
not significantly lower than those without iliac crest auto-
graft, and iliac crest bone grafting was not associated with
an increase in the complication rates or rates of reopera-
tion. With regard to the timing of surgery, in 1 subgroup
analysis, no difference was reported in the operative out-
comes in DS patients who had symptoms for more or less
than 12 months at the time of their surgery.30 However, all
the retrospective studies should be scrutinized carefully for
potential bias as the questions being asked of the subgroup
cohort may not have been what the study was initially
designed to answer. That being said, the importance of a
large database of uniformly collected prospective data such
as the SPORT database cannot be understated.
As the argument continues to be more and more
heavily weighted in favor of surgery for the treatment of
DS, it is now turning toward how much surgery is nec-
essary. The addition of anterior column support or 360-
degree fusion has many theoretical benefits. Proponents
will argue that anterior column support improves fusion
rates by increasing the surface area available for fusion, it
offers indirect decompression, and that it helps to restore
normal lumbar lordosis. There are several ways to achieve
anterior support (ie, posteriorly, anteriorly, and trans-
psoas), each with its own benefits and unique set of
complications. However, there are no prospective,
randomized studies comparing a standard posterolateral
fusion with a posterolateral fusion with the addition of
anterior column support, and thus there are no definitive
data demonstrating the clinical superiority of one over
another. In today’s cost-saving era, the additional surgery
and subsequent increased costs need to be weighed
against the benefits in clinical outcomes.31
AUTHORS’ PREFERRED TREATMENT
ALGORITHM
The authors’ preferred treatment approach remains
conservative: successful treatment requires patient edu-
cation and management of expectations. When patients
present to the clinic with neurogenic claudication or
radicular complaints, the authors will utilize flexion/ex-
tension lateral radiographs. Although the utility of such
radiographs have not been proven, it will play a role in
decision making with regard to surgery should that be-
come necessary. An MRI is also essential to determine
levels of stenosis with the understanding that it may un-
derestimate the degree of stenosis.
Although surgery appears to afford better clinical
outcomes, not every patient needs surgery. The SPORT
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Koreckij and Fischgrund
trial has shown that nonoperative management results in
improved clinical outcomes and these improvements may
be enough for some patients. We also know from the
SPORT trial that significant neurological deterioration is
unlikely to occur while attempting nonoperative man-
agement. Thus, the authors feel that it is important to
place all patients through a formal course of physical
therapy and NSAIDs ± epidural steroid injection de-
pending on patient preference. Opiates should be used
very sparingly. We attempt to use a multimodal approach
by empowering all treatments at once. For instance, the
authors will frequently attempt an epidural steroid in-
jection contemporaneously with physical therapy in the
hope that it may provide pain relief and allow the patient
to derive maximum benefit out of the therapy.
After the nonoperative treatment measures have been
exhausted and the patients’ symptoms are still negatively
impacting their quality of life, surgery is considered. Al-
though surgery provides benefit in older patients32 and the
above studies demonstrate superiority in laminectomy with
fusion, the authors do not feel that all DS patients require
the “full court press.” In medically infirm patients with a
low functional capacity, a laminoforaminotomy (for uni-
lateral symptoms) or laminectomy (for bilateral symptoms)
can offer tremendous relief. This is especially true for pa-
tients who lack evidence of dynamic instability on flexion/
extension radiographs. It is the authors’ opinion that the
majority of these patients will not go onto progressive
symptomatic instability. However, in young, healthy pa-
tients, the authors will perform a laminectomy with in-
strumented posterolateral fusion in the majority of the
cases. Anterior column support is added on rare occasions
for significant dynamic instability, more radicular symp-
toms, or evidence of significant focal kyphosis at the in-
strumented level. Although not addressed in this article, the
authors will use bone graft extenders in the form of either
demineralized bone matrix or allograft in the posterolateral
gutter to augment fusion. We have shown lower than pre-
viously reported CT-proven fusion rates with the use of
local autograft alone (manuscript in submission).
Postoperatively, patients are instructed to avoid
bending, lifting, and twisting. Weight-lifting restrictions
are placed at not more than 10 pounds. These restrictions
are retained in place for 3 months. At 3 months, physical
therapy is started if the patients feel as though they have
suffered significant deconditioning since their surgery.
Patients are followed for at least 2 years, at which point
they are discharged to follow-up as needed.
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