Spondylolisthesis PDF

Introduction/Guideline Methodology
Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis | NASS Clinical Guidelines 1
Evidence-Based Clinical Guidelines for Multidisciplinary

Spine Care
Diagnosis and Treatment of

Degenerative Lumbar
Spondylolisthesis
2nd Edition
NASS Evidence-Based Clinical Guidelines Committee

Paul Matz, MD R.J. Meagher, MD Tim Lamer, MD William Tontz Jr, MD
Committee Co-Chair Diagnosis/Imaging Medical/Interventional Surgical Treatment and
and Surgical Treatment Section Chair Section Chair Value Section Chair
Section Chair
Thiru M. Annaswamy, MD John E. Easa, MD Terrence D. Julien, MD Jonathan N. Sembrano, MD
R. Carter Cassidy, MD Dennis E. Enix, DC, MBA Matthew B. Maserati, MD Alan T. Villavicencio, MD
Charles H. Cho, MD, MBA Bryan A. Gunnoe, MD Robert C. Nucci, MD Jens-Peter Witt, MD
Paul Dougherty, DC Jack Jallo, MD, PhD, FACS John E. O’Toole, MD, MS
North American Spine Society

Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis
Copyright © 2014 North American Spine Society
7075 Veterans Boulevard
Burr Ridge, IL 60527 USA
630.230.3600
www.spine.org
This clinical
ISBN guideline should
1-929988-36-2 not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-
ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physi-
cian and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.
Introduction/Guideline Methodology 2 Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis | NASS Clinical Guidelines
Financial Statement
This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating
authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy. Disclosures are listed below:
Paul G. Matz, Co-Chair: Speaking and/or teaching arrangements: AO Spine North America (Financial, Honoraria for Faculty at AO Advance
Concepts Courses and AO Aging Bone Symposium); Board of Directors:
AO Spine North America Executive Committee (Nonfinancial, Remu- Range Key:
neration for Travel to AONASEC meeting). (1/29/13) Level A. $100 to $1,000
Thiru M. Annaswamy: Board of Directors: Association of Academic Physiatrists (AAP) (Nonfi- Level B. $1,001 to $10,000
nancial, No remuneration. I am on the board of trustees of AAP); Grants: Level C. $10,001 to $25,000
Innovative Neurotronics (Level D, Research Grant from Sponsor for Level D. $25,001 to $50,000
INSTRIDE study on Foot drop in stroke), NSF (0, Subcontract award for
Level E. $50,001 to $100,000
research on developing a virtual reality based tele-rehabilitation system.
PI: Dr. Prabhakaran, UT Dallas), Health & Human Services-Via University Level F. $100,001 to $500,000
of Washington; BOLD-LESS study (Level C, Subcontract award for re- Level G. $500,001 to $1M
search on use of steroids in lumbar epidural steroid injections in lumbar Level H. $1,000,001 to $2.5M
spinal stenosis; the LESS study. PI: Dr. Friedly, U. of Washington, Seattle); Level I. Greater than $2.5M
Other: AAPMR (Nonfinancial, Committee Chair of the Evidence Commit-
tee at AAPMR). (1/31/13)
R. Carter Cassidy: Relationships Outside the One Year Requirement: Synthes USA (Upcoming Committee Meeting [Evidence Based
Guidelines Committee], 12/2010, Speaking and/or Teaching Arrangement, Level A). (1/30/13)
Charles H. Cho: Other Office: American Society of Spine Radiology (Nonfinancial, Executive Committee (March 2012 - February
2013). (1/29/13)
Paul Dougherty: Nothing to disclose. (1/29/13)
John E. Easa: Stock Ownership: Janus Biotherapeutics (Level E, 3, Janus Biotherapeutics is an auto-immunity company, Paid
directly to institution/employer). (1/29/13)
Dennis E. Enix: Research Support (Investigator Salary): Logan College (Level D of my salary amount is paid from HRSA Chiroprac-
tic Demonstration Projects Grant number 1R18HP15125-01-00., Paid directly to institution/employer), Standard
Process (Level C of my salary amount is paid from a grant from the Standard Process Company., Paid directly to
institution/employer); Grants: HRSA (Level D of my salary amount is paid from HRSA Chiropractic Demonstration
Projects Grant number 1R18HP15125-01-00., Paid directly to institution/employer). (1/31/13)
Bryan A. Gunnoe: Nothing to disclose. (2/1/13)
Jack Jallo: Nothing to disclose. (1/31/13)
Terrence D. Julien: Consulting: Stryker Spine (Both, Consulting for product lines), Biomet Spine (Both, Consulting for product lines);
Speaking and/or teaching arrangements: Stryker Spine (Both, Teach hands-on cadaveric and didactic lectures for
MIS procedures), Globus Medical (Both, Teach hands-on cadaveric and didactic lectures for MIS procedures).
(1/30/13)
Tim Lamer: Board of Directors: American Academy of Pain Medicine (Nonfinancial). (2/1/13)
Matthew B. Maserati: Nothing to disclose. (2/8/13)
R.J. Meagher: Nothing to disclose. (1/29/13)
Robert C. Nucci: Nothing to disclose. (1/30/13)
John E. O’Toole: Royalties: Globus Medical Inc. (Level A); Consulting: Globus Medical Inc. (Level B), Pioneer Surgical (Level B).
(1/9/13)
Jonathan N. Sembrano: Board of Directors: Society of Lateral Access Surgeons (SOLAS) (Nonfinancial), Philippine Minnesota Medical
Association (PMMA) (Nonfinancial), University of the Philippines Alumni of Minnesota (UPAM) (Nonfinancial); Re-
search Support (Staff/Materials): NuVasive (0, Study site for a multicenter RCT of XLIF vs. MIS TLIF for degenera-
tive spondylolisthesis. Approved January 2010. Enrollment just ended 12/31/12. Nine patients enrolled from our
site. Patients will be followed for two years postop. Study sponsor compensates for study coordinator efforts, but
not for the investigator, Paid directly to institution/employer). (1/31/13)
William L. Tontz, Jr.: Stock Ownership: Phygen (1, 6, Physician owned implant company involved in development and distribution of spi-
nal implants, Paid directly to institution/employer); Other Office: Board of Managers (Financial, Paid Level B dollars
for board of manager term from 2009-2010). (1/31/13)
Alan T.Villavicencio: Stock Ownership: Lanx (Level I, 2, Founder); Board of Directors: Justin Parker Neurological Institute (Nonfinancial,
Not for profit); Other Office: Boulder Neurosurgical Associates, LLC (Nonfinancial, managing partner); Research
Support (Investigator Salary): Profibrix, Medtronic (Level F, Paid directly to institution/employer). (2/5/13)
Jens-Peter Witt: Relationships Outside the One Year Requirement: Aesculap (Upcoming Committee Meeting [Evidence-based
Guideline Committee], 12/2008, Speaking and/or Teaching Arrangement). (2/1/13)
Comments
Comments regarding the guideline may be submitted to the North American Spine Society and will be considered in develop-
ment of future revisions of the work.
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-
Table of Contents
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
II. Guideline Development Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
III. Recommendation Summary: Comparison of 2008 and Current Recommendations . . . . . . . . . . 8
IV. Definition for Degenerative Lumbar Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
V. Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis . . 16

A. Diagnosis/Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
B. Outcome Measures for Medical/Interventional and Surgical Treatment . . . . . . . . . . . . . . . . . . . . 37
C. Medical/Interventional Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
D. Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
E. Value of Spine Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

VI. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
A. Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
B. Levels of Evidence for Primary Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
C. Grades of Recommendations for Summaries or Reviews of Studies . . . . . . . . . . . . . . . . . . . . . 100
D. Linking Levels of Evidence to Grades of Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
E. NASS Literature Search Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

VII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
A technical report, including the literature search parameters and evidentiary tables developed by
the authors, can be accessed at https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/
DegenerativeSpondylolisthesisTechReport.pdf
I. Introduction
Objective THIS GUIDELINE DOES NOT REPRESENT A “STAN-
The objective of the North American Spine Society (NASS) Clin- DARD OF CARE,” nor is it intended as a fixed treatment pro-
ical Guideline for the Diagnosis and Treatment of Degenerative tocol. It is anticipated that there will be patients who will require
Lumbar Spondylolisthesis is to provide evidence-based recom- less or more treatment than the average. It is also acknowledged
mendations to address key clinical questions surrounding the di- that in atypical cases, treatment falling outside this guideline
agnosis and treatment of degenerative lumbar spondylolisthesis. will sometimes be necessary. This guideline should not be seen
The guideline is intended to update the original guideline on this as prescribing the type, frequency or duration of intervention.
topic, published in 2008. This guideline is based upon a system- Treatment should be based on the individual patient’s need and
atic review of the evidence and reflects contemporary treatment doctor’s professional judgment. This document is designed to
concepts for symptomatic degenerative lumbar spondylolisthe- function as a guideline and should not be used as the sole reason
sis as reflected in the highest quality clinical literature available for denial of treatment and services. This guideline is not intend-
on this subject as of May 2013. The goals of the guideline recom- ed to expand or restrict a health care provider’s scope of practice
mendations are to assist in delivering optimum, efficacious treat- or to supersede applicable ethical standards or provisions of law.
ment and functional recovery from this spinal disorder.
Patient Population
Scope, Purpose and Intended User The patient population for this guideline encompasses adults (18
This document was developed by the North American Spine So- years or older) with a chief complaint of low back pain and/or
ciety Evidence-based Guideline Development Committee as an lower extremity symptoms related to spinal stenosis and degen-
educational tool to assist practitioners who treat patients with erative lumbar spondylolisthesis. In general, the nature of the
degenerative lumbar spondylolisthesis. The goal is to provide pain and associated patient characteristics (eg, age) are more
a tool that assists practitioners in improving the quality and typical of a diagnosis of spinal stenosis with degenerative lumbar
efficiency of care delivered to these patients. The NASS Clini- spondylolisthesis than discogenic low back pain, lumbar sprain/
cal Guideline for the Diagnosis and Treatment of Degenerative strain, or mechanical low back pain with degenerative spondy-
Lumbar Spondylolisthesis provides a definition of this disorder, lolisthesis.
outlines a reasonable evaluation of patients suspected to have
degenerative lumbar spondylolisthesis and outlines treatment
options for adult patients with this diagnosis.
II. Guideline Development Methodology

Through objective evaluation of the evidence and transparency Levels of Evidence and Grades of
in the process of making recommendations, it is NASS’ goal Recommendation
to develop evidence-based clinical practice guidelines for the NASS has adopted standardized levels of evidence (Appendix
diagnosis and treatment of adult patients with various spinal B) and grades of recommendation (Appendix C) to assist
conditions. These guidelines are developed for educational practitioners in easily understanding the strength of the
purposes to assist practitioners in their clinical decision- evidence and recommendations within the guidelines. The
making processes. It is anticipated that where evidence is very levels of evidence range from Level I (high quality randomized
strong in support of recommendations, these recommendations controlled trial) to Level V (expert consensus). Grades of
will be operationalized into performance measures. recommendation indicate the strength of the recommendations
made in the guideline based on the quality of the literature.
Multidisciplinary Collaboration Grades of Recommendation:
With the goal of ensuring the best possible care for adult patients A: Good evidence (Level I studies with consistent findings) for
suffering with spinal disorders, NASS is committed to multidis- or against recommending intervention.
ciplinary involvement in the process of guideline and perfor- B: Fair evidence (Level II or III studies with consistent findings)
mance measure development. To this end, NASS has ensured for or against recommending intervention.
that representatives from both operative and non-operative, C: Poor quality evidence (Level IV or V studies) for or against
medical, interventional and surgical spine specialties have par- recommending intervention.
ticipated in the development and review of NASS guidelines. To I: Insufficient or conflicting evidence not allowing a recom-
ensure broad-based representation, NASS welcomes input from mendation for or against intervention.
other societies and specialties.
Levels of evidence have very specific criteria and are assigned
to studies prior to developing recommendations. Recommenda-
Evidence Analysis Training of All NASS tions are then graded based upon the level of evidence. To better
Guideline Developers understand how levels of evidence inform the grades of recom-
All Evidence-Based Guideline Development Committee Mem- mendation and the standard nomenclature used within the rec-
bers have completed NASS’ Fundamentals of Evidence-Based ommendations see Appendix D.
Medicine Training. Members have the option to attend a one-day Guideline recommendations are written utilizing a standard
course or complete training via an online program. In conjunc- language that indicates the strength of the recommendation.
tion with Qwogo Inc., a University of Alberta affiliated enterprise, “A” recommendations indicate a test or intervention is “recom-
NASS offers an online training program geared toward educating mended”; “B” recommendations “suggest” a test or intervention
guideline developers about evidence analysis and guideline de- and “C” recommendations indicate a test or intervention “may
velopment. All participants in guideline development for NASS be considered” or “is an option.” “I” or “Insufficient Evidence”
have completed the live or online training prior to participating statements clearly indicate that “there is insufficient evidence to
in the guideline development program at NASS. Both trainings make a recommendation for or against” a test or intervention.
include a series of readings and exercises, or interactivities, to Work group consensus statements clearly state that “in the ab-
prepare guideline developers for systematically evaluating litera- sence of reliable evidence, it is the work group’s opinion that” a
ture and developing evidence-based guidelines. The live course test or intervention may be appropriate.
takes approximately 8-9 hours to complete and the online course The levels of evidence and grades of recommendation imple-
takes approximately 15-30 hours to complete. Participants are mented in this guideline have also been adopted by the Journal of
awarded CME credit upon completion of the course. Bone and Joint Surgery, the American Academy of Orthopaedic
Surgeons, Clinical Orthopaedics and Related Research, the journal
Disclosure of Potential Conflicts of Interest Spine and the Pediatric Orthopaedic Society of North America.
All participants involved in guideline development have In evaluating studies as to levels of evidence for this guide-
disclosed potential conflicts of interest to their colleagues line, the study design was interpreted as establishing only a po-
in accordance with NASS’ Disclosure Policy for committee tential level of evidence. As an example, a therapeutic study de-
members (https://www.spine.org/Documents/WhoWeAre/ signed as a randomized controlled trial would be considered a
DisclosurePolicy.pdf) and their potential conflicts have potential Level I study. The study would then be further analyzed
been documented in this guideline. NASS does not restrict as to how well the study design was implemented and signifi-
involvement in guidelines based on conflicts as long as cant shortcomings in the execution of the study would be used to
members provide full disclosure. Individuals with a conflict downgrade the levels of evidence for the study’s conclusions. In
relevant to the subject matter were asked to recuse themselves the example cited previously, reasons to downgrade the results of
from deliberation. Participants have been asked to update their a potential Level I randomized controlled trial to a Level II study
disclosures regularly throughout the guideline development would include, among other possibilities: an underpowered
study (patient sample too small, variance too high), inadequate
process.
randomization or masking of the group assignments and lack of the Literature Search Protocol. Following these protocols en-
validated outcome measures. sures that NASS recommendations (1) are based on a thorough
In addition, a number of studies were reviewed several times review of relevant literature; (2) are truly based on a uniform,
in answering different questions within this guideline. How comprehensive search strategy; and (3) represent the current
a given question was asked might influence how a study was best research evidence available. NASS maintains a search his-
evaluated and interpreted as to its level of evidence in answering tory in Endnote, for future use or reference.
that particular question. For example, a randomized controlled
trial reviewed to evaluate the differences between the outcomes Step 5: Review of Search Results/Identification of
of surgically treated versus untreated patients with lumbar disc Literature to Review
herniation with radiculopathy might be a well designed and im- Work group members reviewed all abstracts yielded from the
plemented Level I therapeutic study. This same study, however, literature search and identified the literature they will review
might be classified as providing Level II prognostic evidence if in order to address the clinical questions, in accordance with
the data for the untreated controls were extracted and evaluated the Literature Search Protocol. Members have identified the
prognostically. best research evidence available to answer the targeted clinical
questions. That is, if Level I, II and or III literature is available to
Guideline Development Process answer specific questions, the work group was not required to
Step 1: Identification of Clinical Questions review Level IV or V studies.
The clinical questions from the original guideline, published in
2008, are included in this guideline update. Since 2008, an ad- Step 6: Evidence Analysis
ditional section addressing value in spine care has been added. Members have independently developed evidentiary tables sum-
Trained guideline participants were asked to submit a list of new marizing study conclusions, identifying strengths and weakness-
additional clinical questions that the guideline should address in es and assigning levels of evidence. In order to systematically
addition to the questions included in the original guideline. The control for potential biases, at least two work group members
lists of new questions were compiled into a master list, which have reviewed each article selected and independently assigned
was then circulated to each member with a request that they levels of evidence to the literature using the NASS levels of evi-
independently rank the questions in order of importance for dence. Any discrepancies in scoring have been addressed by two
consideration in the guideline. The questions from the previous or more reviewers. Final ratings are completed at a final meeting
guideline and most highly ranked new questions, as determined of all section workgroup members including the section chair
by the participants, served to focus the guideline. and the guideline chair. The consensus level (the level upon
which two-thirds of reviewers were in agreement) was then as-
Step 2: Identification of Work Groups signed to the article.
Multidisciplinary teams were assigned to work groups and as- As a final step in the evidence analysis process, members
signed specific clinical questions to address. Because NASS is have identified and documented gaps in the evidence to educate
comprised of surgical, medical and interventional specialists, it guideline readers about where evidence is lacking and help guide
is imperative to the guideline development process that a cross- further needed research by NASS and other societies.
section of NASS membership is represented on the work group.
This also helps to ensure that the potential for inadvertent biases Step 7: Formulation of Evidence-Based
in evaluating the literature and formulating recommendations is Recommendations and Incorporation of Expert
minimized. Consensus
Work groups held web-conferences and face-to-face meetings
Step 3: Identification of Search Terms and Parameters to discuss the evidence-based answers to the clinical questions,
One of the most crucial elements of evidence analysis is the the grades of recommendations and the incorporation of expert
comprehensive literature search. Thorough assessment of the consensus. Work group members incorporated evidence find-
literature is the basis for the review of existing evidence and the ings from the original guideline in the guideline update. Where
formulation of evidence-based recommendations. In order to there was no new evidence, the work group re-reviewed the orig-
ensure a thorough literature search, NASS has instituted a Lit- inal literature and recommendation statements to ensure agree-
erature Search Protocol (Appendix E) which has been followed ment with original findings. When new literature was found,
to identify literature for evaluation in guideline development. In work group members included existing evidence when updating
keeping with the Literature Search Protocol, work group mem- recommendations statements.
bers have identified appropriate search terms and parameters Expert consensus was incorporated only where Level I-IV
to direct the literature search. Specific search strategies, includ- evidence is insufficient and the work group has deemed that a
ing search terms, parameters and databases searched, are docu- recommendation is warranted. Transparency in the incorpora-
mented in the technical report that accompanies this guideline. tion of consensus is crucial, and all consensus-based recommen-
dations made in this guideline very clearly indicate that Level
Step 4: Completion of the Literature Search I-IV evidence is insufficient to support a recommendation and
Once each work group identified search terms/parameters, the that the recommendation is based only on expert consensus.
literature search was implemented by a medical/research librar-
ian at InfoNOW at the University of Minnesota, consistent with
Consensus Development Process

Voting on guideline recommendations was conducted using Step 10: Submission for Publication and National
a modification of the nominal group technique in which each Guideline Clearinghouse (NGC) Inclusion
work group member independently and anonymously ranked Following NASS Board approval, the guidelines have been slat-
a recommendation on a scale ranging from 1 (“extremely inap- ed for publication and submitted for inclusion in the National
propriate”) to 9 (“extremely appropriate”). Consensus was ob- Guidelines Clearinghouse (NGC). No revisions were made after
tained when at least 80% of work group members ranked the submission to NGC, but comments have been and will be saved
recommendation as 7, 8 or 9. When the 80% threshold was not for the next iteration.
attained, up to three rounds of discussion and voting were held
to resolve disagreements. If disagreements were not resolved af- Step 11: Review and Revision Process
ter these rounds, no recommendation was adopted. The guideline recommendations will be reviewed every three to
After the recommendations were established, work group five years by an EBM-trained multidisciplinary team and revised
members developed the guideline content, addressing the litera- as appropriate based on a thorough review and assessment of
ture supporting the recommendations. relevant literature published since the development of this ver-
sion of the guideline.
Step 8: Submission of the Draft Guidelines for Review/
Comment Use of Acronyms
Guidelines were submitted to the full Evidence-Based Guideline Throughout the guideline, readers will see many acronyms with
Development Committee and the Research Council for review which they may not be familiar. A glossary of acronyms is avail-
and comment. Revisions to recommendations were considered able in Appendix A.
for incorporation only when substantiated by a preponderance
of appropriate level evidence. Nomenclature for Medical/Interventional Treatment
Throughout the guideline, readers will see that what has tra-
Step 9: Submission for Board Approval ditionally been referred to as “nonoperative,” “nonsurgical” or
Once any evidence-based revisions were incorporated, the drafts “conservative” care is now referred to as “medical/interventional
were prepared for NASS Board review and approval. Edits and care.” The term medical/interventional is meant to encompass
revisions to recommendations and any other content were con- pharmacological treatment, physical therapy, exercise therapy,
sidered for incorporation only when substantiated by a prepon- manipulative therapy, modalities, various types of external stim-
derance of appropriate level evidence. ulators and injections.
8 Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis | NASS Clinical Guidelines
III. Recommendation Summary

Comparison of 2008 and Current Guideline Recommendations
Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation
*See reccomendation sections for supporting text
Definition and Natural History
What is the best working An acquired anterior displacement of one Maintained.
definition of degenerative vertebra over the subjacent vertebra,
lumbar spondylolisthesis? associated with degenerative changes,
without an associated disruption or defect in
the vertebral ring.
Workgroup Consensus Statement
What is the natural history The majority of patients with symptomatic Not addressed in guideline update. The literature
of degenerative lumbar degenerative lumbar spondylolisthesis and to address natural history is limited and efforts to
spondylolisthesis? an absence of neurologic deficits will do develop recommendations are often unsuccessful.
well with conservative care. Patients who Therefore, natural history questions have been
Recommendation Summary
present with sensory changes, muscle eliminated from this guideline.

weakness or cauda equina syndrome, are
more likely to develop progressive functional
decline without surgery. Progression of slip
correlates with jobs that require repetitive
anterior flexion of the spine. Slip progression
is less likely to occur when the disc has
lost over 80% of its native height and
intervertebral osteophytes have formed.
Progression of clinical symptoms does not
correlate with progression of the slip.
Diagnosis and Imaging
What are the most Obtaining an accurate history and physical In the absence of evidence to address this question,
appropriate historical and examination is essential to the formulation it is the work group’s opinion that obtaining an
physical examination of the appropriate clinical questions to guide accurate history and physical examination is
findings consistent with the the physician in developing a plan for the important for the diagnosis and treatment of
diagnosis of degenerative treatment of patients with degenerative patients with degenerative lumbar spondylolisthesis.
lumbar spondylolisthesis? lumbar spondylolisthesis. Formulating appropriate clinical questions is
Work Group Consensus Statement essential to obtaining an accurate history that
can be used in developing a treatment plan for
In older patients presenting with patients.
radiculopathy and neurogenic intermittent Work Group Consensus Statement
claudication, with or without back pain,
a diagnosis of degenerative lumbar In patients with imaging evidence of degenerative
spondylolisthesis should be considered. lumbar spondylolisthesis, the following clinical
Grade of Recommendation: B characteristics have been reported: asymptomatic
with only occasional back pain; chronic low back
pain with or without radicular symptoms and with or
without positional variance; radicular symptoms with
or without neurologic deficit, with or without back
pain; and intermittent neurogenic claudication. Study
summaries are provided as background support to
help further define the clinical characteristics that
may be associated with a diagnosis of degenerative
lumbar spondylolisthesis.
ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-
sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution

What are the most The most appropriate, noninvasive The lateral radiograph is the most appropriate,
appropriate diagnostic tests test for detecting degenerative lumbar noninvasive test for detecting degenerative lumbar
for degenerative lumbar spondylolisthesis is the lateral radiograph. spondylolisthesis.
spondylolisthesis? Grade of Recommendation: B Grade of Recommendation: B (Suggested)
In the absence of reliable evidence, it is the work
The most appropriate, noninvasive test group’s opinion that the lateral radiograph should be
for imaging the stenosis accompanying obtained in the standing position whenever possible.
degenerative lumbar spondylolisthesis is the Work Group Consensus Statement
MRI.
Work Group Consensus Statement The most appropriate, noninvasive test for imaging
stenosis accompanying degenerative lumbar
spondylolisthesis is MRI.
Plain myelography or CT myelography are
Work Group Consensus Statement
useful studies to assess spinal stenosis
in patients with degenerative lumbar Facet joint effusion greater than 1.5mm on
spondylolisthesis. supine MRI may be suggestive of the presence
Grade of Recommendation: B of degenerative lumbar spondylolisthesis. Further
evaluation for the presence of degenerative lumbar
CT is a useful noninvasive study in patients spondylolisthesis should be considered, including
who have a contraindication to MRI, for using plain standing radiographs.
whom MRI findings are inconclusive or for Grade of Recommendation: B
whom there is a poor correlation between There is insufficient evidence to make a
symptoms and MRI findings, and in whom recommendation for or against the utility of the
CT myelogram is deemed inappropriate. upright seated MRI in the diagnosis of degenerative
Work Group Consensus Statement lumbar spondylolisthesis.
Grade of Recommendation: I (Insufficient
Evidence)
There is insufficient evidence to make a
recommendation for or against the use of axial
loaded MRI to evaluate the dural sac cross
sectional area in patients with degenerative lumbar
spondylolisthesis and spinal stenosis.
Evidence)
Plain myelography or CT myelography are useful
studies to assess spinal stenosis in patients with
degenerative lumbar spondylolisthesis especially in
those who have contraindications to MRI.
Grade of Recommendation: B (Suggested)
In patients with degenerative lumbar spondylolisthesis
with associated spinal stenosis for whom MRI is either
contraindicated or inconclusive, CT myelography is
the most appropriate test to confirm the presence of
anatomic narrowing of the spinal canal or the presence
of nerve root impingement.
In patients with degenerative spondylolisthesis
with associated spinal stenosis for whom MRI and
CT myelography are contraindicated, inconclusive
or inappropriate, CT is suggested as the most
appropriate test to confirm the presence of anatomic
narrowing of the spinal canal or the presence of
nerve room impingement.

What are the most Not addressed There is insufficient evidence to make a
appropriate diagnostic recommendation on the most appropriate
or physical exam tests diagnostic or physical exam test consistent with
consistent with the fixed or dynamic deformity in degenerative lumbar
diagnosis of fixed versus spondylolisthesis patients due to the lack of uniform
dynamic deformity? reference standards which define instability.
There is no universally accepted standard to

diagnose fixed versus dynamic spondylolisthesis.
To evaluate instability, many studies employ the
use of lateral flexion extension radiographs, which
may be done in the standing or recumbent position;
however, there is wide variation in the definition
of instability. To assist readers, the definitions
for instability (when provided) in degenerative
spondylolisthesis patients, are bolded below.

Evidence)
Is dynamic MRI and/or Not addressed There is insufficient evidence to make a
dynamic CT myelography recommendation for or against the utility of dynamic
imaging (including standing MRI and dynamic CT myelography in the diagnosis
imaging, imaging with of degenerative lumbar spondylolisthesis.
axial loading) helpful in Grade of Recommendation: I (Insufficient
the diagnostic testing Evidence)
for degenerative lumbar
spondylolisthesis?
Outcome Measures for Medical/Interventional and Surgical Treatment
What are the appropriate TheZurich Claudication Questionnaire An updated literature search was not conducted. For
outcome measures for the (ZCQ)/Swiss Spinal Stenosis Questionnaire more information on appropriate outcome measures
treatment of degenerative (SSS), Oswestry Disability Index (ODI), for degenerative lumbar spondylolisthesis, the
lumbar spondylolisthesis? Likert Five-Point Pain Scale and 36- North American Spine Society has a publication
Item Short Form Health Survey (SF-36) entitled Compendium of Outcome Instruments for
are appropriate measures for assessing Assessment and Research of Spinal Disorders. To
treatment of degenerative lumbar purchase a copy of the Compendium, visit https://
spondylolisthesis. webportal.spine.org/Purchase/ProductDetail.
Grade of Recommendation: A aspx?Product_code=68cdd1f4-c4ac-db11-95b2-
001143edb1c1.
The Japanese Orthopedic Association
(JOA) Score and the calculated Recovery For additional information about the Compendium,
Rate may be useful in assessing outcome in please contact the NASS Research Department at
degenerative lumbar spondylolisthesis. nassresearch@spine.org.
Grade of Recommendation: B
The Shuttle Walking Test (SWT), Oxford

Claudication Score (OCS), Low Back
Pain Bothersome Index and Stenosis
Bothersome Index are potential outcome
measures in studying degenerative
lumbar spondylolisthesis. Grade of
Recommendation: I (Insufficient
Evidence)

Medical and Interventional Treatment
• Do medical/ interventional A systematic review of the literature yielded Not addressed in guideline update; the literature
treatments improve no studies to adequately address any of the to address natural history is limited and efforts to
outcomes in the treatment medical/interventional treatment questions develop recommendations are often unsuccessful.
of degenerative lumbar posed. Therefore, natural history questions have been
spondylolisthesis compared eliminated from this guideline.
to the natural history of the Medical/interventional treatment for
disease? degenerative lumbar spondylolisthesis, Maintained. An updated systematic review of
• What is the role of when the radicular symptoms of stenosis the literature yielded no studies to adequately
pharmacological treatment predominate, most logically should be address any of the medical/interventional treatment
in the management of similar to treatment for symptomatic questions posed (except for injections).
degenerative lumbar degenerative lumbar spinal stenosis.
spondylolisthesis? Work Group Consensus Statement There is insufficient evidence to make a
• What is the role recommendation for or against the use of
of physical therapy/ injections for the treatment of degenerative lumbar
exercise in the treatment spondylolisthesis.
of degenerative lumbar Grade of Recommendation: I (Insufficient
spondylolisthesis? Evidence)
•What is the role of
manipulation in the Maintained. Medical/interventional treatment for
treatment of degenerative degenerative lumbar spondylolisthesis, when
lumbar spondylolisthesis? the radicular symptoms of stenosis predominate,
•What is the role of most logically should be similar to treatment for
ancillary treatments such symptomatic degenerative lumbar spinal stenosis.
as bracing, traction, Work Group Consensus Statement
electrical stimulation and
transcutaneous electrical
stimulation (TENS) in the
treatment of degenerative
lumbar spondylolisthesis?
•What is the long-
term result of medical/
interventional management
of degenerative lumbar
spondylolisthesis?
• What is the role of
injections for the treatment
of degenerative lumbar
spondylolisthesis?
Surgical Treatment
Do surgical treatments Surgery is recommended for treatment of Not addressed in guideline update; the literature
improve outcomes in the patients with symptomatic spinal stenosis to address natural history is limited and efforts to
treatment of degenerative associated with low grade degenerative develop recommendations are often unsuccessful.
lumbar spondylolisthesis spondylolisthesis whose symptoms have Therefore, natural history questions have been
compared to the natural been refractory to a trial of medical/ eliminated from this guideline.
history of the disease? interventional treatment.

Does surgical Direct surgical decompression is Direct surgical decompression may be considered
decompression alone recommended for treatment of patients with for the treatment of patients with symptomatic spinal
improve surgical outcomes symptomatic spinal stenosis associated stenosis associated with low grade degenerative
in the treatment of with low grade degenerative lumbar lumbar spondylolisthesis whose symptoms have
degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional
spondylolisthesis compared been recalcitrant to a trial of medical/ treatment.
to medical/interventional interventional treatment. Grade of Recommendation: C
treatment alone or the Grade of Recommendation: I (Insufficient
natural history of the Evidence) There is insufficient evidence to make a
disease? recommendation for or against the use of indirect
Indirect surgical decompression is surgical decompression for the treatment of patients
recommended for treatment of patients with with symptomatic spinal stenosis associated with
symptomatic spinal stenosis associated low grade degenerative lumbar spondylolisthesis
with low grade degenerative lumbar whose symptoms have been recalcitrant to a trial of
spondylolisthesis whose symptoms have medical/interventional treatment.
been recalcitrant to a trial of medical/ Grade of Recommendation: I (Insufficient
interventional treatment. Evidence)

Evidence)
Does the addition of lumbar Surgical decompression with fusion is Surgical decompression with fusion is suggested for
fusion, with or without recommended for the treatment of patients the treatment of patients with symptomatic spinal
instrumentation, to surgical with symptomatic spinal stenosis and stenosis and degenerative lumbar spondylolisthesis
decompression improve degenerative lumbar spondylolisthesis to to improve clinical outcomes compared with
surgical outcomes in the improve clinical outcomes compared with decompression alone.
treatment of degenerative decompression alone. Grade of Recommendation: B
lumbar spondylolisthesis Grade of Recommendation: B
compared to treatment by For symptomatic single level degenerative
decompression alone? spondylolisthesis that is low-grade (<20%) and
without lateral foraminal stenosis, decompression
alone with preservation of midline structures
provides equivalent outcomes when compared to
surgical decompression with fusion.
Does the addition of lumbar Not addressed Surgical decompression with fusion, with or without
fusion, with or without instrumentation, is suggested to improve the
instrumentation, to surgical functional outcomes of single-level degenerative
decompression improve spondylolisthesis compared to medical/
surgical outcomes in the interventional treatment alone.
treatment of degenerative Grade of Recommendation: B
lumbar spondylolisthesis
compared to medical/ There is insufficient evidence to make a
interventional treatment recommendation for or against efficacy of surgical
alone? decompression with fusion, with or without
instrumentation, for treatment of multi-level
degenerative lumbar spondylolisthesis compared to
medical/interventional treatment alone.
Evidence)
Does the addition of The addition of instrumentation is The addition of instrumentation is suggested to
instrumentation to recommended to improve fusion rates in improve fusion rates in patients with symptomatic
decompression and patients with symptomatic spinal stenosis spinal stenosis and degenerative lumbar
fusion for degenerative and degenerative lumbar spondylolisthesis. spondylolisthesis.
lumbar spondylolisthesis Grade of Recommendation: B Grade of Recommendation: B
improve surgical
outcomes compared with The addition of instrumentation is The addition of instrumentation is not suggested
decompression and fusion not recommended to improve clinical to improve clinical outcomes for the treatment of
alone? outcomes for the treatment of patients patients with symptomatic spinal stenosis and
with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.
degenerative lumbar spondylolisthesis. Grade of Recommendation: B

How do outcomes of Because of the paucity of literature There is insufficient evidence to make a
decompression with addressing this question, the work group recommendation for or against the use of either
posterolateral fusion was unable to generate a recommendation decompression with posterolateral fusion or 360°
compare with those for to answer this question. fusion in the surgical treatment of patients with
360° fusion in the treatment degenerative lumbar spondylolisthesis.
of degenerative lumbar Grade of Recommendation: I (Insufficient
spondylolisthesis? Evidence)
Does 360° fusion with Not addressed No evidence was found to address this question.
decompression lead to Due to the paucity of literature addressing this
better outcomes versus question, the work group was unable to generate a
360° fusion without recommendation to answer this question.
decompression for
treatment of degenerative
Do flexible fusions improve Not addressed No evidence was found to address this question.
outcomes in the treatment Due to the paucity of literature addressing this
of degenerative lumbar question, the work group was unable to generate a
spondylolisthesis compared recommendation to answer this question.
to nonoperative treatment?
Does the use of Not addressed There is insufficient and conflicting evidence
interspinous spacers in the to make a recommendation for or against the
treatment of degenerative efficacy of interspinous spacers versus medical/
lumbar spondylolisthesis interventional treatment in the management of
improve outcomes degenerative lumbar spondylolisthesis patients.
compared to nonoperative Grade of Recommendation: I (Insufficient
treatment? Evidence)
What is the role of Reduction with fusion and internal fixation of There is insufficient evidence to make a
reduction (deliberate patients with low grade degenerative lumbar recommendation for or against the use of reduction
attempt to reduce via spondylolisthesis is not recommended to with fusion in the treatment of degenerative lumbar
surgical technique) with improve clinical outcomes. spondylolisthesis.
fusion in the treatment Grade of Recommendation: I (Insufficient Grade of Recommendation: I (Insufficient
of degenerative lumbar Evidence) Evidence)
spondylolisthesis?
For patients undergoing Not addressed Due to the paucity of literature addressing this
posterolateral fusion, does question, the work group was unable to generate a
the use of autogenous recommendation to answer this question.
bone graft improve surgical
outcomes compared to There is insufficient evidence to make a
those fused with bone graft recommendation for or against the use of
substitutes? autogenous bone graft or bone graft substitutes
in patients undergoing posterolateral fusion for
the surgical treatment of degenerative lumbar
spondylolisthesis.
Evidence)
Do minimally invasive Not addressed No evidence was found to assess the efficacy of
surgical treatments minimally invasive surgical techniques versus open
improve outcomes in the decompression alone in the surgical treatment of
treatment of degenerative degenerative lumbar spondylolisthesis.
lumbar spondylolisthesis
compared to: While both minimally invasive techniques and
a. conventional open open decompression and fusion, with or without
decompression instrumentation, demonstrate significantly improved
(laminectomy)? clinical outcomes for the surgical treatment of
b. conventional (open) degenerative lumbar spondylolisthesis, there is
lumbar decompression conflicting evidence which technique leads to better
and fusion, with or outcomes.
without instrumentation? Grade of Recommendation: I (Insufficient/
Conflicting Evidence)

What is the long-term Decompression and fusion is recommended Decompression and fusion may be considered as a
result (four+ years) of as a means to provide satisfactory long- means to provide satisfactory long-term results for
surgical management term results for the treatment of patients the treatment of patients with symptomatic spinal
of degenerative lumbar with symptomatic spinal stenosis and stenosis and degenerative lumbar spondylolisthesis.
spondylolisthesis? degenerative lumbar spondylolisthesis. Grade of Recommendation: C
Grade of Recommendation: C
Which patient-specific Not addressed There is insufficient evidence to make a
characteristics influence recommendation for or against the influence of a
outcomes (and prognosis) nonorganic pain drawing on the outcomes/prognosis
in the treatment (surgical of treatments for patients with degenerative lumbar
or any) of degenerative spondylolisthesis.
lumbar spondylolisthesis? Grade of Recommendation: I (Insufficient
Evidence)
recommendation regarding the influence of age
and three or more comorbidities on the outcomes
of patients undergoing treatment for degenerative

lumbar spondylolisthesis.
Evidence)
recommendation regarding the influence of
symptom duration on the treatment outcomes of
patients with degenerative lumbar spondylolisthesis.
Evidence)
recommendation regarding the influence of obesity
(BMI >30) and its impact on treatment outcomes in
patients with degenerative lumbar spondylolisthesis.
Evidence)
What is the effect of Not addressed There was no evidence found to address this
postsurgical rehabilitation question. Due to the paucity of evidence, a
including exercise, spinal recommendation cannot be made regarding the
mobilization/manipulation effect of postsurgical rehabilitation the outcomes
or psychosocial of patients undergoing surgical treatment for
interventions on outcomes degenerative lumbar spondylolisthesis.
in the management of
degenerative lumbar
spondylolisthesis
(compared to patients
who do not undergo
postsurgical rehabilitation)?
Value of Spine Care
What is the cost- Not addressed There was no evidence found to address this
effectiveness of the question. Due to the paucity of evidence, a
surgical treatment of recommendation cannot be made regarding the
degenerative lumbar cost-effectiveness of surgical treatment compared
spondylolisthesis to nonoperative treatment for the management of
compared to nonoperative patients with degenerative lumbar spondylolisthesis.
management (consider
with and without fusion
separately)?
What is the cost- Not addressed There is insufficient evidence to make a
effectiveness of minimal recommendation for or against the cost-
access-based surgical effectiveness of minimal access-based surgical
treatments of degenerative treatments compared to traditional open
lumbar spondylolisthesis surgical treatments for degenerative lumbar
compared to traditional spondylolisthesis.
open surgical treatments? Grade of Recommendation: I (Insufficient
Evidence)
IV. Definition of Degenerative Lumbar

Spondylolisthesis
Original Guideline Question:
What is the best working definition of degenerative
An acquired anterior displacement of one vertebra over the subjacent

vertebra, associated with degenerative changes, without an associated
disruption or defect in the vertebral ring. Maintained from original
guideline
The literature search revealed several reports that describe vari- Degenerative spondylolisthesis is an anatomic finding. The
ants of degenerative spondylolisthesis in which the degree of clinical symptoms of degenerative spondylolisthesis, however,
anterior displacement is measurably affected by the posture are varied. Patients with degenerative lumbar spondylolisthe-
and position of the patient. These observations on position de- sis can be asymptomatic. They can also present with back pain,
pendent deformities may have significant implications for the or with neurogenic claudication and/or radicular pain, with or
pathophysiology and natural history of degenerative spondy- without axial back pain. Therefore, the work group agreed upon
lolisthesis; however, no longitudinal studies have yet addressed this anatomic definition, but also evaluated the relevant litera-
this issue. ture inclusive of the variations of clinical presentation.
Definition for Degenerative Lumbar

Spondylolisthesis
V. Recommendations for Diagnosis and

Treatment of Degenerative Lumbar
Spondylolisthesis
A. Diagnosis and Imaging
What are the most appropriate historical and physical
examination findings consistent with the diagnosis of
degenerative lumbar spondylolisthesis?
In the absence of evidence to address this question, it is the work group’s

opinion that obtaining an accurate history and physical examination is
important for the diagnosis and treatment of patients with degenerative
lumbar spondylolisthesis. Formulating appropriate clinical questions is
essential to obtaining an accurate history that can be used in developing
a treatment plan for patients. Maintained from original guideline with minor
word modifications
In patients with imaging evidence of degenerative lumbar

spondylolisthesis, the following clinical characteristics have been reported:
asymptomatic with only occasional back pain; chronic low back pain with
or without radicular symptoms and with or without positional variance;
radicular symptoms with or without neurologic deficit, with or without
back pain; and intermittent neurogenic claudication. The summaries
below are provided as background support to help further define
the clinical characteristics that may be associated with a diagnosis of
degenerative lumbar spondylolisthesis.
Studies obtained from updated literature search: processes between the two groups were statistically significant
Chen et al1 conducted an age- and sex-matched case-control (p<0.05). Using multivariate logistic regression analysis, this
study to identify the predisposing factors of degenerative lum- study suggests that antero-inferior disc height and lumbar index
bar spondylolisthesis. A total of 66 women, aged 45 to 64 years, are independent variables of predisposing factors of degenera-
with a first time lumbar spondylolisthesis diagnosis were com- tive lumbar spondylolisthesis.
Recommendations for Diagnosis and Treatment
pared to 66 controls. A physiatrist confirmed the grade of the Pearson et al2 conducted a retrospective analysis of data from
of Degnerative Lumbar Spondylolisthesis
anterior displacement of the lumbar spine according to Neu- the Spine Patient Outcomes Trial (SPORT) to compare base-
man’s classification and assessed the anthropometric parameters line characteristics and the surgical and nonoperative outcomes
from the lateral view of L-spine radiograph and KUB, which in- between degenerative spondylolisthesis and spinal stenosis pa-
cluded angles of the lumbar and sacral spine. In the case group, tients. The degenerative spondylolisthesis cohort included 601
most parameters, including disc height, body height, and angles patients and the spinal stenosis cohort included 634 patients.
tended to be lower than those in the control group, whereas the Primary outcome measures included the SF-36 bodily pain,
length of the transverse process of L5 (TPL), the width of the physical function scores and the Oswestry Disability Index
transverse process of L5 (TPW) and TP-AREA were higher than (ODI). Comparison of baseline characteristics between the de-
the control group. The differences in disc height, lumbar index, generative spondylolisthesis and spinal stenosis groups revealed
sacral inclination angle, sacral horizontal angle and transverse statistically significant differences. The degenerative spondylo-
listhesis group included a higher proportion of women (69% Postacchini et al6 performed a retrospective study which
vs 39%, p<0.001) and was about 18 months older (66.1 vs 64.6 reported on the clinical features of 77 patients with degenera-
years, p<0.021) than the spinal stenosis group. Fewer degen- tive lumbar spondylolisthesis. Within these patients, 18% re-
erative spondyolisthesis patients reported heart (20% vs 26%, ported chronic low back pain as the only symptom; 12% had
p<0.021) or bowel (7% vs 14%, p<0.001) problems compared to lower extremity symptoms felt to be nonvertebral in origin (eg,
spinal stenosis patients, while more reported depression (16% hip arthritis) and reported no low back pain; 47% had radicular
vs. 11%, p<0.009). There were no significant differences on any symptoms and low back pain; and 23% reported only radicu-
of the primary (SF-36 BP, PF or ODI) or secondary (Stenosis lar symptoms. Radiculopathy presented as pain alone, pain and
Bothersome Index or Low Back Pain) outcome measures at sensory symptoms or pain and sensorimotor changes. Lasegue
baseline between the 2 diagnostic groups. In addition, degenera- test was negative in almost all cases. The most common neuro-
tive spondylolisthesis patients were found to have similar lev- logical signs were absent ankle jerks, weak extensor hallucis lon-
els of disability when compared to spinal stenosis patients. This gus (EHL), weak anterior tibialis or loss of knee jerk reflex. The
study suggests that degenerative spondylolisthesis patients tend- authors reviewed five clinical patterns and three radiographic
ed to be female, older, with more depression and similar levels of patterns as defined by Fitzgerald and MacNab. Clinical patterns
disability, but less heart and bowel problems when compared to included the following:
spinal stenosis patients. 1. no symptoms, occasional back pain;
2. chronic low back pain with no radicular symptoms;
Studies included in original guideline: 3. radicular symptoms with no root compression, with or
Cauchioux et al3 described a study in which the diagnostic without back pain;
evaluation of 26 patients with degenerative spondylolisthesis in- 4. radicular symptoms with neurologic deficit; or
cluded plain radiographs and myelography. The study included 5. intermittent claudication.
26 patients with nerve root compression secondary to degenera-
tive slip, with 80% reporting back pain, 46% reporting primary Radiological findings included slight central stenosis, lateral
chronic sciatica and 54% reporting primary neurogenic claudi- root canal stenosis or combined central and root canal stenosis.
cation. Sciatica tended to occur in older patients and neurogenic The authors concluded that degenerative lumbar spondylolis-
claudication in younger subjects. In critique of this study, this thesis is not always symptomatic. Patients may complain of low
is a characterization of a subset of patients with degenerative back pain, but the etiology is uncertain. Patients largely com-
lumbar spondylolisthesis referred for evaluation of neurologi- plain of radicular symptoms or intermittent claudication, which
cal symptoms. These data offer background for the neurological is secondary to an associated stenosis.
symptoms associated with degenerative lumbar spondylolisthe- Rosenberg et al7 conducted a retrospective study which char-
sis. acterized symptoms in 200 consecutive patients with degenera-
Fitzgerald et al4 conducted a study of 43 patients with symp- tive lumbar spondylolisthesis. Back, buttock or thigh pain were
tomatic spondylolisthesis which examined various parameters. the principal complaints in a large majority of patients. Of the
It is unclear if the patients represented a consecutive or noncon- 200 patients, 61 had leg symptoms. Some patients described gait
secutive series. In addition to a description of plain radiographic abnormalities. Seven patients had sacral nerve root symptoms.
findings of the spine, as well as concomitant hip arthritis, the au- Acute radiculopathy occurred in 19 instances and a disc hernia-
thors provided a detailed description of the presentation (symp- tion was confirmed on myelography. Symptoms included ach-
tom) pattern of the patients. In summary, they found that 34 ing, pulling, weakness, heaviness, numbness or burning. Lower
patients had back pain without leg pain and signs of nerve root extremity symptoms could be unilateral, bilateral or alternating.
compression, 5 cases with leg pain with or without back pain Neurogenic claudication was uncommon. Examination of the
with signs of nerve root compression and four cases in which pa- patients demonstrated that many were supple and able to touch
tients reported neurogenic claudication. As a diagnostic history toes, 10% had back spasms and 42% had neurologic deficits, pri-
and physical examination study, the study presents a spectrum marily L5 with decreased sensation in the lateral thigh or inabil-
of symptoms and signs in patients with degenerative lumbar ity to walk on heels. Atrophy occurred occasionally and 20% had
spondylolisthesis. altered deep tendon reflexes.
Matsunaga et al5 conducted a prospective observational Vogt et al8 described a retrospective, cross-sectional study of
study to determine the clinical course of nonsurgically man- 788 women greater than 65 years of age enrolled in the Study of
aged patients with degenerative spondylolisthesis as well as the Osteoporotic Fractures. The presence of olisthesis (degenerative
indications for surgery. A total of 145 nonsurgically managed spondylolisthesis and retrodisplacement) was defined as greater
patients with degenerative spondylolisthesis were examined an- than 3mm of translational change. Of the women enrolled in the
nually for a minimum of 10 years. Lumbar rheumatism, with or study, 29% had anterior olisthesis (degenerative spondylolisthe-
without pain in the lower extremities was a common complaint sis) and 14% had retrolisthesis. Ninety percent of degenerative
at initial examination. Conservative treatment for these patients spondylolisthesis and 88% of retrolisthesis occurred at one level.
consisted of brace wearing, use of antiiflammatory drugs and/ Prevalence was not associated with smoking status, diabetes or
or lumbar exercises. Twenty-nine (83%) of the 35 patients who oophorectomy. Unlike retrolisthesis, degenerative spondylolis-
had neurological symptoms, such as intermittent claudication or thesis was not associated with back pain. This study suggests that
vesicorectal disorder, at initial examination and refused surgical degenerative spondylolisthesis is relatively common in elderly
treatment experienced neurological deterioration. Caucasian women and does not correlate with back pain.
Future Directions For Research 7. Chen IR, Wei TS. Disc height and lumbar index as independent
The work group identified the following potential studies that predictors of degenerative spondylolisthesis in middle-aged
women with low back pain. Spine. 2009;34(13), 1402-1409.
would generate meaningful evidence to assist in identifying the
8. Elhawary Y, Azzazi A. Dynamic stabilization using X-stop vs.
most appropriate historical and physical examination findings trans-pedicular screw fixation in the treatment of lumbar canal
consistent with the diagnosis of degenerative lumbar spondylo- stenosis: Comparative study of the clinical outcome. Spine J.
listhesis: 2010;10(9)Supplement, S130.
9. Ferreiro Perez A, Garcia Isidro M, Ayerbe E, Castedo J, Jinkins
Recommendation #1: JR. Evaluation of intervertebral disc herniation and hypermobile
Sufficiently-powered observational studies evaluating the pre- intersegmental instability in symptomatic adult patients under-
dictive value of physical examination tests in diagnosing degen- going recumbent and upright MRI of the cervical or lumbosa-
erative lumbar spondylolisthesis. cral spines. Eur J Radiol. 2007;62(3):444-448.
10. Gilbert JW, Wheeler GR, Kreft MP, Upadhyay SP, Storey BB,
Spitalieri JR, Gibbs RA. Repeat upright positional magnetic
Recommendation #2: resonance imaging for diagnosis of disorders underlying
Large multicenter registry database studies are needed to better chronic noncancer lumbar pain. J Manipulative Physiol Ther.
understand the importance of certain patient characteristics or 2008;31(8):627-631.
clinical presentation associated with the diagnosis of degenera- 11. Glassman, SD, Carreon LY, Djurasovic M, Dimar JR, Johnson
tive lumbar spondylolisthesis. JR, Puno RM, Campbell MJ. Lumbar fusion outcomes stratified
by specific diagnostic indication. Spine J. 2009(1):13-21.
12. Helenius I, Remes V, Poussa M. Uninstrumented in situ fusion
References for high-grade childhood and adolescent isthmic spondylolis-
1. Chen, I.R, & Wei, TS. Disc height and lumbar index as indepen-
thesis: long-term outcome. Surgical technique. JBone Joint Surg
dent predictors of degenerative spondylolisthesis in middle-aged
Am. 2008;90(Suppl 2 Pt 1):145-152.
women with low back pain. Spine. 2009 Jun 1;34(13):1402-1409.
13. Huang KY, Lin RM, Lee YL, Li JD. Factors affecting disability
2. Pearson A, Blood E, Lurie J, Tosteson, T, Abdu WA, Hillibrand
and physical function in degenerative lumbar spondylolisthe-
A, Weinstein J Degenerative spondylolisthesis versus spinal ste-
sis of L4-5: evaluation with axially loaded MRI. Eur Spine J.
nosis: does a slip matter? Comparison of baseline characteristics
2009;18(12):1851-1857.
and outcomes (SPORT). Spine. 2010 Feb 1;35(3):298-305.
14. Huang TY, Lee KS, Tsai TH, Su YF, Hwang SL. Posterior
3. Cauchoix J, Benoist M, Chassaing V. Degenerative spondylolis-
epidural migration of sequestrated lumbar disc fragments into
thesis. Clin Orthop Relat Res. 1976(115):122-129.
the bilateral facet joints: Case report. Neurosurgery. 2011;69(5):
4. Fitzgerald JA, Newman PH. Degenerative spondylolisthesis. J
E1148-E1151.
Bone Joint Surg Br. 1976 May;58(2):184-192.
15. Hussain NS, Hanscom D, Oskouian RJ. Chyloretroperito-
5. Matsunaga S, Ijiri K, Hayashi K Nonsurgically managed patients
neum following anterior spinal surgery. J Neurosurg Spine.
with degenerative spondylolisthesis: a 10- to 18-year follow-up
2012;17(5):415-421.
study. J Neurosurg. 2000;93(Suppl):194–198.
16. Kalichman L, Hunter DJ. Diagnosis and conservative manage-
6. Postacchini F, Perugia D. Degenerative lumbar spondylolisthe-
ment of degenerative lumbar spondylolisthesis. Eur Spine J.
sis. Part I: Etiology, pathogenesis, pathomorphology, and clinical
2008;17(3):327-335.
features. Ital J Orthop Traumatol. 1991;17(2):165-173.
17. Karabekir HS, Atar EK, Yaycioglu S, Yildizhan A. Comparison
7. Rosenberg NJ. Degenerative spondylolisthesis. Predisposing fac-
of unilateral posterior lumbar interbody fusion and bilateral
tors. J Bone Joint Surg Am. 1975;57(4):467-474.
posterior interbody fusion with simple discectomy at degenera-
8. Vogt MT, Rubin D, Valentin RS, et al. Lumbar olisthesis and
tive disc herniations. Neurosciences., 2008;13(3):248-252.
lower back symptoms in elderly white women. The Study of
18. Korovessis P, Repantis T, Zacharatos S, Zafiropoulos A. Does
Osteoporotic Fractures. Spine. 1998;23(23):2640-2647.
Wallis implant reduce adjacent segment degeneration above
lumbosacral instrumented fusion? Eur Spine J. 2009:18(6):830-
Bibliography from updated literature search 840.
1. Bartynski WS, Petropoulou KA. The MR imaging features and 19. Lamberg T, Remes V, Helenius I, Schlenzka D, Seitsalo S, Pous-
clinical correlates in low back pain-related syndromes. Magnetic sa M. Uninstrumented in situ fusion for high-grade childhood
Reson Imaging Clinics N Am. 2007 May;15(2), 137-154. and adolescent isthmic spondylolisthesis: long-term outcome. J
2. Bolesta M J, Winslow L, Gill K. A comparison of film and Bone Joint Surg Am. 2007;89(3):512-518.
computer workstation measurements of degenerative spondy- 20. Lindley EM, McCullough MA, Burger EL, Brown CW, Patel VV.
lolisthesis: intraobserver and interobserver reliability. Spine. Complications of axial lumbar interbody fusion: Clinical article.
2010;35(13):1300-1303. J Neurosurg Spine. 2011;15(3): 273-279.
3. Cansever T, Civelek E, Sencer A, Karasu A, Turantan I. Inter- 21. Lindley EM, Sherman B, Ohnmeiss D, Zigler J, Kasow D, Jans-
mittent priapism in degenerative lumbar spinal stenosis: Case sen M, Patel VV. The positive predictive value of provocative
report. Turk Neurosurg. 2007;17(4):260-263. discography in artificial disc replacement. Spine J. 2010; SUPPL.
4. Carrino JA, Lurie JD, Tosteson ANA, Tosteson TD, Carragee (1), 68S-69S.
EJ, Kaiser J, Herzog R. Lumbar spine: Reliability of MR imaging 22. Ly JQ. Systematic Approach to Interpretation of the Lumbar
findings. Radiology. 2009;250(1):161-170. Spine MR Imaging Examination. Magnetic Reson Imaging Clin
5. Chad DA Lumbar Spinal Stenosis. Neurol Clin. 2007;25(2):407- N Am. 2007;15(2):155-166.
418. 23. Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S.
6. Chaput C, Padon D, Rush J, Lenehan E, Rahm M. The signifi- Preliminary results of a randomized, equivalence trial of fluoro-
cance of increased fluid signal on magnetic resonance imaging scopic caudal epidural injections in managing chronic low back
in lumbar facets in relationship to degenerative spondylolisthe- pain: Part 4--Spinal stenosis. Pain Physician. 2008;11(6):833-
sis. Spine. 2007;32(17):1883-1887. 848.
24. Martin BI, Mirza SK, Franklin GM, Lurie JD, MacKenzie TA, 29. Tanaka M, Shimizu H, Yato Y, Asazuma T, Nemoto K. Acute
Deyo RA. Hospital and surgeon variation in complications and pyogenic discitis in a degenerative intervertebral disc in an
repeat surgery following incident lumbar fusion for common adult. 2010 Aug 4;3:77-80.
degenerative diagnoses. Health Serv Res. 2013 Feb;48(1):1-25. 30. Wang J, Yang X. Age-related changes in the orientation of lum-
25. Maus, T Imaging the Back Pain Patient. Phys Med Rehabil Clin bar facet joints. Spine. 2009;34(17:E596-598.
N Am. 2010;21(4):725-766. 31. Watters WC 3rd, Bono CM, Gilbert TJ, Kreiner DS, Mazanec
26. Ozawa H, Kanno H, Koizumi Y, Morozumi N, Aizawa T, Kusak- DJ, Shaffer WO, et al. An evidence-based clinical guideline for
abe T, Itoi E. Dynamic changes in the dural Sac cross-sectional the diagnosis and treatment of degenerative lumbar spondylolis-
area on axial loaded MR imaging: Is there a difference between thesis. Spine J. 2009;9(7):609-614.
degenerative spondylolisthesis and spinal stenosis? Am J Neuro- 32. Yee A J, Yoo JU, Marsolais EB, Carlson G, Poe-Kochert C, Bohl-
rad. 2012;33(6), 1191-1197. man HH, Emery SE. Use of a postoperative lumbar corset after
27. Roy C, Chatterjee N. Does the diagnosis of spondylolisthesis lumbar spinal arthrodesis for degenerative conditions of the
matter? Pain Physician. 2012 May-June;15(3)E353. Chatterjee, spine. A prospective randomized trial. J Bone Joint Surg Am.
Nilay [added]. 2008;90(10):2062-2068.
28. Skowronski J, Wojnar J, Bielecki M. Interbody fusion and trans-
pedicular fixation in the treatment of spondylolisthesis. Ortop
Traumatol Rehabil. 2007;9(2):149-155.

What are the most appropriate diagnostic tests for
degenerative lumbar spondylolisthesis?
The lateral radiograph is the most appropriate, noninvasive test for

detecting degenerative lumbar spondylolisthesis. Maintained from original
guideline with minor word modifications
In the absence of reliable evidence, it is the work group’s opinion that the
lateral radiograph should be obtained in the standing position whenever
possible. New consensus statement
Study obtained from updated literature search: the relative value showed an ST of 5.9 ± 3.9% in standing flexion-
Cabraja et al1 analyzed the images of 100 symptomatic patients extension radiograph and 7.8 ± 5.4% in standing and recumbent
with low-grade spondylolisthesis who underwent surgical radiograph and also differed significantly (p = 0.008). The
fusion to test the hypothesis that in symptomatic patients, vertebral anterior translation was highest during flexion and
imaging in the standing and recumbent position that is done lowest during recumbent supine position. The measurement
as part of the routine diagnostics with CT and radiography of ST in the recumbent supine position showed an absolute
reveals a higher sagittal translation (ST) and sagittal rotation value of 4.6 ± 2.5 mm and differed significantly from ST in the
(SR) compared to lumbar flexion-extension radiographs in the standing flexion-extension position (p = 0.001) and standing
standing position. To determine the ST and SR in the standing and recumbent position (p = 0.045). The analysis of the relative
and recumbent position, the authors compared the images taken value showed an ST of 9.2 ± 5.7% in radiography in the flexion
in the recumbent position in the CT with images taken in the and recumbent spine position. This differed significantly from
standing position during the routine plain radiography. ST and standing flexion-extension (p = 0.0062), but did not reach the
SR were measured on the dynamic radiographs by subtraction level of significance when comparing the relative values with the
from flexion to extension; on the plain radiographs (standing standing and recumbent position (p = 0.062). The measurement
position) and on the CT (recumbent supine position) by of SR revealed no significant differences between standing
subtraction from plain standing position and supine recumbent flexion-extension, standing and recumbent position and flexion
position, respectively. Results indicated that the absolute values in a recumbent position; however there was at least a trend that
of measurement of ST differed significantly (p=0.001) with 2.3 ± standing flexion-extension evokes a greater SR than standing
1.5 mm in standing flexion-extension radiograph and 4.0 ± 2.0 and recumbent position (p = 0.051). The authors concluded
mm in the standing and recumbent radiograph. The analysis of that in symptomatic patients with a low-grade spondylolisthesis,
radiography in the standing and recumbent position evokes a tion of the presentation (symptom) pattern of the patients. In
greater ST than the standing flexion-extension radiograph in summary, they found that 34 patients had back pain without leg
most patients. In critique, it is unclear if these patients were pain and signs of nerve root compression, 5 cases with leg pain
consecutive and there was no subgroup analysis separating with or without back pain with signs of nerve root compression
the results of the 17 patients with isthmic spondylolisthesis and four cases in which patients reported neurogenic claudica-
patients. This study offers Level III diagnostic evidence that tion. As a diagnostic study, the primary imaging method was
for evaluation of ST in symptomatic patients with degenerative plain radiographs; however, plain myelography was also per-
spondylolisthesis, imaging in the standing and recumbent formed in 7 of the 9 patients with neurological symptoms. In
position appears to be more suitable than flexion-extension, critique of this study, one must presume that the patients were
while a pathological SR is better identified in flexion-extension not consecutively enrolled. The only two imaging methods used
radiographs in the standing position. were plain radiographs and myelography, which were not uni-
formly performed in all patients. This study provides Level III
Studies included in original guideline: diagnostic evidence that plain radiographs and myelography are
Brown et al2 reported findings from a retrospective study of pa- useful modalities with which to diagnose and evaluate degenera-
tients with degenerative spondylolisthesis, which examined a tive spondylolisthesis in the lumbar spine.
number of different parameters, including diagnostic features Kanayama et al5 conducted a case series of 19 patients with
on plain radiographs. These patients were selected from a review symptomatic degenerative lumbar spondylolisthesis who were
of 2,348 consecutive charts of patients with low back pain; 132 candidates for instrumented lumbar arthrodesis and decom-
(5.6%) had radiographic evidence of degenerative spondylolis- pression. Patients were assessed according to radiographic pa-
thesis. Of patients included in the study, 88 were female and 44 rameters including disc angle, range of motion (ROM), percent
were male. The average age was 63.5 years for the female group slip, percent posterior height, which were then compared with
and 65.2 years for the male group. Seventy-eight percent had distraction stiffness in the operating room. The authors conclud-
back pain with proximal leg referral lasting between one week ed that disc angle in flexion and ROM were highly correlated
and 40 years; 17% had instability symptoms (eg, catch in the with distraction stiffness. Patients with segmental kyphosis with
back, tiredness in back, inability to walk one hour, limitation of flexion showed lower stiffness compared to those with lordosis
forward bend, inability to lift weights, back pain with coughing in flexion. In critique of this study, it assessed an intraoperative
or sneezing, significant back pain with twisting). In critique, this and nonvalidated test. The clinical application of such a test re-
study does not present peer-reviewed data. There was no com- mains unknown. Although the study presents potential Level II
parison of diagnostic tests. As the study was performed in the diagnostic evidence, the authors failed to mention whether the
early 1980s, the primary radiographic modality was plain radio- patients were consecutively assigned, thus the study was down-
graphs. These data offer Level III diagnostic evidence that plain graded to Level III evidence. The study provides Level III diag-
radiographs are a useful test for identifying patients with degen- nostic evidence that standing flexion and extension radiographs
erative spondylolisthesis. are predictive of instability.
Cauchioux et al3 conducted a diagnostic evaluation on 26 Postacchini et al6 described a study of 77 patients with de-
patients with degenerative spondylolisthesis using plain radio- generative spondylolisthesis in which flexion-extension radio-
graphs and myelography. The study included 26 patients with graphs, CT and/or MRI, and myelography were obtained. The
nerve root compression secondary to degenerative slip, with 80% various findings were reported. Dynamic radiographs “showed
reporting back pain, 46% reporting chronic sciatica and 54% re- hypermobility of L4 in approximately half of the cases.” My-
porting neurogenic claudication. Sciatica tended to occur in the elography revealed neural structure compression in the spinal
older patient and neurogenic claudication in the younger sub- canal in all cases in which it was performed. (Note: myelogra-
jects. Myelography was performed in 17 patients to detect nerve phy may have only been performed if patients had neurologic
root/cauda equina compression. Although not supported by sta- symptoms.) CT was useful for assessing the facet joint. MRI, CT
tistical analysis, the authors claimed that lateral recess stenosis and myelography were useful in identifying stenosis in patients
was “most important.” In critique of this study, the authors did with neurological symptoms. In critique, the diagnostic stud-
not state whether patients were consecutively selected; thus, it ies were applied inconsistently across patients. Not all patients
was assumed that they were nonconsecutive patients. The study received all studies, preventing comparison between diagnostic
did not include comparison of diagnostic modalities. Admitted- modalities. This article presented comprehensive descriptions of
ly, in the mid to late 1970s, plain radiograph and myelography the findings with each of the diagnostic modalities. These data
were the most advanced imaging methods available. By default, offer Level III diagnostic evidence of the utility of dynamic ra-
they would have been considered gold standard diagnostic tests diographs, CT, MRI and myelography for evaluation of degen-
for degenerative spondylolisthesis and spinal stenosis. These erative spondylolisthesis.
data offer Level III diagnostic evidence that plain radiographs
and myelography are useful diagnostic tests for this disorder. The most appropriate, noninvasive test
Fitzgerald et al4 described a study of 43 patients with symp- for imaging the stenosis accompanying
tomatic spondylolisthesis. It is unclear if the patients represented
a consecutive or nonconsecutive series. In addition to a descrip- degenerative lumbar spondylolisthesis is
tion of plain radiographic findings of the spine, as well as con- MRI. Maintained from original guideline
comitant hip arthritis, the authors provided a detailed descrip- Work Group Consensus Statement
Based on NASS’ Clinical Guideline for Diagnosis and Treat- 64.7 years. Results indicated that in 12 patients (23.1%) in the
ment of Degenerative Lumbar Spinal Stenosis (2011)7, MRI is series, radiographic signs of degenerative lumbar spondylolis-
suggested as the most appropriate, noninvasive test to confirm thesis were present, and in 10 of these 12, the degenerative spon-
the presence of anatomic narrowing of the spinal canal or the dylolisthesis was not evident on the sagittal MRI; in 8 cases out
presence of nerve root impingement in patients with history of 12, degenerative spondylolisthesis was present at L4–L5, and
and physical examination findings consistent with degenera- in the remaining 4 cases at L3–L4. Among these 12 patients with
tive lumbar spinal stenosis (Grade B Recommendation). This radiographic signs of degenerative spondylolisthesis, the MRI
Work Group Consensus has been made with the understand- showed exaggerated fluid in the facet joints at the correspond-
ing that the symptoms of degenerative lumbar spondylolisthesis ing level in 8 patients (66%). Facet joint effusion was evident
are related to the presence of anatomic narrowing or nerve root on MRI (range 1.5–3mm) in 7 patients (13.4%), but no radio-
impingement, which are similar to imaging findings in lumbar graphic signs of corresponding lumbar instability were found.
spinal stenosis. Althogether, 15 patients (28.8%) presented with increased lum-
bar facet joint fluid on the axial T2 MRI. According to their con-
Facet joint effusion greater than 1.5mm clusions, the authors observed a statistical correlation between
on supine MRI may be suggestive of increased fluid in the lumbar facet joints on the supine axial T2
MRI and degenerative spondylolisthesis seen on standing lateral
the presence of degenerative lumbar flexion–extension lumbosacral radiographs. In critique of this
spondylolisthesis. Further evaluation for study, the investigators did not incorporate a blinded evaluation,
the presence of degenerative lumbar there was no control group of asymptomatic patients, and sta-
spondylolisthesis should be considered, tistical analysis comparing patients with degenerative spondylo-
including using plain standing radiographs. listhesis and increased facet fluid to those without degenerative
spondylolisthesis and increased facet fluid was not performed.
New recommendation statement This potential Level II study has been downgraded to level III
Grade of Recommendation: B due to these limitations. This study provides Level III diagnostic
evidence that increased facet fluid as seen on MRI may be asso-
Studies obtained from updated literature search: ciated with degenerative spondylolisthesis.
In a retrospective radiographic review, Chaput et al8 evaluated
the association between facet joint effusion seen on MRI and There is insufficient evidence to make a
spondylolisthesis seen on standing lateral flexion-extension recommendation for or against the utility of
(SLFE) radiographs in patients with degenerative spondylolis-
the upright seated MRI in the diagnosis of
thesis. A total of 193 patients were studied, including 139 with-
out degenerative spondylolisthesis and 54 with degenerative degenerative lumbar spondylolisthesis. New
spondylolisthesis. Degenerative spondylolisthesis was consid- recommendation statement
ered present if anterior translation of L4 on L5 was >5% on SLFE Grade of Recommendation: I (Insufficient
films. When reviewing radiographic indicators for degenera-
tive spondylolisthesis, degenerative spondylolisthesis patients Evidence)
were more likely to have synovial cysts (p<0.0001), higher os-
teoarthritis grade (p<0.0001) and larger effusions (p< 0.0001) Study obtained from updated literature search:
compared to nondiseased patients. After adjusting for age and Ferreiro-Perez et al10 evaluated the differences in imaging find-
osteoarthritis grade, every 1mm increase in effusion increased ings between recumbent and upright-sitting MRI of the cervical
the odds of having degenerative spondylolisthesis by 5.6 fold and lumbosacral spine. A total of 89 patients were included in
(OR=5.6). An effusion > 1.5mm was not found in the negative the analysis, including 45 lumbosacral spine patients and 44 cer-
degenerative spondylolisthesis group. Using facet effusion as the vical spine patients. When determining pathology, degenerative
only variable in univariate logistic regression, the probability of spondylolisthesis was seen in 13 patients, including 11 anterior
having spondylolisthesis when 1mm effusion was present on and 2 posterior. Anterior spondylolisthesis was only seen on the
MRI was 29.6%, 60.3% when 2mm of effusion was present and upright-sitting examination in 4 patients (31%). Anterior spon-
84.6% when 3mm of effusion was present. This study provides dylolisthesis was comparatively greater in degree on the upright-
seated study in 7 patients (54%). Posterior spondylolisthesis was
Level II diagnostic evidence that an effusion >1.5 mm is predic-

comparatively greater in degree on the recumbent examination
tive of degenerative spondylolisthesis and the increasing size of

the effusion may be correlated to the increased probability of in 2 patients (15%). The authors suggest that the upright-seated
degenerative spondylolisthesis. MRI was found to be superior to recumbent MRI. In critique
In a prospective diagnostic study, Caterini et al9 analyzed su- of this study, the sample size was small, it was unclear which
pine weight-bearing flexion–extension lumbosacral radiographs patients received which type of MRI and statistical analysis of re-
and lumbosacral MRI for 52 patients with low back pain and/ sults was not performed. Due to these limitations, this potential
or radiculopathy to determine the incidence of increased fluid Level III study has been downgraded to a Level IV. This study
in the lumbar facet joints seen on the supine axial T2 MRI and provides Level IV diagnostic evidence that upright-seated MRI
to evaluate whether this finding is correlated with radiographic may be superior to recumbent MRI of the spine in cases of an-
evidence of lumbar instability. The patients had a mean age of terior spondylolisthesis. The seated upright MRI may make an-
terior spondylolisthesis more visible when compared to supine Plain myelography or CT myelography are
MRI. useful studies to assess spinal stenosis
in patients with degenerative lumbar
spondylolisthesis especially in those who
recommendation for or against the use
have contraindications to MRI. Maintained
of axial loaded MRI to evaluate the dural
from original guideline
sac cross sectional area in patients with
degenerative lumbar spondylolisthesis Grade of Recommendation: B (Suggested)
and spinal stenosis. New recommendation
Studies included in original guideline:
statement Cauchioux et al3 conducted a diagnostic evaluation of 26 pa-
Grade of Recommendation: I (Insufficient tients with degenerative spondylolisthesis which included plain
radiographs and myelography. Specifically, the authors stated
Evidence)
that they made the diagnosis based on the “presence of a slip
of one vertebra on the vertebra below in the absence of a defect
Study obtained from updated literature search:
of the pars interarticularis.” The study included 26 patients with
Ozawa et al11 compared the dural sac cross sectional area
nerve root compression secondary to degenerative slip, with
(DCSA) in patients with degenerative spondylolisthesis versus
80% reporting back pain, 46% reporting chronic sciatica and
patients with spinal stenosis (without degenerative spondylolis-
54% reporting neurogenic claudication. Sciatica tended to occur
thesis) on axially loaded MR imaging. All patients had neuro-
in the older patient and neurogenic claudication in the younger
genic intermittent claudication and leg pain or numbness and
subject. Myelography was performed in 17 patients to detect
associated neurologic signs. Lumbar spinal canal narrowing was
nerve root/cauda equina compression. Although not supported
radiographically confirmed on cross-sectional imaging in all
by statistical analysis, the authors claimed that lateral recess ste-
patients. For the comparative analysis in this study, the patients
nosis was “most important.” In critique of this study, the authors
with >3mm spondylolisthesis were assigned to the degenerative
did not state whether patients were consecutively selected, thus
spondylolisthesis group, while the other patients were assigned
it was assumed that they were nonconsecutive patients. There
to the spinal stenosis group. A total of 88 patients were included
was no comparison of diagnostic modalities. Admittedly, in the
in the study, including 40 with degenerative spondylolisthesis
mid- to late-1970s, plain radiographs and myelography were
patients. All patients received MR imaging. After convention-
the most advanced imaging methods available. By default, they
al MR imaging, axial loading was applied by using an external
would have been considered gold standard diagnostic tests for
commercially available nonmagnetic compression device. The
degenerative spondylolisthesis and spinal stenosis. These data
DCSA was measured from the L2-3 to L5-S1 on the axial im-
offer Level III diagnostic evidence that plain radiographs and
age. The measurement was performed three times and the mean
myelography are useful diagnostic tests for this disorder.
value was calculated and used for analysis in this study. Results
Fitzgerald et al4 described a study of 43 patients with symp-
indicated that a >15-mm2 change in the DCSA was found in 8
tomatic spondylolisthesis. It is unclear if the patients represented
patients (16.7%) in the spinal stenosis group and 25 patients
a consecutive or nonconsecutive series. In addition to a descrip-
(62.5%) in the degenerative spondylolisthesis group. In the de-
tion of plain radiographic findings of the spine, as well as con-
generative spondylolisthesis group, patients with a >15-mm2
comitant hip arthritis, the authors provided a detailed descrip-
change had a significantly larger DCSA on conventional MR im-
tion of the presentation (symptom) pattern of the patients. In
aging (58 ± 26 mm2) than those with a <15 mm2 change (41 ±
summary, they found that 34 patients had back pain without leg
18 mm2) (p=0.028), while the axial loaded MR imaging showed
pain and signs of nerve root compression, five cases with leg pain
no significant difference between the patients with a >15 and a
with or without back pain with signs of nerve root compression,
<15-mm2 change in the DCSA (p =0.897). The authors conclude
and four cases in which patients reported neurogenic claudica-
that DCSA in patients with degenerative spondylolisthesis is
tion. As a diagnostic study, the primary imaging method was
more likely to be decreased by axial loading than in those with
plain radiographs. However, plain myelography was also per-
spinal stenosis. Axial loaded MRI may be a more useful tool for
formed in 7 of the 9 patients with neurological symptoms. In
the assessment of spinal canal narrowing in patients with degen-
critique of this study, one must presume that the patients were
erative spondylolisthesis than those with spinal stenosis without

not consecutively enrolled. The only 2 imaging methods used
spondylolisthesis. In critique, use of a 15mm2 criterion as sig-

were plain radiographs and myelography, which were not uni-
nificant change in DCSA is not a universally accepted diagnostic
formly performed in all patients. This study provides Level III
standard; therefore, this study has been downgraded from Level
diagnostic evidence that plain radiographs and myelography are
II to III. This study provides Level III diagnostic evidence that
useful modalities with which to diagnose and evaluate degenera-
axially loaded MRI may reveal more severe stenosis in patients
tive spondylolisthesis in the lumbar spine.
with degenerative spondylolisthesis than might be apparent on
Postacchini et al6 described a study of 77 patients with de-
conventional MRI.
generative spondylolisthesis in which flexion-extension radio-
graphs, CT and/or MRI, and myelography were obtained. The
various findings were reported. Dynamic radiographs “showed
hypermobility of L4 in approximately half of the cases.” My- In patients with degenerative lumbar
elography revealed neural structure compression in the spinal spondylolisthesis with associated
canal in all cases in which it was performed. (Note: myelogra-
phy may have only been performed if patients had neurologic
spinal stenosis for whom MRI is either
symptoms.) CT was useful for assessing the facet joint. MRI, CT contraindicated or inconclusive, CT
and myelography were useful in identifying stenosis in patients myelography is suggested as the most
with neurological symptoms. In critique, the diagnostic stud- appropriate test to confirm the presence of
ies were applied inconsistently across patients. Not all patients anatomic narrowing of the spinal canal or
received all studies, preventing comparison between diagnostic
modalities. This article presented comprehensive descriptions of
the presence of nerve root impingement.
the findings with each of the diagnostic modalities. These data New Consensus Statement
offer Level III diagnostic evidence of the utility of dynamic ra- Work Group Consensus Statement
diographs, CT, MRI and myelography for evaluation of degen-
erative spondylolisthesis.
Rosenberg et al12 conducted a retrospective study which
In patients with degenerative
characterized 200 consecutive patients with degenerative lum- spondylolisthesis with associated spinal
bar spondylolisthesis. This cohort contained a subgroup of 39 stenosis for whom MRI and CT myelography
patients with severe unremitting symptoms; 29 underwent my- are contraindicated, inconclusive or
elography and showed an hourglass constriction of the dura inappropriate, CT is suggested as the most
at the level of slippage. Seven patients also had a protrusion.
Surgical findings included absence of epidural fat, pale pulse-
appropriate test to confirm the presence of
less dura and decreased capacity of the spinal canal. In critique anatomic narrowing of the spinal canal or
of this study, data were collected retrospectively and tests were the presence of nerve room impingement.
not uniformly applied across patients. However, from the diag- New Consensus Statement
nostic perspective, this small subgroup of 29 patients provides a
consecutive series of patients that was retrospectively analyzed. Work Group Consensus Statement
These subgroup data provide Level II diagnostic evidence that
myelography is useful in identifying stenosis in patients with de- Based on NASS’ Clinical Guideline for Diagnosis and Treatment
generative spondylolisthesis and neurological symptoms. of Degenerative Lumbar Spinal Stenosis (2011)7, CT was demon-
Satomi et al13 reported findings from a retrospective case strated to be an effective diagnostic tool to detect degenerative
series of patients with degenerative spondylolisthesis who were lumbar spinal stenosis. As many patients included in the review
evaluated with CT myelography in order to plan the optimal had degenerative spondylolisthesis, it is logical to conclude that
surgical procedure. CT myelograms were compared with plain CT would be useful in this group as well. However, only one
radiographic myelograms to evaluate the sites of dural compres- disease-specific study was found, necessitating reference to the
sion. Patients who underwent anterior lumbar interbody fusion NASS Clinical Guideline on Lumbar Spinal Stenosis to support
(ALIF) were included in Group A. Patients were selected for this consensus statement.
the posterior decompression group (Group B) if their imaging
showed displacement at 2 or more discs, had CT myelographic Study included in original guideline:
findings indicating lateral stenosis or were deemed inappropri- Rothman et al14 conducted a retrospective review of the CT find-
ate candidates for ALIF due to age. Group A consisted of 27 pa- ings of 150 patients with degenerative spondylolisthesis. The au-
tients; discography was performed in 22. Based on the novel CT thors described the pathological findings, which included canal
myelogram classification used in the study, 38% of these patients stenosis, facet overgrowth, joint-capsule hypertrophy, ligamen-
had stage 3 stenotic changes. Group B consisted of 14 patients, tum flavum enlargement and gas within the facet joints. All pa-
5 of whom underwent fusion. Of these patients, 4 reported back tients were examined on GE 8800 CT scanners using axial scans
pain; neurogenic intermittent claudication was more severe in of 5mm-thick sections at every 3mm spacing (2mm overlap),
Group B. Discography was performed in 2 patients. Based on with sagittal and coronal reformats. The authors found only 19%
myelogram classification used in the study, 62% of these patients had subluxation greater than 6mm. Severe facet degeneration
had stage 3 stenotic changes. Stenosis over two disc space lev- with marked hypertrophy, erosive changes or gas within an ir-
regular joint was noted in 91 patients. Severe canal stenosis was

els was present in 92% of these patients. The authors concluded

that information on CT myelography was useful for identify- detected in 15 patients due to narrowing of the central canal
ing pathologic processes and for planning surgery. In critique secondary to a combination of subluxation, facet bony over-
of this study, the authors did not evaluate a list of diagnostic growth, joint-capsule hypertrophy, ligamentous hypertrophy,
criteria a priori. The authors failed to indicate whether patients bulging and end plate osteophyte formation. Foraminal stenosis
were selected consecutively. These data offer Level III diagnostic was observed in 38 patients. Anterior soft tissue bulge/hernia-
evidence that CT myelography is a useful imaging study for this tion of greater than 5mm was present in only three patients. The
disorder. authors concluded that CT is useful in evaluating the severity
of stenosis in patients with symptomatic degenerative spondylo-
listhesis. Stenosis is frequently secondary to soft tissue changes
and facet hypertrophy, and does not always correlate with the
severity of slip. In critique, this was a study of nonconsecutive 14. Rothman SL, Glenn WV, Jr., Kerber CW. Multiplanar CT in the
patients, radiological findings were not correlated with clinical evaluation of degenerative spondylolisthesis. A review of 150
signs or symptoms, and no gold standard was employed. The cases. Comput Radiol. Jul-Aug 1985;9(4):223-232.
data offers Level IV diagnostic evidence that CT is a useful mo-
dality in the diagnosis of stenosis in patients with degenerative Bibliography from updated literature search
spondylolisthesis. 1. Bagheri MH, Hosseini MM, Foroughi AA Pseudolisthesis sec-
ondary to small L5. Eur J Radiol. 2011;80(3):802-804.
2. Been E, Li L, Hunter DJ, Kalichman L. Geometry of the ver-
Future Directions for Research tebral bodies and the intervertebral discs in lumbar segments
The work group recommends prospective, appropriately pow- adjacent to spondylolysis and spondylolisthesis: Pilot study. Eur
ered studies to better assess the utility of supine recumbent, axial Spine J. 2011;20(7):1159-1165.
loaded and positional MRI in the detection and evaluation of 3. Boden SD. Spinescope. Semin Spine Surg. 2011;23(2):151-156.
stenosis in the setting of degenerative lumbar spondylolisthesis. 4. Bolesta MJ, Winslow L, Gill K. A comparison of film and
computer workstation measurements of degenerative spondy-
lolisthesis: intraobserver and interobserver reliability. Spine.
References 2010;35(13):1300-1303.
1. Cabraja M, Mohamed E, Koeppen D, Kroppenstedt S. The anal-
5. Bourassa-Moreau E, Mac-Thiong JM, Labelle H. Redefining the
ysis of segmental mobility with different lumbar radiographs in
technique for the radiologic measurement of slip in spondylolis-
symptomatic patients with a spondylolisthesis. Eur Spine J. 2012
thesis. Spine. 2010;35(14):1401-1405.
Feb;21(2):256-61.
6. Carreon LY, Djurasovic M, Canan CE, Burke LO, Glassman SD.
2. Brown MD, Lockwood JM. Degenerative spondylolisthesis.
SF-6D values stratified by specific diagnostic indication. Spine.
Instr Course Lect. 1983;32:162-169.
2012;37(13):E804-E808.
3. Cauchoix J, Benoist M, Chassaing V. Degenerative spondylolis-
7. Carrino JA, Lurie JD, Tosteson ANA, Tosteson TD, Carragee
thesis. Clin Orthop Relat Res. Mar-Apr 1976(115):122-129.
EJ, Kaiser J, Herzog R. Lumbar spine: Reliability of MR imaging
4. Fitzgerald JA, Newman PH. Degenerative spondylolisthesis. J
findings. Radiology. 2009;250(1):161-170.
Bone Joint Surg Br. May 1976;58(2):184-192.
8. Chen IR, Wei TS. Disc height and lumbar index as independent
5. Kanayama M, Hashimoto T, Shigenobu K, Oha F, Ishida T,
predictors of degenerative spondylolisthesis in middle-aged
Yamane S. Intraoperative biomechanical assessment of lumbar
women with low back pain. Spine. 2009;34(13): 1402-1409.
spinal instability: validation of radiographic parameters indicat-
9. Don AS, Robertson PA. Facet joint orientation in spondylolysis
ing anterior column support in lumbar spinal fusion. Spine. Oct
and isthmic spondylolisthesis. J Spinal Disord Tech. 2008;21(2),
15 2003;28(20):2368-2372.
112-115.
6. Postacchini F, Perugia D. Degenerative lumbar spondylolisthe-
10. Hasegawa K, Kitahara K, Hara T, Takano K, Shimoda H, Hom-
sis. Part I: Etiology, pathogenesis, pathomorphology, and clini-
ma T. Evaluation of lumbar segmental instability in degenerative
cal features. Ital J Orthop Traumatol. Jun 1991;17(2):165-173.
diseases by using a new intraoperative measurement system. J
7. North American Spine Society. Diagnosis and Treatment of
Neurosur Spine. 2008;8(3):255-262.
Degenerative Lumbar Spinal Stenosis: Evidence-Based Clinical
11. Hasegawa K, Shimoda H, Kitahara K, Sasaki K, Homma T.
Guidelines for Multidisciplinary Spine Care. 2011. Burr Ridge,
What are the reliable radiological indicators of lumbar segmen-
IL. Available at: https://www.spine.org/Documents/Research-
tal instability? J Bone Joint Surg Br. 2011 May;93(5):650-657.
ClinicalCare/Guidelines/LumbarStenosis.pdf
12. Huang KY, Lin RM, Lee YL., Li JD. Factors affecting disability
8. Chaput C, Padon D, Rush J, Lenehan E, Rahm M. The signifi-
and physical function in degenerative lumbar spondylolisthe-
cance of increased fluid signal on magnetic resonance imaging
sis of L4-5: evaluation with axially loaded MRI. Eur Spine J.
in lumbar facets in relationship to degenerative spondylolisthe-
2009;18(12):1851-1857.
sis. Spine 2007;32(17):1883-1887.
13. Kalpakcioglu B, Altinbilek T, Senel K. Determination of spon-
9. Caterini R, Mancini F, Bisicchia S, Maglione P, Farsetti P. The
dylolisthesis in low back pain by clinical evaluation. J Back
correlation between exaggerated fluid in lumbar facet joints and
Musculoskelet Rehabil. 2009;22(1):27-32.
degenerative spondylolisthesis: prospective study of 52 patients.
14. Kang CH, Shin MJ, Kim SM, Lee SH, Lee CS. MRI of para-
J Orthop Traumatol. 2011 Jun;12(2):87-91.
spinal muscles in lumbar degenerative kyphosis patients and
10. Ferreiro Perez A, Garcia Isidro M, Ayerbe E, Castedo J, Jinkins
control patients with chronic low back pain. Clin Radiol.
JR. Evaluation of intervertebral disc herniation and hypermobile
2007;62(5):479-486.
intersegmental instability in symptomatic adult patients under-
15. Kim KS, Chin DK, Park JY. Herniated nucleus pulposus in
going recumbent and upright MRI of the cervical or lumbosa-
isthmic spondylolisthesis: Higher incidence of foraminal and
cral spines. Eur J Radiol. 2007;62(3):444-448.
extraforaminal types. Acta Neurochir. 2009;151(11):1445-1450.
11. Ozawa H, Kanno H, Koizumi Y, Morozumi N, Aizawa T, Kusak-
16. Lee JY, Hohl JB, Fedorka CJ, Devin C, Brodke DS, Branch Jr,
abe T, Itoi E. Dynamic changes in the dural sac cross-sectional
CLJ, Vaccaro AR. Surgeons agree to disagree on surgical options

area on axial loaded MR imaging: is there a difference between
for degenerative conditions of the cervical and lumbar spine.
degenerative spondylolisthesis and spinal stenosis? AJNR Am J
Spine. 2011;36(3):E203-E212.
Neuroradiol. 2012;33(6):1191-1197.
17. Mariconda M, Galasso O, Imbimbo L, Lotti G, Milano C. Rela-
12. Rosenberg NJ. Degenerative spondylolisthesis. Predisposing
tionship between alterations of the lumbar spine, visualized with
factors. J Bone Joint Surg Am. Jun 1975;57(4):467-474.
magnetic resonance imaging, and occupational variables. Eur
13. Satomi K, Hirabayashi K, Toyama Y, Fujimura Y. A clinical
Spine J. 2007;16(2):255-266.
study of degenerative spondylolisthesis. Radiographic analysis
18. Maus T. Imaging the Back Pain Patient. Phys Med Rehabil Clin
and choice of treatment. Spine. Nov 1992;17(11):1329-1336.
N Am. 2010;21(4):725-766.
19. Pearson A, Blood E, Lurie J, Tosteson T, Abdu WA, Hillibrand the diagnosis and treatment of degenerative lumbar spondylolis-
A, Weinstein J. Degenerative spondylolisthesis versus spinal ste- thesis. Spine J. 2009;9(7):609-614.
nosis: does a slip matter? Comparison of baseline characteristics 21. Yao Q, Wang S, Shin JH, Li G, Wood KB. Lumbar facet joint
and outcomes (SPORT). Spine. 2010;35(3):298-305. motion in patients with degenerative spondylolisthesis. J Spinal
20. Watters WC 3rd, Bono CM, Gilbert TJ, Kreiner DS, Mazanec Disord Tech. 2013;26(1):E19-E27.
DJ, Shaffer WO, et al. An evidence-based clinical guideline for
New Guideline Question:

What are the most appropriate diagnostic
or physical exam tests consistent with the
diagnosis of fixed versus dynamic deformity?
There is insufficient evidence to make a recommendation on the most

appropriate diagnostic or physical exam test consistent with fixed or
dynamic deformity in degenerative lumbar spondylolisthesis patients due
to the lack of uniform reference standards which define instability.
There is no universally accepted standard to diagnose fixed versus

dynamic spondylolisthesis. To evaluate instability, many studies employ
the use of lateral flexion extension radiographs, which may be done in the
standing or recumbent position; however, there is wide variation in the
definition of instability. To assist the readers, the definitions for instability
(when provided) in degenerative spondylolisthesis patients, are bolded
below.
Grade of Recommendation: I (Insufficient Evidence)
In a prospective diagnostic study, Caterini et al1 analyzed su- lumbar instability were found. Altogether, 15 patients (28.8%)
pine weight-bearing flexion–extension lumbosacral radiographs presented with increased lumbar facet joint fluid on the axial
and lumbosacral MRI for 52 patients with low back pain and/or T2 MRI. The authors observed a statistical correlation between
radiculopathy to determine the incidence of increased fluid in increased fluid in the lumbar facet joints on the supine axial T2
the lumbar facet joints seen on the supine axial T2 MRI and to MRI and degenerative spondylolisthesis seen on standing lateral
evaluate whether this finding is correlated with radiographic ev- flexion–extension lumbosacral radiographs. In critique of this
idence of lumbar instability. The patients had a mean age of 64.7 study, the investigators did not incorporate a blinded evaluation,
years. Degenerative spondylolisthesis was considered posi- there was no control group of asymptomatic patients and sta-
tive when the vertebral slippage was greater than 4.5 mm or tistical analysis comparing patients with degenerative spondylo-
greater than 15% of the width of the vertebral body on flexion listhesis and increased facet fluid to those without degenerative
x-rays. In 12 patients (23.1%) in the series, radiographic signs of
spondylolisthesis and increased facet fluid was not performed.
degenerative lumbar spondylolisthesis were present, and in 10 This potential Level II study has been downgraded to III due
of these 12, the degenerative spondylolisthesis was not evident to these limitations. This study provides level III diagnostic evi-
on the sagittal MRI. In 8 cases out of 12, degenerative spondy- dence that increased facet fluid may be associated with degen-
lolisthesis was present at L4–L5, and in the remaining 4 cases at erative spondylolisthesis on lateral plain films even when not
L3–L4. Among these 12 patients with radiographic signs of de- evident on MRI.
generative spondylolisthesis, the MRI showed exaggerated fluid In a retrospective radiographic review, Chaput et al2
in the facet joints at the corresponding level in 8 patients (66%). evaluated the association between facet joint effusion found on
Facet joint effusion was evident on MRI (range 1.5–3mm) in 7 MRI and spondylolisthesis found on standing lateral flexion-
patients (13.4%), but no radiographic signs of corresponding extension (SLFE) radiographs in patients with degenerative
spondylolisthesis. A total of 193 patients were studied, including joints were analyzed for the amount of facet fluid using the im-
139 without degenerative spondylolisthesis and 54 with age showing the widest portion of the facets. The facet fluid in-
degenerative spondylolisthesis. Degenerative spondylolisthesis dex was calculated from the ratio of the sum of the amounts of
was considered present if anterior translation of L4 on L5 was facet fluid found in the right plus left facets over the sum of the
>5% on SLFE films. When reviewing radiographic indicators for average widths of the right plus left facet joints. Facet fluid was
degenerative spondylolisthesis, it was found that degenerative noted on MR images in 29 of 54 patients (53.7%) with a mean
spondylolisthesis patients were more likely to have synovial DMI of 6.349 ± 2.726. Patients without facet fluid on MR imag-
cysts (p<0.0001), higher osteoarthritis grade (p<0.0001) and ing had a mean DMI of 1.542 ± 0.820. The difference between
larger effusions (p< 0.0001) compared to nondiseased patients. the mean DMI’s of patients with and without facet fluid on MR
After adjusting for age and osteoarthritis grade, every 1mm imaging was statistically significant (p < 0.001). In the patients
increase in effusion increased the odds of having degenerative who exhibited facet fluid on MRI, there was a positive linear as-
spondylolisthesis by 5.6 fold (OR=5.6). An effusion > 1.5mm sociation between the facet fluid index and DMI (Pearson corre-
was not found in the negative degenerative spondylolisthesis lation coefficient 0.560, p < 0.01). In the subgroup of 29 patients
group, and the authors suggest that an effusion > 1.5mm is with L4–5 DS and facet fluid on MR images, flexion-extension
highly predictive of degenerative spondylolisthesis. Using facet plain radiographs showed anterolisthesis in 10 (34.5%) patients,
effusion as the only variable in univariate logistic regression, but corresponding MR images did not show anterolisthesis. The
the probability of having spondylolisthesis when 1mm effusion authors conclude that there is a linear correlation between the
was present on MRI was 29.6%, 60.3% when 2mm of effusion degree of segmental motion seen on flexion-extension plain
was present and 84.6% when 3mm of effusion was present. radiography in patients with DS at L4–5 and the amount of
This study provides Level II diagnostic evidence that there is a L4–5 facet fluid on MR images. If L4–5 facet fluid is seen on
probability of progressive spondylolisthesis with increasing facet MR images in DS patients, a corresponding anterolisthesis on
joint effusion size, even if spondylolisthesis is not evident on weight-bearing flexion-extension lateral radiographs should also
supine MRI. MRI findings of large facet effusion and synovial been seen. In critique of this study, it is unclear whether the pa-
cysts are suggestive of degenerative spondylolisthesis. tients included were consecutive. This study provides Level III
Hammouri et al3 conducted a retrospective radiographic diagnostic evidence that when facet fluid is present, the use of
review to assess use of lateral dynamic flexion-extension radio- weight-bearing flexion-extension plain radiography will prevent
graphs in the initial evaluation of patients with degenerative the clinician from missing the anterior slippage caused by a hy-
lumbar deformities. Anteroposterior and lateral lumbar radio- permobile segment of the lumbar spine not visualized on a su-
graphs were taken with the patients in their natural posture. pine MR image.
Flexion and extension lumbar films were taken by asking the D’Andrea et al5 evaluated the use of the supine-prone posi-
patient to achieve his or her maximum effort at flexion and ex- tion in performing dynamic x-ray examination in patients with
tension in the standing position. The measurement of spondy- low grade spondylolisthesis. Segmental lumbar instability was
lolisthesis was made by determining the relative AP distance defined as translation movement exceeding 3 mm from flex-
between the posterior borders of adjacent vertebral bodies. A ion to extension and supine to prone. A total of 75 patients had
minimum measurement of 2mm was used to achieve this defi- a standard lateral x-ray films in the supine position, and then
nition. In review of the spondylolisthesis patients, 67 (20%) pain the prone position. At supine-prone examination, the authors
tients had anterolisthesis and 46 (13%) had retrolisthesis, includ- observed 46 patients with grade I spondylolisthesis versus only
ing 54% at L4-5 and 31% at L5-S1. Only 2 out of 342 patients had 32 positive cases at standard dynamic examination, 29 versus 24
new findings on flexion/extension not visible on anteroposterior grade I-II spondylolisthesis, and the 19 negative results, prior
and lateral lumbar radiographs. Fifteen patients had change in observed, disappeared. Nineteen patients had new diagnosis of
degree of listhesis with flexion/extension/ anteroposterior/lat- spondylolisthesis, 19 had higher grade of spondylolisthesis and
eral lumbar radiograph, without any change in their Meyerd- 56 had no change in diagnosis. In critique, it is unclear whether
ing grade. This study provides Level II diagnostic evidence that the patients were consecutive and how many patients had a di-
standing lateral extension films are not indicated in patients who agnosis of degenerative spondylolisthesis. This study provides
do not demonstrate a degenerative spondylolisthesis on stand- Level III diagnostic evidence that using the supine-prone posi-
ing radiograph. tion for performing a dynamic x-ray examination is simple, safe
Cho et al4 assessed the correlatation between the degree of and economically effective in diagnosis lumbar spinal instability
L4–5 spondylolisthesis on plain flexion-extension radiographs in patients with degenerative spondylolisthesis.
and the corresponding amount of L4–5 facet fluid visible on In a retrospective radiographic study, Lattig et al6 evaluated
MR images. Only patients diagnosed with L4–5 degenerative whether facet joint effusion seen on supine MRI was an indi-
spondylolisthesis (DS) and who had both lumbosacral flexion- cator of increased abnormal motion in patients with degenera-
extension radiographs and MR images available for review were tive spondylolisthesis and rotational translation. The sample
eligible for this study. The authors did not provide a specific defi- included 160 patients with degenerative spondylolisthesis and
nition for a positive diagnosis of degenerative spondylolisthesis. varying degrees of narrowing of the spinal canal who had under-
Dynamic motion index (DMI) was measured using the lateral gone decompression only or decompression with instrumented
lumbosacral plain radiograph and calculated as the percentage fusion. All patients had preoperative upright x-ray films in AP
of the degree of anterior slippage seen on flexion versus that seen and lateral views and supine MRI. A cut off value of >3% was
on extension. Axial T2-weighted MR images of the L4–5 facet arbitrarily chosen to represent the threshold for a real difference.
The imaging studies were assessed for the following parameters: downgraded from Level II to III. This study provides Level III
percent of slippage, absolute value of facet joint effusion, facet diagnostic evidence that axially loaded MRI may reveal more
angles, degree of facet degeneration and spinal canal central nar- severe stenosis in patients with degenerative spondylolisthesis
rowing, disc height, presence of facet cysts and the presence of than might be apparent on conventional MRI.
rotational translation in the AP x-ray study. Results indicated Tokuhashi et al8 analyzed the utility of the treadmill provoca-
that both mean and maximum facet joint effusion were signifi- tion test in evaluating clinical lumbar instability. A total of 82
cantly greater (p = 0.0001) in the group with >3% MRI–x-ray patients were included in the study, including 18 degenerative
slip difference than in the <3% group. In the group with <3% spondylolisthesis patients, 17 herniated lumbar disc patients, 10
MRI–x-ray slip difference, there was a significantly lower pro- isthmic spondylolisthesis patients and 37 canal stenosis patients.
portion of facet joint cysts (p = 0.045) and a lower mean facet The treadmill exercise began at a speed of 0.6 mile/hr and gradu-
joint angle (p = 0.04) compared to the group with >3% slip dif- ally accelerated up to 1.8 mile/hr at different rates depending
ference. According to findings, the extent of effusion correlated on the patient’s age and symptoms. The symptoms elicited by
significantly with the relative slippage difference between stand- the treadmill exercise, such as low-back pain, pain of the lower
ing and supine positions (r = 0.64, p<0.001). The extent of the extremities and intermittent claudication, were analyzed and di-
left/right difference in effusion was also found to be associated vided into groups. The 0 group had no symptoms after 10 min-
with the presence of rotational translation (RT 1.31 ± 0.8mm vs. utes; the 1+ group reproduced symptoms after treadmill exercise
no-RT 0.23 ± 0.17mm, p<0.0001). The authors suggest that in with the same distances of walking that formally elicited symp-
degenerative spondylolisthesis, facet joint effusion on MRI and toms on a flat road; the 2+ group reproduced symptoms after
reduction in slip between standing x-ray and supine MRI should far less exercise; and the 3+ group were unusually and severely
be used in surgical decision making. This study provides Level induced symptoms that had not occurred when the patient was
III diagnostic evidence that there is a significant correlation be- walking on a flat road. The authors utilized radiographs to com-
tween the extent of effusion of the facet joints on MRI and the pare the symptoms after treadmill exercise to the segmental ab-
difference in the degree of slippage between the standing and normality of the lumbar spine on radiographs. Results indicated
lying positions in patients with degenerative spondylolisthesis. that symptoms were elicited at a relatively higher rate in patients
Ozawa et al7 compared the dural sac cross sectional area with degenerative spondylolisthesis. The dynamic abnormality
(DCSA) in patients with degenerative spondylolisthesis and of segmental movement was evaluated as translational move-
spinal stenosis on axially loaded MR imaging. All patients had ment over 3mm anteriorly or posteriorly, or abnormal tilting
neurogenic intermittent claudication and leg pain or numbness movement on the flexion-extension radiograph. Patients with
with associated neurologic signs and had radiographically con- instability/movement on flexion-extension radiograph did not
firmed lumbar spinal canal narrowing on cross-sectional imag- correlate with treadmill provocation. The reproduction rates
ing. For the comparative analysis in this study, the patients of symptoms after treadmill exercise were more affected in the
with >3mm spondylolisthesis were assigned to the degenera- clinical symptomatic instability than in the findings of abnormal
tive spondylolisthesis group, while the other patients were as- structure or movement on the radiograph. In critique, this study
signed to the spinal stenosis group. A total of 88 patients were had a small sample size, it is unclear whether the patients were
included in the study, including 40 with degenerative spondy- consecutive and it’s important to note that this study is evalu-
lolisthesis patients. All patients received MR imaging. After ating clinical instability, not radiographic instability. This
conventional MR imaging, axial loading was applied by using study provides Level III diagnostic evidence that the treadmill
an external commercially available nonmagnetic compression provocation test can be useful in evaluating the lumbar spine.
device. The DCSA was measured from the L2/3 to L5/S1 on the Ferreiro-Perez et al9 evaluated the differences in imaging find-
axial image. The measurement was performed three times and ings between recumbent and upright-sitting MRI of the cervical
the mean value was calculated and used for analysis in this study. and lumbosacral spine. A total of 89 patients were included in
Results indicated that a >15mm2 change in the DCSA was found the analysis including, 45 lumbosacral spine patients and 44 cer-
in 8 patients (16.7%) in the spinal stenosis group and 25 patients vical spine patients. When determining pathology, degenerative
(62.5%) in the degenerative spondylolisthesis group. In the de- spondylolisthesis was seen in 13 patients, including 11 anterior
generative spondylolisthesis group, patients with a >15mm2 and 2 posterior; however, the authors’ definition of degenerative
change had a significantly larger DCSA on conventional MR spondylolisthesis was not provided. Anterior spondylolisthesis
imaging (58 ± 26 mm2) than those with a <15mm2 change (41 ± was only seen on the upright-sitting examination in 4 patients
18 mm2) (p=0.028), while the axial loaded MR imaging showed (31%). Anterior spondylolisthesis was comparatively greater in
no significant difference between the patients with a >15 and a degree on the upright-seated study in 7 patients (54%). Posterior
<15mm2 change in the DCSA (p=0.897). The authors conclude spondylolisthesis was comparatively greater in degree on the re-
that DCSA in patients with degenerative spondylolisthesis is cumbent examination in 2 patients (15%). The authors suggest
more likely to be decreased by axial loading than in those with that the upright-seated MRI was found to be superior to recum-
spinal stenosis and that axial loaded MRI may be a more useful bent MRI. In critique of this study, the sample size was small,
tool to provide valuable imaging findings for the assessment of it was unclear which patients received which type of MRI, and
spinal canal narrowing in patients with degenerative spondy- statistical analysis of results was not performed. Due to these
lolisthesis than those with spinal stenosis. In critique, use of a limitations, this potential Level III study has been downgraded
15mm2 criterion as significant change in DCSA is not a univer- to a Level IV. This study provides Level IV diagnostic evidence
sally accepted diagnostic standard; therefore, this study has been that upright-seated MRI may be superior to recumbent MRI of
the spine in cases of anterior spondylolisthesis. The seated up- had received laminectomy with or without fusion for progressed
right MRI may make anterior spondylolisthesis more visible degenerative spondylolisthesis, defined as slip percentage >10%
when compared to supine MRI; however, the significance of this at lateral flexion position with spinal canal stenosis, were includ-
finding is unclear. ed in the study. Sagittal plane unstable motion was defined
Friberg et al10 conducted a radiographic analysis to study the according to the criteria that translatory displacement was >
dynamic behavior of the lumbar spine segments when subject to 4mm (translatory hypermobility) or rotatory displacement
traction and compression. A total of 117 patients were included was >10° (rotatory hypermobility). The following 9 param-
in the study; however, only 7 patients had the diagnosis of degen- eters were investigated retrospectively as the candidate factors
erative spondylolisthesis. Patients were examined for segmental to determine whether the affected segments were restabilized or
translatory instability using a new method in which lateral spot not at the time of operation: age, sex, BMI, disc level, grade of
radiographs of the lumbosacral spine were taken during axial disc degeneration, grade of disc spur formation, facet effusion
traction and compression. Axial compression of the spine was size, length of facet spur formation and angle between facets.
brought about by positioning the patient to stand erect with a Radiographic measurements were taken by x-ray, CT and MRI.
sac filled with 20kg of sand. The lumbar spine was subjected to Multiple regression analysis for all candidate factors (except for
gravitational traction by patients suspended from a horizontal sex and disc level) indicated that translatory displacement signif-
bar. The compressive force consisted of the weight of the entire icantly correlated with facet effusion size positively (p < 0.001),
torso, compressive preloads, and the extra load of 20kg. During and that rotatory displacement significantly correlated with facet
the evaluation, every patient could carry the 20kg load without effusion size positively (p < 0.001) and with age (p = −0.042)
difficulty during the radiographic tests, but one female patient and grade of disc degeneration (p = −0.033) negatively. Logistic
was unable to hang from the bar because of a stiff and painful regression analysis for all candidate factors demonstrated that
shoulder. As a sign of instability, distinct movement was found increased facet effusion size (OR 1.656, 95% CI 1.182–2.321) was
in patient with degenerative spondylolisthesis of L4. The mean the only independent factor for the presence of unstable motion
amount of malalignment was 8mm (SD-1.3mm). The mean at the time of operation. This study provides Level IV diagnostic
amount of translatory movement at the spondylolisthetic evidence that facet effusion size is correlated to translational in-
level, measured on traction-compression radiography, was stability (translator displacement >4mm).
6.2mm (SD=1.7mm). In critique, the degenerative spondylo-
listhesis sample size was small, there was no clear comparison Future Directions For Research
with a control group and the gold standard of lateral flexion-ex- The work group identified the following potential studies that
tension x-ray films were not used. This potential Level III study would generate meaningful evidence to assist in defining the
provides Level IV diagnostic evidence that traction-compression most appropriate diagnostic or physical exam tests consistent
radiography of the lumbar spine can be used to assess for trans- with the diagnosis of fixed versus dynamic deformity in patients
lational instability. with degenerative lumbar spondylolisthesis:
McGregor et al11 conducted a radiographic study to investi-
gate patterns of intervertebral mobility (using flexion-extension Recommendation #1:
positions in open MRI) in subjects with spondylolisthesis to de- Future studies are needed to establish a consistent, universally
termine the level of spinal instability. In this case-control study, agreed upon reference standard for instability with a confirmed
29 patients, including 15 with a diagnosis of isthmic spondylo- validated clinical relevance.
listhesis and 14 with a diagnosis of degenerative spondylolisthe-
sis, were enrolled and compared with a preexisting database of Recommendation #2:
12 patients with no history of back pain (controls). The motion The diagnosis of instability needs to be further validated by cor-
characteristics of these patients in flexed and extended positions relation with symptom severity, prognosis and response to treat-
were investigated using open MRI of known precision. In all of ment.
the subjects, the level of resting pain, grade of slip, and level of
defect were evaluated. No mobility differences of angular or References
translatory motion were found between the spondylolisthesis 1. Caterini R, Mancini F, Bisicchia S, Maglione P, Farsetti P. The
(degenerative or isthmic) group and asymptomatic controls. It correlation between exaggerated fluid in lumbar facet joints and
is unclear how patients were recruited to this study and whether degenerative spondylolisthesis: Prospective study of 52 patients.
there was consecutive enrollment. The authors concluded that
J Orthop Traumatol. 2011;12(2):87-91.

there is no evidence to support that subjects with spondylolis- 2. Chaput C, Padon D, Rush J, Lenehan E, Rahm M. The signifi-
thesis will have an unstable spine. This study provides Level IV cance of increased fluid signal on magnetic resonance imaging
diagnostic evidence that the presence of degenerative spondylo- in lumbar facets in relationship to degenerative spondylolisthe-
sis. Spine. 2007;32(17):1883-1887.
listhesis does not lead to hypermobility. Additionally, this study
3. Hammouri QM, Haims AH, Simpson AK, Alqaqa A, Grauer
suggests that dynamic MRI may not be able to differentiate be- JN. The utility of dynamic flexion-extension radiographs in
tween dynamic and fixed deformity. the initial evaluation of the degenerative lumbar spine. Spine.
In a case-control study, Oishi et al12 assessed which factors 2007;32(21):2361-2364.
determined whether the involved disc levels were restabilized 4. Cho BY, Murovic JA, Park J. Imaging correlation of the degree
(from initial assessment to the time of surgery) or remained un- of degenerative L4-5 spondylolisthesis with the correspond-
stable at the time of operation in 195 consecutive Japanese pa- ing amount of facet fluid: Clinical article. J Neurosurg Spine.
tients with degenerative lumbar spondylolisthesis. Patients who 2009;11(5): 614-619.
5. D’Andrea G, Ferrante L, Dinia L, Caroli E, Orlando ER. “Supine- 11. Bjarke Christensen F, Stender Hansen E, Laursen M, Thomsen
prone” dynamic X-ray examination: new method to evaluate K, Bünger CE. Long-term functional outcome of pedicle screw
low-grade lumbar spondylolisthesis. J Spinal Disord Tech. instrumentation as a support for posterolateral spinal fusion:
2005;18(1):80-83. Randomized clinical study with a 5-year follow-up. Spine.
6. Lattig F, Fekete TF, Grob D, Kleinstück FS, Jeszenszky D, 2002;27(12):1269-1277.
Mannion AF Lumbar facet joint effusion in MRI: A sign 12. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2)133-137.
of instability in degenerative spondylolisthesis? Eur Spine J. 13. Bolesta MJ, Bohlman HH. Degenerative spondylolisthesis. Instr
2012;21(2):276-281. Course Lect. 1989;38:157-165.
7. Ozawa H, Kanno H, Koizumi Y, Morozumi N, Aizawa T, Kusak- 14. Bono CM, Lee CK. The influence of subdiagnosis on radio-
abe T, Itoi E. Dynamic changes in the dural sac cross-sectional graphic and clinical outcomes after lumbar fusion for degen-
area on axial loaded MR imaging: is there a difference between erative disc disorders: an analysis of the literature from two
degenerative spondylolisthesis and spinal stenosis? AJNR Am J decades. Spine 2005;30(2):227-234.
Neuroradiol. 2012;33(6):1191-1197. 15. Brown MD, Wehman KF, Heiner AD. The clinical useful-
8. Tokuhashi Y, Matsuzaki H, Sano S. Evaluation of clinical lumbar ness of intraoperative spinal stiffness measurements. Spine.
instability using the treadmill. Spine. 1993;18(15):2321-2324. 2002;27(9):959-961.
9. Ferreiro Perez A, Garcia Isidro M, Ayerbe E, Castedo J, Jinkins 16. Cansever T, Civelek E, Kabatas S, Ylmaz C, Caner H, Altinrs
JR. Evaluation of intervertebral disc herniation and hypermobile MN. Dysfunctional segmental motion treated with dynamic
intersegmental instability in symptomatic adult patients under- stabilization in the lumbar spine. World Neurosurg. 2011;75(5-
going recumbent and upright MRI of the cervical or lumbosa- 6):743-749.
cral spines. Eur J Radiol. 2007;62(3):444-448. 17. Carreon LY, Djurasovic M, Canan CE, Burke LO, Glassman SD.
10. Friberg O. Lumbar instability: A dynamic approach by traction- SF-6D values stratified by specific diagnostic indication. Spine.
compression radiography. Spine. 1987;12(2):119-129. 2012;37(13):E804-E808.
11. McGregor AH, Anderton L, Gedroyc WMW, Johnson J, Hughes 18. Cauchoix J, Benoist M, Chassaing V. Degenerative spondylolis-
SPF. The use of interventional open MRI to assess the kinemat- thesis. Clin Orthop Relat Res. 1976 Mar-Apr;(115):122-129.
ics of the lumbar spine in patients with spondylolisthesis. Spine. 19. Çavuşoǧlu, H., Türkmenoǧulu O, Kaya RA, Tuncer C, Çolak I,
2001;27(14):1582-1586. Şahin Y, Aydin Y. Efficacy of unilateral laminectomy for bilat-
12. Oishi Y, Murase M, Hayashi Y, Ogawa T, Hamawaki JI. Smaller eral decompression in lumbar spinal stenosis. Turk Neurosurg.
facet effusion in association with restabilization at the time of 2007;17(2):100-108.
operation in Japanese patients with lumbar degenerative spon- 20. Crawford CH, Smail J, Carreon LY, Glassman SD. Health-
dylolisthesis: Clinical article. J Neurosurg Spine. 2010;12(1):88- related quality of life after posterolateral lumbar arthrod-
95. esis in patients seventy-five years of age and older. Spine.
2011;36(13):1065-1068.
Bibliography 21. D’Andrea G, Ferrante L, Dinia L, Caroli E, Orlando ER.
1. Acosta FL Jr, Thompson TL, Campbell S, Weinstein PR, Ames “Supine-prone” dynamic X-ray examination: new method to
CP. Use of intraoperative isocentric C-arm 3D fluoroscopy for evaluate low-grade lumbar spondylolisthesis. J Spinal Disord
sextant percutaneous pedicle screw placement: Case report and Tech. 2005;18(1):80-83.
review of the literature. Spine J. 2005;5(3):339-343. 22. Dean, CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH.
2. Adachi K, Futami T, Ebihara A, Yamaya T, Kasai N, Nakazawa Degenerative spondylolisthesis of the cervical spine: analysis of
T, Imura T. Spinal canal enlargement procedure by restorative 58 patients treated with anterior cervical decompression and
laminoplasty for the treatment of lumbar canal stenosis. Spine J. fusion. Spine J. 2009;9(6), 439-446.
2003;3(6):471-478. 23. DeWald CJ, Vartabedian JE, Rodts MF, Hammerberg KW.
3. Aiki H, Ohwada O, Kobayashi H, Hayakawa M, Kawaguchi Evaluation and management of high-grade spondylolisthesis in
S, Takebayashi T, Yamashita T. Adjacent segment stenosis adults. Spine. 2005;30(6 Suppl):S49-59.
after lumbar fusion requiring second operation. J Orthop Sci. 24. Dimar JR, Djurasovic M, Carreon, LY. Surgical management of
2003;10(5):490-495. degenerative and postsurgical spondylolisthesis. Semin Spine
4. Atlas SJ, Delitto A. Spinal stenosis: Surgical versus nonsurgical Surg. 2005;17(3):186-194.
treatment. Clin Orthop Relat Res. 2006;(443):198-207. 25. Dong YL, Jung TG, Lee SH. Single-level instrumented mini-
5. Axelsson P, Johnsson R, Strömqvist B. Is there increased inter- open transforaminal lumbar interbody fusion in elderly
vertebral mobility in isthmic adult spondylolisthesis? A matched patients. J Neurosurg Spine. 2008;9(2):137-144.
comparative study using roentgen stereophotogrammetry. 26. Dupuis PR, Yong-Hing K, Cassidy JD, Kirkaldy-Willis WH.
Spine. 2000;25(13), 1701-1703. Radiologic diagnosis of degenerative lumbar spinal instability.
6. Baker ADL, Sanderson P. Spinal surgery in older people: Indica- Spine. 1985;10(3):262-276.
27. Elhawary Y, Azzazi A. Dynamic stabilization using X-stop vs.
tions, techniques and outcomes. Rev Clin Gerontol., 2011;21(4),
trans-pedicular screw fixation in the treatment of lumbar canal
277-285.
7. Bashir EF, Ajani O. (2012). Management of lumbar spine juxta- stenosis: Comparative study of the clinical outcome. Spine J.
facet cysts. World Neurosurg. 2012;77(1):141-146. 2010;10(9):S130.
8. Belfi LM, Ortiz AO, Katz DS. Computed tomography evalu- 28. Epstein NE. Evaluation of varied surgical approaches used in
ation of spondylolysis and spondylolisthesis in asymptomatic the management of 170 far-lateral lumbar disc herniations:
patients. Spine. 2006;31(24), E907-910. Indications and results. J Neurosurg. 1995;83(4):648-656.
9. Bendo JA, Ong B. Importance of correlating static and dynamic 29. Epstein NE. Primary fusion for the management of ‘unstable’
imaging studies in diagnosing degenerative lumbar spondylolis- degenerative spondylolisthesis. Neuro-Orthopedics. 1998;23(1-
thesis. Am J Orthop. 2001;30(3):247-250. 2):45-52.
10. Benini A, Plotz G. Reduction and stabilization without laminec- 30. Epstein NE. Lumbar Laminectomy for the Resection of
tomy for unstable degenerative spondylolisthesis: a preliminary Synovial Cysts and Coexisting Lumbar Spinal Stenosis or
report. Neurosurgery. 1995;37(4):843-844. Degenerative Spondylolisthesis: An Outcome Study. Spine.
2004;29(9):1049-1055. ing in lumbar degenerative diseases indicating segmental insta-

31. Epstein NE. An analysis of noninstrumented posterolateral bility: Clinical article. J Neurosurg Spine. 2010;12(6):687-693.
lumbar fusions performed in predominantly geriatric patients 51. Hasegawa K, Shimoda H, Kitahara K, Sasaki K, Homma T.
using lamina autograft and beta tricalcium phosphate. Spine J. What are the reliable radiological indicators of lumbar segmen-
2008;8(6):882-887. tal instability? J Bone Joint Surg Br. 2011 May;93(5):650-657.
32. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura 52. Hashimoto T, Oha F, Shigenobu K, Kanayama M, Harada M,
K, Yuan HA. Radiostereometric analysis of postoperative mo- Ohkoshi Y, Yamane S. Mid-term clinical results of Graf stabiliza-
tion after application of dynesys dynamic posterior stabilization tion for lumbar degenerative pathologies. a minimum 2-year
system for treatment of degenerative spondylolisthesis. J Spinal follow-up. Spine J. 2001;1(4):283-289.
Disord Tech., 2010;23(4):236-241. 53. Heo DH, Cho YJ, Cho SM, Choi HC, Kang SH. Adjacent seg-
33. Ferrari S, Costa F, Fornari M. Conservative treatment with ment degeneration after lumbar dynamic stabilization using
spontaneous stabilization of Grade II isthmic spondylolisthesis pedicle screws and a nitinol spring rod system with 2-year
L5/S1 in a forty-four-year old woman, with a six-year follow-up: minimum follow-up. J Spinal Disord Tech. 2012;25(8): 409-414.
a case report. Eur J Phys Rehabil Med., 2012;48(2):275-281. 54. Herkowitz HN, Abraham DJ, Albert TJ. Management of degen-
34. Fitzgerald JAW, Newman PH. Degenerative spondylolisthesis. J erative disc disease above an L5-S1 segment requiring arthrod-
Bone Joint Surg Br. 1976;58(2):184-192. esis. Spine. 199924(12):1268-1270.
35. Flynn JC, Hoque MA. Anterior fusion of the lumbar spine. End- 55. Hilibrand AS, Rand N. Degenerative lumbar stenosis: diagnosis
result study with long-term follow-up. J Bone Joint Surg Am. and management. J Am Acad Orthop Surg. 1999;7(4):239-249.
1979;61(8):1143-1150. 56. Hirabayashi S, Kumano K, Kuroki T. Cotrel-Dubousset pedicle
36. Fraser J, Gebhard, H., Irie, D., Parikh, K., & Härtl, R. Iso-C/3-di- screw system for various spinal disorders: Merits and problems.
mensional neuronavigation versus conventional fluoroscopy for Spine. 1991;16(11):1298-1304.
minimally invasive pedicle screw placement in lumbar fusion. 57. Hrabálek L, Wanek T, Adamus M. Treatment of Degenerative
Minim Invasive Neurosurg. 2010;53(4):184-190. Spondylolisthesis of the Lumbosacral Spine by Decompression
37. Friberg O. Lumbar instability: A dynamic approach by traction- and Dynamic Transpedicular Stabilisation. Acta Chir Orthop
compression radiography. Spine 1987;12(2):119-129. Traumatol Cech. 2011;78(5):431-436.
38. Fujiya M, Saita M, Kaneda K, Abumi K. Clinical study on 58. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob-
stability of combined distraction and compression rod instru- servation of the Dynesys neutralization system for the treatment
mentation with posterolateral fusion for unstable degenerative of degenerative disease of the lumbar vertebrae. Orthop Surg.
spondylolisthesis. Spine. 1990;15(11):1216-1222. 2011;3(3):167-175.
39. Gaetani P, Aimar E, Panella L, Levi D, Tancioni F, Di Leva A, 59. Huang KY, Lin RM, Lee YL, Li JD. Factors affecting disability
Rodriguez y Baena R. Functional disability after instrumented and physical function in degenerative lumbar spondylolisthe-
stabilization in lumbar degenerative spondylolisthesis: A follow- sis of L4-5: evaluation with axially loaded MRI. Eur Spine J.
up study. Funct. Neurol. 2006;21(1):31-37. 2009;18(12):1851-1857.
40. Gelalis ID, Kang JD. Thoracic and lumbar fusions for degenera- 60. Ibrahimi DM, Beaty NB, Crandall KM, Hamilton DK, Sansur
tive disorders: Rationale for selecting the appropriate fusion CA. A review of lumbar spondylolisthesis. Eur Musculoskel Rev.
techniques. Orthop Clin N Am. 1998;29(4):829-842. 2011;6(2):110-113.
41. Gertzbein SD, Seligman J, Holtby R, Chan KH, Kapasouri A, 61. Ido K, Urushidani H. Radiographic evaluation of posterolateral
Tile M, Cruickshank B. Centrode patterns and segmental insta- lumbar fusion for degenerative spondylolisthesis: long-term
bility in degenerative disc disease. Spine. 1985;10(3):257-261. follow-up of more than 10 years vs. midterm follow-up of 2-5
42. Ghiselli G, Wang JC, Hsu WK, Dawson EG. L5-S1 segment years. Neurosurg Rev. 2001;24(4):195-199.
survivorship and clinical outcome analysis after L4-L5 isolated 62. Ikuta K, Tono O, Oga M. Prevalence and clinical features of in-
fusion. Spine. 2003;28(12):1275-1280. traspinal facet cysts after decompression surgery for lumbar spi-
43. Glassman SD, Carreon LY, Djurasovic M, Dimar JR, Johnson JR, nal stenosis: Clinical article. J Neurosurg Spine. 2009;10(6):617-
Puno RM, Campbell MJ. Lumbar fusion outcomes stratified by 622.
specific diagnostic indication. Spine J. 2009;9(1):13-21. 63. Ito K. Reviewer’s comments concerning “biomechanical evalua-
44. Haberl H, Cripton PA, Orr TE, Beutler T, Frei H, Lanksch WR, tion of segmental instability in degenerative lumbar spondylolis-
Nolte LP. Kinematic response of lumbar functional spinal units thesis” by K. Hasegawa et al. (ESJO-D-08-00441R1). Eur Spine J.
to axial torsion with and without superimposed compression 2009;18(4):471-472.
and flexion/extension. Eur Spine J. 2004;13(6):560-566. 64. Iwamoto J, Takeda T. Effect of surgical treatment on physical ac-
45. Hahn F, Kissling R, Weishaupt D, Boos N. The extremes of tivity and bone resorption in patients with neurogenic intermit-
spinal motion: A kinematic study of a contortionist in an open- tent claudication. J Orthop Sci. 7(1):84-90.
configuration magnetic resonance scanner: Case report. Spine. 65. Jayakumar P, Nnadi C, Saifuddin A, Macsweeney E, Casey
2006;31(16):E565-E567. A. Dynamic degenerative lumbar spondylolisthesis: diag-
46. Hambly MF, Wiltse LL, Raghavan N, Schneiderman G, Koenig nosis with axial loaded magnetic resonance imaging. Spine.
C. The transition zone above a lumbosacral fusion. Spine. 2006;31(10):E298-301.

1998;23(16):1785-1792. 66. Jiang SD, Jiang LS, Dai LY. Degenerative cervical spondylolis-
47. Hanley Jr EN. The indications for lumbar spinal fusion with and thesis: a systematic review. Int Orthop. 2011;35(6):869-875.
without instrumentation. Spine. 1995;20(24 SUPPL.):143S-153S. 67. Jinkins JR. Acquired degenerative changes of the intervertebral
48. Hanley Jr EN. Indications for fusion in the lumbar spine. Bull segments at and supradjacent to the lumbosacral junction: A
Hosp Jt Dis. 1996;55(3):154-157. radioanatomic analysis of the discal and nondiscal structures
49. Hasegawa K, Kitahara K, Hara T, Takano K, Shimoda H, Hom- of the spinal column and perispinal soft tissues. Neuroradiol J.
ma T. Evaluation of lumbar segmental instability in degenerative 2002;15(4):359-392.
diseases by using a new intraoperative measurement system. J 68. Kalichman L, Hunter DJ. Diagnosis and conservative manage-
Neurosurg Spine. 2008;8(3):255-262. ment of degenerative lumbar spondylolisthesis. Eur Spine J.
50. Hasegawa K, Kitahara K, Shimoda H, Hara T. Facet joint open- 2008;17(3):327-335.
69. Kamioka Y, Yamamoto H. Lumbar trapezoid plate for lumbar 87. Lee SH, Lee JH, Hong SW, Shim CS, Chung SE, Yoo SH, Lee
spondylolisthesis. A clinical study on preoperative and postop- HY. Factors affecting clinical outcomes in treating patients with
erative instability. Spine. 1990;15(11):1198-1203. grade 1 degenerative spondylolisthesis using interspinous soft
70. Kanayama M, Hashimoto T, Shigenobu K, Oha F, Ishida T, stabilization with a tension band system: a minimum 5-year
Yamane S. Intraoperative biomechanical assessment of lumbar follow-up. Spine. 2012;37(7): 563-572.
spinal instability: Validation of radiographic parameters indicat- 88. Lee TC. Reduction and stabilization without laminectomy for
ing anterior column support in lumbar spinal fusion. Spine. unstable degenerative spondylolisthesis: a preliminary report.
2003;28(20):2368-2372. Neurosurgery. 1994;35(6):1072-1076.
71. Kaner T, Dalbayrak S, Oktenoglu T, Sasani M, Aydin AL, Ozer 89. Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lum-
AF. Comparison of posterior dynamic and posterior rigid bar spondylolysis: A review. Skeletal Radiol. 2011;40(6):683-700.
transpedicular stabilization with fusion to treat degenerative 90. Liao JC, Chen WJ, Chen LH, Niu CC. Outcome of the L5-S1
spondylolisthesis. Orthopedics. 2010;33(5). segment after posterior instrumented spinal surgery in degen-
72. Kang BU, Choi WC, Lee SH, Sang HJ, Jong DP, Dae HM, Choi erative lumbar diseases. Chang Gung Med J. 2009;32(1):81-88.
YG. An analysis of general surgery-related complications in a 91. Mahmud T, Basu D, Dyson PH. Crystal arthropathy of the
series of 412 minilaparotomic anterior lumbosacral procedures: lumbar spine: a series of six cases and a review of the literature. J
Clinical article. J Neurosurg Spine. 2009;10(1):60-65. Bone Joint Surg Br. 2005;87(4), 513-517.
73. Kauppila LI, Eustace S, Kiel DP, Felson DT, Wright AM. Degen- 92. Malter AD, McNeney B, Loeser JD, Deyo RA. 5-year reopera-
erative displacement of lumbar vertebrae: A 25-year follow-up tion rates after different types of lumbar spine surgery. Spine.
study in Framingham. Spine. 1998;23(17): 1868-1874. 1998;23(7):814-820.
74. Khan AM, Girardi F. Spinal lumbar synovial cysts. Diagnosis 93. Margulies JY, Seimon LP. Clinical efficacy of lumbar and lumbo-
and management challenge. Eur Spine J. 2006;15(8), 1176-1182. sacral fusion using the Boucher facet screw fixation technique.
75. Khan AM, Synnot K, Cammisa FP, Girardi FP. Lumbar synovial Bull Hosp Jt Dis. 2000;59(1): 33-39.
cysts of the spine: An evaluation of surgical outcome. J Spinal 94. Mariconda M, Fava R, Gatto A, Longo C, Milano C. Unilateral
DisordTech. 2005;18(2): 127-131. laminectomy for bilateral decompression of lumbar spinal
76. Kim SY, Maeng DH, Lee SH, Jang JS. Anterior lumbar interbody stenosis: a prospective comparative study with conservatively
fusion for lumbosacral junction in steep sacral slope. J Spinal treated patients. 2002 Feb;15(1):39-46.
Disord Tech. 2008;21(1), 33-38. 95. Markwalder TM. Surgical management of neurogenic claudica-
77. Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra tion in 100 patients with lumbar spinal stenosis due to degener-
in spinal tuberculosis. Eur Spine J. 2011;20(1):1-5. ative spondylolisthesis. Acta Neurochir. 1993;120(3-4):136-142.
78. Klopfenstein JD, Kim LJ, Feiz-Erfan I, Dickman CA. Retroperi- 96. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo
toneal approach for lumbar interbody fusion with anterolateral RA. Are lumbar spine reoperation rates falling with greater
instrumentation for treatment of spondylolisthesis and degen- use of fusion surgery and new surgical technology? Spine.
erative foraminal stenosis. Surg Neurol. 2006;65(2):111-116. 2007;32(19), 2119-2126.
79. Konno S, Kikuchi S. Prospective study of surgical treatment of 97. Mazzocchio R, Scarfò GB, Cartolari R, Bolognini A, Mariottini
degenerative spondylolisthesis: comparison between decom- A, Muzii VF, Palma L. Abnormalities of the soleus H-reflex in
pression alone and decompression with graf system stabiliza- lumbar spondylolisthesis: A possible early sign of bilateral S1
tion. Spine 2000;25(12):1533-1537. root dysfunction. J Spinal Disord. 13(6), 487-495.
80. Kristof RA, Aliashkevich AF, Schuster M, Meyer B, Urbach H, 98. McAfee PC, DeVine JG, Chaput CD, Prybis BG, Fedder I L,
Schramm J. Degenerative lumbar spondylolisthesis-induced Cunningham BW, Vigna FE. The indications for interbody fu-
radicular compression: Nonfusion-related decompression in sion cages in the treatment of spondylolisthesis: Analysis of 120
selected patients without hypermobility on flexion-extension cases. Spine. 2005;30(6 Suppl):S60-S65.
radiographs. J Neurosurg. 2002;97(3 SUPPL.):281-286. 99. McGregor AH, Cattermole HR, Hughes SPF. Global spinal
81. Kroppenstedt S, Gulde M, Schönmayr R. Radiological compari- motion in subjects with lumbar spondylolysis and spondylolis-
son of instrumented posterior lumbar interbody fusion with one thesis: Does the grade or type of slip affect global spinal motion?
or two closed-box plasmapore coated titanium cages: Follow-up Spine. 2001;26(3):282-286.
study over more than seven years. Spine. 2008;33(19):2083- 100. Métellus P, Fuentes S, Adetchessi T, Levrier O, Flores-Parra I,
2088. Talianu D, Grisoli F. Retrospective study of 77 patients har-
82. Kuroki H, Tajima N, &Kubo, S. Clinical results of posterolateral bouring lumbar synovial cysts: Functional and neurological
fusion for degenerative lumbar spinal diseases: A follow-up outcome. Acta Neurochir. 2006;148(1):47-54.
study of more than 10 years. J Orthop Sci. 2003;7(3), 317-324. 101. Miscusi M, Petrozza V, Polli FM, Forcato S, Rocca CD, Raco
83. Lawhorne III TW, Girardi FP, Mina CA, Pappou I, Cammisa A. Symptomatic ganglion cyst of ligamentum flavum as a
Jr FP Treatment of degenerative spondylolisthesis: Potential late complication of lumbar fixation. Neurol Neurochir Pol.
impact of dynamic stabilization based on imaging analysis. Eur 2012;46(1):82-86.
Spine J. 2009;18(6):815-822. 102. Molina M, Wagner P, Campos M Spinal lumbar stenosis. An

84. Lee SE, Park SB, Jahng TA, Chung CK, Kim HJ. Clinical experi- update. Rev Med Chil. 2011;139(11):1488-1495.
ence of the dynamic stabilization system for the degenerative 103. Moller J, Wittenberg RH, Nolte LP, Jergas M, Willburger R,
spine disease. J Kor Neurosurg Soc., 2008;43(5):221-226. Kramer J. Results of lumbosacral distraction spondylodesis for
85. Lee SH, Kang BU, Sang HJ, Jong DP, Dae HM, Choi YG, Choi the treatment of spondylolisthesis, failed-back syndrome, and
WC. Revision surgery of the lumbar spine: Anterior lumbar in- lumbar instability. Eur Spine J. 1992;1(2):117-124.
terbody fusion followed by percutaneous pedicle screw fixation. 104. Morishita Y, Ohta H, Naito M, Matsumoto Y, Huang G, Tatsumi
J Neurosurg Spine. 2006;5(3):228-233. M, Kida H. Kinematic evaluation of the adjacent segments
86. Lee SH, Lee JH, Hong SW, Chung SE, Yoo SH, Lee HY. Spi- after lumbar instrumented surgery: A comparison between
nopelvic alignment after interspinous soft stabilization with a rigid fusion and dynamic non-fusion stabilization. Eur Spine J.
tension band system in grade 1 degenerative lumbar spondylo- 2011;20(9):1480-1485.
listhesis. Spine. 2010;35(15):E691-701. 105. Murat Müslüman A, Cansever T, Yilmaz A, Çavuşoǧlu H, Yüce
I, Aydin Y. Midterm outcome after a microsurgical unilat- 123. Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz
eral approach for bilateral decompression of lumbar degen- PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Had-
erative spondylolisthesis: Clinical article. J Neurosurg Spine. ley MN; American Association of Neurological Surgeons Con-
2012;16(1):68-76. gress of Neurological Surgeons. Guidelines for the performance
106. Nagaosa Y, Kikuchi S, Hasue M, Sato S. Pathoanatomic mecha- of fusion procedures for degenerative disease of the lumbar
nisms of degenerative spondylolisthesis. A radiographic study. spine. Part 12: pedicle screw fixation as an adjunct to postero-
Spine. 1998;23(13):1447-1451. lateral fusion for low-back pain. J Neurosurg Spine. 2005;2(6):
107. Nakashima H, Sato K, Ando T, Inoh H, Nakamura H. Compari- 700-706.
son of the percutaneous screw placement precision of isocentric 124. Sachs BL, Zindrick MR, Beasley RD. Reflex sympathetic dystro-
C-arm 3-dimensional fluoroscopy-navigated pedicle screw im- phy after operative procedures on the lumbar spine. J Bone Joint
plantation and conventional fluoroscopy method with minimal- Surg Am. 1993;75(5):721-725.
ly Invasive Surgery. J Spinal Disord Tech. 2009;22(7):468-472. 125. Sandu N, Schaller B, Arasho B, Orabi M. Wallis interspinous
108. Nathan M, Keller TS. Measurement and analysis of the in implantation to treat degenerative spinal disease: Description of
vivo posteroanterior impulse response of the human thoraco- the method and case series. Expert Rev Neurother. 2011;11(6),
lumbar spine: A feasibility study. JManipulative Physiol Ther. 799-807. doi: 10.1586/ern.10.187
1994;17(7):431-441. 126. Sapkas GS, Mavrogenis AF, Themistocleous GS, Zachos VC,
109. Newman PH. Degenerative spondylolisthesis. Orthop Clin Kelalis G, Papagelopoulos PJ. Posterior lumbar interbody fusion
North Am. 1975;6(1):197-198. versus circumferential fusion using the B-Twin expandable
110. Nizard RS, Wybier M, Laredo JD. Radiologic assessment of lum- spinal system. J Long Term Eff Med Imp. 2007;17(3):217-227.
bar intervertebral instability and degenerative spondylolisthesis. 127. Schiffman M, Brau SA, Henderson R, Gimmestad G. Bilateral
Radiol Clin North Am. 2001;39(1):55-71. implantation of low-profile interbody fusion cages: subsidence,
111. Oh IS, Ha KY. Matrix metalloproteinase-3 on ligamentum lordosis, and fusion analysis. Spine J. 2003;3(5):377-387.
flavum in degenerative lumbar spondylolisthesis. Spine. 128. Sears W. Posterior lumbar interbody fusion for degenerative
2009;34(16):E552-557. spondylolisthesis: restoration of sagittal balance using insert-
112. Ohmori K, Suzuki K, Ishida Y. Translamino-pedicular screw and-rotate interbody spacers. Spine J. 2005;5(2):170-179.
fixation with bone grafting for symptomatic isthmic lumbar 129. Sienkiewicz PJ, Flatley TJ. Postoperative spondylolisthesis. Clin
spondylolysis. Neurosurgery. 1992;30(3):379-384. Orthop Relat Res. 1987 Aug;(220):172-180.
113. Ohtori S, Yamashita M, Inoue G, Yamauchi K, Koshi T, Suzuki 130. Sirvanci M, Ulusoy L, Duran C. Pedicular stress fracture in
M, Takahashi K. Rotational hypermobility of disc wedging using lumbar spine. Clin Imaging. 2002;26(3):187-193.
kinematic CT: Preliminary study to investigate the instability of 131. Soini J, Slatis P, Kannisto M, Sandelin J. External transpedicular
discs in degenerated scoliosis in the lumbar spine. Eur Spine J. fixation test of the lumbar spine correlates with the outcome
2010;19(6):989-994. of subsequent lumbar fusion. Clinical Orthop Relat Res. 1993
114. Panagiotis ZE, Athanasios K, Panagiotis D, Minos T, Charis M, Aug;(293):89-96.
Elias L.. Functional outcome of surgical treatment for multilevel 132. Song KJ, Lee KB. Spontaneous fusion of L5-S1 isthmic spondy-
lumbar spinal stenosis. Acta Orthop. 2006;77(4):670-676. lolisthesis. J Back Musculoskel Rehabil. 2007;20(4):177-179.
115. Park H, Zhang HY, Cho BY, Park JY. Change of lumbar motion 133. Sonntag VK, Marciano FF. Is fusion indicated for lumbar spinal
after multi-level posterior dynamic stabilization with bioflex sys- disorders? Spine. 1995;20(24 Suppl):138S-142S.
tem: 1 Year follow up. J Korean Neurosurg Soc. 2009;46(4):285- 134. Takahashi T, Hanakita J, Minami M, Kitahama Y, Kuraishi K,
291. Watanabe M, Uesaka T. Clinical outcomes and adverse events
116. Park JH, Hyun SJ, Roh SW, Rhim SC A comparison of unilateral following transforaminal interbody fusion for lumbar degenera-
laminectomy with bilateral decompression and fusion surgery in tive spondylolisthesis in elderly patients. Neurologia Med Chi.
the treatment of grade I lumbar degenerative spondylolisthesis. 2011;51(12), 829-835.
Acta Neurochir. 154(7), 1205-1212 135. Tarantino U, Fanucci E, Iundusi R, Celi M, Altobelli S, Gasbarra
117. Park Y, Ha JW, Lee YT, Sung NY. The effect of a radiographic E, Manenti G. Lumbar spine MRI in upright position for diag-
solid fusion on clinical outcomes after minimally invasive trans- nosing acute and chronic low back pain: Statistical analysis of
foraminal lumbar interbody fusion. Spine J. 2011;11(3):205-212. morphological changes. JOrthop Traumatol. 2013;14(1):15-22.
118. Piñera AR, Duran C, Lopez B, Saez I, Correia E, Alvarez L. doi:
Instrumented lumbar arthrodesis in elderly patients: prospective 136. Taylor JA, Bussières A. Diagnostic imaging for spinal disorders
study using cannulated cemented pedicle screw instrumenta- in the elderly: a narrative review. Chiropr Man Therap. 2012
tion. Eur Spine J. 2011;20 Suppl 3, 408-414. May 24;20:16.
119. Postacchini F, Cinotti G, Perugia D, Gumina S. The surgical 137. Tillich M, Trummer M, Lindbichler F, Flaschka G. Symptom-
treatment of central lumbar stenosis. Multiple laminotomy atic intraspinal synovial cysts of the lumbar spine: Correlation
compared with total laminectomy. J Bone Joint Surg Br. of MR and surgical findings. Neuroradiology 2001;43(12):1070-
1993;75(3):386-392. 1075.
120. Raley DA, Mobbs RJ. Retrospective computed tomography scan 138. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Mat-
analysis of percutaneously inserted pedicle screws for posterior suda H. Clinical outcome of microsurgical bilateral decompres-
transpedicular stabilization of the thoracic and lumbar spine: sion via unilateral approach for lumbar canal stenosis: Mini-
accuracy and complication rates. Spine. 2012;37(12):1092-1100. mum five-year follow-up. Spine. 2011;36(5):410-415.
121. Reddy SJ, Al-Holou WN, Leveque JC, La Marca F, Park P. Trau- 139. Tsai KH, Chang GL, Lin HT, Kuo DC, Chang LT, Lin RM. Dif-
matic lateral spondylolisthesis of the lumbar spine with a uni- ferences of lumbosacral kinematics between degenerative and
lateral locked facet: description of an unusual injury, probable induced spondylolisthetic spine. Clin Biomech. 2003;18(6):S10-
mechanism, and management. J Neurosurg Spine. 2009;9(6): S16.
576-580. 140. Tsutsumimoto T, Shimogata M, Yoshimura Y, Misawa H. Union
122. Resnick D. Degenerative diseases of the vertebral column. Radi- versus nonunion after posterolateral lumbar fusion: a compari-
ology. 1985;156(1):3-14. son of long-term surgical outcomes in patients with degenera-
tive lumbar spondylolisthesis. Eur Spine J. 2008;17(8):1107- patients for lumbar spinal fusion. Acta Orthop Suppl. 2013
1112. Feb;84(349):1-35.
141. Vaccaro AR, Whang PG, Patel T, Phillips FM, Anderson DG, 145. Wiltse LL, Guyer RD, Spencer CW, Glenn WV, Porter IS. Alar
Albert TJ, Fischgrund JS. The safety and efficacy of OP-1 (rh- transverse process impingement of the L5 spinal nerve: The far-
BMP-7) as a replacement for iliac crest autograft for posterolat- out syndrome. Spine. 1984;9(1): 31-41.
eral lumbar arthrodesis: minimum 4-year follow-up of a pilot 146. Zhang HY, Park JY, Cho BY The BioFlex System as a dynamic
study. Spine J. 2008;8(3):457-465. stabilization device: Does it preserve lumbar motion? J Korean
142. Vital JM, Gille O, Pointillart V, Pedram M, Bacon P, Razanabola Neurosurg Soc. 2009;46(5):431-436.
F, Azzouz S. Course of Modic 1 six months after lumbar poste- 147. Zhang ZM, Jin DD, Chen JT. Comparative study of dynamic
rior osteosynthesis. Spine. 2003;28(7): 715-720. fixation with rigid fixation in the management of degenera-
143. Vitzthum HE, Konig A, Seifert V. Dynamic examination of the tive lumbar spondylosis. Zhonghua Wai Ke Za Zhi. 2008 Mar
lumbar spine by using vertical, open magnetic resonance imag- 1;46(5):346-9.
ing. Journal Neurosurg. 2000;93(1 Suppl): 58-64.
144. Willems P. Decision making in surgical treatment of chronic
low back pain: The performance of prognostic tests to select

Is dynamic MRI and/or dynamic CT myelography
imaging (including standing imaging,
imaging with axial loading) helpful in the
diagnostic testing for degenerative lumbar
spondylolisthesis?
There is insufficient evidence to make a recommendation for or against
the utility of dynamic MRI and dynamic CT myelography in the diagnosis
of degenerative lumbar spondylolisthesis.
Huang et al1 investigated the effect of axial loading on spine and sis of L4–L5 under axially loaded MRI. The mean values of the
spinal canal morphology in patients with degenerative spondy- SA under preload and postload were 7.14° and 5.90° at L4–L5
lolisthesis of L4–5 and evaluated the correlation between mor- (listhetic level), respectively. The mean values of the LLA under
phologic changes and disability and physical functioning. A preload and postload were 37.03° and 39.28°, respectively. There
total of 32 consecutive cases with degenerative L4–5 spondylo- were significant correlations only between the ODI, PF, and the
listhesis, grade 1–2, intermittent claudication and low back pain difference of SA, and between PF and the postloaded LLA. The
without sciatica were included in this study. All patients under- changes in SA (L4–L5) during axial loading were well correlated
went unloaded and axially loaded MRI of the lumbosacral spine to the ODI and PF scores. In addition, the LLA (L1–L5) under
in supine position to elucidate the morphological findings and axial loading was well correlated to the PF of patients with de-
to measure the parameters of MRI, including disc height (DH), generative L4–L5 spondylolisthesis. The authors conclude that
sagittal translation (ST), segmental angulation (SA), dural sac axially loaded MRI is a useful tool for study of the anatomi-
cross-sectional area (DCSA) at L4–5, and lumbar lordotic angles cal changes of the spinal canal of the lumbar spine. It can also
(LLA) at L1–5 between the unloaded and axially loaded con- aid diagnosis of instability, or occult spinal disorders, such as
dition. Each patient’s disability was evaluated by the Oswestry equivocal herniated discs or stenosis, by simulating the upright
Disability Index (ODI) questionnaire and physical functioning position under normal gravity. This study provides Level IV
(PF) was evaluated by the Physical Function scale. Comparisons prognostic evidence that axially loaded MRI using the Dynawell
and correlations were done to determine which parameters were device demonstrates morphological changes in patients with
critical to the patient’s disability and PF. The morphologies of symptomatic degenerative spondylolisthesis and that segmental
the lumbar spine changed after axially loaded MRI. In 6 patients, angulation at L4-5 was correlated with physical disability (ODI).
the authors observed adjacent segment degeneration (4 at L3– In a study by McGregor et al2, authors conducted a radio-
L4 and 2 at L5–S1) coexisting with degenerative spondylolisthe- graphic study to investigate patterns of intervertebral mobility
(using flexion-extension positions in open MRI) in subjects with Future Directions for Research
spondylolisthesis to determine level of spinal instability. Twenty- The work group recommends prospective, appropriately pow-
nine patients, including 15 with a diagnosis of isthmic spondylo- ered studies to better assess the utility of dynamic MRI and/or
listhesis and 14 with a diagnosis of degenerative spondylolisthe- CT myleography in the diagnostic testing for degenerative spon-
sis, were enrolled and compared with a preexisting database of dylolisthesis.
12 patients with no history of back pain (controls). The motion
characteristics of these patients in flexed and extended positions References
were investigated using open MRI. In all of the subjects, the level 1. Huang KY, Lin RM, Lee YL, Li JD. Factors affecting disability
of resting pain, grade of slip and level of defect were evaluated. and physical function in degenerative lumbar spondylolisthe-
No mobility differences of angular or translatory motion were sis of L4-5: evaluation with axially loaded MRI. Eur Spine J.
found between the spondylolisthesis (degenerative or isthmic) 2009;18(12):1851-1857.
and asymptomatic controls. In critique of this study, it is unclear 2. McGregor AH, Anderton L, Gedroyc WM, Johnson J, Hughes
how patients were recruited, whether there was consecutive en- SP. The use of interventional open MRI to assess the kinematics
rollment and a clear subgroup analysis was not included. This of the lumbar spine in patients with spondylolisthesis. Spine.
2002;27(14):1582-1586.
study provides Level IV diagnostic evidence that that the pres-
3. Ozawa H, Kanno H, Koizumi Y, Morozumi N, Aizawa T, Kusak-
ence of degenerative spondylolisthesis does not lead to hyper- abe T, Itoi E. Dynamic changes in the dural sac cross-sectional
mobility. A spondylolytic defect may not lead to detectable in- area on axial loaded MR imaging: is there a difference between
stability or hypermobility in the lumbar spine on dynamic MRI. degenerative spondylolisthesis and spinal stenosis? Am J Neuro-
Ozawa et al3 compared the dural sac cross sectional area radiol. 2012;33(6):1191-1197.
(DCSA) in patients with degenerative spondylolisthesis and spi-
nal stenosis on axially loaded MR imaging. All patients had neu- Bibliography
rogenic intermittent claudication and leg pain or numbness with 1. Alexander E Jr, Kelly DL Jr, Davis CH Jr, McWhorter JM, Brown
associated neurologic signs and had radiographically confirmed W. Intact arch spondylolisthesis. A review of 50 cases and
lumbar spinal canal narrowing on cross-sectional imaging. For description of surgical treatment. J Neurosurg. 1985;63(6):840-
the comparative analysis in this study, the patients with >3mm 844.
spondylolisthesis were assigned to the degenerative spondylolis- 2. Barrey C, Jund J, Perrin G, Roussouly P. Spinopelvic alignment
of patients with degenerative spondylolisthesis. Neurosurgery.
thesis group, while the other patients were assigned to the spi-
2007;61(5):981-986.
nal stenosis group. A total of 88 patients were included in the 3. Bendo JA, Ong B. Importance of correlating static and dynamic
study, including 40 with degenerative spondylolisthesis patients. imaging studies in diagnosing degenerative lumbar spondylolis-
All patients received MR imaging. After conventional MR imag- thesis. Am J Orthop. 2001;30(3), 247-250.
ing, axial loading was applied by using an external commercially 4. Berlemann U, Jeszenszky DJ, Buhler DW, Harms J. Mechanisms
available nonmagnetic compression device. The DCSA was mea- of retrolisthesis in the lower lumbar spine. A radiographic study.
sured from the L2-3 to L5-S1 on the axial image. The measure- Acta Orthop Belg. 1999;65(4):472-477.
ment was performed three times and the mean value was calcu- 5. Berlemann U, Jeszenszky DJ, Buhler DW, Harms J. The role of
lated and used for analysis in this study. Results indicated that lumbar lordosis, vertebral end-plate inclination, disc height,
and facet orientation in degenerative spondylolisthesis. J Spinal
a >15mm2 change in the DCSA was found in 8 patients (16.7%)
Disord. 1999;12(1):68-73.
in the spinal stenosis group and 25 patients (62.5%) in the de- 6. Boden SD Spinescope. Semin Spine Surg. 2012;24(2):133-137.
generative spondylolisthesis group. In the degenerative spondy- 7. Cansever T, Civelek E, Kabatas S, Yilmaz C, Caner H, Altinors
lolisthesis group, patients with a >15mm2 change had a signifi- MN. Dysfunctional segmental motion treated with dynamic
cantly larger DCSA on conventional MR imaging (58 ± 26mm2) stabilization in the lumbar spine. World Neurosurg. 2011;75(5-
than those with a <15mm2 change (41 ± 18mm2) (p=0.028), 6):743-749.
while the axial loaded MR imaging showed no significant dif- 8. Caterini R, Mancini F, Bisicchia S, Maglione P, Farsetti P. The
ference between the patients with a >15 and a <15mm2 change correlation between exaggerated fluid in lumbar facet joints and
in the DCSA (p=0.897). The authors conclude that DCSA in degenerative spondylolisthesis: prospective study of 52 patients.
J Orthop Traumatol. 2011;12(2):87-91.
patients with degenerative spondylolisthesis is more likely to
9. Chaput C, Padon D, Rush J, Lenehan E, Rahm M. The signifi-
be decreased by axial loading than in those with spinal stenosis. cance of increased fluid signal on magnetic resonance imaging
Axial loaded MRI may be a more useful tool to provide valuable in lumbar facets in relationship to degenerative spondylolisthe-
imaging findings for the assessment of spinal canal narrowing
sis. Spine 2007;32(17):1883-1887.

in patients with degenerative spondylolisthesis than those with 10. Cho BY, Murovic JA, Park J. Imaging correlation of the degree
spinal stenosis. In critique, use of a 15mm2 criterion as signifi- of degenerative L4-5 spondylolisthesis with the corresponding
cant change in DCSA is not a universally accepted diagnostic amount of facet fluid. J Neurosurg Spine. 2009;11(5):614-9.
standard; therefore, this study has been downgraded from Level 11. Gaetani P, Aimar E, Panella L, Levi D, Tancioni F, Di Ieva A,
II to III. This study provides Level III diagnostic evidence that Rodriguez y Baena R. Functional disability after instrumented
stabilization in lumbar degenerative spondylolisthesis: a follow-
axially loaded MRI may reveal more severe stenosis in patients
up study. Functional Neurol. 2006;21(1):31-37.
with degenerative spondylolisthesis than might be apparent on 12. Gilbert JW, Wheeler GR, Kreft MP, et al. Repeat upright posi-
conventional MRI. tional magnetic resonance imaging for diagnosis of disorders
underlying chronic noncancer lumbar pain. J Manipulative
Physiol Ther. 2008;31(8):627-31.
13. Haberl H, Cripton PA, Orr TE, Beutler T, Frei H, Lanksch WR, raminal extradural gas pseudocyst. J Korean Neurosurg Soc.
Nolte LP. Kinematic response of lumbar functional spinal units 2010;47(3):232-4.
to axial torsion with and without superimposed compression 32. Manenti G, Liccardo G, Sergiacomi G, Ferrante L, D’Andrea G,
and flexion/extension. Eur Spine J. 2004;13(6):560-566. Konda D, Masala S. Axial loading MRI of the lumbar spine. In
14. Hasegawa K, Kitahara K, Hara T, Takano K, Shimoda H, Hom- Vivo. 2003;17(5):413-420.
ma T. Evaluation of lumbar segmental instability in degenerative 33. McCulloch JA. Microdecompression and uninstrumented
diseases by using a new intraoperative measurement system. J single-level fusion for spinal canal stenosis with degenerative
Neurosurg Spine. 2008;8(3):255-62. spondylolisthesis. Spine. 1998;23(20):2243-2252.
15. Hayeri MR, Tehranzadeh J. Diagnostic imaging of spinal fusion 34. Miyazaki M, Morishita Y, Takita C, Yoshiiwa T, Wang JC, Tsu-
and complications. App Radiol. 2009;38(7-8):14-28. mura H. Analysis of the relationship between facet joint angle
16. Heo DH, Cho YJ, Cho SM, Choi HC, KangSH. Adjacent seg- orientation and lumbar spine canal diameter with respect to
ment degeneration after lumbar dynamic stabilization using the kinematics of the lumbar spinal unit. J Spinal Disord Tech.
pedicle screws and a nitinol spring rod system with 2-year 2010;23(4):242-248.
minimum follow-up. J Spinal Disord Tech. 2012;25(8):409-414. 35. Moke L, Debeer P, Moens P. Spondylolisthesis in twins: mul-
17. Hong SW, Lee HY, Kim KH, Lee SH. Interspinous ligamen- tifactorial etiology: a case report and review of the literature.
toplasty in the treatment of degenerative spondylolisthesis: Spine. 2011;36(11):E741-746.
midterm clinical results. J Neurosurg Spine. 2010;13(1):27-35. 36. Morishita Y, Ohta H, Naito M, Matsumoto Y, Huang G, Tatsumi
18. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob- M, Kida H. Kinematic evaluation of the adjacent segments
servation of the Dynesys neutralization system for the treatment after lumbar instrumented surgery: A comparison between
of degenerative disease of the lumbar vertebrae. Orthop Surg. rigid fusion and dynamic non-fusion stabilization. Eur Spine J.
2011;3(3):167-75. 2011;20(9):1480-1485.
19. Jagannathan J, Sansur CA, Oskouian RJ, Fu KM, Shaffrey CI. 37. Murtagh RD, Quencer RM, Castellvi AE, Yue JJ. New tech-
Radiographic restoration of lumbar alignment after transforam- niques in lumbar spinal instrumentation: What the radiologist
inal lumbar interbody fusion. Neurosurgery. 2009;64(5):955-63. needs to know. Radiology. 2011;260(2):317-330.
20. Jayakumar P, Nnadi C, Saifuddin A, Macsweeney E, Casey 38. Naderi S, Manisali M, Acar F, Ozaksoy D, Mertol T, Arda MN.
A. Dynamic degenerative lumbar spondylolisthesis: diag- Factors affecting reduction in low-grade lumbosacral spondylo-
nosis with axial loaded magnetic resonance imaging. Spine. listhesis. J Neurosurg. 2003;99(2 Suppl) :151-156.
2006;31(10):E298-301. 39. Niggemann P, Simons P, Kuchta J, Beyer HK, Frey H,
21. Kalpakcioglu B, Altinbilek T, Senel K. Determination of spon- Grosskurth D. Spondylolisthesis and posterior instability. Acta
dylolisthesis in low back pain by clinical evaluation. J Back Radiol. 2009;50(3):301-305.
Musculoskelet Rehabil. 2009;22(1):27-32 40. Ohtori S, Yamashita M, Inoue G, Yamauchi K, Koshi T, Suzuki
22. Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Suc- M, Takahashi K. Rotational hypermobility of disc wedging using
cess and failure of minimally invasive decompression for focal kinematic CT: Preliminary study to investigate the instability of
lumbar spinal stenosis in patients with and without deformity. discs in degenerated scoliosis in the lumbar spine. Eur Spine J.
Spine. 2010;35(19):E981-7. 2010;19(6): 989-994.
23. Khan JA, Bajracharya AR. Surgical treatment of isthmic spon- 41. Oishi Y, Murase M, Hayashi Y, Ogawa T, Hamawaki J. Smaller
dylolisthesis with radicular pain in adults. Journal Nepal Med facet effusion in association with restabilization at the time of
Assoc. 2007;46(168):170-174. operation in Japanese patients with lumbar degenerative spon-
24. Kizilkilic O, Yalcin O, Sen O, Aydin MV, Yildirim T, Hurcan C. dylolisthesis. J Neurosurg Spine. 2010;12(1):88-95.
The role of standing flexion-extension radiographs for spon- 42. Paajanen H, Tertti M. Association of incipient disc degenera-
dylolisthesis following single level disk surgery. Neurol Res. tion and instability in spondylolisthesis. A magnetic resonance
2007;29(6):540-3. and flexion-extension radiographic study of 20-year-old low
25. Konno S, Kikuchi S, Tanaka Y, Yamazaki K, Shimada Y, Takei back pain patients. Arch Orthop Trauma Surg. 1991;111(1):16-
H, et al. A diagnostic support tool for lumbar spinal stenosis: 19.
A self-administered, self-reported history questionnaire. BMC 43. Palmer S, Turner R, Palmer R. Bilateral decompression of
Musculoskel Disord. 2007 Oct 30;8:102. lumbar spinal stenosis involving a unilateral approach with mi-
26. Korovessis P, Repantis T, Zacharatos S, Zafiropoulos A. Does croscope and tubular retractor system. J Neurosurg. 2002;97(2
Wallis implant reduce adjacent segment degeneration above Suppl):213-217.
lumbosacral instrumented fusion?. Eur Spine J. 2009;18(6):830- 44. Ranjith RK, Mullett JH, Burke TE. Hangman’s fracture caused
40. by suspected child abuse. A case report. J Pediatr Orthop B.
27. Lakdawala RH, Rahmat R, Tan L, Wong HK. Aortic flap valve 2002;11(4):329-332.
presenting as neurogenic claudication: a case report. Spine 45. Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz
2004;29(4):E79-81. PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Had-
28. Langerak NG, Vaughan CL, Hoffman EB, Figaji AA, Fieggen ley MN; American Association of Neurological Surgeons Con-
AG, Peter JC. Incidence of spinal abnormalities in patients with gress of Neurological Surgeons. (Guidelines for the performance
spastic diplegia 17 to 26 years after selective dorsal rhizotomy. of fusion procedures for degenerative disease of the lumbar
Childs Nerv Syst. 2009;25(12):1593-1603. spine. Part 12: pedicle screw fixation as an adjunct to posterolat-
29. Lattig F, Fekete TF, Grob D, Kleinstuck F S, Jeszenszky D, Man- eral fusion for low-back pain. J Neurosurg Spine. 2005;2(6):700-
nion AF. Lumbar facet joint effusion in MRI: a sign of instability 706.
in degenerative spondylolisthesis? Eur Spine J. 2012;21(2):276- 46. Schlenzka D, Remes V, Helenius I, Lamberg T, Tervahartiala
281. P, Yrjonen T, Poussa M. Direct repair for treatment of symp-
30. Lauryssen C. Appropriate selection of patients with lumbar tomatic spondylolysis and low-grade isthmic spondylolisthe-
spinal stenosis for interspinous process decompression with the sis in young patients: no benefit in comparison to segmental
X STOP device. Neurosurg Foc. 2007;22(1):E5. fusion after a mean follow-up of 14.8 years. Eur Spine J.
31. Lee DY, Lee SH. L2 radicular compression caused by a fo- 2006;15(10):1437-1447.
47. Schlenzka D, Seitsalo S, Poussa M, Osterman K. Operative 51. Van den heuvel R, Hertel M, Gallagher J, Naidoo V. A toddler
treatment of symptomatic lumbar spondylolysis and mild who refused to stand or walk: lumbar spondylodiscitis. BMJ
isthmic spondylolisthesis in young patients: direct repair of the Case Rep. 2012;
defect or segmental spinal fusion? Eur Spine J. 1993;2(2):104- 52. Vitzthum HE, Konig A, Seifert, V. Dynamic examination of the
112. lumbar spine by using vertical, open magnetic resonance imag-
48. Schuller S, Charles YP, Steib JP. Sagittal spinopelvic alignment ing. J Neurosurg. 2000;93(1 Suppl):58-64.
and body mass index in patients with degenerative spondylolis- 53. Wildermuth S, Zanetti M, Duewell S, Schmid MR, Romanowski
thesis. Eur Spine J. 2011;20(5):713-719. B, Benini A, Hodler J. Lumbar spine: quantitative and qualita-
49. Stone AT, Tribus CB. Acute progression of spondylolysis to isth- tive assessment of positional (upright flexion and extension) MR
mic spondylolisthesis in an adult. Spine 2002;27(16), E370-372. imaging and myelography. Radiology. 1998;207(2):391-398.
50. Tarantino U, Fanucci E, Iundusi R, et al. Lumbar spine MRI 54. Zhao Y, Wang YP, Qiu GX, Zhao H, Zhang JG, Zhou X. Ef-
in upright position for diagnosing acute and chronic low back ficacy of the dynamic interspinous assisted motion system in
pain: statistical analysis of morphological changes. J Orthop clinical treatment of degenerative lumbar disease. Chin Med J.
Traumatol. 2013;14(1):15-22. 2010;123(21):2974-2977.
B. Outcome Measures for Medical/Interventional and

Surgical Treatment

What are the appropriate outcome measures
for the treatment of degenerative lumbar
spondylolisthesis?
An updated literature search was not conducted. For more information on appropriate outcome mea-
sures for degenerative lumbar spondylolisthesis, the North American Spine Society has a publication en-
titled Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. To purchase
a copy of the Compendium, visit https://webportal.spine.org/Purchase/ProductDetail.aspx?Product_
code=68cdd1f4-c4ac-db11-95b2-001143edb1c1.
For additional information about the Compendium, please contact the NASS Research Department at
nassresearch@spine.org.

C. Medical and Interventional Treatment
An updated systematic review of the literature yielded no studies to adequately

address any of the medical/interventional treatment questions from the original
guideline posed below:
• What is the role of pharmacological treatment in the management of degenerative lumbar

spondylolisthesis?
• What is the role of physical therapy/exercise in the treatment of degenerative lumbar
spondylolisthesis?
• What is the role of manipulation in the treatment of degenerative lumbar spondylolisthesis?
• What is the role of ancillary treatments such as bracing, traction, electrical stimulation
and transcutaneous electrical stimulation (TENS) in the treatment of degenerative lumbar
spondylolisthesis?
• What is the long-term result (4+ years) of medical/interventional management of degenerative
Results from the Spine Patient Outcomes Research Trial tic care (25%), anti-inflammatory medications (63%) and opioid
(SPORT), a research trial analyzing nonoperative and surgical analgesics (30%). Going forward, the nonoperative protocol was
treatment effects in patients with degenerative spondylolisthe- ‘‘usual recommended care,’’ which included, at least, active phys-
sis associated with spinal stenosis, are summarized below. Due ical therapy, education and counseling with instructions regard-
to the uncontrolled nonoperative protocol, lack of nonopera- ing home exercise, and nonsteroidal anti-inflammatory drugs
tive treatment details and high treatment cross-over rate of the if the patient could tolerate them. In the randomized cohort,
SPORT Trial at 4 years, the work group is cautioned to use this 159 patients were assigned to surgery and 145 were assigned to
trial as support for a recommendation for or against the role or nonsurgical treatment. Of the 145 patients assigned to receive
long term efficacy of any specific medical/interventional treat- nonoperative care, 54% underwent surgery by 4 years. In the ob-
ment for the management of degenerative lumbar spondylolis- servational cohort, 173 initially chose surgery and 130 initially
thesis. However, given the paucity of nonoperative treatment chose nonsurgical care. Of the 130 patients who initially chose
evidence from the original and current guideline literature nonoperative treatment, 33% underwent surgery by 4 years. Pa-
searches, the work group included the summary below as back- tients were evaluated over 4 years using the SF-36 for bodily pain
ground information. and physical function scores and the modified Oswestry Disabil-
Weinstein et al1,2 compared the surgical and nonsurgical ity Index. Results indicated that patients enrolled in the nonop-
outcomes in patients enrolled in either a randomized or obser- erative treatment group experienced modest improvement from
vational cohort of the Spine Patient Outcomes Research Trial baseline over a period of four years. In patients with neurogenic
(SPORT). All patients in the trial had neurogenic claudication claudication, the SF-36 score improved 12.9 points, SF-36 physi-
or radicular leg pain with associated neurologic signs, spinal ste- cal function score improved 8.3 points, and the Oswestry Dis-
nosis shown on cross-sectional imaging and degenerative spon- ability Index decreased 7.4 points. Additionally, results from a
dylolisthesis shown on lateral radiographs obtained with the pa- post hoc analysis of SPORT,3 analyzing whether the duration of
tient in a standing position. Investigators enrolled 304 patients symptoms (less than or more than one year) affect outcomes af-
in the randomized cohort and 303 in the observational cohort. ter the treatment of degenerative spondylolisthesis, suggest that
Pre-enrollment nonoperative care was not specified, but includ- symptom duration does not impact nonoperative or surgical
ed physical therapy (68%), epidural injections (55%), chiroprac- treatment success for patients with this disease.

What is the role of injections for the treatment
of degenerative lumbar spondylolisthesis?
There is insufficient evidence to make a recommendation for or
against the use of injections for the treatment of degenerative lumbar
spondylolisthesis. New recommendation statement
New study retrieved from the updated literature lize a validated outcome measurement tool to evaluate treatment
search: success. According to their criteria, treatment response was con-
Klessinger et al4 conducted a retrospective case-series study sidered positive if at least a 50% reduction in pain was achieved.
of 40 patients to determine if radiofrequency neurotomy is an A pain reduction of at least 50% and satisfying results for the pa-
effective treatment option for patients with low back pain and tients in the radiofrequency group for a minimum of 3 months
degenerative spondylolisthesis. An electronic medical record was achieved in 26 patients (65%). Eight of these patients had a
system was used to identify all patients in a single spine center minimum of 50% pain relief; 18 had a minimum of 80%. Eleven
with a positive MRI diagnosis of degenerative spondylolisthesis patients did not respond to radiofrequency neurotomy. In ad-
who had received lumbar radiofrequency neurotomy during a dition, 3 patients with a positive response to radiofrequency
3-year period. Most of the patients (82.1%) were tested before neurotomy, but with pain relief lasting only one month, were
the neurotomy with controlled medial branch blocks; the other treated as negative successes. All patients with pain relief of 3
patients only had single medial branch blocks before radio- months had continuing pain relief at a mean follow-up of 18.6
frequency neurotomy. A radiofrequency neurotomy was only months. This study provides level IV therapeutic evidence that
considered after positive testing (at least 80% pain relief). In- degenerative facet joints represent one possible pain generator
jections were performed with fluoroscopic visualization using in patients with degenerative spondylolisthesis. Radiofrequency
bupivacaine (0.25%). Patients had a mean age of 67.8 years, were neurotomy may lead to pain reduction in a subset of patients
mostly women, had Grade 1 or 2 spondylolisthesis according to with degenerative spondylolisthesis who have symptomatic facet
Meyerding grades, and included in the analysis only if they had joint pain diagnosed by controlled medial branch nerve blocks.
at least 3 months treatment follow-up. The authors did not uti-
Medical/interventional treatment for degenerative lumbar

spondylolisthesis, when the radicular symptoms of stenosis predominate,
most logically should be similar to treatment for symptomatic
degenerative lumbar spinal stenosis. Consensus Statement maintained from
original guideline
Treatment recommendations and the supporting evidence are Recommendation #1:

available in the NASS clnical guideline Diagnosis and Treatment Future outcome studies of degenerative lumbar spondylolisthe-
of Degenerative Lumbar Spinal Stenosis (2011)5 available on the sis should include results specific to each of the medical/inter-
NASS website at www.spine.org. ventional treatment methods, presenting results stratified by pa-
tient symptomatology (eg, axial back pain only, combination of

Future Directions For Research axial back pain and radiculopathy).
The work group identified the following suggestions for future
studies which would generate meaningful evidence to assist in Recommendation #2:
further defining the role of medical treatment for degenerative Although the review was devoid of studies examining the
lumbar spondylolisthesis. benefits of physical therapy with a directional preference (eg,
avoiding extension) in patients with degenerative lumbar spon-
dylolisthesis, this appears to be an area of growing interest. Ac-
cordingly, the work group suggests that a randomized controlled man bone morphogenetic protein-2. J Bone Joint Surg Am.
study comparing the benefits of physical therapy with directional 2009;91(5):1181-1189.
preference versus non-preferential therapy for the treatment of 9. Butt MF, Hakeem IH, Halwal MA, Farooq M, Mir MR, Kangu
degenerative lumbar spondylolisthesis would be useful. Ideally KA. Complication of variable screw placement system (VSP)
in instrumented fusion of non-traumatic lumbosacral spinal
the directional preference study would also address inter-rater
disorders. JK Pract. 2007;14(2), 84-87.
reliability as there is some evidence in low back pain literature 10. Carragee EJ, Cheng I. Minimum acceptable outcomes after
that clinician training in mechanical diagnosis and treatment af- lumbar spinal fusion. Spine J. 2010;10(4): 313-320.
fects the clinician’s ability to identify directional preference and 11. Carreon LY, Glassman SD, Howard J. Fusion and nonsurgi-
symptomatic patterns within the exam.6-7 cal treatment for symptomatic lumbar degenerative disease: a
systematic review of Oswestry Disability Index and MOS Short
Recommendation #3: Form-36 outcomes (Structured abstract). Spine J. 2008;8(5):747-
The work group recommends the undertaking of large multi- 755.
center registry database studies with long term follow-up evalu- 12. Cavusoglu H, Turkmenoglu O, Kaya RA, Tuncer C, Colak I,
Sahin Y, et al. Efficacy of unilateral laminectomy for bilateral
ating the outcomes of various medical/interventional treatments
decompression in lumbar spinal stenosis. Turk Neurosurg.
for the management of degenerative lumbar spondylolisthesis. 2007;17(2):100-108.
13. Chad DA. Lumbar Spinal Stenosis. Neurol Clin. 2007;25(2):407-
References 418.
1. Radcliff KE, Rihn J, Hilibrand A, Diiorio T, Tosteson T, Lurie 14. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO,
JD, Weinstein JN. Does the duration of symptoms in patients Loeser JD. Surgery for low back pain: a review of the evidence
with spinal stenosis and degenerative spondylolisthesis affect for an American Pain Society Clinical Practice Guideline. Spine.
outcomes?: Analysis of the spine outcomes research trial. Spine. 2009;34(10):1094-109.
2011;36(25):2197-2210. 15. Clarke JA, van Tulder MW, Blomberg SE, de Vet HC, van der
2. Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson Heijden GJ, Brønfort G, Bouter LM. Traction for low-back
AN, Blood EA, et al. Surgical versus nonsurgical treatment for pain with or without sciatica Cochrane Database Syst Rev.
lumbar degenerative spondylolisthesis. N Engl J Med. 2007 May 2007;8:CD003010.
31;356(22):2257-2270. 16. Cloyd JM, Acosta Jr FL, Ames CP. Complications and outcomes
3. Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, of lumbar spine surgery in elderly people: A review of the litera-
Tosteson AN, et al. Surgical compared with nonoperative ture. J Am Geriatr Soc. 2008;56(7):1318-1327.
treatment for lumbar degenerative spondylolisthesis. four-year 17. Dai F, Belfer I, Schwartz CE, Banco R, Martha JF, Tighioughart
results in the Spine Patient Outcomes Research Trial (SPORT) H, Kim DH. Association of catechol-O-methyltransferase
randomized and observational cohorts. J Bone Joint Surg Am. genetic variants with outcome in patients undergoing surgi-
2009;91(6):1295-1304. cal treatment for lumbar degenerative disc disease. Spine J.
4. Klessinger S. Radiofrequency neurotomy for treatment of low 2010;10(11):949-957.
back pain in patients with minor degenerative spondylolisthesis. 18. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH.
Pain Physician. 2012;Jan-Feb;15(1):E71-8. Degenerative spondylolisthesis of the cervical spine: analysis of
5. Aina S, May S, Clare H. The centralization phenomenon of spi- 58 patients treated with anterior cervical decompression and
nal symptoms - a systematic review. Man Ther. 2004;9:134-43. fusion. Spine J. 2009;9(6):439-446.
6. Werneke M, Deutscher D, Hart D, et al. McKenzie Lumbar Clas- 19. Debusscher F, Troussel S. Direct repair of defects in lumbar
sification: Inter-rater Agreement by Physical Therapists With spondylolysis with a new pedicle screw hook fixation: Clinical,
Different Levels of Formal McKenzie Postgraduate Training. functional and Ct-assessed study. Eur Spine J. 2007;16(10):1650-
Spine. February 2014;39(3):E182–E190. 1658.
20. Delawi D, Dhert WJ, Rillardon L, Gay E, Prestamburgo D,
Bibliography from updated literature search Garcia-Fernandez C, et al. A prospective, randomized, con-
1. Abbott AD, Tyni-Lenne R, Hedlund R. Early rehabilitation trolled, multicenter study of osteogenic protein-1 in instrument-
targeting cognition, behavior, and motor function after lumbar ed posterolateral fusions: report on safety and feasibility. Spine.
fusion: a randomized controlled trial. Spine. 2010;35(8):848-857. 2010 May 20;35(12):1185-1191.
2. Adogwa O, Parker SL, Bydon A, Cheng J, McGirt MJ. Compara- 21. Ekman P, Moller H, Shalabi A, Yu YX, Hedlund R. A prospec-
tive effectiveness of minimally invasive versus open transfo- tive randomised study on the long-term effect of lumbar fusion
raminal lumbar interbody fusion: 2-year assessment of narcotic on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-
use, return to work, disability, and quality of life. J Spinal Disord 1186.
22. Eliyas JK, Karahalios D. Surgery for Degenerative Lumbar Spine
Tech. 2011;24(8):479-484.
Disease. Dis Mon. 2011;57(10):592-606.
3. Aliabadi H, Isaacs R. Lumbar spinal stenosis: A brief review.

Neurosurg Q. 2009;19(3), 200-206. 23. Excoffon SG, Wallace H. Chiropractic and rehabilitative
4. Baker AD, Sanderson P. Spinal surgery in older people: Indica- management of a patient with progressive lumbar disk injury,
tions, techniques and outcomes. Rev Clinical Gerontology, spondylolisthesis, and spondyloptosis. J Manipulative Physiol
2011;21(4):277-285. Ther. 2006;29(1): 66-71.
5. Bashir el F, Ajani O. Management of lumbar spine juxtafacet 24. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D,
cysts. World Neurosurg. 2012;77(1):141-6. Giannini S. Surgical treatment of symptomatic degenerative
6. Boden SD. Spinescope. Semin Spine Surg. 2011;23(2), 151-156. lumbar spondylolisthesis by decompression and instrumented
7. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2), 133-137. fusion. J Orthop Traumatol. 2007;8(3):128-133.
8. Burkus JK, Gornet MF, Schuler TC, Kleeman TJ, Zdeblick TA. 25. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura
Six-year outcomes of anterior lumbar interbody arthrodesis K, Yuan HA. Radiostereometric analysis of postoperative mo-
with use of interbody fusion cages and recombinant hu- tion after application of dynesys dynamic posterior stabilization
system for treatment of degenerative spondylolisthesis. J Spinal 43. Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hov-
Disord Tech. 2010;23(4):236-241. ing JL, et al. (2012). Exercises for mechanical neck disorders.
26. Ferrari S, Costa F, Fornari M. Conservative treatment with Cochrane Database Syst Rev. 2012 Aug 15;8:CD004250.
spontaneous stabilization of Grade II isthmic spondylolisthesis 44. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari-
L5/S1 in a forty-four-year old woman, with a six-year follow-up: son of surgical and conservative treatment for degenerative
a case report. Eur J Phys Rehabil Med. 2012;48(2), 275-281. lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5.
27. Fersum KV, Dankaerts W, O’Sullivan PB, Maes J, Skouen JS, 45. Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S.
Bjordal JM, Kvale A. Integration of subclassification strate- Preliminary results of a randomized, equivalence trial of fluoro-
gies in randomised controlled clinical trials evaluating manual scopic caudal epidural injections in managing chronic low back
therapy treatment and exercise therapy for non-specific chronic pain: Part 4--Spinal stenosis. Pain physician. 2008; 11(6):833-
low back pain: a systematic review. Br J Sports Med. 2010 848.
Nov;44(14):1054-1062. 46. Lawhorne TW 3rd, Girardi FP, Mina CA, Pappou I, Cammisa
28. Furlan AD, Yazdi F, Tsertsvadze A, Lao L, Sherman K, Ammen- FP Jr. Treatment of degenerative spondylolisthesis: potential
dolia C, Wang E, Shin BC, Wakayama I, van Tulder MW. Acu- impact of dynamic stabilization based on imaging analysis. Eur
puncture for (sub)acute non-specific low-back pain (Protocol). Spine J. 2009;18(6):815-822.
Cochrane Database Syst Rev. 2011;8:CD009265 47. Lee JW, Myung JS, Park KW, Yeom JS, Kim KJ, Kim HJ, Kang
29. Gibson JN, Waddell G. Surgery for degenerative lumbar HS. Fluoroscopically guided caudal epidural steroid injection
spondylosis. Cochrane Database System Rev. 2005 Oct 19;(4) for management of degenerative lumbar spinal stenosis: Short-
CD001352. term and long-term results. Skeletal Radiol. 2010;39(7):691-699.
30. Gilbert JW, Wheeler GR, Kreft MP, Upadhyay SP, Storey BB, 48. Lee SC, Chen JF, Wu CT, Lee ST In situ local autograft for in-
Spitalieri JR, Gibbs RA. Repeat Upright Positional Magnetic strumented lower lumbar or lumbosacral posterolateral fusion. J
Resonance Imaging for Diagnosis of Disorders Underlying Clin Neurosci. 2009;16(1):37-43.
Chronic Noncancer Lumbar Pain. J Manipulative Physiol Ther. 49. Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L.
2008;31(8):627-631. Lumbar spondylolysis: A review. Skeletal Radiol. 2011;40(6),
31. Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines 683-700.
T, Burnie SJ, et al. Mechanical traction for neck pain with or 50. Lindley EM, McCullough MA, Burger EL, Brown CW, Patel VV.
without radiculopathy. Cochrane Database Syst Rev. 2008 Jul Complications of axial lumbar interbody fusion: Clinical article.
16;(3):CD006408. J Neurosurg Spine. 2011;15(3):273-279.
32. Grob D. Surgery for degenerative lumbar disease: Transforami- 51. Majid K, Fischgrund JS. Degenerative lumbar spondylo-
nal lumbar interbody fusion. Eur Spine J. 2009;18(12):1991- listhesis: trends in management. J Am Acad Orthop Surg.
1992. 2008;16(4):208-215.
33. Gross A, Forget M, St George K, Fraser MM, Graham N, Perry 52. Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S.
L, et al. Patient education for neck pain. Cochrane Database of Preliminary results of a randomized, equivalence trial of fluoro-
Syst Rev. 2012 Mar 14;3:CD005106. scopic caudal epidural injections in managing chronic low back
34. Herkowitz HN. Degenerative lumbar spondylolisthesis: pain: Part 4 - Spinal stenosis. Pain Physician. 2008;11(6):833-
A surgeon’s perspective of 30 years in practice. Spine J. 848.
2010;10(10):916-917. 53. McAfee PC, Cunningham BW, Tortolani PJ, Fedder IL, Sefter
35. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical JC, Davis C. 100 Consecutive Cases of Degenerative Lumbar
observation of the Dynesys neutralization system for the treat- Conditions Using a Non-Threaded Locking Screw System With
ment of degenerative disease of the lumbar vertebrae. Orthop a 90-Degree Locking Cap. SAS J. 2009;3(1):1-11.
Audiosynop Contin Med Educ. 2011;3(3):167-175. 54. Mcgregor AH, Probyn K, Cro S, et al. Rehabilitation following
36. Huang TY, Lee KS, Tsai TH, Su YF, Hwang SL. Posterior surgery for lumbar spinal stenosis. Cochrane Database Syst Rev.
epidural migration of sequestrated lumbar disc fragments 2013;12:CD009644.
into the bilateral facet joints: Case report. Neurosurgery. 55. Mercaitis OP, Dropkin, B. M., Kaufman, E. L., & Carl, A. L.
2011;69(5):E1148-E1151. (2009). Epidural granuloma arising from epidural catheter
37. Ibrahimi, DM, Beaty NB, Crandall KM, Hamilton DK, Sansur placement. Orthopedics, 32(4), 293.
CA. A review of lumbar spondylolisthesis. Eur Musculoskel Rev. 56. Miyamoto H, Sumi M, Uno K, Tadokoro K, Mizuno K. Clinical
2011;6(2), 110-113. outcome of nonoperative treatment for lumbar spinal stenosis,
38. Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S. and predictive factors relating to prognosis, in a 5-year mini-
Medicinal and injection therapies for mechanical neck disor- mum follow-up. J Spinal Disord Tech. 2008;21(8):563-8.
ders. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000319. 57. Molina M, Wagner P, Campos M. Spinal lumbar stenosis. An
39. Jacobs W, Van der Gaag NA, Tuschel A, de Kleuver M, Peul W, update. Rev Med Chil. 2011;139(11):1488-1495.
Verbout AJ, et al. Total disc replacement for chronic back pain 58. Monticone M, Giovanazzi E. Usefulness of a cognitive be-
in the presence of disc degeneration. 2012 Sep 12;9:CD008326. havioural and rehabilitative approach to enhance long lasting
40. Kalichman L, Hunter DJ. Diagnosis and conservative manage- benefit after lumbar spinal stenosis and degenerative spon-
ment of degenerative lumbar spondylolisthesis. Eur Spine J. dylolisthesis surgery. A case report. Eur J Phys Rehabil Med.
2008;17(3):327-335. 2008;44(4):467-471.
41. Kanayama M, Hashimoto, T, Shigenobu K, Oha F, Togawa D. 59. Musluman AM, Cansever T, Yilmaz A, Cavusoglu H, Yuce I,
Effective prevention of surgical site infection using a Centers Aydin Y. Midterm outcome after a microsurgical unilateral
for Disease Control and Prevention guideline-based antimicro- approach for bilateral decompression of lumbar degenerative
bial prophylaxis in lumbar spine surgery. J Neurosurg Spine. spondylolisthesis. J Neurosurg Spine. 2012;16(1):68-76.
2007;6(4):327-329. 60. Niemisto L, Kalso E, Malmivaara A, Seitsalo S, Hurri H. Ra-
42. Kanayama M, Hashimoto T, Shigenobu K, Togawa D, Oha F. A diofrequency denervation for neck and back pain. A systematic
minimum 10-year follow-up of posterior dynamic stabilization review of randomized trials. Cochrane Database Syst Rev.
using Graf artificial ligament. Spine. 2007;32(18):1992-6. 2003;(1): CD004058.
61. Ohtori S, Inoue G, Orita S, Yamauchi K, Eguchi Y, Ochiai N, interventions for preventing work disability. Cochrane Database
Toyone T Teriparatide accelerates lumbar posterolateral fusion Syst Rev. 2009;(2):CD006955.
in women with postmenopausal osteoporosis: Prospective study. 72. Wang HL1, Lü FZ, Jiang JY, Ma X, Xia XL, Wang LX. Minimally
Spine. 2012;37(23):E1464-E1468. invasive lumbar interbody fusion via MAST Quadrant retractor
62. Palmer S, Davison L. Minimally invasive surgical treatment of versus open surgery: A prospective randomized clinical trial.
lumbar spinal stenosis: Two-year follow-up in 54 patients. Surg Chin Med J. 2011;124(23):3868-3874.
Neurol Int. 2012;3(1):41. 73. Welch WC, Cheng BC, Awad TE, Davis R, Maxwell JH,
63. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno- Delamarter R, Macenski MM. Clinical outcomes of the Dynesys
sis lead to poorer outcomes?: a subanalysis of the Spine Patient dynamic neutralization system: 1-year preliminary results. Neu-
Outcomes Research Trial (SPORT) lumbar stenosis study. Spine. rosurg Focus. 2007;22(1):E8.
2010;35(4):439-46. 74. Jacobs W, Van der gaag NA, Tuschel A, et al. Total disc replace-
64. Parker SL, Adogwa O, Bydon A, Cheng J, McGirt MJ. Cost- ment for chronic back pain in the presence of disc degeneration.
effectiveness of minimally invasive versus open transforaminal Cochrane Database Syst Rev. 2012;9:CD008326.
lumbar interbody fusion for degenerative spondylolisthesis 75. Willems P. Decision making in surgical treatment of chronic low
associated low-back and leg pain over two years. World Neuro- back pain: The performance of prognostic tests to select patients
surg. 2012;78(1-2), 178-184. for lumbar spinal fusion. Acta Orthop. 2013;84(349S):1-37.
65. Pearson A, Blood E, Lurie J, et al. Degenerative spondylolis- 76. Wu RH, Fraser JF, Hartl R. Minimal access versus open transfo-
thesis versus spinal stenosis: does a slip matter? Comparison raminal lumbar interbody fusion: meta-analysis of fusion rates.
of baseline characteristics and outcomes (SPORT). Spine. Spine. 2010;35(26):2273-2281.
2010;35(3):298-305. 77. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz
66. Peloso P1, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie TE. The utility of repeated postoperative radiographs after lum-
S; Cervical Overview Group. (2007). Medicinal and injection bar instrumented fusion for degenerative lumbar spine. Spine.
therapies for mechanical neck disorders. Cochrane Database 2011;36(23):1955-60.
Syst Rev. 2007;(3):CD000319. 78. Yao N, Wang W, Liu Y. Percutaneous endoscopic lumbar dis-
67. Rihn JA, Radcliff K, Hilibrand AS, et al. (2012). Does obesity cectomy and interbody fusion with B-Twin expandable spinal
affect outcomes of treatment for lumbar stenosis and degenera- spacer. Arch Orthop Trauma Surg. 2011;131(6):791-6.
tive spondylolisthesis? Analysis of the Spine Patient Outcomes 79. Yee AJ, Yoo JU, Marsolais EB, et al. Use of a postoperative
Research Trial (SPORT). Spine. 2012;37(23):1933-1946. lumbar corset after lumbar spinal arthrodesis for degenerative
68. Tanaka M, Shimizu H, Yato Y, Asazuma T, Nemoto K. Acute conditions of the spine. A prospective randomized trial. J Bone
pyogenic discitis in a degenerative intervertebral disc in an adult Joint Surg Am. 2008;90(10):2062-8.
2010; 3:77-80. 80. Yoshimoto, H., Sato, S., Nakagawa, I., Hyakumachi, T., Yanagi-
69. Templin CR, Garfin SR. Surgical Management of Scoliosis and/ bashi, Y., Nitta, F., & Masuda, T. Deep vein thrombosis due to
or Spondylolisthesis Associated with Spinal Stenosis. Semin migrated graft bone after posterior lumbosacral interbody fu-
Spine Surg. 2007;19(3):187-199. sion: Case report. J Neurosurg Spine. 2007;6(1), 47-51.
70. Terao T, Ishii T, Tani S, Abe T. Combination therapy of radiofre- 81. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
quency lumbar facet joint denervation and epidural spinal cord non-surgical treatment for lumbar spinal stenosis. Cochrane
stimulation for failed back surgery syndrome. Neurol Med Chir. Database Syst Rev. 2012;(12).
2011;51(11):805-809.
71. Van oostrom SH, Driessen MT, De vet HC, et al. Workplace
D. Surgical Treatment

Does surgical decompression alone improve
surgical outcomes in the treatment of
degenerative lumbar spondylolisthesis
compared to medical/interventional treatment
alone?
Direct surgical decompression may be considered for the treatment of

patients with symptomatic spinal stenosis associated with low grade
degenerative lumbar spondylolisthesis whose symptoms have been
recalcitrant to a trial of medical/interventional treatment. Updated
recommendation statement
Study obtained from updated literature search: spondylolisthesis patients whose symptoms did not improve af-
Murat et al1 conducted a prospective case series of 84 patients ter at least 6 months of conservative treatment.
with degenerative spondylolisthesis to evaluate the efficacy of
bilateral decompression using a unilateral approach. Patients Study included in original guideline:
had a mean age of 62 years old, had lower back pain with or Matsudaira et al2 conducted a retrospective comparative study
without sciatica, neurogenic claudication that had not improved of patients with spinal stenosis and grade I degenerative spondy-
after at least 6 months of conservative treatment and a radio- lolisthesis. Eighteen patients underwent decompressive lamino-
logical diagnosis of Grade I degenerative spondylolisthesis and plasty without fusion and 16 patients, who served as the control
lumbar stenosis. The surgical technique involved the midline group, were treated conservatively. All patients received a trial
approach, with special attention given to maintaining stability of conservative therapy, which included medication and nerve
of the supraspinous ligaments and spinous processes. Patients blocks, for at least three months prior to surgery. At a mini-
were followed for a minimum of 24 months and evaluated via mum of 2 years follow-up, decompressive laminoplasty patients
Visual Analog Scale (VAS), Oswestry Disability Index (ODI) showed significantly better improvements in Japanese Ortho-
and Neurogenic Claudication Outcomes Score (NCOS). Results paedic Association (JOA) scores than the conservative treat-
indicated that neural and dynamic slip percentages did not sig- ment group (p<0.001). The L4-5 range of motion showed no
nificantly change after surgery. Spinal canal size increased from change in the conservative treatment group, whereas it showed
50.6 to 102.8 (p<0.001). The ODI decreased significantly in both a significant decrease in the decompressive laminoplasty group
the early and late follow-up evaluations, and good to excellent (9.1± 4.5 to 9.1 ± 4.3 vs. 11.1 ± 3.8 to 9.3 ± 4.0, p=0.0443). The
results were obtained in 64 cases. The NCOS demonstrated im- L4-5 angle on flexion also showed no change in the conserva-
provement in late follow-up results (p<0.001). Among all of the tive treatment group, whereas posterior enlargement tended to
treated spine levels, 4 patients experienced accidental durotomy; decrease in the decompressive laminoplasty group (p=0.0671).
however, these durotomies were not associated with noticeable In critique of this study, the sample size was modest, particularly
postoperative morbidity. One patient experienced a wound in- considering there were only 16 patients in the medical/interven-
fection requiring antibiotic therapy, and one patient required tional group. This paper provides Level III therapeutic evidence
secondary fusion due to progressively increasing back pain. that decompressive surgery alone in the form of a decompressive
While this study doesn’t directly address the efficacy of medical/ laminoplasty results in better outcomes than conservative treat-
interventional treatment alone, it does provide Level IV thera- ment in patients with spinal stenosis and Grade I degenerative
peutic evidence that bilateral decompression via a unilateral ap- spondylolisthesis.
proach is a safe and effective treatment option for degenerative
There is insufficient evidence to make a comparing surgical to medical/interventional treatment in the

recommendation for or against the use of North American patient population. It is unlikely that higher
quality data are achievable for the comparison of surgical and
indirect surgical decompression for the medical/interventional treatment.
treatment of patients with symptomatic
spinal stenosis associated with low grade A greater number of nonindustry-sponsored, independent,
degenerative lumbar spondylolisthesis retrospective or prospective studies need to be done to further
whose symptoms have been recalcitrant to investigate a potentially effective and minimally invasive means
(interspinous spacers) of decompressing the spinal canal in pa-
a trial of medical/interventional treatment. tients with symptomatic spinal stenosis and degenerative lumbar
Maintained from original guideline spondylolisthesis.
Grade of Recommendation: I (Insufficient In addition, with increased focus on and use of data registries,
Evidence) the work group recommends the undertaking of large multi-
center registry database studies with long term follow-up evalu-
The updated literature search did not retrieve new evidence to ating the outcomes of both surgical and medical/interventional
support a recommendation for the use of indirect surgical de- treatment outcomes in the management of degenerative lumbar
compression over medical/interventional treatment in patients spondylolisthesis.
with spinal stenosis and low grade degenerative lumbar spondy-
lolisthesis. The Anderson study, included in the original guide- References
line, was the only study retrieved that addressed the clinical 1. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal stenosis in
question and is summarized below. grade I degenerative lumbar spondylolisthesis: a comparative
study of outcomes following laminoplasty and laminectomy
with instrumented spinal fusion. J Orthop Sci. 2005;10(3):270-
Study included in original guideline: 276.
Anderson et al3 performed a subgroup analysis of 75 patients 2. Murat MA, Cansever T, Yilmaz A, Çavuşoğlu H, Yüce I, Aydin
with Grade I degenerative spondylolisthesis who were originally Y. Midterm outcome after a microsurgical unilateral approach
included in the pivotal randomized controlled trial comparing for bilateral decompression of lumbar degenerative spondylolis-
the X-STOP device and medical/interventional treatment for thesis: Clinical article. J Neurosurg Spine. 2012;16(1):68-76.
spinal stenosis with neurogenic claudication that was relieved 3. Anderson PA, Tribus CB, Kitchel SH. Treatment of neurogenic
by flexion and sitting. Although examined prospectively, this claudication by interspinous decompression: application of the
subgroup was not appropriated to surgical and medical/inter- X STOP device in patients with lumbar degenerative spondylo-
listhesis. J Neurosurg Spine. 2006;4(6):463-471.
ventional treatment in a truly randomized fashion. Forty-two
4. Kim DH, Shanti N, Tantorski ME, Shaw JD, Li L, Martha JF,
patients had the X-STOP device placed, while 33 had medical/ Kwon B. (2012). Association between degenerative spondylo-
interventional treatment that included at least one epidural ste- listhesis and spinous process fracture after interspinous process
roid injection, medications and physical therapy as needed. Only spacer surgery. Spine J. 2012;12(6):466-472.
70 of 75 patients had a minimum of 2-year follow-up. Of patients 5. Verhoof OJ, Bron JL, Wapstra FH, van Royen BJ. High failure
in the X-STOP group, 63% had significant improvements in the rate of the interspinous distraction device (X-Stop) for the treat-
Zurich Claudication Questionnaire (ZCQ) score, while 12% in ment of lumbar spinal stenosis caused by degenerative spondy-
the medical/interventional group had significant improvements. lolisthesis. Eur Spine J. 2008;17(2):188-192.
In critique of this study, although labeled by the authors as a ran-
domized controlled trial, it was not such for patients with degen- Bibliography from updated literature search
erative spondylolisthesis. Patient numbers were relatively low. In 1. Aliabadi H, Isaacs R. Lumbar spinal stenosis: A brief review.
support of their findings, there was a low attrition rate (7% at Neurosurgery Q. 2009;19(3):200-206.
2. Bashir EF, Ajani O. Management of lumbar spine juxtafacet
2-year follow-up). Furthermore, the investigators utilized a vali-
cysts. World Neurosurg. 2012;77(1):141-146.
dated outcome instrument, the ZCQ. This study offers Level III 3. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2):133-137.
therapeutic evidence that an interspinous distraction device that 4. Çavuşoğlu H, Türkmenoğulu O, Kaya RA, Tuncer C, Çolak I,
provides indirect decompression leads to better outcomes in pa- Şahin Y, Aydin Y. Efficacy of unilateral laminectomy for bilateral
tients with spinal stenosis and Grade I degenerative spondylo- decompression in lumbar spinal stenosis. Turk Neurosurg.
listhesis than does medical/interventional treatment. Although 2007;17(2):100-108.

use of the interspinous spacers in the setting of listhesis has been 5. Chad DA. Lumbar Spinal Stenosis. Neurol Clin. 2007;25(2):407-
associated with high complication rates.4,5 418.
6. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO,
Loeser JD. Surgery for low back pain: A review of the evidence
Future Directions for Research for an American pain society clinical practice guideline. Spine.
Due to the lack of clarity of the ideal candidate for decompression 2009;34(10):1094-1109.
alone, a large scale randomized controlled trial may be logisti- 7. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH.
cally and ethically difficult to perform. The work group acknowl- Degenerative spondylolisthesis of the cervical spine: analysis of
edges that previously published high profile studies (SPORT tri- 58 patients treated with anterior cervical decompression and
als) demonstrated the intrinsic difficulties in conducting RCTs fusion. Spine J. 2009;9(6):439-446.
8. Delawi D, Dhert WJ, Rillardon L, Gay E, Prestamburgo D, 22. Musluman AM, Cansever T, Yilmaz A, Cavusoglu H, Yuce I,
Garcia-Fernandez C, Oner FC. A prospective, randomized, Aydin Y. Midterm outcome after a microsurgical unilateral
controlled, multicenter study of osteogenic protein-1 in instru- approach for bilateral decompression of lumbar degenerative
mented posterolateral fusions: report on safety and feasibility. spondylolisthesis. J Neurosurg Spine. 2012;16(1):68-76.
Spine. 2010;35(12):1185-1191. 23. Osman SG. Endoscopic transforaminal decompression,
9. Di Silvestre M, Lolli, F, Bakaloudis G, Parisini P. Dynamic sta- interbody fusion, and percutaneous pedicle screw implanta-
bilization for degenerative lumbar scoliosis in elderly patients. tion of the lumbar spine: A case series report. Int J Spine Surg.
Spine. 2010;35(2):227-234. 2012;6(1):157-166.
10. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- 24. Pao JL, Chen WC, Chen PQ. Clinical outcomes of microen-
tive randomised study on the long-term effect of lumbar fusion doscopic decompressive laminotomy for degenerative lumbar
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175- spinal stenosis. Eur Spine J. 2009;18(5):672-678.
1186. 25. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno-
11. Eliyas JK, Karahalios D. Surgery for Degenerative Lumbar Spine sis lead to poorer outcomes?: a subanalysis of the Spine Patient
Disease. Dis Mon. 2011;57(10):592-606. Outcomes Research Trial (SPORT) lumbar stenosis study. Spine
12. Gilbert JW, Wheeler GR, Kreft MP, Upadhyay SP, Storey BB, 2010;35(4):439-446.
Spitalieri JR, Gibbs RA. Repeat Upright Positional Magnetic 26. Pearson A, Blood E, Lurie J, et al. Degenerative spondylolis-
Resonance Imaging for Diagnosis of Disorders Underlying thesis versus spinal stenosis: Does a slip matter? Comparison
Chronic Noncancer Lumbar Pain. J Manipulative Physiol Ther. of baseline characteristics and outcomes (SPORT). Spine.
2008;31(8):627-631. 2010;35(3):298-305.
13. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical 27. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect
evaluation and self-assessment by patients after decompres- outcomes of treatment for lumbar stenosis and degenerative
sion surgery for degenerative lumbar canal stenosis. Spine J. spondylolisthesis? Analysis of the Spine Patient Outcomes
2008;8(2):380-384. Research Trial (SPORT). Spine. 2012;37(23):1933-1946.
14. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob- 28. Surace MF, Fagetti A, Fozzato S, Cherubino P. (2012). Lumbar
servation of the Dynesys neutralization system for the treatment spinal stenosis treatment with aperius perclid interspinous
of degenerative disease of the lumbar vertebrae. Orthop Surg. system. Eur Spine J. 2012;21 Suppl 1:S69-S74.
2011;3(3): 167-175. 29. Terao T, Ishii T, Tani S, Abe T. Combination therapy of radiofre-
15. Ibrahimi DM, Beaty NB, Crandall KM, Hamilton DK, Sansur quency lumbar facet joint denervation and epidural spinal cord
CA. A review of lumbar spondylolisthesis. Eur Musculoskel Rev. stimulation for failed back surgery syndrome. Neurol Med Chir.
2011;6(2):110-113. 2011;51(11):805-809.
16. Ikuta K, Tono O, Oga M. Prevalence and clinical features of 30. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy
intraspinal facet cysts after decompression surgery for lumbar of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
spinal stenosis. J Neurosurg Spine. 2009;10(6):617-22. posterolateral lumbar arthrodesis: minimum 4-year follow-up of
17. Jones TR, Rao RD. Adult isthmic spondylolisthesis. J Am Acad a pilot study. Spine J. 2008;8(3):457-465.
Orthop Surg. 2009;17(10):609-617. 31. Weinstein JN, Lurie JD, Tosteson TD, et al. (2007). Surgical
18. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari- versus nonsurgical treatment for lumbar degenerative spondylo-
son of surgical and conservative treatment for degenerative listhesis. N Engl J Med. 356(22), 2257-2270.
lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5. 32. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared
19. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- with nonoperative treatment for lumbar degenerative spon-
strumented lower lumbar or lumbosacral posterolateral fusion. J dylolisthesis. four-year results in the Spine Patient Outcomes
Clin Neurosci. 2009;16(1):37-43. Research Trial (SPORT) randomized and observational cohorts.
20. Majid K, Fischgrund JS. Degenerative lumbar spondylolis- J Bone Joint Surg Am. 2009;91(6):1295-1304.
thesis: trends in management. J Am Acad Orthop Surgeons. 33. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
2008;16(4):208-215. non-surgical treatment for lumbar spinal stenosis. Cochrane
21. McAfee PC, Cunningham BW, Tortolani PJ, Fedder IL, Sefter Database Syst Rev. 2012;CD010264.
JC, Davis C. 100 Consecutive Cases of Degenerative Lumbar
Conditions Using a Non-Threaded Locking Screw System With
a 90-Degree Locking Cap. SAS J. 2009;3(1):1-11.


Does the addition of lumbar fusion, with
or without instrumentation, to surgical
decompression improve surgical outcomes
in the treatment of degenerative lumbar
spondylolisthesis compared to treatment by
decompression alone?
Surgical decompression with fusion is suggested for the treatment

of patients with symptomatic spinal stenosis and degenerative
lumbar spondylolisthesis to improve clinical outcomes compared with
decompression alone. Maintained from original guideline with minor word
modifications

For symptomatic single-level degenerative spondylolisthesis that is low-
grade (<20%) and without lateral foraminal stenosis, decompression alone
with preservation of midline structures provide equivalent outcomes when
compared to surgical decompression with fusion. New recommendation
statement
Studies obtained from updated literature search: health were greater in patients in the MED group compared to
Aihara et al1 conducted a prospective, comparative study of 50 the fusion group; however, the differences were not statistically
consecutive patients to compare decompression with fusion significant between groups. Degree of improvement in lumbar
to microendoscopic decompression (MED) for the treatment function was significantly greater in the decompression with fu-
of degenerative lumbar spondylolisthesis. The first 17 patients sion group compared to the MED group in regard to the per-
underwent decompression with fusion and the next 33 patients centage of slipping in neutral position among those with over
underwent MED. In the fusion group, 14 patients had slippage 20% slipping (p=0.0396). Although not statistically significant,
at L4 and 3 patients had slippage at both L3 and L4. In the MED degrees of improvement in low-back pain, walking ability, social
group, 21 patients had slippage at L4, 7 patients had slippage at life function and mental health were greater in the decompres-
L3, one patient at L5, and 4 patients at both L3 and L4. Before sion and fusion group compared to the MED group among those
the operation, plain radiographs of the lumbosacral spine were with over 20% slippage. Postoperative complications included
taken in all patients to measure the intervertebral angle between one patient with transient foot drop and 2 patients with pseud-
the adjacent vertebral end-plates at the operative level as seen arthrosis in the decompression and fusion group and 2 patients
on the lateral flexion-extension radiographs and to measure the with transient urinary retention in the MED group. No major
percentage of slipping at the level of the slip. These radiographs internal complications or surgical site infections were observed.
were repeated at follow-up, which ranged from 25 to 40 months This study provides therapeutic Level II evidence that decom-
for both groups. Clinical outcomes were also evaluated using the pression with fusion and MED for the treatment of degenerative
Japanese Orthopaedic Association Back Pain Evaluation Ques- lumbar spondylolisthesis result in similar outcomes for lower
tionnaire (JOABPEQ), which consists of 5 functional scores grade slips. When the slippage exceeds 20%, posterior decom-
selected from the Roland Morris Disability Questionnaire and pression and fusion with pedicular screws may be the preferred
SF-36. Operation time, blood loss and postoperative hospital- surgical treatment.
ization were significantly less in the MED group (p=0.0000431, In a retrospective comparative study, Kleinstueck et al2 exam-
p=0.00000859, p-0.00141, respectively). As measured by the ined whether the outcomes of surgery for degenerative lumbar
JOABPEQ, the degrees of improvement for low-back pain, lum- spondylolisthesis varied depending on the predominant baseline
bar function, walking ability, social life function and mental symptoms and the treatment administered. A total of 213 pa-
tients underwent surgical treatment including 56 with decom- nificance of this finding is questionable. There was no significant
pression alone and 157 with decompression and fusion. Patients difference in the mean ODI, SF-36 PCS, SF-36 MCS and NRS
were followed for 12 months and outcomes were evaluated using of leg pain between the groups. Excellent or good outcomes
the multidimensional Core Outcome Measures Index (COMI) occurred in 13 ULBD and 14 fusion group patients based on
questionnaire. At 12 months, there was greater reduction in back Odom’s criteria. In the ULBD group, 3 patients had residual pain
pain, leg pain and neurological deficit in the decompression and 3 had recurrent pain. The 3 patients with residual pain had
and fusion group compared to the decompression alone group nonquantified preoperative foraminal narrowing. Complaints of
(p=0.04). Using the global outcome measure of either “good” recurrent pain occurred 1, 1.5 and 2 years after surgery. Those
or “poor,” 86.2% of patients in the decompression and fusion with recurrent pain had unilaterally more collapsed discs on the
group had a good outcome compared to 70.4% of patients in painful side on preoperative AP radiograph. In comparison, no
the decompression-only group (p=0.01). Multivariable regres- patients in the fusion group had residual pain and 5 had recur-
sion analysis suggested that decompression and fusion was a sig- rent pain and intermittent radiculopathy. Radiologically, the
nificant predictor for the 12 month COMI and Global outcomes. ULBD group showed a 2.1 ± 3.10% change in mean slippage,
An odds ratio of 2.6 was calculated favoring decompression and a 0.15 ± 1.58 mm change in mean translation, a 0.91 ± 4.48
fusion over decompression alone. The level of back pain and leg degrees change in mean angular difference and a -1.83 ± 1.69
pain, and the category of the main problem at baseline had no mm change in mean disc height. In the fusion the mean reduc-
significant influence on outcome. There were no statistically sig- tions in upper and lower disc heights were 1.38 ± 1.10 mm and
nificant differences in complication rates between the groups. In 1.19 ± 0.80 mm, respectively. In critique, the sample size of this
the decompression only group 7 of 56 patients experienced sur- study was small and the diagnostic methods used for the initial
gical complications, including 2 bleeding in spinal canal, 2 dura diagnosis of degenerative lumbar spondylolisthesis were vaguely
lesion, one wound infection, one continuing back pain and one described; however, the group did not feel that these were suf-
wound dehiscence. In the decompression and fusion group, 14 ficient reasons to downgrade the study. In conclusion, this study
of 157 experienced complications, including one bleeding in spi- provides Level III therapeutic evidence that in patients with sta-
nal canal, 3 bleeding outside spinal canal, 6 dural tears, 2 wound ble degenerative lumbar spondylolisthesis, results of unilateral
infections and 2 necrotic wounds. In critique of this study, there laminectomy and bilateral decompression may be similar to in-
was a statistically significant difference in age between the two strumented fusion for functional outcomes and lower extremity
groups, with an average age of 73 years ± 8 in the decompression pain scores.
alone group and 67.4 years ± 9.4 in the decompression and fu- Kim et al4 compared the cost effectiveness of decompression
sion group (p<0.0001). Although multivariate regression analy- with and without instrumented fusion in patients undergoing
sis suggested that increased age was not an independent predic- surgical treatment for degenerative spondylolisthesis. The pri-
tor of poor outcome, the favored results in the decompression mary study outcome was the incremental cost/utility ratio (ICR)
and fusion group should be interpreted cautiously as the analysis expressed as the differential cost per relative gain in quality-
may have not accounted for all variables associated with mor- adjusted life-year (QALY). A total of 115 patients underwent
bidity in older aged individuals. This study provides Level III surgery, including 57 in the decompression group and 58 in the
therapeutic evidence that instrumented fusion and decompres- decompression with fusion group. Patients were included in
sion may provide superior outcomes to decompression alone in the study if postoperative data, including SF-6D health utility
patients under 70 years old regardless of baseline symptoms. scores, hospital cost/case rates and revision rates were available
Park et al3 retrospectively compared the outcomes of patients for at least one year after surgery. A Markov Cost Model was
undergoing either decompression alone or decompression with developed for a 10-year period with a one-year cycle for a hypo-
fusion and fixation for the treatment of degenerative spondy- thetical cohort of 1,000 surgical candidates undergoing decom-
lolisthesis. A total of 45 patients underwent surgical treatment pression only or decompression with fusion. Average costs for
after being unresponsive to conservative treatment for 3 or more these surgeries over a period of 4 years was captured and calcu-
months, including 20 unilateral laminectomy and bilateral de- lated in the Markov model. The average cost used for the cohort
compression (ULBD) patients and 25 decompression and in- simulation was $18,161 per case for decompression with instru-
strumented fusion patients. All patients had stable Grade I, sin- mented fusion and $5,243 per case for decompression alone. All
gle level degenerative spondylolisthesis with translation < 5mm. costs were represented in 2010 Canadian dollars. The authors
Patients were followed for a minimum of 3 years and outcomes suggest that for a specific subpopulation of degenerative lum-
were assessed using the numeric rating scale (NRS) for back bar spondylolisthesis patients (ie, those with leg-dominant pain
and leg pain, the Oswestry Disability Index (ODI), the physical and stable spondylolisthesis), decompression alone and decom-
component summary (PCS), the mental component summary pression plus fusion are almost similar in clinical effectiveness
(MCS), and Short Form 36 (SF-36). Radiological outcomes were with a slight advantage for fusion. However, this small advantage
analyzed by determining changes in slippage, disc height transla- comes at a large cost ($185,878/QALY gained compared with
tion, and angular difference on simple and dynamic x-ray films. decompression alone) that makes it unfavorable in the context
Results suggested that there was a statistically significant greater of health-care decision making with limited resources. Due to
decrease in the mean NRS for back pain in the fusion group (6.6 the limited clinical outcomes provided in the study’s results, this
± 2.4 to 2.4 ± 1.88) compared to the ULBD group (2.8 ± 3.10 to study has been included to provide background support only
1.2 ± 2.20, p=0.0001). However, it is important to note that fu- and has been not assigned a level of evidence grade to provide
sion patients had much higher preoperative and postoperative support to the recommendation.
back pain scores compared to ULBD patients; therefore, the sig-
Studies from original guideline: comprehensive literature search to identify studies published in
Bridwell et al5 described a prospective, comparative study of 44 English peer-reviewed journals between 1970 and 1993 address-
surgically treated patients with degenerative lumbar spondylo- ing degenerative spondylolisthesis with radicular leg pain or
listhesis followed for a minimum of two years. Of the 44 patients, neurogenic claudication. Inclusion criteria included a minimum
9 underwent laminectomy alone, 10 had laminectomy and non- of 4 cases reviewed and reporting of the primary outcome vari-
instrumented fusion and 24 had laminectomy and instrumented able of fusion in articles in which this was part of the treatment.
fusion (18 single-level, 6 two-level). Patients were radiographi- Clinical outcome variables of back pain, leg pain, function, neu-
cally assessed and a functional assessment was conducted by rogenic claudication and global outcome scores were recorded
asking whether they felt their ability to walk distances was worse when available. A total of 25 papers representing 889 patients
(-), the same (0) or significantly better (+). Of the 44 patients, 43 were accepted for inclusion. Twenty-one were retrospective,
were followed for 2 years or more. The authors determined that nonrandomized and uncontrolled. One paper was retrospec-
instrumented fusion had higher fusion rates than noninstru- tive and nonrandomized, but compared 2 different treatments.
mented fusion (ρ=0.002). The authors further observed greater Three prospective, randomized studies were included. The pri-
progression of spondylolisthesis in patients treated with lami- mary outcome variable, fusion, was determined by each author.
nectomy alone (44%) and in laminectomy without instrumented The most constant clinical outcome variable reported was pain
fusion (70%) compared to patients who received laminectomy with 16 papers reporting pain only, 6 papers reporting pain and
with instrumented fusion (4%,ρ=0.001). A higher proportion function, and 2 papers reporting patient-determined outcomes.
of the patients without slippage progression reported that they Patient function was reported in 6 papers and referred to the
were helped by the surgery than those whose slippage progressed presence or absence of neurogenic claudication. In addition to
postoperatively (ρ<0.01). In critique, this was a small study in these clinical outcomes, four papers reported a global evalua-
which selection bias entered into the randomization process, re- tion. Two used Kaneda’s rating system and two used the Japanese
viewers were not masked to patient treatment and validated out- Orthopedic Association (JOA) score. Excellent and good results
come measures were not utilized. Because of these weaknesses, were reassigned as satisfactory; poor results were classified as
this potential Level II study was downgraded to Level III. This unsatisfactory. The authors reported that in the decompression
study provides Level III therapeutic evidence that instrumented alone category, 11 papers representing 216 patients accepted for
fusion patients had less chance of progressive slippage postop- inclusion in the decompression category. Sixty-nine percent of
eratively than laminectomy alone or noninstrumented fusions patients had a satisfactory outcome. The incidence of worsened
and a higher proportion of patients with stable or unchanged postoperative slip was 31% but was not associated with a poorer
spondylolisthesis reported greater improvement after surgery. clinical result in the majority of patients. In the category of de-
Herkowitz et al6 conducted a prospective, comparative study compression with fusion and no instrumentation, 6 papers qual-
of 50 patients with degenerative lumbar spondylolisthesis to ified for inclusion. In one paper, only fusion data were broken
determine if concomitant intertransverse process arthrodesis out for the diagnosis of degenerative spondylolisthesis and were
provided better results than decompression alone. Clinical out- used just for this outcome variable. Ninety percent of the patients
comes were assessed using a rudimentary outcome scale (excel- in this category had a satisfactory outcome; 86% achieved solid
lent, good, fair, poor) with a mean follow-up of 3 years. Preop- spinal fusion. With regard to clinical outcome, the difference
erative and postoperative plain radiographs of the lumbosacral between patients treated with decompression without fusion
spine were also taken. The authors reported that of the 25 patients (69% satisfactory) and those treated with decompression and
treated with decompression and fusion, 11 reported excellent re- fusion without instrumentation (90% satisfactory) was statisti-
sults, 13 good, one fair and zero poor. Of the 25 patients treated cally significant (p< 0.0001). In the decompression with fusion
with decompression alone, 2 reported excellent results, 9 good, and pedicle screws category, 5 studies met the inclusion criteria.
12 fair and 2 poor. Improved results in the patients who had an Fusion status was analyzed in 101 patients. Eighty-five patients
arthrodesis concomitantly with decompression were significant were analyzed with respect to clinical outcome. One paper did
by the Fisher exact test (ρ=0.0001). The authors concluded that not separately analyze clinical data, but did so for fusion data;
in patients who had a concomitant arthrodesis, the results were therefore, only fusion data were included. The proportionally
significantly better with respect to relief of low back pain and weighted fusion rates for this group were 93%. When compar-
lower limb pain. In critique, this was a small study which did not ing the fusion without instrumentation group to the fusion with
utilize validated clinical outcome measures or describe baseline pedicle screw group, there was not a statistically significant in-
crease in fusion rate (p = 0.08). Analysis of the clinical outcomes
characteristics of the groups. Because of these weaknesses, this

potential level II study was downgraded to Level III. This study reveals an 86% satisfactory rating for the pedicle screw group.
offers Level III therapeutic evidence that decompression with ar- This compares favorably to the 69% satisfactory rate in the de-
throdesis in patients with degenerative lumbar spondylolisthesis compression without fusion group (p <0.0001). In the anterior
provides significantly better relief of low back pain and leg pain spinal fusion category, three papers presenting the results for 72
than decompression alone. patients who received anterior spinal fusion for the treatment
Mardjetko et al7 performed a meta-analysis of primarily of degenerative spondylolisthesis were included. Pooling the
Level III studies. The objective of the study was to analyze the data from these three studies yielded a 94% fusion rate with an
published data on degenerative spondylolisthesis to evaluate the 86% rate of patient satisfaction. The authors concluded that the
feasibility of its use as a literature control to compare with the his- meta-analysis results support the clinical impression that, in the
torical cohort pedicle screw study data. The authors conducted a surgical management of degenerative lumbar spondylolisthesis,
spinal fusion significantly improves patient satisfaction. In cri- limited to studies where the majority of patients were reported
tique of this study, only 3 Level II studies were reviewed and data to be experiencing neurologic symptoms such as intermittent
was very heterogeneous. This paper offers Level III therapeutic claudication and/or leg pain. Six studies were included in the
evidence that the addition of fusion with or without instrumen- instrumented fusion versus noninstrumented fusion analysis,
tation to decompression improves clinical outcomes. including three RCTs. The use of adjunctive instrumentation
Martin et al8 conducted a systematic review designed to significantly increased the probability of attaining solid fusion
identify and analyze comparative studies that examined the (relative risk, 1.37; 95% confidence interval, 1.07–1.75; P < 0.05),
surgical management of degenerative lumbar spondylolisthe- but no significant improvement in clinical outcome was record-
sis, specifically the differences in outcomes between fusion and ed (relative risk, 1.19; 95% confidence interval, 0.92–1.54). There
decompression alone, and between instrumented fusion and was a nonsignificant trend towards a lower repeat operation rate
noninstrumented fusion. Relevant randomized controlled trials in the fusion group compared with both decompression alone
(RCTs) and comparative observational studies were identified in and instrumented fusion. The authors concluded there is mod-
a comprehensive literature search (1966 to June 2005). The in- erate evidence that fusion may lead to a better clinical outcome
clusion criteria required that a study be an RCT or comparative compared with decompression alone. Evidence that the use of
observational study that investigated the surgical management adjunctive instrumentation leads to improved fusion status and
of degenerative lumbar spondylolisthesis by comparing: less risk of pseudarthrosis is also moderate. No conclusion could
1. fusion to decompression and/or be made about the clinical effectiveness of instrumented fusion
2. instrumented fusion to noninstrumented fusion. versus noninstrumented fusion. In critique of this study, it was
A minimum one-year follow-up was required. Studies also a systematic review of studies ranging down to Level III, and is
had to include at least 5 patients per treatment group. A study thus classified as a Level III systematic review. Limitations were
was excluded if it included patients who had received previous found in the methodologies of all RCTs, specifically in the pseu-
spine surgery or patients with cervical injuries, spinal fractures, dorandomization, absence of masking and/or the lack of vali-
tumors or isthmic spondylolisthesis. A study was also excluded dated outcome measures to assess clinical outcomes. This paper
if it was not possible to analyze patients with degenerative spon- offers Level III therapeutic evidence that fusion leads to a better
dylolisthesis separately from another included patient popula- clinical outcome compared with decompression alone and the
tion or if it was not clearly a comparative study. Data from the use of adjunctive instrumentation leads to improved fusion sta-
included studies were extracted by 2 independent reviewers us- tus and less risk of pseudarthrosis. Their data does not demon-
ing a standard data abstraction sheet. The data abstraction sheet strate any difference in clinical outcomes between instrumented
identified the following information: and noninstrumented fusions.
1. patient population’s age, sex, symptoms and degree of Matsudaira et al9 described a retrospective, comparative
spondylolisthesis; study of 55 patients with spinal stenosis and Grade I degenera-
2. type of decompression, fusion, instrumentation, bone tive lumbar spondylolisthesis. Of the 55 patients, 20 underwent
graft material, and preoperative and postoperative treat- laminectomy plus posterolateral fusion and pedicle screw instru-
ment; mentation (Group 1), 19 underwent laminoplasty alone (Group
3. study design and methodological quality using the Co- 2) and 16 refused surgery and received medical/interventional
chrane RCT/CCT/Crossover Studies Checklist, modified treatment (Group 3). One patient in each surgical group was lost
by the additional criterion that observational studies state to follow-up. Outcomes were assessed by the Japanese Orthope-
the use of a consecutive series of patients; and dic Association (JOA) score, along with radiographic evaluation
4. study outcomes. at minimum 2-year follow-up. The authors reported that alle-
The main abstracted outcomes were clinical outcome, re- viation of symptoms was noted in the fusion and laminoplasty
operation rate and solid fusion status. An attempt was made to groups but not in the medical/interventional treatment group.
compare patient-centered, validated and disease-specific out- No statistically significant difference in clinical improvement
comes, complications and spondylolisthesis progression, but was noted between the fusion and laminoplasty groups. The per-
because of heterogeneity in reporting these outcomes in the pri- cent slip increased significantly in groups 2 and 3, whereas spon-
mary studies, no pooled analysis could be performed on these dylolisthesis was stabilized in Group 1. The authors concluded
outcomes. When appropriate, a study’s clinical outcome rating that decompression with preservation of the posterior elements
scale was altered to match a dichotomous rating scale of “satis- can be useful in treating patients with symptomatic lumbar spi-
factory” or “unsatisfactory” clinical outcome, and results were nal stenosis resulting from Grade I degenerative spondylolisthe-
entered into Review Manager 4.2 for weighted grouped analysis. In critique of this study, the numbers were small, patients
ses. The authors reported that 8 studies were included in the fu- were not randomized and no clearly defined indications for spe-
sion versus decompression alone analysis, including two RCTs. cific treatment selections were included. This paper offers Level
Limitations were found in the methodologies of both RCTs and III therapeutic evidence that decompression with posterolateral
most of the observational studies. Grouped analysis detected a fusion and instrumentation, as well as laminoplasty alone yield
significantly higher probability of achieving a satisfactory clini- improved outcomes in the treatment of symptomatic lumbar
cal outcome with spinal fusion than with decompression alone spinal stenosis resulting from Grade I degenerative spondylolis-
(relative risk, 1.40; 95% confidence interval, 1.04–1.89; P < 0.05). thesis as compared with medical/interventional treatment alone.
The clinical benefit favoring fusion decreased when analysis was
Future Directions for Research 3. Aliabadi H, Isaacs R. Lumbar spinal stenosis: A brief review.
Because of the lack of clarity of the ideal candidate for decom- Neurosurg Q. 2009;19(3):200-206.
4. Allen RT, Rihn JA, Glassman SD, Currier B, Albert TJ, Phillips
pression alone, a large scale randomized controlled trial may be
FM. An evidence-based approach to spine surgery. Am J Med
logistically and ethically difficult to perform in comparison to Qual. 2009;24; 6 Suppl:15S-24S.
decompression and fusion. 5. Aono H, Iwasaki M, Ohwada T, Okuda S, Hosono N, Fuji T,
Yoshikawa H. Surgical outcome of drop foot caused by degen-
The work group recommends the undertaking of large multi- erative lumbar diseases. Spine. 2007;32(8):E262-E266.
center registry database studies with long term follow-up evalu- 6. Bashir EF, Ajani O. Management of lumbar spine juxtafacet
ating the outcomes of various surgical techniques, including de- cysts. World Neurosurg. 2012;77(1):141-146.
compression with and without fusion, for the surgical treatment 7. Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, McIsaac
of degenerative lumbar spondylolisthesis. It will be important WJ, Wright JG. Who’s in the driver’s seat? The influence of
patient and physician enthusiasm on regional variation in
for these databases to be populated with comprehensive demo-
degenerative lumbar spinal surgery: a population-based study.
graphic and radiographic detail in order to appropriately distin- Spine. 2011;36(6):481-489.
guish various cohorts. 8. Boden SD. Spinescope. Semin Spine Surg. 2011;23(2):151-156.
9. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2):133-137.
References 10. Bono CM, Kadaba M, Vaccaro AR. Posterior pedicle fixation-
1. Aihara T, Toyone T, Aoki Y, et al. Surgical management of based dynamic stabilization devices for the treatment of
degenerative lumbar spondylolisthesis. Journal of Musculoskelet degenerative diseases of the lumbar spine. J Spinal Disord Tech.
Res. 2012;15(4):1250020. 2009;22(5):376-383.
2. Kleinstueck FS, Fekete TF, Mannion AF, Grob D, Porchet F, 11. Brower RS, Vickroy NM. A case of psoas ossification from
Mutter U, Jeszenszky D. To fuse or not to fuse in lumbar degen- the use of BMP-2 for posterolateral fusion at L4-L5. Spine.
erative spondylolisthesis: do baseline symptoms help provide the 2008;33(18):E653-655.
answer? Eur Spine J. 2012;21(2):268-275. 12. Cansever T, Civelek E, Sencer A, Karasu A, Turantan I. Inter-
3. Park JH, Hyun SJ, Roh SW, Rhim SC. A comparison of unilater- mittent priapism in degenerative lumbar spinal stenosis: Case
al laminectomy with bilateral decompression and fusion surgery report. Turk Neurosurg. 2007;17(4):260-263.
in the treatment of grade I lumbar degenerative spondylolisthe- 13. Chad DA. Lumbar Spinal Stenosis. Neurol Clin. 2007;25(2):407-
sis. Acta Neurochir. 2012;154(7):1205-1212. 418.
4. Kim S, Mortaz Hedjri S, Coyte PC, Rampersaud YR. Cost-utility 14. Chaudhary KS, Groff MW. Minimally invasive transforaminal
of lumbar decompression with or without fusion for patients lumbar interbody fusion for degenerative spine. Tech Orthop.
with symptomatic degenerative lumbar spondylolisthesis. Spine 2011;26(3):146-155.
J. 2012;12(1):44-54. 15. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO,
5. Bridwell KH, Sedgewick TA, O’Brien MF, Lenke LG, Baldus Loeser JD. Surgery for low back pain: A review of the evidence
C. The role of fusion and instrumentation in the treatment of for an American pain society clinical practice guideline. Spine.
degenerative spondylolisthesis with spinal stenosis. J Spinal 2009;34(10): 1094-1109.
Disord. 1993;6(6):461-472. 16. Cole CD, McCall TD, Schmidt MH, Dailey AT. Comparison of
6. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis low back fusion techniques: Transforaminal lumbar interbody
with spinal stenosis. A prospective study comparing decompres- fusion (TLIF) or posterior lumbar interbody fusion (PLIF) ap-
sion with decompression and intertransverse process arthrod- proaches. Cur Rev Musculoskelet Med. 2009;2(2):118-126.
esis. J Bone Joint Surg Am. 1991;73(6):802-808. 17. Dantas FL, Prandini MN, Ferreira MA. Comparison between
7. Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spon- posterior lumbar fusion with pedicle screws and posterior
dylolisthesis. A meta-analysis of literature 1970-1993. Spine. lumbar interbody fusion with pedicle screws in adult spondylo-
1994;19(20 Suppl):2256S-2265S. listhesis. Arq Neuropsiquiatr. 2007;65(3B):764-770.
8. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, 18. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH.
O’Neil J, Wai EK. The surgical management of degenera- (2009). Degenerative spondylolisthesis of the cervical spine:
tive lumbar spondylolisthesis: A systematic review. Spine. analysis of 58 patients treated with anterior cervical decompres-
2007;32(16):1791-1798. sion and fusion. Spine J. 2009;9(6):439-446.
9. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal stenosis in 19. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random-
grade I degenerative lumbar spondylolisthesis: A comparative ized, controlled, multicenter study of osteogenic protein-1 in
study of outcomes following laminoplasty and laminectomy instrumented posterolateral fusions: report on safety and feasi-
with instrumented spinal fusion. J Orthop Sci. 2005;10(3):270- bility. Spine. 2010;35(12):1185-1191.
276. 20. Desai A, Ball PA, Bekelis K, et al. Surgery for lumbar degen-
erative spondylolisthesis in Spine Patient Outcomes Research

Trial: does incidental durotomy affect outcome? Spine.

Bibliography from updated literature search 2012;37(5):406-413.
1. Abdul Q, Qayum M, Saradhi M, Panigrahi M, Sreedhar V.
21. Di Silvestre M, Lolli F, Bakaloudis G, Parisini P. Dynamic sta-
Clinico-radiological profile of indirect neural decompression
bilization for degenerative lumbar scoliosis in elderly patients.
using cage or auto graft as interbody construct in posterior
Spine. 2010;35(2):227-234.
lumbar interbody fusion in spondylolisthesis: Which is better. J
22. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec-
Craniovertebr Junction Spine 2011;2(1):12-16.
tive randomised study on the long-term effect of lumbar fusion
2. Agabegi SS, Majid K, Fischgrund JS, Vaccaro AR, Patel T. Can
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86.
preoperative radiographic parameters be used to predict fusion
23. Eliyas JK, Karahalios D. Surgery for Degenerative Lumbar Spine
in non-instrumented posterolateral fusion for degenerative
Disease. Dis Mon. 2011;57(10): 592-606.
spondylolisthesis? Spine. 2011;36(26):E1709-1714.
24. Epstein NE. An analysis of noninstrumented posterolateral
lumbar fusions performed in predominantly geriatric patients Am. 2008;90 Suppl 2 Pt 1:145-52.
using lamina autograft and beta tricalcium phosphate. Spine J. 41. Herkowitz HN. Degenerative lumbar spondylolisthesis: evolu-
2008;8(6):882-887. tion of surgical management. Spine J. 2009;9(7):605-606.
25. Epstein NE. X-Stop: foot drop. Spine J. 2009;9(5):e6-e9. 42. Hong SW, Lee HY, Kim KH, Lee SH. Interspinous ligamen-
26. Eskander MS, Eskander JP, Drew JM, Pelow-Aidlen JL, Eslami toplasty in the treatment of degenerative spondylolisthesis:
MH, Connolly PJ. (2010). A modified technique for dowel fibu- midterm clinical results. J Neurosurg Spine. 2010;13(1):27-35.
lar strut graft placement and circumferential fusion in the set- 43. Hrabálek L, Wanek T, Adamus M. Treatment of Degenerative
ting of L5-S1 spondylolisthesis and multilevel degenerative disc Spondylolisthesis of the Lumbosacral Spine by Decompression
disease. Neurosurgery. 2010;67(3 Suppl Operative):ons91-95; and Dynamic Transpedicular Stabilisation. Acta Chir Orthop
discussion ons95. Traumatol Cech. 2011;78(5):431-436.
27. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D, 44. Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and
Giannini S. Surgical treatment of symptomatic degenerative spondylolysis. Instr Course Lect. 2008;57:431-445.
lumbar spondylolisthesis by decompression and instrumented 45. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob-
fusion. J Orthop Traumatol. 2007;8(3):128-133. servation of the Dynesys neutralization system for the treatment
28. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura of degenerative disease of the lumbar vertebrae. Orthop Surg.
K, Yuan HA. Radiostereometric analysis of postoperative mo- 2011;3(3):167-75.
tion after application of dynesys dynamic posterior stabilization 46. Huang TY, Lee KS, Tsai TH, Su YF, Hwang SL. Posterior epidur-
system for treatment of degenerative spondylolisthesis. J Spinal al migration of sequestrated lumbar disc fragments into the bi-
Disord Tech. 2010;23(4):236-241. lateral facet joints: case report. Neurosurgery. 2011;69(5):E1148-
29. Fernandez-Fairen M, Sala P, Ramirez H, Gil J. A prospective 51.
randomized study of unilateral versus bilateral instrumented 47. Hunt T, Shen FH, Shaffrey CI, Arlet V. Contralateral radiculopa-
posterolateral lumbar fusion in degenerative spondylolisthesis. thy after transforaminal lumbar interbody fusion. Eur Spine J.
Spine. 2007;32(4):395-401. 2007;16 Suppl 3:311-314.
30. Fransen P. Increasing pedicle screw anchoring in the os- 48. Hussain NS, Hanscom D, Oskouian RJ. Chyloretroperito-
teoporotic spine by cement injection through the implant: neum following anterior spinal surgery. J Neurosurg Spine.
Technical note and report of three cases. J Neurosurg Spine. 2012;17(5):415-21.
2007;7(3):366-369. 49. Hwang CJ, Vaccaro AR, Hong J, et al. Immunogenicity of
31. Fujimoto K, Yamazaki M, Hayashi K, et al. Posterior decom- osteogenic protein 1: results from a prospective, randomized,
pression with instrumented fusion in a patient with cervical controlled, multicenter pivotal study of uninstrumented lumbar
myelopathy thirty years after cadaveric renal transplantation. posterolateral fusion. J Neurosurg Spine. 2010;13(4):484-93
Chiba Med J. 2011;87(1):11-15. 50. Ikuta K, Tono O, Oga M. Clinical outcome of microendoscopic
32. Gavaskar AS, Achimuthu R. Transfacetal fusion for low-grade posterior decompression for spinal stenosis associated with
degenerative spondylolisthesis of the lumbar spine: results degenerative spondylolisthesis--minimum 2-year outcome of 37
of a prospective single center study. J Spinal Disord Tech. patients. Minim Invasive Neurosurg. 2008;51(5):267-71.
2010;23(3):162-165. 51. Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with au-
33. Gelalis ID, Arnaoutoglou C, Christoforou G, Lykissas MG, tologous iliac bone versus local bone graft in posterior lumbar
Batsilas I, Xenakis T. Prospective analysis of surgical outcomes interbody fusion. Spine. 2010;35(21):E1101-5.
in patients undergoing decompressive laminectomy and pos- 52. Jiang SD, Jiang LS, Dai LY. Degenerative cervical spondylolisthe-
terior instrumentation for degenerative lumbar spinal stenosis. sis: a systematic review. Int Orthop. 2011;35(6):869-75.
Acta Orthop Traumatol Turc. 2010;44(3):235-40. 53. Jones TR, Rao RD. Adult isthmic spondylolisthesis. J Am Acad
34. Gilbert JW, Wheeler GR, Kreft MP, et al. Repeat upright posi- Orthop Surg. 2009;17(10):609-617.
tional magnetic resonance imaging for diagnosis of disorders 54. Kaner T, Dalbayrak S, Oktenoglu T, Sasani M, Aydin AL, Ozer
underlying chronic noncancer lumbar pain. J Manipulative AF. Comparison of posterior dynamic and posterior rigid
Physiol Ther. 2008;31(8):627-31. transpedicular stabilization with fusion to treat degenerative
35. Ha KY, Na KH, Shin JH, Kim KW. Comparison of posterolateral spondylolisthesis. Orthopedics. 2010;33(5)
fusion with and without additional posterior lumbar interbody 55. Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Suc-
fusion for degenerative lumbar spondylolisthesis. J Spinal Dis- cess and failure of minimally invasive decompression for focal
ord Tech. 2008;21(4):229-34. lumbar spinal stenosis in patients with and without deformity.
36. Hara M, Nishimura Y, Takemoto M, Nakamura S, Wakabayashi Spine. 2010;35(19):E981-7.
T. Posterior fixation for lumbar degenerative spondylosis: Mini- 56. Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra
open TLIF. Japan J Neurosurg. 2012;21(2):118-127. in spinal tuberculosis. Eur Spine J. 2011;20(1):1-5.
37. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical 57. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari-
evaluation and self-assessment by patients after decompres- son of surgical and conservative treatment for degenerative
sion surgery for degenerative lumbar canal stenosis. Spine J. lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5.
2008;8(2):380-384. 58. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid-

38. Harris EB, Sayadipour A, Massey P, Duplantier NL, Anderson term clinical results of minimally invasive decompression and
DG. Mini-open versus open decompression and fusion for lum- posterolateral fusion with percutaneous pedicle screws versus
bar degenerative spondylolisthesis with stenosis. A J Orthop. conventional approach for degenerative spondylolisthesis with
2011;40(12):E257-261. spinal stenosis. Eur Spine J. 2012;21(6):1171-7.
39. Hart RA, Prendergast MA. Spine surgery for lumbar degenera- 59. Lattig F, Fekete TF, Grob D, Kleinstück FS, Jeszenszky D, Man-
tive disease in elderly and osteoporotic patients. Instr Course nion AF. Lumbar facet joint effusion in MRI: a sign of instability
Lect. 2007;56:257-272. in degenerative spondylolisthesis?. Eur Spine J. 2012;21(2):276-
40. Helenius I, Remes V, Poussa M. Uninstrumented in situ fusion 81.
for high-grade childhood and adolescent isthmic spondylolis- 60. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP.
thesis: long-term outcome. Surgical technique. J Bone Joint Surg Treatment of degenerative spondylolisthesis: potential impact
of dynamic stabilization based on imaging analysis. Eur Spine J. outcomes after lumbar fusion for degenerative spondylolisthesis
2009;18(6):815-22. with large joint replacement surgery and population norms.
61. Lee DY, Lee SH, Shim CS, Lee HY. Decompression and inter- Spine J. 2010;10(4):306-12.
spinous dynamic stabilization using the locker for lumbar canal 78. Mori E, Okada S, Ueta T, et al. Spinous process-splitting open
stenosis associated with low-grade degenerative spondylolisthe- pedicle screw fusion provides favorable results in patients with
sis. Minim Invasive Neurosurg. 2010;53(3):117-21. low back discomfort and pain compared to conventional open
62. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- pedicle screw fixation over 1 year after surgery. Eur Spine J.
strumented lower lumbar or lumbosacral posterolateral fusion. J 2012;21(4):745-53.
Clin Neurosci. 2009;16(1):37-43. 79. Müslüman AM, Cansever T, Yılmaz A, Çavuşoğlu H, Yüce İ,
63. Lee SE, Park SB, Jahng TA, Chung CK, Kim HJ. Clinical experi- Aydın Y. Midterm outcome after a microsurgical unilateral
ence of the dynamic stabilization system for the degenerative approach for bilateral decompression of lumbar degenerative
spine disease. J Korean Neurosurg Soc. 2008;43(5):221-6. spondylolisthesis. J Neurosurg Spine. 2012;16(1):68-76.
64. Lekovic GP, Han PP, Kenny KJ, Dickman CA. Bone dowels 80. Ohta H, Matsumoto Y, Morishita Y, Sakai T, Huang G, Kida H,
in anterior lumbar interbody fusion. J Spinal Disord Tech. Takemitsu Y. Surgical results of dynamic nonfusion stabilization
2007;20(5):374-379. with the Segmental Spinal Correction System for degenerative
65. Liao JC, Chen WJ, Chen LH, Niu CC. Outcome of the L5-S1 lumbar spinal diseases with instability: Minimum 2-year follow-
segment after posterior instrumented spinal surgery in degen- up. SAS J. 2011;5(3):69-74.
erative lumbar diseases. Chang Gung Medical J. 2009;32(1):81- 81. Ohtori S, Inoue G, Orita S, et al. Teriparatide accelerates lumbar
88. posterolateral fusion in women with postmenopausal osteopo-
66. Liao JC, Chen WJ, Chen LH, Niu CC, Keorochana G. Surgi- rosis: prospective study. Spine. 2012;37(23):E1464-8.
cal outcomes of degenerative spondylolisthesis with L5-S1 disc 82. Oishi, Y., Murase, M., Hayashi, Y., Ogawa, T., & Hamawaki, J.
degeneration: comparison between lumbar floating fusion and (2010). Smaller facet effusion in association with restabilization
lumbosacral fusion at a minimum 5-year follow-up. Spine. at the time of operation in Japanese patients with lumbar degen-
2011;36(19):1600-7. erative spondylolisthesis. Journal of Neurosurgery Spine, 12(1),
67. Long H, Kazunasa U, Liu S, Akio S, Taito I. Preliminary ap- 88-95.
plication of one-level posterior lumbar interbody fusion with 83. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic
prospace and facet fusion using local autograft. Zhongguo Xiu assessment of the ability of the extreme lateral interbody fusion
Fu Chong Jian Wai Ke Za Zhi. 2007;21(11):1155-1159. procedure to indirectly decompress the neural elements. Spine.
68. Majid K, Fischgrund JS. Degenerative lumbar spondylo- 2010;35(26 Suppl):S331-7.
listhesis: Trends in management. J Am Acad Orthop Surg. 84. Osman SG. Endoscopic transforaminal decompression,
2007;16(4):208-215. interbody fusion, and percutaneous pedicle screw implanta-
69. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo tion of the lumbar spine: A case series report. In J Spine Surg.
RA. Are lumbar spine reoperation rates falling with greater 2012;6(1):157-166.
use of fusion surgery and new surgical technology? Spine. 85. Ozkan N, Sandalcioglu IE, Petr O, et al. Minimally invasive
2007;32(19):2119-2126. transpedicular dorsal stabilization of the thoracolumbar and
70. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo lumbar spine using the minimal access non-traumatic insertion
RA. Reoperation rates following lumbar spine surgery and the system (MANTIS): preliminary clinical results in 52 patients. J
influence of spinal fusion procedures. Spine. 2007;32(3):382- Neurol Surg A Cent Eur Neurosurg. 2012;73(6):369-76.
387. 86. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno-
71. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, sis lead to poorer outcomes?: a subanalysis of the Spine Patient
O’Neil J, Wai EK. The surgical management of degenera- Outcomes Research Trial (SPORT) lumbar stenosis study. Spine.
tive lumbar spondylolisthesis: A systematic review. Spine. 2010;35(4):439-46.
2007;32(16):1791-1798. 87. Park H, Zhang HY, Cho BY, Park JY. Change of lumbar motion
72. McAfee P, Khoo LT, Pimenta L, Capuccino A, Sengoz A, Coric after multi-level posterior dynamic stabilization with bioflex sys-
D, Anekstein Y. Treatment of lumbar spinal stenosis with a total tem : 1 year follow up. J Korean Neurosurg Soc. 2009;46(4):285-
posterior arthroplasty prosthesis: implant description, surgical 91.
technique, and a prospective report on 29 patients. Neurosurg 88. Park JH, Hyun SJ, Roh SW, Rhim SC. A comparison of unilater-
Focus. 2007;22(1). al laminectomy with bilateral decompression and fusion surgery
73. McAfee PC, Cunningham BW, Tortolani PJ, Fedder IL, Sefter in the treatment of grade I lumbar degenerative spondylolisthe-
JC, Davis C. 100 Consecutive Cases of Degenerative Lumbar sis. Acta Neurochir (Wien). 2012;154(7):1205-12.
Conditions Using a Non-Threaded Locking Screw System With 89. Park JY, Chin DK, Cho YE. Accelerated L5-S1 Segment Degen-
a 90-Degree Locking Cap. SAS J. 2009;3(1):1-11. eration after Spinal Fusion on and above L4-5 : Minimum 4-Year
74. Mehta VA, Mcgirt MJ, Garcés ambrossi GL, et al. Trans-foram- Follow-Up Results. J Korean Neurosurg Soc. 2009;45(2):81-4.
inal versus posterior lumbar interbody fusion: comparison of 90. Park SC, Yoon SH, Hong YP, Kim KJ, Chung SK, Kim HJ.
surgical morbidity. Neurol Res. 2011;33(1):38-42. Minimum 2-year follow-up result of degenerative spinal stenosis
75. Min JH, Jang JS, Kim SK, Maeng DH, Lee SH. The ligamen- treated with interspinous u (coflex). J Korean Neurosurg Soc.
totactic effect on a herniated disc at the level adjacent to the 2009;46(4):292-9.
anterior lumbar interbody fusion : report of two cases. J Korean 91. Park Y, Ha JW, Lee YT, Sung NY. The effect of a radiographic
Neurosurg Soc. 2009;46(1):65-7. solid fusion on clinical outcomes after minimally invasive trans-
76. Miscusi M, Petrozza V, Polli FM, Forcato S, Rocca CD, Raco foraminal lumbar interbody fusion. Spine J. 2011;11(3):205-12.
A. Symptomatic ganglion cyst of ligamentum flavum as a 92. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost-
late complication of lumbar fixation. Neurol Neurochir Pol. effectiveness of minimally invasive versus open transforaminal
2012;46(1):82-6. lumbar interbody fusion for degenerative spondylolisthesis
77. Mokhtar SA, Mccombe PF, Williamson OD, Morgan MK, White associated low-back and leg pain over two years. World Neuro-
GJ, Sears WR. Health-related quality of life: a comparison of surg. 2012;78(1-2):178-84.
93. Pateder DB, Benzel E. Noninstrumented facet fusion in patients back patients: a long-term follow-up study spanning 11-13
undergoing lumbar laminectomy for degenerative spondylolis- years. Eur Spine J. 2012;21(11):2140-8.
thesis. J Surg Orthop Adv. 2010;19(3):153-8. 107. Vaccaro AR, Lawrence JP, Patel T, et al. The safety and efficacy
94. Quraishi NA, Lewis SJ, Kelleher MO, Sarjeant R, Rampersaud of OP-1 (rhBMP-7) as a replacement for iliac crest autograft in
YR, Fehlings MG. Intraoperative multimodality monitoring posterolateral lumbar arthrodesis: a long-term (>4 years) pivotal
in adult spinal deformity: analysis of a prospective series of study. Spine. 2008;33(26):2850-62.
one hundred two cases with independent evaluation. Spine. 108. Vaccaro AR, Stubbs HA, Block JE. Demineralized bone matrix
2009;34(14):1504-12. composite grafting for posterolateral spinal fusion. Orthopedics.
95. Rampersaud YR, Wai EK, Fisher CG, et al. Postoperative im- 2007;30(7):567-70.
provement in health-related quality of life: a national compari- 109. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy
son of surgical treatment for focal (one- to two-level) lumbar of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
spinal stenosis compared with total joint arthroplasty for posterolateral lumbar arthrodesis: minimum 4-year follow-up of
osteoarthritis. Spine J. 2011;11(11):1033-41. a pilot study. Spine J. 2008;8(3):457-65.
96. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect 110. Vanek P, Saur K. (2007). Transforaminal lumbar interbody
outcomes of treatment for lumbar stenosis and degenerative fusion (TLIF) and instruments. Prospective study with the
spondylolisthesis? Analysis of the Spine Patient Outcomes minimum of 20-month follow-up. Cesk Neurol Neurochir.
Research Trial (SPORT). Spine. 2012;37(23):1933-46. 2007;70(5), 552-557.
97. Rodgers WB, Lehmen JA, Gerber EJ, Rodgers JA. Grade 2 111. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure
spondylolisthesis at L4-5 treated by XLIF: safety and midterm rate of the interspinous distraction device (X-Stop) for the treat-
results in the “worst case scenario”. ScientificWorldJournal. ment of lumbar spinal stenosis caused by degenerative spondy-
2012;2012:356712. lolisthesis. Eur Spine J. 2008;17(2):188-92.
98. Rouben D, Casnellie M, Ferguson M. Long-term durability of 112. Watters WC, Bono CM, Gilbert TJ, et al. An evidence-based
minimal invasive posterior transforaminal lumbar interbody fu- clinical guideline for the diagnosis and treatment of degenera-
sion: a clinical and radiographic follow-up. J Spinal Disord Tech. tive lumbar spondylolisthesis. Spine J. 2009;9(7):609-14.
2011;24(5):288-96. 113. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non-
99. Sasai K, Umeda M, Maruyama T, Wakabayashi E, Iida H. Mi- surgical treatment for lumbar degenerative spondylolisthesis. N
crosurgical bilateral decompression via a unilateral approach for Engl J Med. 2007;356(22):2257-70.
lumbar spinal canal stenosis including degenerative spondylolis- 114. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared
thesis. J Neurosurg Spine. 2008;9(6):554-9. with nonoperative treatment for lumbar degenerative spon-
100. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow- dylolisthesis. four-year results in the Spine Patient Outcomes
up of spinal stenosis with degenerative spondylolisthesis Research Trial (SPORT) randomized and observational cohorts.
treated with decompression and dynamic stabilization. Spine. J Bone Joint Surg Am. 2009;91(6):1295-304.
2008;33(18):E636-42. 115. Welch WC, Cheng BC, Awad TE, et al. Clinical outcomes of
101. Shen NJ, Lin MX, Lin QB, Wang XA, Chen J, Wang GJ. Do- the Dynesys dynamic neutralization system: 1-year preliminary
mestic vertebral internal fixation system for treating lumbar results. Neurosurg Focus. 2007;22(1):E8.
spondylolisthesis in 55 cases. A follow-up study. J Clin Rehabil 116. Wong Chung-Ting M, Chan Pak-Ho A, Cheung KK. A Prospec-
Tissue Eng Res. 2009;13(9):1793-1796. tive Study on the Outcome of Degenerative Lumbar Spinal
102. Skowroński J, Wojnar J, Bielecki M. Interbody fusion and trans- Stenosis Treated With Open Laminotomy. J Orthop Trauma
pedicular fixation in the treatment of spondylolisthesis. Ortop Rehabil. 2012;16(2), 62-65.
Traumatol Rehabil. 2007;9(2):149-55. 117. Xu H, Tang H, Li Z. Surgical treatment of adult degenerative
103. Sugawara A, Isu T, Kim K, Morimoto D, Isobe M, Matsumoto spondylolisthesis by instrumented transforaminal lumbar
R, Ogasawara K. Surgical results using only posterior decom- interbody fusion in the Han nationality. J Neurosurg Spine.
pression for lumbar canal stenosis with lumbar degenerative 2009;10(5):496-9.
spondylolisthesis. Japan J Neurosurg. 2012;21(2), 111-117. 118. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz
104. Tokuhashi Y, Ajiro Y, Umezawa N. Subsidence of metal inter- TE. The utility of repeated postoperative radiographs after lum-
body cage after posterior lumbar interbody fusion with pedicle bar instrumented fusion for degenerative lumbar spine. Spine.
screw fixation. Orthopedics, 2009;32(4):259. 2011;36(23):1955-60.
105. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Mat- 119. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
suda H. Clinical outcome of microsurgical bilateral decompres- results of pediculo-body fixation and posterolateral fusion for
sion via unilateral approach for lumbar canal stenosis: mini- lumbar spondylolisthesis. Eur Spine J. 2009;18 Suppl 1:151-5.
mum five-year follow-up. Spine. 2011;36(5):410-5. 120. Zaina F, Tomkins-Lane, C, Carragee E, Negrini S. Surgical ver-
106. Turunen V, Nyyssönen T, Miettinen H, et al. Lumbar instru- sus non-surgical treatment for lumbar spinal stenosis. Cochrane
mented posterolateral fusion in spondylolisthetic and failed Database Syst Rev. 2012;(12):CD010264

Does the addition of lumbar fusion, with
or without instrumentation, to surgical
decompression improve surgical outcomes
in the treatment of degenerative lumbar
spondylolisthesis compared to medical/
interventional treatment alone?
Surgical decompression with fusion, with or without instrumentation,

is suggested to improve the functional outcomes of single-level
degenerative lumbar spondylolisthesis compared to medical/
interventional treatment alone.

against efficacy of surgical decompression with fusion, with or without
instrumentation, for treatment of multi-level degenerative lumbar
spondylolisthesis compared to medical/interventional treatment alone.
In a retrospective comparative study, Matsudaira et al1 com- extension showed little change in the decompression only and
pared the surgical and medical management of Japanese patients control group, but was almost eliminated in the decompres-
undergoing treatment for Grade I lumbar degenerative spon- sion and instrumented fusion group. In critique, the diagnostic
dylolisthesis. A total of 53 patients were included in the study, methods used to diagnosis degenerative spondylolisthesis are
including 19 patients treated with decompression laminectomy vaguely described, the medical/interventional treatment was not
with posterolateral fusion and pedicle screw instrumentation, standardized, and the sample size was small. This study provides
18 patients treated with decompression alone and 16 control level III therapeutic evidence that patients with single level spi-
patients treated with conservative therapy after refusing surgi- nal stenosis due to Grade I degenerative spondylolisthesis show
cal treatment. All patients had undergone a trial of conserva- significantly greater alleviation of symptoms when treated with
tive therapy, which included medication and nerve blocks, for at decompression and instrumented fusion compared to a control
least 3 months before being offered surgery. Clinical outcomes group.
were evaluated according to the Japanese Orthopedic Associa- Weinstein et al2 evaluated the surgical and nonsurgical out-
tion Score (JOA). At 2-years follow-up, the JOA score of subjec- comes in patients enrolled in either a randomized or observa-
tive symptoms showed no significant improvement compared to tional cohort of the Spine Patient Outcomes Research Trial
baseline measurements in the control patients, but significant (SPORT). All patients in the trial had neurogenic claudication
improvement in symptoms in the surgical groups (p<0.0001). or radicular leg pain with associated neurologic signs, spinal
The total JOA score did not improve in the control group (17.3 stenosis shown on cross-sectional imaging, and degenerative
pre vs 17.1 post), but significantly improved in the decompres- spondylolisthesis shown on lateral radiographs obtained with
sion and fusion group (14.1 pre vs 21.7 post, p<0.0001) and the the patient in a standing position. Investigators enrolled 304 pa-
decompression only group (13.4 pre vs 23.4 post, p<0.0001). The tients in the randomized cohort and 303 in the observational
degree of improvement was significantly greater in the surgi- cohort. Treatment was standard decompressive laminectomy,
cal groups compared to the control group (p<0.001), but there with or without fusion, or usual nonsurgical care, which includ-
were no significant differences in scores between the surgical ed at least physical therapy, education or counseling on home
groups. When evaluating radiographic findings, the slippage exercises, and nonsteroidal anti-inflammatory agents, if toler-
increased significantly in the decompression only and control ated. In the randomized cohort, 6% underwent decompression
groups compared to the decompression and instrumented fu- only, 21% underwent fusion without instrumentation and 73%
sion groups. The difference in percent slip between flexion and underwent fusion with instrumentation. In the observational
cohort, 5% received decompression only, 21% received fusion treatment included decompression with or without fusion or
without instrumentation, and 74% underwent fusion with in- standard nonoperative care. A total of 607 degenerative spon-
strumentation. In the randomized cohort, 159 patients were as- dylolisthesis patients were enrolled in the study, including 304
signed to surgery and 145 were assigned to nonsurgical treat- into the randomized cohort and 303 in the observational co-
ment. In the observational cohort, 173 initially chose surgery hort. Of these groups, 328 patients received surgical treatment.
and 130 initially chose nonsurgical care. The one year cross-over The authors do not discuss the specific number of patients en-
rates were high in the randomized cohort (approximately 40% in rolled in the nonoperative care group; however, through deduc-
each direction), but moderate in the observational cohort (17% tion, one may assume that 279 patients were initially enrolled
to surgery and 3% to non-surgical care). Patients were evaluated in this group. Results suggest that the surgical outcomes were
over 2years using the SF-36 for bodily pain and physical function significantly better at 2 years in the single-level degenerative
scores and the modified Oswestry Disability Index. It is impor- spondylolisthesis patients compared to those with multilevel
tant to note that in the randomized cohort, only 6% received de- spinal stenosis. Surgical treatment demonstrated significant
compression only, 21% received fusion without instrumentation treatment improvement over nonoperative measures within
and 73% received fusion with instrumentation. Results suggest each subgroup of degenerative spondylolisthesis patients. This
that there were no significant differences in treatment effects be- study provides Level III therapeutic evidence that patients with
tween the randomized and observational surgical cohorts. For concomitant degenerative spondylolisthesis and single-level ste-
the nonsurgical group, treatment effects at 2 years were 1.5 for nosis have better surgical outcomes than those with additional
SF-36 bodily pain (95% confidence interval [CI], –4.2 to 7.3; P levels of stenosis. In these patients, decompression and fusion
= 0.52), 1.9 for physical function (95% CI, –3.7 to 7.5; P = 0.71), of stenotic levels improves outcomes compared to nonoperative
and 2.2 for the Oswestry Disability Index (95% CI, –2.3 to 6.8; management.
P = 0.68). Combined treatment effects for the surgical groups at Mardjetko et al5 performed a meta-analysis of literature from
2 years were 18.1 for SF-36 bodily pain (95% CI, 14.5 to 21.7), 1970-1993 to evaluate the outcomes of surgical fusion treatment
18.3 for physical function (95% CI, 14.6 to 21.9), and −16.7 for for degenerative spondylolisthesis. The studies included in this
the Oswestry Disability Index (95% CI, −19.5 to −13.9). The au- analysis were primarily Level III or IV studies. Prior to undertak-
thors suggest that patients with degenerative spondylolisthesis ing the review, the authors identified a null hypothesis that pos-
and spinal stenosis treated surgically showed substantially great- terior decompression with posterolateral spinal fusion (PLSF)
er improvement in pain and function after 2 years compared to performed with pedicular instrumentation demonstrates equiv-
nonsurgical patients. alent fusion rates and clinical outcomes to alterative techniques
In a follow-up analysis of SPORT, Weinstein et al3 reported of PLSF without instrumentation or controlled instrumenta-
the treatment effects after 4 years. An as-treated analysis com- tion. In review of the articles, the authors accepted 11 papers
bining the randomized and observational cohorts that adjusted for the decompression without fusion category representing 216
for potential confounders demonstrated that the clinically rel- patients. Results from these surgical decompression procedures
evant advantages of surgery that had been previously reported suggested that 69% of patients had a satisfactory outcome. Six
through 2 years were maintained at 4 years, with treatment ef- papers, representing 74 patients, met inclusion for decompres-
fects of 15.3 (95% confidence interval, 11 to 19.7) for bodily sion with fusion without instrumentation. Results suggested that
pain, 18.9 (95% confidence interval, 14.8 to 23) for physical 90% of patients had a satisfactory outcome and 86% achieved a
function, and -14.3 (95% confidence interval, -17.5 to -11.1) for solid spinal fusion. Four papers, representing 138 patients, were
the Oswestry Disability Index. In critique, conservative treat- included in the decompression with fusion with control device
ments were not controlled, there was high-cross over rates in the category with 90% of patients achieving a satisfactory outcome.
SPORT Trial, and some groups had less than 80% follow-up at 4 In the decompression with fusion with pedicle screws category,
years. These 2 studies provide Level II therapeutic evidence that including 5 studies representing 101 patients, 93% of patients
in patients undergoing treatment for degenerative spondylolis- had successful fusion rates. The pooling of three studies in the
thesis, decompression and fusion provided greater improvement anterior spinal fusion category, representing 72 patients, sug-
in pain, function and patient satisfaction outcomes compared to gested a 94% fusion rate with an 86% patient satisfaction rate.
medical management after 2- and 4-years follow-up. When comparing the pooled results, the authors found a sta-
Park et al4 conducted a post hoc retrospective subgroup anal- tistically significant difference in satisfactory clinical outcomes
ysis of SPORT to compare multilevel spinal stenosis outcomes between the decompression without fusion and decompression
to single level spinal stenosis outcomes, including a subset of and fusion without instrumentation (69% vs. 90%, p<0.0001),
patients with spondylolisthesis, against those who did not have fusion rates between the fusion/no instrumentation group and
surgery (“usual nonoperative care”). Outcomes were measured fusion with control device group (86% vs. 96%, p=0.009), and
by Bodily Pain and Physical Function scales of the Medical Out- satisfactory outcome rates of the decompression without fusion
comes Study 36-item Short-Form General Health Survey (SF- compared to decompression with fusion with pedicle screws
36) and the modified Oswestry Disability Index at 6 weeks, 3 groups (69% vs. 86%, p<0.0001). The authors suggest that in
months, 6 months, one year and 2 years. Secondary outcome patients undergoing the surgical management of degenerative
measures included the stenosis bothersomeness index, leg pain spondylolisthesis, spinal fusion significantly improves patient
bothersomeness, low back pain bothersomeness and patient satisfaction and the adjunctive spinal instrumentation enhances
satisfaction. In the degenerative spondylolisthesis group, only fusion rates. In critique of this study, the groups were very het-
patients with one level of spondylolisthesis were included and erogeneous for comparison purposes and the studies included
were primarily retrospective and of lower quality. In addition, long-term follow-up comparing the outcomes of various surgi-
this study doesn’t evaluate the efficacy of fusion and decompres- cal techniques, including decompression with fusion (with or
sion versus medical/interventional treatment for the manage- without instrumentation) to medical/interventional treatments
ment of degenerative lumbar spondylolisthesis. However, it does for the management of single level and multi-level degenerative
provide background information on the effectiveness of adding lumbar spondylolisthesis.
lumbar fusion to decompression procedures. This potential Lev-
el III study provides Level IV therapeutic evidence that the addi- References
tion of fusion to decompression results in satisfactory outcomes 1. Mardjetko SM, Connolly PJ, Shott S. (1994). Degenerative lum-
and the use of adjunctive spinal instrumentation increases fu- bar spondylolisthesis: A meta-analysis of literature 1970- 1993.
sion success. Spine, 19(20 SUPPL.), 2256S-2265S.
Surgical decompression with fusion, with or without instru- 2. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non-
mentation, has been shown to improve the functional outcomes surgical treatment for lumbar degenerative spondylolisthesis. N
Engl J Med. 2007;356(22):2257-70.
of single-level degenerative spondylolisthesis in patients with a
3. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared
BMI > 30 compared to medical/interventional treatment alone with nonoperative treatment for lumbar degenerative spon-
with an understanding that the risk of surgical complications in- dylolisthesis. four-year results in the Spine Patient Outcomes
creases. Although this clinical question was not developed to ad- Research Trial (SPORT) randomized and observational cohorts.
dress the impact of obesity (BMI > 30) on treatment outcomes, J Bone Joint Surg Am. 2009;91(6):1295-304.
the work group felt it was important to include the findings be- 4. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno-
low from a post hoc analysis of SPORT. As addressing this ques- sis lead to poorer outcomes?: a subanalysis of the Spine Patient
tion was not the primary intent of the work group, the literature Outcomes Research Trial (SPORT) lumbar stenosis study. Spine.
search was not designed to address obesity. The summary below 2010;35(4):439-46.
5. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal stenosis in
is included for information purposes only.
grade I degenerative lumbar spondylolisthesis: a comparative
In another post hoc retrospective subgroup analysis of study of outcomes following laminoplasty and laminectomy
SPORT, Rihn et al6 evaluated the impact of obesity on the treat- with instrumented spinal fusion. J Orthop Sci. 2005;10(3):270-6.
ment outcomes for lumbar stenosis and degenerative spondylo- 6. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect
listhesis patients. In the cohort of degenerative spondylolisthe- outcomes of treatment for lumbar stenosis and degenerative
sis patients, there were 376 patients with a BMI of less than 30 spondylolisthesis? Analysis of the Spine Patient Outcomes Re-
(non-obese) and 225 patients with a BMI more than 30 (obese). search Trial (SPORT). Spine. 2012;37(23):1933-46.
It is important to note that in addition to obesity, obese patients
had a significantly higher incidence of comorbidities, includ- Bibliography
ing hypertension, diabetes, and stomach problems (p<0.001). 1. Agabegi SS, Majid K, Fischgrund JS, Vaccaro AR, Patel T. Can
A higher proportion of obese patients underwent instrumented preoperative radiographic parameters be used to predict fusion
fusion and fewer underwent decompression alone compared to in non-instrumented posterolateral fusion for degenerative
spondylolisthesis?. Spine. 2011;36(26):E1709-14.
nonobese patients. The incidence of intraoperative complica-
tions was significantly lower in the obese patient group; how- Neurosurg Q. 2009;19(3):200-206.
ever, there was a trend toward increase rate of wound infec- 3. Allen RT, Rihn JA, Glassman SD, Currier B, Albert TJ, Phillips
tion in the obese patients compared to nonobese patients (5% FM. An evidence-based approach to spine surgery. Am J Med
vs. 1%, p=0.051). At 4-year follow-up, there was a significantly Qual. 2009;24(6 Suppl):15S-24S.
higher rate of reoperation in the obese patient group compared 4. Anderson PA, Tribus CB, Kitchel SH. Treatment of neurogenic
to the nonobese group (20% vs. 11%, p=0.013). At four year claudication by interspinous decompression: application of the
follow-up in the nonoperative group, obese patients had SF-36 X STOP device in patients with lumbar degenerative spondylo-
physical function scores that worsened from baseline by a mean listhesis. J Neurosurg Spine. 2006;4(6):463-71.
5. Aoki Y, Yamagata M, Nakajima F, Ikeda Y, Takahashi K. Poste-
of 3.5 compared to a mean improvement of 13.9 points in the
rior migration of fusion cages in degenerative lumbar disease
non-obese group (p<0.001). The treatment effect for the SF-36 treated with transforaminal lumbar interbody fusion: a report of
Physical Function score was significantly higher for the obese three patients. Spine. 2009;34(1):E54-8.
surgical patient group compared to nonoperative obese patient 6. Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical
group (25.6 vs. 14, p=0.004) suggesting that surgery has a signifi- treatment. Clin Orthop Relat Res. 2006;443:198-207.
cantly greater benefit over nonsurgical treatment of degenerative
7. Bashir el F, Ajani O. Management of lumbar spine juxtafacet

spondylolisthesis in obese patients. This study provides Level III cysts. World Neurosurg. 2012;77(1):141-6.
therapeutic evidence that decompression and fusion in patients 8. Bassewitz H, Herkowitz H. Lumbar stenosis with spondylolis-
with BMIs greater than 30 with degenerative spondylolisthesis thesis: current concepts of surgical treatment. Clin Orthop Relat
Res. 2001;(384):54-60.
may prove beneficial due to the poor progress they make with
9. Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, Mcisaac
nonoperative therapy. However, risk of infection and reopera- WJ, Wright JG. Who’s in the driver’s seat? The influence of
tion after four years is greater compared to nonobese surgical patient and physician enthusiasm on regional variation in
patients. degenerative lumbar spinal surgery: a population-based study.
Future Directions for Research Spine. 2011;36(6):481-489.
The work group recommends the undertaking of large pro- 10. Boden SD Spinescope. Semin Spine Surg. 2012;24(2):133-137.
spective studies or multicenter registry database studies with 11. Bolesta MJ, Bohlman HH. Degenerative spondylolisthesis. Instr
Course Lect. 1989;38:157-165.
12. Bose B. Fracture of S1-2 after L4-S1 decompression and fusion. dylosis. Cochrane Database Syst Rev. 2005;(4):CD001352.
Case report and review of the literature. J Neurosurg. 2003;99(3 34. Gibson JN, Waddell G, Grant IC. Surgery for degen-
Suppl):310-2. erative lumbar spondylosis. Cochrane Database Syst Rev.
13. Bridwell KH, Sedgewick TA, O’brien MF, Lenke LG, Baldus 2000;(2):CD001352.
C. The role of fusion and instrumentation in the treatment of 35. Gibson JN, Waddell G. Surgery for degenerative lumbar spon-
degenerative spondylolisthesis with spinal stenosis. J Spinal dylosis: Updated Cochrane review. Spine. 2005;30(20):2312-
Disord. 1993;6(6):461-72. 2320.
14. Brown MD, Lockwood, JM. Degenerative spondylolisthesis. 36. Gilbert JW, Wheeler GR, Kreft MP, et al. Repeat upright posi-
Instr Course Lect. 1983;32:162-169. tional magnetic resonance imaging for diagnosis of disorders
15. Brown MD, Wehman KF, Heiner AD. The clinical useful- underlying chronic noncancer lumbar pain. J Manipulative
ness of intraoperative spinal stiffness measurements. Spine. Physiol Ther. 2008;31(8):627-31.
2002;27(9):959-61. 37. Grobler LJ, Robertson PA, Novotny JE, Ahern JW. Decom-
16. Cauchoix J, Benoist M, Chassaing V. Degenerative spondylolis- pression for degenerative spondylolisthesis and spinal ste-
thesis. Clin Orthop Relat Res. 1976;115:122-129. nosis at L4-5. The effects on facet joint morphology. Spine.
17. Chad DA. Lumbar Spinal Stenosis. Neurol Clin. 2007;25(2):407- 1993;18(11):1475-82. Hanley EN. Decompression and distrac-
418. tion-derotation arthrodesis for degenerative spondylolisthesis.
18. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Spine. 1986;11(3):269-76.
Loeser JD. Surgery for low back pain: a review of the evidence 38. Hanley EN. The indications for lumbar spinal fusion with and
for an American Pain Society Clinical Practice Guideline. Spine. without instrumentation. Spine. 1995;20(24 Suppl):143S-153S.
2009;34(10):1094-109. 39. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical
19. Cloyd JM, Acosta FL, Ames CP. Complications and outcomes of evaluation and self-assessment by patients after decompres-
lumbar spine surgery in elderly people: a review of the literature. sion surgery for degenerative lumbar canal stenosis. Spine J.
J Am Geriatr Soc. 2008;56(7):1318-27. 2008;8(2):380-4.
20. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH. 40. Herkowitz HN. Spine update degenerative lumbar spondylolis-
Degenerative spondylolisthesis of the cervical spine: analysis of thesis. Spine. 1995;20(9):1084-1090.
58 patients treated with anterior cervical decompression and 41. Herkowitz HN, Kurz LT. (1991). Degenerative lumbar spondy-
fusion. Spine J. 2009;9(6):439-46. lolisthesis with spinal stenosis: A prospective study comparing
21. Deinsberger R, Kinn E, Ungersböck K. Microsurgical treatment decompression with decompression and intertransverse process
of juxta facet cysts of the lumbar spine. J Spinal Disord Tech. arthrodesis. Journal of Bone and Joint Surgery - Series A,
2006;19(3):155-60. 1991;73(6):802-808.
22. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random- 42. Herron LD, Newman MH. The failure of ethylene oxide gas-
ized, controlled, multicenter study of osteogenic protein-1 in sterilized freeze-dried bone graft for thoracic and lumbar spinal
instrumented posterolateral fusions: report on safety and feasi- fusion. Spine. 1989;14(5):496-500.
bility. Spine. 2010;35(12):1185-91. 43. Hilibrand AS, Rand N. Degenerative lumbar stenosis: diagnosis
23. Detwiler PW, Porter RW, Han PP, Karahalios DG, Masferrer R, and management. J Am Acad Orthop Surg. 1999;7(4):239-249.
Sonntag VK. Surgical treatment of lumbar spondylolisthesis. 44. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob-
Adv Tech Stand Neurosurg. 2000;26:331-346. servation of the Dynesys neutralization system for the treatment
24. Di silvestre M, Lolli F, Bakaloudis G, Parisini P. Dynamic sta- of degenerative disease of the lumbar vertebrae. Orthop Surg.
bilization for degenerative lumbar scoliosis in elderly patients. 2011;3(3):167-75.
Spine. 2010;35(2):227-34. 45. Indar R, Tsiridis E, Morgan M, Aldham CH, Hussein AA. In-
25. Dimar JR II, Djurasovic M, Carreon LY. Surgical management traspinal lumbar synovial cysts: diagnosis and surgical manage-
of degenerative and postsurgical spondylolisthesis. Semin Spine ment. Surgeon. 2004;2(3):141-4.
Surg. 2005;17(3 Spec Iss):186-194. 46. Irwin ZN, Hilibrand A, Gustavel M, et al. Variation in surgi-
26. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- cal decision making for degenerative spinal disorders. Part I:
tive randomised study on the long-term effect of lumbar fusion lumbar spine. Spine. 2005;30(19):2208-13.
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. 47. Jackson RK, Boston DA, Edge AJ. Lateral mass fusion. A pro-
27. Eliyas JK, Karahalios D. Surgery for degenerative lumbar spine spective study of a consecutive series with long-term follow-up.
disease. Dis Mon. 2011;57(10):592-606. Spine. 1985;10(9):828-32.
28. Epstein JA, Epstein BS, Lavine LS, Rosenthal AD, Decker RE, 48. Jayakumar P, Nnadi C, Saifuddin A, Macsweeney E, Casey
Carras R. Obliterative arachnoiditis complicating lumbar spinal A. Dynamic degenerative lumbar spondylolisthesis: diag-
stenosis. J Neurosurg. 1978;48(2):252-8. nosis with axial loaded magnetic resonance imaging. Spine.
29. Feffer HL, Wiesel SW, Cuckler JM, Rothman RH. Degenerative 2006;31(10):E298-301.
spondylolisthesis: To fuse or not to fuse. Spine. 1985;10(3):287- 49. Jones TR, Rao RD. Adult isthmic spondylolisthesis. J Am Acad
289. Orthop Surg. 2009;17(10):609-617.

30. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective 50. Khan AM, Girardi F. Spinal lumbar synovial cysts. Diagnosis
randomized study of unilateral versus bilateral instrumented and management challenge. Eur Spine J. 2006;15(8):1176-82.
posterolateral lumbar fusion in degenerative spondylolisthesis. 51. Khan AM, Synnot K, Cammisa FP, Girardi FP. Lumbar synovial
Spine. 2007;32(4):395-401. cysts of the spine: an evaluation of surgical outcome. J Spinal
31. Frazier DD, Lipson SJ, Fossel AH, Katz JN. Associations be- Disord Tech. 2005;18(2):127-31.
tween spinal deformity and outcomes after decompression for 52. Kim DH, Albert TJ. Update on use of instrumentation in
spinal stenosis. Spine. 1997;22(17):2025-9. lumbar spine disorders. Best Pract Res Clin Rheumatol.
32. Gibson JN, Grant IC, Waddell G. The Cochrane review of 2002;16(1):123-40.
surgery for lumbar disc prolapse and degenerative lumbar spon- 53. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari-
dylosis. Spine. 1999;24(17):1820-32. son of surgical and conservative treatment for degenerative
33. Gibson, JN, Waddell G. Surgery for degenerative lumbar spon- lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5.
54. Knaub MA, Won DS, Mcguire R, Herkowitz HN. Lumbar spinal 71. Sachs BL, Zindrick MR, Beasley RD. Reflex sympathetic dystro-
stenosis: indications for arthrodesis and spinal instrumentation. phy after operative procedures on the lumbar spine. J Bone Joint
Instr Course Lect. 2005;54:313-9. Surg Am. 1993;75(5):721-725.
55. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid- 72. Schnee CL, Freese A, Ansell LV. Outcome analysis for adults
term clinical results of minimally invasive decompression and with spondylolisthesis treated with posterolateral fusion and
posterolateral fusion with percutaneous pedicle screws versus transpedicular screw fixation. J Neurosurg. 1997;86(1):56-63.
conventional approach for degenerative spondylolisthesis with 73. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis. Treat-
spinal stenosis. Eur Spine J. 2012;21(6):1171-7. ment strategies and indications for surgery. Orthop Clin North
56. Laus M, Tigani D, Alfonso C, Giunti A. Degenerative spondy- Am. 2003;34(2):281-95.
lolisthesis: lumbar stenosis and instability. Chir Organi Mov. 74. Sengupta DK, Herkowitz HN. Degenerative spondylolisthesis:
1992;77(1):39-49. review of current trends and controversies. Spine. 2005;30(6
57. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP. Suppl):S71-81.
Treatment of degenerative spondylolisthesis: potential impact 75. Sheehan JM, Shaffrey CI, Jane JA. Degenerative lumbar ste-
of dynamic stabilization based on imaging analysis. Eur Spine J. nosis: the neurosurgical perspective. Clin Orthop Relat Res.
2009;18(6):815-22. 2001;(384):61-74.
58. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- 76. Sienkiewicz PJ, Flatley TJ. Postoperative spondylolisthesis. Clin
strumented lower lumbar or lumbosacral posterolateral fusion. J Orthop Relat Res. 1987;(221):172-180.
Clin Neurosci. 2009;16(1):37-43. 77. Soren A, Waugh TR. Spondylolisthesis and related disorders.
59. 59. Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer A correlative study of 105 patients. Clin Orthop Relat Res.
C 3rd. Treatment of degenerative spondylolisthesis. Spine. 1985;(193):171-7.
1985;10(9):821-827. 78. Templin CR, Garfin SR. Surgical Management of Scoliosis and/
60. Majid K, Fischgrund JS. Degenerative lumbar spondylo- or Spondylolisthesis Associated with Spinal Stenosis. Semin
listhesis: trends in management. J Am Acad Orthop Surg. Spine Surg. 2007;19(3):187-199.
2008;16(4):208-15. 79. Tile M, McNeil SR, Zarins RK, Pennal GF, Garside SH.
61. McAfee PC, Cunningham BW, Tortolani PJ, Fedder IL, Sefter Spinal stenosis. Results of treatment. Clin Orthop Relat Res.
JC, Davis C. 100 Consecutive Cases of Degenerative Lumbar 1976;(115):104-108.
Conditions Using a Non-Threaded Locking Screw System With 80. Vaccaro AR, Patel T, Fischgrund J, et al. A 2-year follow-up pilot
a 90-Degree Locking Cap. SAS J. 2009;3(1):1-11. study evaluating the safety and efficacy of op-1 putty (rhbmp-7)
62. Mcculloch JA. Microdecompression and uninstrumented single- as an adjunct to iliac crest autograft in posterolateral lumbar
level fusion for spinal canal stenosis with degenerative spondy- fusions. Eur Spine J. 2005;14(7):623-9.
lolisthesis. Spine. 1998;23(20):2243-52. 81. Vaccaro AR, Patel T, Fischgrund J, et al. A 2-year follow-up pilot
63. Molina M, Wagner P, Campos M. Spinal lumbar stenosis. An study evaluating the safety and efficacy of op-1 putty (rhbmp-7)
update. Rev Med Chil. 2011;139(11):1488-1495. as an adjunct to iliac crest autograft in posterolateral lumbar
64. Müslüman AM, Cansever T, Yilmaz A, Çavuşoğlu H, Yüce fusions. Eur Spine J. 2005;14(7):623-9.
I, Aydin Y. Midterm outcome after a microsurgical unilat- 82. Vaccaro AR, Patel T, Fischgrund J, et al. A pilot study evaluating
eral approach for bilateral decompression of lumbar degen- the safety and efficacy of OP-1 Putty (rhBMP-7) as a replace-
erative spondylolisthesis: Clinical article. J Neurosurg Spine. ment for iliac crest autograft in posterolateral lumbar arthrod-
2012;16(1):68-76. esis for degenerative spondylolisthesis. Spine. 2004;29(17):1885-
65. Nasca RJ. Lumbar spinal stenosis: surgical considerations. J 1892.
South Orthop Assoc. 2002;11(3):127-134. 83. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure
66. Ohtori S, Inoue G, Orita S, et al. Teriparatide accelerates lumbar rate of the interspinous distraction device (X-Stop) for the treat-
posterolateral fusion in women with postmenopausal osteopo- ment of lumbar spinal stenosis caused by degenerative spondy-
rosis: prospective study. Spine. 2012;37(23):E1464-8. lolisthesis. Eur Spine J. 2008;17(2):188-92.
67. Onda A, Otani K, Konno S, Kikuchi S. Mid-term and long- 84. Watters WC 3rd. If, when, and how to fuse when treating lum-
term follow-up data after placement of the Graf stabilization bar degenerative stenosis. Semin Spine Surg. 2011;23(4):218-
system for lumbar degenerative disorders. J Neurosurg Spine. 221.
2006;5(1):26-32. 85. Yong-hing K. Pathophysiology and rationale for treatment
68. Osman SG. Endoscopic transforaminal decompression, in lumbar spondylosis and instability. Chir Organi Mov.
interbody fusion, and percutaneous pedicle screw implanta- 1994;79(1):3-10.
tion of the lumbar spine: A case series report. Int J Spine Surg. 86. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
2012;6(1):157-166. non-surgical treatment for lumbar spinal stenosis (Protocol).
69. Robertson PA, Grobler LJ, Novotny JE, Katz JN. Postoperative Cochrane Database Syst Rev. 2012;12:CD010264.
spondylolisthesis at L4-5. The role of facet joint morphology. 87. Zhao J, Wang X, Hou T, He S. One versus two BAK fusion
Spine. 1993;18(11):1483-90. cages in posterior lumbar interbody fusion to L4-L5 degenera-

70. Rubery PT. Degenerative spondylolisthesis. Curr Opin Orthop. tive spondylolisthesis: a randomized, controlled prospective
2001;12(3) 183-188. study in 25 patients with minimum two-year follow-up. Spine.
2002;27(24):2753-7.

Does the addition of instrumentation to
decompression and fusion for degenerative
lumbar spondylolisthesis improve surgical
outcomes compared with decompression and
fusion alone?
The addition of instrumentation is suggested to improve fusion rates

in patients with symptomatic spinal stenosis and degenerative lumbar
spondylolisthesis. Maintained from original guideline with minor word
modifications

The addition of instrumentation is not suggested to improve clinical
outcomes for the treatment of patients with symptomatic spinal stenosis
and degenerative lumbar spondylolisthesis. Maintained from original
guideline with minor word modifications
The updated literature search did not retrieve any new evidence that would provide additional support in
addressing this clinical question; therefore, the work group maintains the above guideline recommendations
from the original guideline.
Articles from original guideline: in higher fusion rates and subjective improvement in walking
Bridwell et al1 described a prospective comparative study of 44 distance when compared with fusion alone.
surgically treated patients with degenerative lumbar spondylo- Fischgrund et al2 conducted a randomized comparative
listhesis followed for a minimum of 2 years. Of the 44 patients, study of 76 consecutive patients with symptomatic spinal steno-
9 underwent laminectomy alone, 10 had laminectomy and non- sis associated with degenerative lumbar spondylolisthesis who
instrumented fusion and 24 had laminectomy and instrumented underwent posterior decompression and posterolateral fusion.
fusion (18 single-level, 6 two-level). Patients were radiographi- Patients were randomized into a transpedicular fixation group
cally assessed and a functional assessment was conducted by or noninstrumented group with a study objective to determine
asking whether they felt their ability to walk distances was worse whether instrumentation improves clinical outcomes and fu-
(-), the same (0) or significantly better (+). Of the 44 patients, 43 sion rates. Outcomes were assessed at 2-year follow-up using a
were followed for 2 years or more. The authors reported that in- five-point visual analog scale (VAS) and an operative result rat-
strumented fusion had higher fusion rates than noninstrument- ing (excellent, good, fair, poor) based on examiner assessment
ed fusion (ρ=0.002) and observed greater progression of spon- of pain and functional level. The authors reported that of the
dylolisthesis in patients treated with laminectomy alone and 76 patients included in the study, 68 (89%) were available at
laminectomy without instrumented fusion compared to patients 2-year follow-up. Clinical outcome with a rating of excellent or
good was achieved in 76% of instrumented patients and 85% of

who received laminectomy with instrumented fusion (ρ=0.001).

A higher proportion of the patients without slippage progres- noninstrumented patients (ρ=0.45). Successful arthrodesis was
sion reported that they were helped by the surgery than those achieved in 82% of instrumented versus 45% of noninstrument-
whose slippage progressed postoperatively (ρ<0.01). In critique, ed patients (ρ=0.0015). The authors found that successful fusion
this was a small study in which selection bias entered into the did not correlate with clinical outcome (ρ=0.435). The authors
randomization process, reviewers were not masked to patient concluded that for single-level degenerative lumbar spondylolis-
treatment and validated outcome measures were not utilized. thesis, use of instrumentation may lead to a higher fusion rate,
Because of these weaknesses, this potential Level II study was but clinical outcome showed no improvement in low back pain
downgraded to Level III. This study provides Level III therapeu- and lower limb pain with their nonvalidated outcome measures.
tic evidence that addition of instrumentation to fusion results In critique of this study, the follow-up may have been too short
to detect the effects of pseudarthrosis in this nonmasked study. these clinical outcomes, 4 papers reported a global evaluation.
Validated outcome measures were not utilized to assess clinical Two used Kaneda’s rating system and two used the Japanese Or-
outcomes. Because of these weaknesses, this potential Level II thopedic Association (JOA) score. Excellent and good results
study was downgraded to Level III. This study offers Level III were reassigned as satisfactory; poor results were classified as
therapeutic evidence that the addition of instrumentation to unsatisfactory. In the decompression alone category, the authors
posterolateral fusion for the treatment of degenerative lumbar reported 11 papers representing 216 patients were accepted for
spondylolisthesis increases the likelihood of obtaining a solid inclusion. Sixty-nine percent of patients had a satisfactory out-
arthrodesis, but does not correlate with improved clinical outcome. The incidence of worsened postoperative slip was 31%,
comes at 2-year follow-up. but was not associated with a poorer clinical result in the ma-
Kimura et al3 described a retrospective, comparative study of jority of patients. In the category of decompression with fusion
57 patients with Grade I or II L4-5 degenerative lumbar spon- and no instrumentation, 6 papers qualified for inclusion. In one
dylolisthesis. Group A consisted of 28 patients who underwent paper, only fusion data were broken out for the diagnosis of de-
decompression and posterolateral fusion without instrumenta- generative spondylolisthesis and were used just for this outcome
tion. Group B was comprised of 29 patients who had decompres- variable. Ninety percent of the patients in this category had a
sion and posterolateral fusion with pedicle screw instrumenta- satisfactory outcome; 86% achieved solid spinal fusion. With re-
tion. Following surgery, Group A was immobilized with bed rest gard to clinical outcome, the difference between patients treated
and a cast for 4-6 weeks, whereas Group B was mobilized much with decompression without fusion (69% satisfactory) and those
more quickly. Outcomes were assessed using the Japanese Or- treated with decompression and fusion without instrumentation
thopedic Association (JOA) scores and radiographs with mean (90% satisfactory) was statistically significant (P < 0.0001). In
follow-up in Group A of 6 years and in Group B of 3 years. The the decompression with fusion and pedicle screws category, 5
authors indicated that patients in Group A (noninstrumented) studies met the inclusion criteria. Fusion status was analyzed in
reported 72.4% satisfaction rate, with an 82.8% fusion rate. Pa- a total of 101. Eighty-five patients were analyzed with respect
tients in Group B (instrumented) reported an 82.1% satisfaction to clinical outcome. One paper did not separately analyze clini-
rate, with a 92.8% fusion rate. The authors did not find any sig- cal data, but did so for fusion data; therefore, only fusion data
nificant differences in outcomes between the 2 groups, except were included. The proportionally weighted fusion rates for this
that Group B (instrumented) had less low back pain. In critique group were 93%. When comparing the fusion without instru-
of this study, patients were not randomized and there was vary- mentation group to the fusion with pedicle screw group, there
ing duration of follow-up between groups. Although there was a was not a statistically significant increase in fusion rate (P =
trend toward improved satisfaction and fusion rates with instru- 0.08). Analysis of the clinical outcomes reveals an 86% satisfac-
mentation, with the numbers available no significant difference tory rating for the pedicle screw group. This compares favorably
was detected. This paper offers Level III therapeutic evidence of to the 69% satisfactory rate in the decompression without fu-
no significant benefit with the addition of instrumentation for sion group (P <0.0001). In the anterior spinal fusion category,
L4-5 degenerative lumbar spondylolisthesis. three papers presenting the results for 72 patients who received
Mardjetko et al4 performed a meta-analysis of primarily anterior spinal fusion for the treatment of degenerative spondy-
Level III studies. The objective of the study was to analyze the lolisthesis were included. Pooling the data from these 3 studies
published data on degenerative spondylolisthesis to evaluate yielded a 94% fusion rate with an 86% rate of patient satisfaction.
the feasibility of its use as a literature control to compare with The authors concluded that the meta-analysis results support
the historical cohort pedicle screw study data. The authors con- that spinal fusion significantly improves patient satisfaction in
ducted a comprehensive literature search to identify studies patients undergoing surgical treatment for degenerative lumbar
published in English peer-reviewed journals between 1970 and spondylolisthesis. In critique of this study, only 3 Level II stud-
1993 addressing degenerative spondylolisthesis with radicular ies were reviewed and data was very heterogeneous. This paper
leg pain or neurogenic claudication. Inclusion criteria included: offers Level III therapeutic evidence that addition of instrumen-
1. a minimum of four cases reviewed, and tation to fusion does not result in improved clinical outcome or
2. reporting of the primary outcome variable of fusion in fusion rate.
articles in which this was part of the treatment. Martin et al5 conducted a systematic review designed to
Clinical outcome variables of back pain, leg pain, function, identify and analyze comparative studies that examined the
neurogenic claudication and global outcome scores were record- surgical management of degenerative lumbar spondylolisthe-
ed when available. A total of 25 papers representing 889 patients sis, specifically the differences in outcomes between fusion and
were accepted for inclusion. Twenty-one were retrospective, decompression alone, and between instrumented fusion and
nonrandomized and uncontrolled. One paper was retrospec- noninstrumented fusion. Relevant randomized controlled trials
tive and nonrandomized, but compared 2 different treatments. (RCTs) and comparative, observational studies were identified
Three prospective, randomized studies were included. The pri- in a comprehensive literature search (1966 to June 2005). The in-
mary outcome variable, fusion, was determined by each author. clusion criteria required that a study be an RCT or comparative
The most constant clinical outcome variable reported was pain observational study that investigated the surgical management
with 16 papers reporting pain only, 6 papers reporting pain and of degenerative lumbar spondylolisthesis by comparing:
function and 2 papers reporting patient-determined outcomes. 1. fusion to decompression and/or
Patient function was reported in 6 papers and referred to the 2. instrumented fusion to noninstrumented fusion.
presence or absence of neurogenic claudication. In addition to A minimum one-year follow-up was required. Studies also
had to include at least 5 patients per treatment group. A study tion, absence of masking and/or the lack of validated outcome
was excluded if it included patients who had received previous measures to assess clinical outcomes. This paper offers Level III
spine surgery, or patients with cervical injuries, spinal fractures, therapeutic evidence that the use of adjunctive instrumentation
tumors or isthmic spondylolisthesis. A study was also excluded leads to improved fusion rates, but failed to show a statistically
if it was not possible to analyze patients with degenerative spon- significant improvement in clinical outcomes.
dylolisthesis separately from another included patient popula-
tion, or if it was not clearly a comparative study. Data from the Future Directions for Research
included studies were extracted by two independent reviewers The work group recommends the undertaking of large pro-
using a standard data abstraction sheet which identified the fol- spective studies or multicenter registry database studies with
lowing information: long-term follow-up to compare the postoperative outcomes
1. patient population’s age, sex, symptoms and degree of of decompression and fusion with and without adjunctive use
spondylolisthesis; of instrumentation in the management of degenerative lumbar
2. type of decompression, fusion, instrumentation, bone spondylolisthesis.
graft material, and preoperative and postoperative treat-
ment; References
3. study design and methodological quality using the Co- 1. Bridwell KH, Sedgewick TA, O’Brien MF, Lenke LG, Baldus
chrane RCT/CCT/Crossover Studies Checklist, modified C. The role of fusion and instrumentation in the treatment of
by the additional criterion that observational studies state degenerative spondylolisthesis with spinal stenosis. J Spinal
the use of a consecutive series of patients; and Disord. 1993;6(6):461-472.
4. study outcomes. 2. Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgom-
Clinical outcome, reoperation rate and solid fusion status ery DM, Kurz LT. 1997 Volvo Award winner in clinical studies.
were the main outcomes evaluated. An attempt was made to Degenerative lumbar spondylolisthesis with spinal stenosis: a
prospective, randomized study comparing decompressive lami-
compare patient-centered, validated and disease-specific out-
nectomy and arthrodesis with and without spinal instrumenta-
comes, complications and spondylolisthesis progression, but tion. Spine. 1997;22(24):2807-2812.
pooled analysis could not be performed due to heterogeneity in 3. Kimura I, Shingu H, Murata M, Hashiguchi H. Lumbar
how outcomes were reported. When appropriate, a study’s clini- posterolateral fusion alone or with transpedicular instrumenta-
cal outcome rating scale was altered to match a dichotomous rat- tion in L4--L5 degenerative spondylolisthesis. J Spinal Disord.
ing scale of “satisfactory” or “unsatisfactory,” and these results 2001;14(4):301-310.
were entered into Review Manager 4.2 for weighted group anlay- 4. Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spon-
sis. The authors reported that 8 studies were included in the fu- dylolisthesis. A meta-analysis of literature 1970-1993. Spine.
sion versus decompression alone analysis, including two RCTs. 1994;19(20 Suppl):2256S-2265S.
5. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah
Limitations were found in the methodologies of both RCTs and
SM, O’Neil J, Wai EK. The surgical management of degen-
most of the observational studies. Grouped analysis detected a erative lumbar spondylolisthesis: a systematic review. Spine.
significantly higher probability of achieving a satisfactory clini- 2007;32(16):1791-1798.
cal outcome with spinal fusion than with decompression alone
(relative risk, 1.40; 95% confidence interval, 1.04–1.89; P < 0.05). Bibliography from updated literature search
The clinical benefit favoring fusion decreased when analysis was 1. Abdul QR, Qayum MS, Saradhi MV, Panigrahi MK, Sreedhar
limited to studies where the majority of patients were reported V. Clinico-radiological profile of indirect neural decompres-
to be experiencing neurologic symptoms such as intermittent sion using cage or auto graft as interbody construct in posterior
claudication and/or leg pain. Six studies were included in the lumbar interbody fusion in spondylolisthesis: Which is better? J
instrumented fusion versus noninstrumented fusion analysis, Craniovertebr Junction Spine. 2011;2(1):12-6.
including three RCTs. The use of adjunctive instrumentation 2. Agabegi SS, Majid K, Fischgrund JS, Vaccaro AR, Patel T. Can
significantly increased the probability of attaining solid fusion preoperative radiographic parameters be used to predict fusion
(relative risk, 1.37; 95% confidence interval, 1.07–1.75; P < 0.05),
spondylolisthesis? Spine. 2011;36(26):E1709-14.
but no significant improvement in clinical outcome was re- 3. Aihara T, Toyone T, Aoki Y, et al. (2012). Surgical management
corded (relative risk, 1.19; 95% confidence interval, 0.92–1.54). of degenerative lumbar spondylolisthesis. J Musculoskel Res.
There was a non-significant trend towards a lower repeat opera- 2012;15(4).
tion rate in the fusion group compared with both decompression

alone and instrumented fusion. The authors concluded there Neurosurg Quart. 2009;19(3):200-206.
is moderate evidence that fusion may lead to a better clinical 5. Allen RT, Rihn JA, Glassman SD, Currier B, Albert TJ, Phillips
outcome compared with decompression alone, and the use of FM. An evidence-based approach to spine surgery. Am J Med
adjunctive instrumentation may lead to improved fusion status Qual. 2009;24(6 Suppl):15S-24S.
6. Aoki Y, Yamagata M, Nakajima F, Ikeda Y, Takahashi K. Poste-
and less risk of pseudarthrosis. Conclusions regarding the clini-
rior migration of fusion cages in degenerative lumbar disease
cal effectiveness of instrumented versus noninstrumented fusion treated with transforaminal lumbar interbody fusion: a report of
could not be made. In critique of this study, it was a systematic three patients. Spine. 2009;34(1):E54-8.
review of studies ranging down to Level III, and is thus classified 7. Baker AD, Sanderson P. Spinal surgery in older people:
as a Level III systematic review. Limitations were found in the Indications, techniques and outcomes. Rev Clin Geront.
methodologies of all RCTs, specifically in the pseudorandomiza- 2011;21(4):277-285.
8. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2):133-137. myelopathy thirty years after cadaveric renal transplantation.
9. Bono CM, Kadaba M, Vaccaro AR. Posterior pedicle fixation- Chiba Med J. 2011;87(1):11-15.
based dynamic stabilization devices for the treatment of 27. Gavaskar AS, Achimuthu R. Transfacetal fusion for low-grade
degenerative diseases of the lumbar spine. J Spinal Disord Tech. degenerative spondylolisthesis of the lumbar spine: results
2009;22(5):376-83. of a prospective single center study. J Spinal Disord Tech.
10. Brotis AG, Paterakis KN, Tsiamalou PM, Fountas KN, Hahji- 2010;23(3):162-5.
georgiou GM, Karavelis A. Instrumented posterior lumbar 28. Gelalis ID, Arnaoutoglou C, Christoforou G, Lykissas MG,
fusion outcomes for lumbar degenerative disorders in a Batsilas I, Xenakis T. Prospective analysis of surgical outcomes
southern European, semirural population. J Spinal Disord Tech. in patients undergoing decompressive laminectomy and pos-
2010;23(7):444-50. terior instrumentation for degenerative lumbar spinal stenosis.
11. Brower RS, Vickroy NM. A case of psoas ossification from Acta Orthop Traumatol Turc. 2010;44(3):235-40.
the use of BMP-2 for posterolateral fusion at L4-L5. Spine. 29. Ha KY, Na KH, Shin JH, Kim KW. Comparison of posterolateral
2008;33(18):E653-E655. fusion with and without additional posterior lumbar interbody
12. Chen KX, Yang QY, Liu XC, Li HJ. [Treatment of degenerative fusion for degenerative lumbar spondylolisthesis. J Spinal Dis-
lumbar spondylolisthesis through posterolateral fusion and fixa- ord Tech. 2008;21(4):229-34.
tion with pedicle screws]. Zhongguo Gu Shang. 2010;23(4):254- 30. Hara M, Nishimura Y, Takemoto M, Nakamura S, Wakabayashi
6. T. Posterior fixation for lumbar degenerative spondylosis: Mini-
13. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, open TLIF. Neurol Med Chir. 2012;21(2):118-127.
Loeser JD. Surgery for low back pain: a review of the evidence 31. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical
for an American Pain Society Clinical Practice Guideline. Spine. evaluation and self-assessment by patients after decompres-
2009;34(10):1094-109. sion surgery for degenerative lumbar canal stenosis. Spine J.
14. Cole CD, Mccall TD, Schmidt MH, Dailey AT. Comparison of 2008;8(2):380-4.
low back fusion techniques: transforaminal lumbar interbody 32. Harris EB, Sayadipour A, Massey P, Duplantier NL, Anderson
fusion (TLIF) or posterior lumbar interbody fusion (PLIF) ap- DG. Mini-open versus open decompression and fusion for lum-
proaches. Curr Rev Musculoskelet Med. 2009;2(2):118-26. bar degenerative spondylolisthesis with stenosis. Am J Orthop.
15. Dantas FL, Prandini MN, Ferreira MA. Comparison between 2011;40(12):E257-61.
posterior lumbar fusion with pedicle screws and posterior 33. Hart RA, Prendergast MA. Spine surgery for lumbar degenera-
lumbar interbody fusion with pedicle screws in adult spondylo- tive disease in elderly and osteoporotic patients. Instr Course
listhesis. Arq Neuropsiquiatr. 2007;65(3B):764-70 Lect. 2007;56:257-72.
16. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random- 34. Herkowitz HN. Degenerative lumbar spondylolisthesis: evolu-
ized, controlled, multicenter study of osteogenic protein-1 in tion of surgical management. Spine J. 2009;9(7):605-6.
instrumented posterolateral fusions: report on safety and feasi- 35. Hrabálek L, Wanek T, Adamus M. [Treatment of degenerative
bility. Spine. 2010;35(12):1185-91. spondylolisthesis of the lumbosacral spine by decompression
17. Di Silvestre M, Lolli F, Bakaloudis G, Parisini P. Dynamic sta- and dynamic transpedicular stabilisation]. Acta Chir Orthop
bilization for degenerative lumbar scoliosis in elderly patients. Traumatol Cech. 2011;78(5):431-6.
Spine. 2010;35(2):227-234. 36. Hwang CJ, Vaccaro AR, Hong J, et al. Immunogenicity of
18. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- osteogenic protein 1: results from a prospective, randomized,
tive randomised study on the long-term effect of lumbar fusion controlled, multicenter pivotal study of uninstrumented lumbar
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. posterolateral fusion. J Neurosurg Spine. 2010;13(4):484-93.
19. Eliyas JK, Karahalios D. Surgery for Degenerative Lumbar Spine 37. Ikuta K, Tono O, Oga M. Clinical outcome of microendoscopic
Disease. Dis Mon. 2011;57(10):592-606. posterior decompression for spinal stenosis associated with
20. Epstein NE. X-Stop: foot drop. Spine J. 2009;9(5):e6-9. degenerative spondylolisthesis--minimum 2-year outcome of 37
21. Eskander MS, Eskander JP, Drew JM, Pelow-aidlen JL, Eslami patients. Minim Invasive Neurosurg. 2008;51(5):267-71.
MH, Connolly PJ. A modified technique for dowel fibular strut 38. Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with au-
graft placement and circumferential fusion in the setting of tologous iliac bone versus local bone graft in posterior lumbar
L5-S1 spondylolisthesis and multilevel degenerative disc disease. interbody fusion. Spine. 2010;35(21):E1101-5.
Neurosurgery. 2010;67(3 Suppl Operative):ons91-5. 39. Kaner T, Dalbayrak S, Oktenoglu T, Sasani M, Aydin AL, Ozer
22. Faldini C, Pagkrati S, Acri F, et al. (2007). Surgical treatment AF. Comparison of posterior dynamic and posterior rigid
of symptomatic degenerative lumbar spondylolisthesis by transpedicular stabilization with fusion to treat degenerative
decompression and instrumented fusion. J Orthop Traumatol. spondylolisthesis. Orthopedics. 2010;33(5)
2007;8(3):128-133. 40. Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra
23. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura in spinal tuberculosis. Eur Spine J. 2011;20(1):1-5.
K, Yuan HA. Radiostereometric analysis of postoperative mo- 41. Kleinstueck FS, Fekete TF, Mannion AF, et al. To fuse or
tion after application of dynesys dynamic posterior stabilization not to fuse in lumbar degenerative spondylolisthesis: do
system for treatment of degenerative spondylolisthesis. J Spinal baseline symptoms help provide the answer?. Eur Spine J.
Disord Tech. 2010;23(4):236-41. 2012;21(2):268-75.
24. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective 42. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari-
randomized study of unilateral versus bilateral instrumented son of surgical and conservative treatment for degenerative
posterolateral lumbar fusion in degenerative spondylolisthesis. lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5.
Spine. 2007;32(4):395-401. 43. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid-
25. Fransen P. Increasing pedicle screw anchoring in the osteoporot- term clinical results of minimally invasive decompression and
ic spine by cement injection through the implant. Technical note posterolateral fusion with percutaneous pedicle screws versus
and report of three cases. J Neurosurg Spine. 2007;7(3):366-9. conventional approach for degenerative spondylolisthesis with
26. Fujimoto K, Yamazaki M, Hayashi K, et al. Posterior decom- spinal stenosis. Eur Spine J. 2012;21(6):1171-7.
pression with instrumented fusion in a patient with cervical 44. Lattig F, Fekete TF, Grob D, Kleinstück FS, Jeszenszky D, Man-
nion AF. Lumbar facet joint effusion in MRI: a sign of instability interbody fusion, and percutaneous pedicle screw implanta-
in degenerative spondylolisthesis?. Eur Spine J. 2012;21(2):276- tion of the lumbar spine: A case series report. Int J Spine Surg.
81. 2012;6(1), 157-166.
45. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP. 62. Ozkan N, Sandalcioglu IE, Petr O, et al. Minimally invasive
Treatment of degenerative spondylolisthesis: potential impact transpedicular dorsal stabilization of the thoracolumbar and
of dynamic stabilization based on imaging analysis. Eur Spine J. lumbar spine using the minimal access non-traumatic insertion
2009;18(6):815-22. system (MANTIS): preliminary clinical results in 52 patients. J
46. Lee DY, Lee SH, Shim CS, Lee HY. Decompression and inter- Neurol Surg A Cent Eur Neurosurg. 2012;73(6):369-76.
spinous dynamic stabilization using the locker for lumbar canal 63. Park H, Zhang HY, Cho BY, Park JY. Change of lumbar mo-
stenosis associated with low-grade degenerative spondylolisthe- tion after multi-level posterior dynamic stabilization with
sis. Minim Invasive Neurosurg. 2010;53(3):117-21. bioflex system : 1 year follow up. J Korean Neurosurg Soc.
47. Lee JC, Jang HD, Shin BJ. Learning curve and clinical outcomes 2009;46(4):285-91.
of minimally invasive transforaminal lumbar interbody fusion: 64. Park JH, Hyun SJ, Roh SW, Rhim SC. A comparison of unilater-
our experience in 86 consecutive cases. Spine. 2012;37(18):1548- al laminectomy with bilateral decompression and fusion surgery
57. in the treatment of grade I lumbar degenerative spondylolisthe-
48. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- sis. Acta Neurochir (Wien). 2012;154(7):1205-12.
strumented lower lumbar or lumbosacral posterolateral fusion. J 65. Park JY, Chin DK, Cho YE. Accelerated L5-S1 Segment
Clin Neurosci. 2009;16(1):37-43. Degeneration after Spinal Fusion on and above L4-5 : Mini-
49. Lekovic GP, Han PP, Kenny KJ, Dickman CA. Bone dowels mum 4-Year Follow-Up Results. J Korean Neurosurg Soc.
in anterior lumbar interbody fusion. J Spinal Disord Tech. 2009;45(2):81-4.
2007;20(5):374-9. 66. Park SC, Yoon SH, Hong YP, Kim KJ, Chung SK, Kim HJ. Mini-
50. Liao JC, Chen WJ, Chen LH, Niu CC. Outcome of the L5-S1 mum 2-year follow-up result of degenerative spinal stenosis
segment after posterior instrumented spinal surgery in degen- treated with interspinous u (coflex). J Korean Neurosurg Soc.
erative lumbar diseases. Chang Gung Med J. 2009;32(1):81-8. 2009;46(4):292-9.
51. Liao JC, Chen WJ, Chen LH, Niu CC, Keorochana G. Surgi- 67. Quraishi NA, Lewis SJ, Kelleher MO, Sarjeant R, Rampersaud
cal outcomes of degenerative spondylolisthesis with L5-S1 disc YR, Fehlings MG. Intraoperative multimodality monitoring
degeneration: comparison between lumbar floating fusion and in adult spinal deformity: analysis of a prospective series of
lumbosacral fusion at a minimum 5-year follow-up. Spine. one hundred two cases with independent evaluation. Spine.
2011;36(19):1600-7. 2009;34(14):1504-12.
52. Long H, Kazunasa U, Liu S, Akio S, Taito I. Preliminary ap- 68. Rampersaud YR, Wai EK, Fisher CG, et al. Postoperative im-
plication of one-level posterior lumbar interbody fusion with provement in health-related quality of life: a national compari-
prospace and facet fusion using local autograft. Zhongguo Xiu son of surgical treatment for focal (one- to two-level) lumbar
Fu Chong Jian Wai Ke Za Zhi. 2007;21(11):1155-9. spinal stenosis compared with total joint arthroplasty for
53. Majid K, Fischgrund JS. Degenerative lumbar spondylo- osteoarthritis. Spine J. 2011;11(11):1033-41.
listhesis: trends in management. J Am Acad Orthop Surg. 69. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow-
2008;16(4):208-15. up of spinal stenosis with degenerative spondylolisthesis
54. Mcafee P, Khoo LT, Pimenta L, et al. Treatment of lumbar spinal treated with decompression and dynamic stabilization. Spine.
stenosis with a total posterior arthroplasty prosthesis: implant 2008;33(18):E636-42.
description, surgical technique, and a prospective report on 29 70. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous
patients. Neurosurg Focus. 2007;22(1):E13. transforaminal lumbar interbody fusion for the treatment of de-
55. McAfee PC, Cunningham BW, Tortolani PJ, Fedder IL, Sefter generative lumbar instability. Neurosurgery. 2007;60(4 SUPPL.
JC, Davis C. 100 Consecutive Cases of Degenerative Lumbar 2):203-212.
Conditions Using a Non-Threaded Locking Screw System With 71. Skowroński J, Wojnar J, Bielecki M. Interbody fusion and trans-
a 90-Degree Locking Cap. SAS Journal. 2009;3(1):1-11. pedicular fixation in the treatment of spondylolisthesis. Ortop
56. Min JH, Jang JS, Kim SK, Maeng DH, Lee SH. The ligamen- Traumatol Rehabil. 2007;9(2):149-55.
totactic effect on a herniated disc at the level adjacent to the 72. Templin CR, Garfin SR. Surgical Management of Scoliosis and/
anterior lumbar interbody fusion : report of two cases. J Korean or Spondylolisthesis Associated with Spinal Stenosis. Semin
Neurosurg Soc. 2009;46(1):65-7. Spine Surg. 2007;19(3):187-199.
57. Mori E, Okada S, Ueta T, et al. Spinous process-splitting open 73. Tokuhashi Y, Ajiro Y, Umezawa N. Subsidence of metal inter-
pedicle screw fusion provides favorable results in patients with body cage after posterior lumbar interbody fusion with pedicle
low back discomfort and pain compared to conventional open screw fixation. Orthopedics. 2009;32(4):259.
pedicle screw fixation over 1 year after surgery. Eur Spine J. 74. Traynelis VC. Comments. Neurosurgery. 2009;64(5):963-964.
2012;21(4):745-53. 75. Turunen V, Nyyssönen T, Miettinen H, et al. Lumbar instru-
58. Ohta H, Matsumoto Y, Morishita Y, et al. Surgical results of mented posterolateral fusion in spondylolisthetic and failed
dynamic nonfusion stabilization with the Segmental Spinal back patients: a long-term follow-up study spanning 11-13
Correction System for degenerative lumbar spinal diseases with years. Eur Spine J. 2012;21(11):2140-8.
instability: Minimum 2-year follow-up. SAS J. 2011;5(3):69-74. 76. Vaccaro AR, Lawrence JP, Patel T, et al. The safety and efficacy
59. Ohtori S, Inoue G, Orita S, et al. Teriparatide accelerates lumbar of OP-1 (rhBMP-7) as a replacement for iliac crest autograft in
posterolateral fusion in women with postmenopausal osteopo- posterolateral lumbar arthrodesis: a long-term (>4 years) pivotal
rosis: prospective study. Spine. 2012;37(23):E1464-8. study. Spine. 2008;33(26):2850-62.
60. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic 77. Vaccaro AR, Stubbs HA, Block JE. Demineralized bone matrix
assessment of the ability of the extreme lateral interbody fusion composite grafting for posterolateral spinal fusion. Orthopedics.
procedure to indirectly decompress the neural elements. Spine. 2007;30(7):567-70.
2010;35(26 Suppl):S331-7. 78. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy
61. Osman SG. Endoscopic transforaminal decompression, of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
posterolateral lumbar arthrodesis: minimum 4-year follow-up of J Bone Joint Surg Am. 2009;91(6):1295-304.
a pilot study. Spine J. 2008;8(3):457-65. 83. Welch WC, Cheng BC, Awad TE, et al. Clinical outcomes of
79. Vanek P, Saur K. Transforaminal lumbar interbody fusion the Dynesys dynamic neutralization system: 1-year preliminary
(TLIF) and instruments. Prospective study with the minimum results. Neurosurg Focus. 2007;22(1):E8.
of 20-month follow-up. [Czech]. Cesk Neurol Neurochir. 84. Xu H, Tang H, Li Z. Surgical treatment of adult degenera-
2007;70(5):552-557. tive spondylolisthesis by instrumented transforaminal lumbar
80. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure interbody fusion in the Han nationality. J Neurosurg Spine.
rate of the interspinous distraction device (X-Stop) for the treat- 2009;10(5):496-9. Yamashita T, Steinmetz MP, Lieberman IH,
ment of lumbar spinal stenosis caused by degenerative spondy- Modic MT, Mroz TE. The utility of repeated postoperative
lolisthesis. Eur Spine J. 2008;17(2):188-92. radiographs after lumbar instrumented fusion for degenerative
81. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non- lumbar spine. Spine. 2011;36(23):1955-60.
surgical treatment for lumbar degenerative spondylolisthesis. N 85. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
Engl J Med. 2007;356(22):2257-70. results of pediculo-body fixation and posterolateral fusion for
82. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared lumbar spondylolisthesis. Eur Spine J. 2009;18 Suppl 1:151-5.
with nonoperative treatment for lumbar degenerative spon- 86. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
dylolisthesis. four-year results in the Spine Patient Outcomes non-surgical treatment for lumbar spinal stenosis. Cochrane
Research Trial (SPORT) randomized and observational cohorts. Database Syst Rev. 2012;(12).

How do outcomes of decompression with
posterolateral fusion compare with those for
360° fusion in the treatment of degenerative
For the purposes of this guideline, the work group defined “360° fusion” as a procedure involving interbody
fusion.

the use of either decompression with posterolateral fusion or 360°
fusion in the surgical treatment of patients with degenerative lumbar
spondylolisthesis. Maintained from original guideline
New article from updated literature search: graphs, were also taken. In the U-PLF group, the VAS decreased
In a retrospective comparative study, Ha et al1 evaluated the ef- by 2.6%±1.9%, and in the U-PLIF group, the VAS decreased by
fects of posterior lumbar interbody fusion (PLIF) after postero- 5.9%±1.8%; the difference between the groups was statistically
lateral fusion (PLF) on patients undergoing surgical treatment significant (p=0.004). Thus, in the unstable group, the U-PLIF
for degenerative spondylolisthesis. Forty patients, who under- group had a significantly greater improvement in the VAS than
went single level decompression and posterior instrumentation the U-PLF group. In the U-PLF group, the ODI decreased by
at L4-5, were followed for at least 2 years. The patients were 22.0%±16.1%, and in the U-PLIF group, the ODI decreased by
divided into 4 groups: the stable PLF group (S-PLF, n=13); the 42.3%±17.9%; the difference between the groups was statistically
stable PLF with additional PLIF group (S-PLIF, n=11); the un- significant (p=0.032). In the unstable group, the U-PLIF group
stable PLF group (U-PLF, n=8); and the unstable PLF with ad- had a significantly higher improvement in the ODI than the U-
ditional PLIF group (U-PLIF, n=8). Clinical and radiographic PLF group. The degree of slip did not change between stable and
comparisons were carried out between the S-PLF and S-PLIF unstable groups with the addition of PLIF; however, disc height
groups and between the U-PLF and U-PLIF groups. The Vi- did change significantly in both groups. This study suggests that
sual Analog Scale (VAS) and Oswestry Disability Index (ODI) preoperative segmental instability may be a criterion for deter-
questionnaires were administered preoperatively and at the final mining whether an additional PLIF would be beneficial in the
follow-up to compare the severity of pain and its effect on the pa- treatment of degenerative spondylolisthesis. In critique of this
tients’ lives. Radiographic assessments, including plain radiogra- study, the sample size was small, initial diagnostic methods were
phy with dynamic flexion and extension standing lateral radio- vaguely described, and there was limited description of patient
characteristics. Without statistical analysis comparing the dif- References

ferences of patient characteristics between groups, it is difficult 1. Ha KY, Na KH, Shin JH, Kim KW. Comparison of posterolateral
to determine the impact of confounding on the outcomes. This fusion with and without additional posterior lumbar interbody
potential Level III study provides Level IV therapeutic evidence fusion for degenerative lumbar spondylolisthesis. J Spinal Dis-
that the addition of PLIF to unstable segments may improve the ord Tech. 2008;21(4):229-34.
surgical outcome for degenerative spondylolisthesis and appears 2. Rousseau MA, Lazennec JY, Bass EC, Saillant G. Predictors of
outcomes after posterior decompression and fusion in degenera-
to improve disc height.
tive spondylolisthesis. Eur Spine J. 2005;14(1):55-60.
Article from original guideline:

Rousseau et al2 conducted a retrospective comparative study of
Bibliography from updated literature search
1. Abdul QR, Qayum MS, Saradhi MV, Panigrahi MK, Sreedhar
24 consecutive patients undergoing decompression and trans- V. Clinico-radiological profile of indirect neural decompres-
pedicular fixation to treat symptomatic degenerative lumbar sion using cage or auto graft as interbody construct in posterior
spondylolisthesis. Of the 24 patients, 8 also underwent posterior lumbar interbody fusion in spondylolisthesis: Which is better?. J
lumbar interbody fusion (PLIF). Outcomes were assessed using Craniovertebr Junction Spine. 2011;2(1):12-6.
the Beaujon scoring system with a mean follow-up of 2.87 years. 2. Agabegi SS, Majid K, Fischgrund JS, Vaccaro AR, Patel T. Can
The authors reported that the Beaujon score was improved in preoperative radiographic parameters be used to predict fusion
all 24 patients (ρ<0.001) and fusion was successful in all cases. in non-instrumented posterolateral fusion for degenerative
Preoperative leg pain and the addition of PLIF were significantly spondylolisthesis?. Spine. 2011;36(26):E1709-14.
3. Aihara T, Toyone T, Aoki Y, et al. Surgical management of
correlated with greater improvement (ρ=0.016 and ρ=0.003),
degenerative lumbar spondylolisthesis. J Musculoskelet Res.
respectively. The authors concluded that posterior decompres- 2012;15(4):1250020.
sion and fusion is successful in treating degenerative lumbar 4. Brower RS, Vickroy NM. A case of psoas ossification from
spondylolisthesis and that the additional circumferential fu- the use of BMP-2 for posterolateral fusion at L4-L5. Spine.
sion yields significant improvement in functional outcomes. In 2008;33(18):E653-655.
critique, this study was retrospective with a small sample size 5. Chen KX, Yang QY, Liu XC, Li HJ. [Treatment of degenerative
of nonrandomized patients. Of the 24 patients included, only 8 lumbar spondylolisthesis through posterolateral fusion and fixa-
underwent PLIF. In addition, of the 24 patients included in the tion with pedicle screws]. Zhongguo Gu Shang. 2010;23(4):254-
study, only 18 (75%) were available for follow-up beyond 2 years 6.
6. Dantas FL, Prandini MN, Ferreira MA. Comparison between
and it is unclear how many of the 8 PLIF patients remained in
posterior lumbar fusion with pedicle screws and posterior
this subset. Because of these deficiencies, this potential Level III lumbar interbody fusion with pedicle screws in adult spondylo-
study was downgraded to Level IV. This study provides Level IV listhesis. Arq Neuropsiquiatr. 2007;65(3B):764-70
therapeutic evidence that posterior decompression and fusion is 7. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH.
successful in treating degenerative lumbar spondylolisthesis and Degenerative spondylolisthesis of the cervical spine: analysis of
that additional circumferential fusion results in slightly better 58 patients treated with anterior cervical decompression and
outcomes than posterior decompression and fusion alone. fusion. Spine J. 2009;9(6):439-46.
8. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random-
ized, controlled, multicenter study of osteogenic protein-1 in
Future Directions for Research instrumented posterolateral fusions: report on safety and feasi-
The work group identified the following suggestions for future bility. Spine. 2010;35(12):1185-91.
studies which would generate meaningful evidence to assist in 9. Di silvestre M, Lolli F, Bakaloudis G. Degenerative lumbar sco-
further evaluating the efficacy of surgical techniques, including liosis in elderly patients: dynamic stabilization without fusion
posterolateral fusion and 360° fusion, for the treatment of de- versus posterior instrumented fusion. Spine J. 2014;14(1):1-10.
generative lumbar spondylolisthesis. 10. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec-
tive randomised study on the long-term effect of lumbar fusion
Recommendation 1: on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86.
11. Epstein NE. An analysis of noninstrumented posterolateral
The work group recommends the undertaking of a retrospec-
lumbar fusions performed in predominantly geriatric patients
tive analysis comparing instrumented posterolateral fusion to using lamina autograft and beta tricalcium phosphate. Spine J.
decompression with 360° (circumferential) instrumented fusion 2008;8(6):882-7.
in patients with degenerative lumbar spondylolisthesis. 12. Eskander MS, Eskander JP, Drew JM, Pelow-aidlen JL, Eslami
MH, Connolly PJ. A modified technique for dowel fibular strut

Recommendation 2: graft placement and circumferential fusion in the setting of L5-

The work group recommends the undertaking of large multi- S1 spondylolisthesis and multilevel degenerative disc disease.
center registry database studies with long term follow up Neurosurgery. 2010;67(3 Suppl Operative):ons91-5.
comparing the outcomes of surgical treatments, including in- 13. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D,
Giannini S. Surgical treatment of symptomatic degenerative
strumented posterolateral fusion to decompression with 360°
lumbar spondylolisthesis by decompression and instrumented
(circumferential) instrumented fusion, in patients with degen- fusion. J Orthop Traumatol. 2007;8(3):128-133
erative lumbar spondylolisthesis. 14. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D,
Giannini S. Surgical treatment of symptomatic degenerative
lumbar spondylolisthesis by decompression and instrumented
fusion. J Orthop Traumatol. 2007;8(3):128-133.
15. Gavaskar AS, Achimuthu R. Transfacetal fusion for low-grade outcomes after lumbar fusion for degenerative spondylolisthesis
degenerative spondylolisthesis of the lumbar spine: results with large joint replacement surgery and population norms.
of a prospective single center study. J Spinal Disord Tech. Spine J. 2010;10(4):306-12.
2010;23(3):162-165 34. Ohtori S, Inoue G, Orita S, et al. Teriparatide accelerates lumbar
16. Gibson JN, Waddell G. Surgery for degenerative lumbar spondy- posterolateral fusion in women with postmenopausal osteopo-
losis. Cochrane Database Syst Rev. 2005;(4):CD001352. rosis: prospective study. Spine. 2012;37(23):E1464-8.
17. Hara M, Nishimura Y, Takemoto M, Nakamura S, Wakabayashi 35. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic
T. Posterior fixation for lumbar degenerative spondylosis: Mini- assessment of the ability of the extreme lateral interbody fusion
open TLIF. Japan J Neurosurg. 2012;21(2):118-127. procedure to indirectly decompress the neural elements. Spine.
18. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical 2010;35(26 Suppl):S331-7.
evaluation and self-assessment by patients after decompres- 36. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost-
sion surgery for degenerative lumbar canal stenosis. Spine J. effectiveness of minimally invasive versus open transforaminal
2008;8(2):380-384. lumbar interbody fusion for degenerative spondylolisthesis
19. Harris EB, Sayadipour A, Massey P, Duplantier NL, Anderson associated low-back and leg pain over two years. World Neuro-
DG. Mini-open versus open decompression and fusion for surg. 2012;78(1-2):178-84.
lumbar degenerative spondylolisthesis with stenosis. A J Orthop. 37. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings
2011;40(12):E257-261. MG. Cost-utility analysis of posterior minimally invasive fusion
20. Helenius I, Remes V, Poussa M. Uninstrumented in situ fusion compared with conventional open fusion for lumbar spondylo-
for high-grade childhood and adolescent isthmic spondylolis- listhesis. SAS J. 2011;5(2):29-35.
thesis: long-term outcome. Surgical technique. J Bone Joint Surg 38. Rodgers WB, Lehmen JA, Gerber EJ, Rodgers JA. Grade 2
Am. 2008;90 Suppl 2 Pt 1:145-52 spondylolisthesis at L4-5 treated by XLIF: safety and midterm
21. Huang TY, Lee KS, Tsai TH, Su YF, Hwang SL. Posterior epidural results in the “worst case scenario”. ScientificWorldJournal.
migration of sequestrated lumbar disc fragments into the bilat- 2012;2012:356712.
eral facet joints: case report. Neurosurgery. 2011;69(5):E1148-51. 39. Rouben D, Casnellie M, Ferguson M. Long-term durability of
22. Hunt T, Shen FH, Shaffrey CI, Arlet V. Contralateral radiculopa- minimal invasive posterior transforaminal lumbar interbody fu-
thy after transforaminal lumbar interbody fusion. Eur Spine J. sion: a clinical and radiographic follow-up. J Spinal Disord Tech.
2007;16 Suppl 3:311-314. 2011;24(5):288-96
23. Hwang CJ, Vaccaro AR, Hong J, et al. Immunogenicity of 40. Shen NJ, Lin MX, Lin QB, Wang XA, Chen J, Wang GJ. Do-
osteogenic protein 1: results from a prospective, randomized, mestic vertebral internal fixation system for treating lumbar
controlled, multicenter pivotal study of uninstrumented lumbar spondylolisthesis in 55 cases. A follow-up study. J Clin Rehabil
posterolateral fusion. J Neurosurg Spine. 2010;13(4):484-93. Tissue Eng Res. 2009;13(9):1793-1796.
24. Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with au- 41. Skowroński J, Wojnar J, Bielecki M. Interbody fusion and trans-
tologous iliac bone versus local bone graft in posterior lumbar pedicular fixation in the treatment of spondylolisthesis. Ortop
interbody fusion. Spine. 2010;35(21):E1101-5. Traumatol Rehabil. 2007;9(2):149-55.
25. Jones TR, Rao RD. Adult isthmic spondylolisthesis. J Am Acad 42. Sugawara A, Isu T, Kim K, Morimoto D, Isobe M, Matsumoto
Orthop Surg. 2009;17(10):609-617. R, Ogasawara K. Surgical results using only posterior decom-
26. Kaner T, Dalbayrak S, Oktenoglu T, Sasani M, Aydin AL, Ozer pression for lumbar canal stenosis with lumbar degenerative
AF. Comparison of posterior dynamic and posterior rigid spondylolisthesis. Neurol Med Chir. 2012;21(2), 111-117.
transpedicular stabilization with fusion to treat degenerative 43. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Matsu-
spondylolisthesis. Orthopedics. 2010;33(5). da H. Clinical outcome of microsurgical bilateral decompression
27. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid- via unilateral approach for lumbar canal stenosis: minimum
term clinical results of minimally invasive decompression and five-year follow-up. Spine. 2011;36(5):410-5.
posterolateral fusion with percutaneous pedicle screws versus 44. Vaccaro AR, Lawrence JP, Patel T, et al. The safety and efficacy
conventional approach for degenerative spondylolisthesis with of OP-1 (rhBMP-7) as a replacement for iliac crest autograft in
spinal stenosis. Eur Spine J. 2012;21(6):1171-7. posterolateral lumbar arthrodesis: a long-term (>4 years) pivotal
28. Lee JC, Jang HD, Shin BJ. Learning curve and clinical outcomes study. Spine. 2008;33(26):2850-62.
of minimally invasive transforaminal lumbar interbody fusion: 44. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy
our experience in 86 consecutive cases. Spine. 2012;37(18):1548- of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
57. posterolateral lumbar arthrodesis: minimum 4-year follow-up of
29. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- a pilot study. Spine J. 2008;8(3):457-65.
strumented lower lumbar or lumbosacral posterolateral fusion. J 45. Vanek P, Saur K. (2007). Transforaminal lumbar interbody
Clin Neurosci. 2009;16(1):37-43. fusion (TLIF) and instruments. Prospective study with the
30. Liao JC, Chen WJ, Chen LH, Niu CC. Outcome of the L5-S1 minimum of 20-month follow-up. Cesk Neurol Neurochir.
segment after posterior instrumented spinal surgery in degen- 2007;70(5), 552-557.

erative lumbar diseases. Chang Gung Med J. 2009;32(1):81-8. 46. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure
31. Liao JC, Chen WJ, Chen LH, Niu CC, Keorochana G. Surgi- rate of the interspinous distraction device (X-Stop) for the treat-
cal outcomes of degenerative spondylolisthesis with L5-S1 disc ment of lumbar spinal stenosis caused by degenerative spondy-
degeneration: comparison between lumbar floating fusion and lolisthesis. Eur Spine J. 2008;17(2):188-92.
lumbosacral fusion at a minimum 5-year follow-up. Spine. 47. Xu H, Tang H, Li Z. Surgical treatment of adult degenera-
2011;36(19):1600-7. tive spondylolisthesis by instrumented transforaminal lumbar
32. Mehta VA, Mcgirt MJ, Garcés ambrossi GL, et al. Trans-foram- interbody fusion in the Han nationality. J Neurosurg Spine.
inal versus posterior lumbar interbody fusion: comparison of 2009;10(5):496-9.
surgical morbidity. Neurol Res. 2011;33(1):38-42. 48. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
33. Mokhtar SA, Mccombe PF, Williamson OD, Morgan MK, White results of pediculo-body fixation and posterolateral fusion for
GJ, Sears WR. Health-related quality of life: a comparison of lumbar spondylolisthesis. Eur Spine J. 2009;18 Suppl 1:151-5.

Does 360° fusion with decompression lead to
better outcomes versus 360° fusion without
decompression for treatment of degenerative
No evidence was found to address this question. Due to the paucity

of literature addressing this question, the work group was unable to
generate a recommendation to answer this question.
Future Directions For Research thesis: long-term outcome. Surgical technique. J Bone Joint Surg
The work group recommends the undertaking of a registry da- Am. 2008;90 Suppl 2 Pt 1:145-52.
8. Jones TR, Rao RD. Adult isthmic spondylolisthesis. J Am Acad
tabase study that would provide outcomes data comparing 360°
Orthop Surg. 2009.17(10), 609-617.
fusion with and without decompression in patients undergoing 9. Kim S, Mortaz hedjri S, Coyte PC, Rampersaud YR. Cost-utility
surgical treatment for degenerative lumbar spondylolisthesis. of lumbar decompression with or without fusion for patients
with symptomatic degenerative lumbar spondylolisthesis. Spine
Bibliography J. 2012;12(1):44-54.
1. Chaloupka R, Krbec, M, Cienciala J, et al. Two year clinical re- 10. Mcafee PC, Devine JG, Chaput CD, et al. The indications for
sults of 360 degree fusion of lumbar spondylolisthesis managed interbody fusion cages in the treatment of spondylolisthesis:
by transpedicular fixation and plif or alif technique. Eur Spine J. analysis of 120 cases. Spine. 2005;30(6 Suppl):S60-5.
2006;15(Suppl 4):S506-s507. 11. Mehta VA, Mcgirt MJ, Garcés ambrossi GL, et al. Trans-foram-
2. Chaudhary KS, Groff MW. Minimally invasive transforaminal inal versus posterior lumbar interbody fusion: comparison of
lumbar interbody fusion for degenerative spine. Tech Orthop. surgical morbidity. Neurol Res. 2011;33(1):38-42.
2011;26(3):146-155. 12. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost-
3. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- effectiveness of minimally invasive versus open transforaminal
tive randomised study on the long-term effect of lumbar fusion lumbar interbody fusion for degenerative spondylolisthesis
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. associated low-back and leg pain over two years. World Neuro-
4. Eskander MS, Eskander JP, Drew JM, Pelow-aidlen JL, Eslami surg. 2012;78(1-2):178-84.
MH, Connolly PJ. A modified technique for dowel fibular strut 13. Rodgers WB, Lehmen JA, Gerber EJ, Rodgers JA. Grade 2
graft placement and circumferential fusion in the setting of L5- spondylolisthesis at L4-5 treated by XLIF: safety and midterm
S1 spondylolisthesis and multilevel degenerative disc disease. results in the “worst case scenario”. ScientificWorldJournal.
Neurosurgery. 2010;67(3 Suppl Operative):ons91-5. 2012;2012:356712.
5. Gibson JN, Waddell G. Surgery for degenerative lumbar spon- 14. Rosenberg WS, Mummaneni PV. Transforaminal lumbar
dylosis. Cochrane Database Syst Rev. 2005;(4):CD001352. interbody fusion: technique, complications, and early results.
6. Gibson JN, Waddell G. Surgery for degenerative lumbar spon- Neurosurgery. 2001;48(3):569-74.
dylosis: updated Cochrane Review. Spine. 2005;30(20):2312-20. 15. Rousseau MA, Lazennec JY, Bass EC, Saillant G. Predictors of
7. Helenius I, Remes V, Poussa M. Uninstrumented in situ fusion outcomes after posterior decompression and fusion in degenera-
for high-grade childhood and adolescent isthmic spondylolis- tive spondylolisthesis. Eur Spine J. 2005;14(1):55-60.


Do flexible fusions improve outcomes in
the treatment of degenerative lumbar
spondylolisthesis compared to nonoperative
treatment?
For the purposes of this guideline, the work group defined “flexible fusion” as a procedure involving dynamic
stabilization without arthrodesis.
No evidence was found to address this question. Due to the paucity

of literature addressing this question, the work group was unable to
generate a recommendation to answer this question.
Although no studies were found to directly address this ques- spondylolisthesis patients who do not require fixation or reduc-
tion, the work group included the case-series summaries below tion.
as background support to demonstrate the safety and effective- Onda et al3 conducted a retrospective case series of 31 pa-
ness of flexible fusions in single-armed studies. tients who underwent decompression and stabilization with a
Fayyazi et al1 conducted a prospective case series study of 6 graf stabilization system. Of the 31 patients enrolled, 23 had a
patients with degenerative spondylolisthesis to evaluate the effi- diagnosis of degenerative spondylolisthesis. Patients were fol-
cacy of the Dynesys posterior dynamic stabilization system. Pa- low-up over 5 years and outcomes were assessed using Japanese
tients were followed over 2 years and outcomes were evaluated Orthopedic Association (JOA) and ODI outcome measures.
by VAS, ODI and radiographic measurements. Results suggest Results indicated that there was significantly better clinical im-
that the stabilization system led to significant decreases in VAS provement from preoperatively to postoperatively in JOA and
and ODI clinical scores after stabilization (p<0.05). Over the VAS scores (6.1 preoperatively vs 2.2 postoperatively and 14.8
24-month follow-up period, mean flexion, extension, left, and preoperatively vs 23.3 postoperatively, respectively). In patients
right lateral bending of the motion segments were noted to be with degenerative spondylolisthesis, the Graf System resulted in
1.0°, 2.4°, 0.6° and 0.6° or less, respectively. There were no statis- motion inhibition only in flexion (p<0.05). The mobility indi-
tically significant changes in the degree of motion. The authors cating a difference in the spondylolisthesis between flexion and
suggest that the Dynesys dynamic instrumentation system sta- extension was significantly reduced in relation to the inhibition
bilizes degenerative spondylolisthesis and may prevent further of that in flexion (p<0.05). Study results indicate that Graf stabi-
progression of listhesis. lization may be associated with satisfactory clinical outcomes in
In a retrospective case series, Lee et al2 evaluated the out- patients undergoing surgery for degenerative spondylolisthesis.
comes of 65 patients who underwent surgical treatment with an Schaeren et al4 conducted a prospective case series to evalu-
interspinous soft stabilization (ISS) and tension band system for ate whether posterior dynamic stabilization in situ with Dynesys
Grade I degenerative spondylolisthesis. Patients were evaluated can maintain enough stability to prevent progression of spondy-
via VAS, ODI and radiographic assessment after a mean follow- lolisthesis in long-term follow-up. Patients were followed-up at a
up of 72.5 months. The patients were divided according to the mean of 52 months using VAS and radiographic measurements.
postsurgical clinical improvements into the optimal (n = 44) and Results indicated that pain on VAS and walking distance signifi-
suboptimal groups (n = 21), and the radiological intergroup dif- cantly improved (p<0.001) at 2 years and remained unchanged
ferences were analyzed. Multiple linear regression analysis was at 4 years follow-up. Radiographically, spondylolisthesis did not
performed to determine the impact of the radiological factors progress and the motion segments remained stable. At 2 year
on the clinical outcomes. Radiologically, total lumbar lordosis follow-up, anterior and posterior disc height had significantly
(TLL) and segmental lumbar lordosis (SLL) were significantly increased from 2.9 to 3.5mm (p=0.02). At 4 years follow-up, an-
improved only in the optimal group, resulting in significant in- terior and posterior disc height did not show significant altera-
tergroup differences in TLL (p = 0.023), SLL (p = 0.001), and tion (p=0.02 and 0.05). At 4 years follow-up, 47% of the patients
the L1 tilt (p = 0.002). All of these measures were closely as- showed some degeneration at adjacent levels. Overall, patient
sociated with postoperative segmental lumbar lordosis, which satisfaction remained high as 95% would undergo the same pro-
also was the most influential radiological variable for the clinical cedure again. Study results suggest that dynamic stabilization
parameters. The study results suggest that dynamic stabilization with Dynesys may be associated with satisfactory clinical and
outcomes were correlated with radiographic improvement and radiographic outcomes after 4 years in patients undergoing sur-
may be an alternative to fusion surgery for Grade I degenerative gery for degenerative spondylolisthesis.
In a prospective case series of 26 patients, Schanake et al5 liosis in elderly patients: dynamic stabilization without fusion
evaluated whether elastic stabilization with the Dynesys sys- versus posterior instrumented fusion. Spine J. 2014;14(1):1-10.
tem provided enough stability to prevent further progression 2. Dimar JR II, Djurasovic M, Carreon LY. Surgical management
of spondylolisthesis as well as instability after decompression of degenerative and postsurgical spondylolisthesis. Semin Spine
Surg. 2005;17(3):186-194.
for spinal stenosis with degenerative spondylolisthesis. Mini-
3. El Elhawary Y, Azzazi A. Dynamic stabilization using X-stop vs.
mum follow-up was 2 years. Results indicated that the mean trans-pedicular screw fixation in the treatment of lumbar canal
pain score on VAS decreased significantly from 80 to 23 (range stenosis: Comparative study of the clinical outcome. Spine J.
0–82) (p < 0.00001). The mean walking distance improved sig- 2010;10(9)Supplement, S130.
nificantly from 250 m to over 1000 m (range 100 to infinite) (p 4. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura
< 0.00001). Radiographically, overall progression of spondylolis- K, Yuan HA. Radiostereometric analysis of postoperative mo-
thesis at follow-up was 2.1% and was not significant (p=0.056). tion after application of dynesys dynamic posterior stabilization
Study results suggest that the use of dynamic stabilization with system for treatment of degenerative spondylolisthesis. J Spinal
Dynesys may be associated with satisfactory clinical and radio- Disord Tech. 2010;23(4):236-41.
5. Gibson JN, Waddell G. Surgery for degenerative lumbar
graphic outcomes after 2 years in patients undergoing surgery
spondylosis. Cochrane Database System Rev. 2005 Oct 19;(4)
for degenerative spondylolisthesis. CD001352.
6. Haberl H, Cripton PA, Orr TE, et al. Kinematic response of
Future Directions for Research lumbar functional spinal units to axial torsion with and without
The work group identified the following suggestions for future superimposed compression and flexion/extension. Eur Spine J.
studies which would generate meaningful evidence to assist in 2004;13(6):560-6.
further evaluating the role of flexible fusions and medical/inter- 7. H Hong SW, Lee HY, Kim KH, Lee SH. Interspinous ligamen-
toplasty in the treatment of degenerative spondylolisthesis:
ventional treatment in the management of degenerative lumbar
midterm clinical results. J Neurosurg Spine. 2010;13(1):27-35.
spondylolisthesis patients. 8. Hrabálek L, Wanek T, Adamus M. [Treatment of degenerative
spondylolisthesis of the lumbosacral spine by decompression
Recommendation 1: and dynamic transpedicular stabilisation]. Acta Chir Orthop
The work group recommends the undertaking of large multi- Traumatol Cech. 2011;78(5):431-6.
center registry database studies with long term follow up com- 9. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob-
paring the outcomes of surgical treatment, including flexible fu- servation of the Dynesys neutralization system for the treatment
sions, to medical/interventional treatment in the management of degenerative disease of the lumbar vertebrae. Orthop Surg.
of degenerative lumbar spondylolisthesis patients. 2011;3(3):167-75.
10. Kanayama M, Hashimoto T, Shigenobu K, Togawa D, Oha F. A
minimum 10-year follow-up of posterior dynamic stabilization
Recommendation 2: using graf artificial ligament. Spine. 2007;32(18):1992-1996.
The work group recommends the undertaking of a prospective 11. Kaner T, Dalbayrak S, Oktenoglu T, Sasani M, Aydin AL, Ozer
study comparing long term outcomes of flexible fusions to medi- AF. Comparison of posterior dynamic and posterior rigid
cal/interventional management in the treatment of degenerative transpedicular stabilization with fusion to treat degenerative
lumbar spondylolisthesis. spondylolisthesis. Orthopedics. 2010;33(5)
12. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP.
Treatment of degenerative spondylolisthesis: potential impact
References of dynamic stabilization based on imaging analysis. Eur Spine J.
1. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura
2009;18(6):815-22.
K, Yuan HA. Radiostereometric analysis of postoperative mo-
13. Lee DY, Lee SH, Shim CS, Lee HY. Decompression and inter-
tion after application of dynesys dynamic posterior stabilization
spinous dynamic stabilization using the locker for lumbar canal
system for treatment of degenerative spondylolisthesis. J Spinal
stenosis associated with low-grade degenerative spondylolisthe-
Disord Tech. 2010;23(4):236-41.
sis. Minim Invasive Neurosurg. 2010;53(3):117-21.
2. Lee SH, Lee JH, Hong SW, et al. Factors affecting clinical out-
14. Lee SH, Lee JH, Hong SW, et al. Factors affecting clinical out-
comes in treating patients with grade 1 degenerative spondylo-
comes in treating patients with grade 1 degenerative spondylo-
listhesis using interspinous soft stabilization with a tension band
listhesis using interspinous soft stabilization with a tension band
system: a minimum 5-year follow-up. Spine. 2012;37(7):563-72.
3. Onda A, Otani K, Konno S, Kikuchi S. Mid-term and long-
15. Morishita Y, Ohta H, Naito M, et al. Kinematic evaluation of the
term follow-up data after placement of the Graf stabilization
adjacent segments after lumbar instrumented surgery: a com-
system for lumbar degenerative disorders. J Neurosurg Spine.

parison between rigid fusion and dynamic non-fusion stabiliza-
2006;5(1):26-32.
tion. Eur Spine J. 2011;20(9):1480-5.
4. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow-
16. Müslüman AM, Cansever T, Yılmaz A, Çavuşoğlu H, Yüce İ,
up of spinal stenosis with degenerative spondylolisthesis
Aydın Y. Midterm outcome after a microsurgical unilateral
treated with decompression and dynamic stabilization. Spine.
approach for bilateral decompression of lumbar degenerative
2008;33(18):E636-42.
spondylolisthesis. J Neurosurg Spine. 2012;16(1):68-76.
5. Schnake KJ, Schaeren S, Jeanneret B. Dynamic stabilization
17. Onda A, Otani K, Konno S, Kikuchi S. Mid-term and long-
in addition to decompression for lumbar spinal stenosis with
term follow-up data after placement of the Graf stabilization
degenerative spondylolisthesis. Spine. 2006;31(4):442-449.
system for lumbar degenerative disorders. J Neurosurg Spine.
2006;5(1):26-32.
Bibliography 18. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow-
1. Di silvestre M, Lolli F, Bakaloudis G. Degenerative lumbar sco- up of spinal stenosis with degenerative spondylolisthesis
treated with decompression and dynamic stabilization. Spine. for a randomized controlled trial. BMC Musculoskelet Disord.
2008;33(18):E636-42. 2011;12:239.
19. Schnake KJ, Schaeren S, Jeanneret B. Dynamic stabilization 23. Stoll TM, Dubois G, Schwarzenbach O. The dynamic neutraliza-
in addition to decompression for lumbar spinal stenosis with tion system for the spine: a multi-center study of a novel non-
degenerative spondylolisthesis. Spine. 2006;31(4):442-449. fusion system. Eur Spine J. 2002;11 Suppl 2:S170-8.
20. Sengupta DK. Point of view: Dynamic stabilization in addition 24. Welch WC, Cheng BC, Awad TE, et al. Clinical outcomes of
to decompression for lumbar spinal stenosis with degenerative the Dynesys dynamic neutralization system: 1-year preliminary
spondylolisthesis. Spine. 2006;31(4):450. results. Neurosurg Focus. 2007;22(1):E8.
21. Sengupta DK, Herkowitz HN. Degenerative spondylolisthesis: 25. Willems P. Decision making in surgical treatment of chronic low
review of current trends and controversies. Spine. 2005;30(6 back pain: the performance of prognostic tests to select patients
Suppl):S71-81. for lumbar spinal fusion. Acta Orthop Suppl. 2013;84(349):1-35.
22. Siewe J, Otto C, Knoell P, et al. Comparison of standard fusion
with a “topping off ” system in lumbar spine surgery: a protocol

Does the use of interspinous spacers in
the treatment of degenerative lumbar
spondylolisthesis improve outcomes compared
to medical/interventional treatment?
There is insufficient and conflicting evidence to make a recommendation

for or against the efficacy of interspinous spacers versus medical/
interventional treatment in the management of degenerative lumbar
spondylolisthesis patients.
Although one study showed clinical benefit of using interspi- stenosis (and not necessarily spondylolisthesis) that were ran-
nous spacers over medical/interventional treatments, 2 studies domized into the X-STOP treatment group and medical/inter-
demonstrated that there may be increased risk of spinous pro- ventional group. Additionally, medical treatments administered
cess fracture and reoperation with the surgical use of interspi- to the medical/interventional patients were not controlled. Due
nous spacers. to these limitations, this study has been downgraded from Level
Anderson et al1 reported subgroup analysis data from a II to III. This potential Level II study offers Level III therapeu-
large, randomized controlled trial dealing with spinal stenosis. tic evidence that interspinous distraction device for indirect de-
The subgroup analysis evaluated 75 patients with Grade I decompression may lead to better outcomes at 2 years in patients
generative spondylolisthesis and spinal stenosis with neurogenic with spinal stenosis and Grade I degenerative spondylolisthesis
claudication who were treated with either the X-STOP device or compared to nonoperative treatment.
medical/interventional treatment. The medical/interventional In a prospective case series, Kim et al2 examined the risk fac-
group received at least one epidural steroid injection, medica- tors associated with early spinous process fracture after interspi-
tions and physical therapy. Outcomes were evaluated by the Zu- nous process spacer surgery (IPS). Of the 38 total patients includ-
rich Claudication Questionnaire (ZCQ), SF-36 and radiographic ed in the study, 20 patients had degenerative spondylolisthesis,
assessment. At 2-years follow-up, there were statistically signifi- which was observed prior to surgery. Postoperatively, patients
cant improvements in the ZCQ score and patient satisfaction in underwent repeat CT imaging within 6 months of surgery and
those treated with X-STOP; however, there were no statistically serial radiographs at 2 weeks, 6 weeks, 3 months, 6 months and
significant improvements in the medical/interventional group. one year. Eleven of 20 patients (55%) with spondylolisthesis ex-
Overall success occurred in 63.4% of X-STOP device treated perienced a fracture within 6 months of surgery. The 18 patients
patients compared to only 12.9% of medical/interventional pa- without spondylolisthesis did not experience a fracture. This dif-
tients (p<0.05). In critique of this study, the cohort of 75 pa- ference was strongly significant (p=0.0001; OR, 29.00; 95% CI,
tients was derived from a larger pool of candidates with spinal 4.11–infinity). The authors concluded that degenerative spon-
dylolisthesis appears strongly associated with the occurrence of interspinous process spacer surgery. Spine J. 2012;12(6):466-72.
spinous process fracture after IPS surgery. While the Anderson 3. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure
study discusses the benefits of using IPS, this study suggests that rate of the interspinous distraction device (X-Stop) for the treat-
there are risks. In critique, this single-armed study’s sample size ment of lumbar spinal stenosis caused by degenerative spondy-
lolisthesis. Eur Spine J. 2008;17(2):188-92.
was small. This study provides Level IV therapeutic evidence
that IPS placement increases the risk of spinous process fracture
when used in degenerative spondylolisthesis patients. Bibliography
1. Austin RC, Branch CL, Alexander JT. Novel bioabsorbable
In a retrospective case series, Verhoof et al3 examined the ef-
interbody fusion spacer-assisted fusion for correction of spinal
fectiveness of the X-STOP interspinous distraction device in the deformity. Neurosurg Focus. 2003;14(1):e11
treatment of symptomatic degenerative lumbar spinal stenosis 2. Caserta S, La maida GA, Misaggi B, et al. Elastic stabilization
caused by degenerative spondylolisthesis. A cohort of 12 con- alone or combined with rigid fusion in spinal surgery: a biome-
secutive patients were evaluated over a period of two years. The chanical study and clinical experience based on 82 cases. Eur
primary endpoint of this study was secondary surgical interven- Spine J. 2002;11 Suppl 2:S192-7.
tion of the lumbar spine. Results suggested that reoperation for 3. Chaput C, Padon D, Rush J, Lenehan E, Rahm M. The signifi-
recurrent symptoms was performed in 7 patients (58%) within cance of increased fluid signal on magnetic resonance imaging
24 months. The authors suggest that the X-STOP interspinous in lumbar facets in relationship to degenerative spondylolisthe-
sis. Spine. 2007;32(17):1883-7.
distraction device showed an extremely high failure rate, defined
4. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO,
as surgical reintervention, after short-term follow-up in patients Loeser JD. Surgery for low back pain: a review of the evidence
with spinal stenosis caused by degenerative spondylolisthesis. X- for an American Pain Society Clinical Practice Guideline. Spine.
STOP is not recommended for the treatment of lumbar spinal 2009;34(10):1094-109.
stenosis with degenerative spondylolisthesis and is considered 5. Cutler AR, Siddiqui S, Mohan AL, Hillard VH, Cerabona F,
a contraindication in these patients. This study provides Level Das K. Comparison of polyetheretherketone cages with femoral
IV therapeutic evidence that the use of X-STOP in unstable de- cortical bone allograft as a single-piece interbody spacer in
generative spondylolisthesis patients may result in a high rate of transforaminal lumbar interbody fusion. J Neurosurg Spine.
short-term reoperations. 2006;5(6):534-9.
6. Gibson JN, Waddell G. Surgery for degenerative lumbar spon-
dylosis. Cochrane Database Syst Rev. 2005;(4):CD001352.
Future Directions for Research 7. Hatta Y, Shiraishi T, Sakamoto A, et al. Muscle-preserving
The work group identified the following suggestions for future interlaminar decompression for the lumbar spine: a minimally
studies which would generate meaningful evidence to assist in invasive new procedure for lumbar spinal canal stenosis. Spine.
further evaluating the role of interspinous spacers and medical/ 2009;34(8):E276-80.
interventional treatment in the management of degenerative 8. Hong SW, Lee HY, Kim KH, Lee SH. Interspinous ligamen-
lumbar spondylolisthesis patients. toplasty in the treatment of degenerative spondylolisthesis:
midterm clinical results. J Neurosurg Spine. 2010;13(1):27-35.
9. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob-
Recommendation 1: servation of the Dynesys neutralization system for the treatment
The work group recommends the undertaking of large multi- of degenerative disease of the lumbar vertebrae. Orthop Surg.
center registry database studies with long term follow up com- 2011;3(3):167-75
paring the outcomes of surgical treatment with interspinous 10. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP.
spacers to medical/interventional treatment in the management Treatment of degenerative spondylolisthesis: potential impact
of degenerative lumbar spondylolisthesis patients. of dynamic stabilization based on imaging analysis. Eur Spine J.
2009;18(6):815-22.
Recommendation 2: 11. Lee DY, Lee SH, Shim CS, Lee HY. Decompression and inter-
spinous dynamic stabilization using the locker for lumbar canal
The work group recommends that the future analysis of interspi-
stenosis associated with low-grade degenerative spondylolisthe-
nous spacers in the treatment of single level degenerative spon- sis. Minim Invasive Neurosurg. 2010;53(3):117-21.
dylolisthesis should include a group treated with decompression 12. Lee SH, Lee JH, Hong SW, Chung SE, Yoo SH, Lee HY. Spi-
with or without fusion in addition to medical management as nopelvic alignment after interspinous soft stabilization with a
patients have benefited from this therapy. tension band system in grade 1 degenerative lumbar spondylo-
listhesis. Spine. 2010;35(15):E691-701.
Recommendation 3: 13. Lee SH, Lee JH, Hong SW, et al. Factors affecting clinical out-
The work group recommends that future analysis of interspinous comes in treating patients with grade 1 degenerative spondylo-
spacers should include longer term outcome analysis to investi- listhesis using interspinous soft stabilization with a tension band
gate whether complication rates fall within acceptable limits.
14. Park SC, Yoon SH, Hong YP, Kim KJ, Chung SK, Kim HJ. Mini-
mum 2-year follow-up result of degenerative spinal stenosis
References treated with interspinous u (coflex). J Korean Neurosurg Soc.
1. Anderson PA, Tribus CB, Kitchel SH. Treatment of neurogenic 2009;46(4):292-9.
claudication by interspinous decompression: application of the 15. Postacchini F, Cinotti G, Perugia D. Degenerative lumbar spon-
X STOP device in patients with lumbar degenerative spondylo- dylolisthesis. II. Surgical treatment. Ital J Orthop Traumatol.
listhesis. J Neurosurg Spine. 2006;4(6):463-71. 1991;17(4):467-77.
2. Kim DH, Shanti N, Tantorski ME, et al. Association between de- 16. Sears W. Posterior lumbar interbody fusion for degenerative
generative spondylolisthesis and spinous process fracture after spondylolisthesis: restoration of sagittal balance using insert-
and-rotate interbody spacers. Spine J. 2005;5(2):170-9. 18. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
17. Surace MF, Fagetti A, Fozzato S, Cherubino P. Lumbar spinal non-surgical treatment for lumbar spinal stenosis. Cochrane
stenosis treatment with Aperius perclid interspinous system. Eur Database Syst Rev. 2012;CD010264.
Spine J. 2012;21 Suppl 1:S69-74.

What is the role of reduction (deliberate
attempt to reduce via surgical technique) with
fusion in the treatment of degenerative lumbar
spondylolisthesis?
the use of reduction with fusion in the treatment of degenerative lumbar
spondylolisthesis. Revised wording, but Recommendation Grade maintained
The updated literature search did not retrieve new evidence to support a recommendation for or against
the use of reduction with fusion; therefore, the work group maintains the original guideline’s “Insufficient
Recommendation” grading. Although reduction and fusion can be performed, the evidence reviewed does
not substantiate any improvement in clinical outcomes and reduction may increase the risk of neurological
complications.
Studies included in original guideline: decompression using the Fixater Interne pedicle fixation device.
Bednar et al1 described a retrospective consecutive case series of Forty-seven patients had low back pain, 40 patients had radicular
56 patients with degenerative spondylolisthesis and symptoms pain and 36 patients had intermittent claudication. Follow-up
of back pain and/or stenosis treated with bilateral foraminoto- was at a minimum of 12 months (range 12-16 months). Subjec-
mies, reduction and instrumented fusion. The procedure had a tive measurement of success was classified as excellent, good, fair
7% major complication rate. Outcomes measures were the Visual and poor for pain. An excellent or good outcome was considered
Analog Scale (VAS), Oswestry Disability Index (ODI) and radio- satisfactory and a fair or poor outcome was considered unsatis-
graphs. Of the 56 patients, 42 were available for follow-up at an factory. A satisfactory outcome (excellent and good results) oc-
average of 33 months (range 14-53 months). Of the 42 patients, curred in 42 of 47 patients with complaints of back pain, 37 of 40
82% experienced relief of leg pain, 75% experienced improve- patients with radicular pain and 31 of 36 patients with claudica-
ment in low back pain, and 77% experienced significant improve- tion. The authors commented that only 2 groups, based on their
ment in their ODI scores (average preoperatively of 56% versus findings, are not good candidates for this procedure: (1) those
average of 26% postoperatively). Only 38 patients were available with a positive Lasegue’s sign and (2) those with borderline insta-
for late review of X-ray studies at an average of 33 months. Aver- bility. In critique of this study, this was a prospective case series,
age preoperative slip was 16%, and of the 38 patients available at which lacked a comparison group, and validated outcome mea-
late review, 75% had perfect reduction. Of the 38 patients, 16% sures were not used. This paper presents Level IV therapeutic
had minor loss of reduction. Outcome measures (VAS and ODI) evidence that patients with degenerative spondylolisthesis who
were not compared based on the presence or absence of a per- do not have borderline instability or a positive Lasegue’s sign can
fect reduction. In critique, this is a moderately small, retrospec- undergo reduction, fixation and fusion without decompression.
tive review of a consecutive case series of surgical patients from Sears et al3 reviewed a prospective case series of 34 patients
one surgeon with no comparison group and with less than 80% with degenerative spondylolisthesis who underwent decompres-
follow-up. This paper offers Level IV therapeutic evidence that sion, reduction, internal fixation and fusion. Twenty-five patients
limited bilateral foraminotomies with instrumented reduction had a one-level fusion and 9 patients had a 2-level fusion. Of the
and fusion for symptomatic degenerative spondylolisthesis and 34 patients, 32 had surgery to relieve leg pain. Outcome measures
stenosis is as effective as laminectomy and in situ fusion without included the VAS, Low Back Pain Outcome Score (LBOS), SF-12
as much operative exposure of neural structures. and patient satisfaction questionnaire. Preoperative and postop-
Lee et al2 reported on a prospective case series of 52 con- erative measurement of slip by radiograph were also recorded.
secutive patients with objectively defined unstable degenerative Mean preoperative slip was 20% (range was 12% to 33%). Follow-
spondylolisthesis who underwent reduction and fusion without up occurred at a mean of 21.2 months (range 12 to 32 months),
with no dropouts. Significant improvements (p<.001) occurred 8. Kepler CK, Rihn JA, Radcliff KE, et al. Restoration of lordosis
in mean VAS and LBOS scores. Ninety-one percent of the pa- and disk height after single-level transforaminal lumbar inter-
tients considered their results excellent or good on the subjective body fusion. Orthop Surg. 2012;4(1):15-20.
satisfaction rating. Radiograph analysis revealed mean slip re- 9. Kim SY, Maeng DH, Lee SH, Jang JS. Anterior lumbar interbody
fusion for lumbosacral junction in steep sacral slope. J Spinal
duction from 20.2% to 1.7% and focal lordosis (available in only
Disord Tech. 2008;21(1):33-8.
17 of 34 patients) increased from 13.1 to 16.1 degrees. Both of 10. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid-
these findings were clinically significant. Three of the 34 patients term clinical results of minimally invasive decompression and
had postoperative nerve root irritation, with 2 of these persisting posterolateral fusion with percutaneous pedicle screws versus
up to the time of final report. There were no procedure-related conventional approach for degenerative spondylolisthesis with
complications were reported postoperatively, but one patient spinal stenosis. Eur Spine J. 2012;21(6):1171-7.
required adjacent level decompression and fusion 12 months 11. Lattig F, Fekete TF, Grob D, Kleinstück FS, Jeszenszky D, Man-
after surgery. In critique, this is a small prospective case series nion AF. Lumbar facet joint effusion in MRI: a sign of instability
on nonconsecutive patients with degenerative spondylolisthesis in degenerative spondylolisthesis?. Eur Spine J. 2012;21(2):276-
81.
with no comparison group. This paper offers Level IV therapeu-
12. Lerner T, Frobin W, Bullmann V, Schulte T, Brinckmann P,
tic evidence that reduction of a degenerative spondylolisthesis Liljenqvist U. Changes in disc height and posteroanterior
with internal fixation and posterior lumbar interbody fusion can displacement after fusion in patients with idiopathic scoliosis: a
provide good deformity correction with few complications and 9-year follow-up study. J Spinal Disord Tech. 2007;20(3):195-202.
good short-term patient outcomes on validated patient outcome 13. Osman SG. Endoscopic transforaminal decompression,
measures. interbody fusion, and percutaneous pedicle screw implanta-
tion of the lumbar spine: A case series report. Int J Spine Surg.
2012;6(1):157-166.
Future Directions For Research 14. Park P, Foley KT. Minimally invasive transforaminal lumbar
The work group recommends the undertaking of comparative interbody fusion with reduction of spondylolisthesis: technique
studies and multicenter registry database studies evaluating re- and outcomes after a minimum of 2 years’ follow-up. Neurosurg
duction spondylolisthesis to fusion in situ. Focus. 2008;25(2):E16.
15. Park SC, Yoon SH, Hong YP, Kim KJ, Chung SK, Kim HJ. Mini-
References mum 2-year follow-up result of degenerative spinal stenosis
1. Bednar DA. Surgical management of lumbar degenerative spinal treated with interspinous u (coflex). J Korean Neurosurg Soc.
stenosis with spondylolisthesis via posterior reduction with 2009;46(4):292-9.
minimal laminectomy. J Spinal Disord Tech. 2002;15(2):105-109. 16. Park Y, Ha JW, Lee YT, Sung NY. The effect of a radiographic
2. Lee TC. Reduction and stabilization without laminectomy for solid fusion on clinical outcomes after minimally invasive trans-
unstable degenerative spondylolisthesis: a preliminary report. foraminal lumbar interbody fusion. Spine J. 2011;11(3):205-12.
Neurosurgery. 1994;35(6):1072-1076. 17. Robertson PA, Plank LD. Prospective cohort analysis of disabil-
3. Sears W. Posterior lumbar interbody fusion for degenerative ity reduction with lumbar spinal fusion surgery in community
spondylolisthesis: restoration of sagittal balance using insert- practice. J Spinal Disord Tech. 2008;21(4):235-40.
and-rotate interbody spacers. Spine J. 2005;5(2):170-179. 18. Schizas C, Tzinieris N, Tsiridis E, Kosmopoulos V. Minimally
invasive versus open transforaminal lumbar interbody fusion:
evaluating initial experience. Int Orthop. 2009;33(6):1683-8.
Bibliography from updated literature search 19. Schulte TL, Leistra F, Bullmann V, et al. Disc height reduction
1. Abdul QR, Qayum MS, Saradhi MV, Panigrahi MK, Sreedhar in adjacent segments and clinical outcome 10 years after lumbar
V. Clinico-radiological profile of indirect neural decompres- 360 degrees fusion. Eur Spine J. 2007;16(12):2152-8.
sion using cage or auto graft as interbody construct in posterior 20. Shen NJ, Lin MX, Lin QB, Wang XA, Chen J, Wang GJ. Do-
lumbar interbody fusion in spondylolisthesis: Which is better?. J mestic vertebral internal fixation system for treating lumbar
Craniovertebr Junction Spine. 2011;2(1):12-6. spondylolisthesis in 55 cases. A follow-up study. J Clin Rehabil
2. Chad DA. Lumbar Spinal Stenosis. Neurol Clin. 2007;25(2):407- Tissue Eng Res. 2009;13(9):1793-1796.
418. 21. St clair S, Tan JS, Lieberman I. Oblique lumbar interbody fixa-
3. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- tion: a biomechanical study in human spines. J Spinal Disord
tive randomised study on the long-term effect of lumbar fusion Tech. 2012;25(4):183-9.
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. 22. Tsutsumimoto T, Shimogata M, Ohta H, Misawa H. Mini-open
4. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D, versus conventional open posterior lumbar interbody fusion for
Giannini S. Surgical treatment of symptomatic degenerative the treatment of lumbar degenerative spondylolisthesis: com-
lumbar spondylolisthesis by decompression and instrumented parison of paraspinal muscle damage and slip reduction. Spine.
fusion. J Orthop Traumatol. 2007;8(3):128-133. 2009;34(18):1923-8.

5. Gibson JN, Waddell G. Surgery for degenerative lumbar spon- 23. Xu H, Tang H, Li Z. Surgical treatment of adult degenerative
dylosis. Cochrane Database Syst Rev. 2005;(2):CD001352. spondylolisthesis by instrumented transforaminal lumbar
6. Harris EB, Sayadipour A, Massey P, Duplantier NL, Anderson interbody fusion in the Han nationality. J Neurosurg Spine.
DG. Mini-open versus open decompression and fusion for lum- 2009;10(5):496-9.
bar degenerative spondylolisthesis with stenosis. Am J Orthop. 24. Yan DL, Pei FX, Li J, Soo CL. Comparative study of PILF and
2011;40(12):E257-61. TLIF treatment in adult degenerative spondylolisthesis. Eur
7. Hrabálek L, Wanek T, Adamus M. [Treatment of degenerative Spine J. 2008;17(10):1311-6.
spondylolisthesis of the lumbosacral spine by decompression 25. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
and dynamic transpedicular stabilisation]. Acta Chir Orthop results of pediculo-body fixation and posterolateral fusion for
Traumatol Cech. 2011;78(5):431-6. lumbar spondylolisthesis. Eur Spine J. 2009;18 Suppl 1:151-5.

For patients undergoing posterolateral fusion,
does the use of autogenous bone graft improve
surgical outcomes compared to those fused
with bone graft substitutes?
Due to the paucity of literature addressing this question, the work group was unable to generate a
recommendation to answer this question.

against the use of autogenous bone graft or bone graft substitutes in
patients undergoing posterolateral fusion for the surgical treatment of
degenerative lumbar spondylolisthesis.
Vaccaro et al1 conducted a randomized controlled trial compar- 77.3% of autograft subjects had a >20% improvement from base-
ing OP-1 (rhBMP-7) with iliac crest autograft in patients with line in ODI. There were no statistical differences between the
symptomatic degenerative spondylolisthesis and spinal stenosis groups at either time point (p=0.839 at 24 months, p=0.201 at
treated with decompression and uninstrumented posterolateral 36+ months). Mean operative time for the OP-1 Putty group was
arthrodesis. All patients had failed at least 6 months of nonopera- significantly shorter than the autograft group (144 minutes for
tive treatment, including physical therapy, lumbar epidural injec- the OP-1 Putty group vs 164 minutes for the autograft group,
tions, anti-inflammatory medications, and activity modifications p<0.006). Mean operative blood loss was also significantly lower
for their spinal symptoms. A total of 335 patients were random- for the OP-1 Putty group than the autograft group (309 cc vs. 471
ized in 2:1 fashion to receive either OP-1 Putty or autograft in cc, p< 0.00004). There were no differences in the mean length of
the setting of an uninstrumented posterolateral arthrodesis. Out stay after surgery (p=0.529). This study provides level I thera-
of the 335 patients, 295 patients were actually treated. A total peutic evidence that OP-1 putty is a safe and effective alterna-
of 208 patients received OP-1 Putty and 87 received autograft. tive to autograft in the setting of uninstrumented posterolateral
Spondylolisthesis
The OP-1 putty consisted of 3.5 mg of rhOP-1 formulated with spinal arthrodesis.
bovine-derived collagen and carboxymethylcellulose to create a
powdered mixture and was reconstituted at the time of surgery The studies below were retrieved in the literature search, but
with the addition of saline. Patients in the autograft group re- did not meet the guideline’s inclusion criteria as they are either
ceived corticocancellous bone harvested from the posterior iliac mixed diagnosis or do not include sub-group analysis of degenera-
crest. After surgery, patients were evaluated clinically and radio- tive lumbar spondylolisthesis patient outcomes. However, as this
graphically at 6 weeks, and at 3, 6, 9, 12, 24, and at a minimum is an area of interest to many, the work group included the studies
of 36 months. Clinical assessments consisted of an evaluation of below as background information.
subjective pain and function using the Oswestry Low Back Pain
Disability (ODI) questionnaire, the Visual Analog Scale (VAS), In a randomized controlled trial, Alexander et al2 compared
neurologic evaluation, and functional outcome assessment via the efficacy of calcium sulfate pellets plus bone obtained from
completion of the Short-Form 36 (SF-36) outcomes survey. decompression with fresh autologous iliac crest bone in postero-
Imaging consisted of anteroposterior (AP), lateral, and flexion- lateral lumbar and lumbosacral spinal fusion with decompres-
extension radiographs. Regarding imaging findings, there were sion. Patients acted as their own controls with one side acting as
no statistical differences between the study groups in terms of the intervention side (decompression bone plus an equal volume
angular or translational motion at either 24 or 36 months follow- of calcium sulfate pellets) and the other side as the control side
up. One hundred seven of 143 (74.8%) of the OP-1 Putty patients (autologous posterior iliac crest bone of equal volume to test ma-
and 41 of 53 (77.4%) of the autograft patients had presence of terial). Thirty-two patients suffering from either degenerative
new bone on CT scan. Bridging bone was detected in 56% of disc disease or spondylolisthesis completed a one-year follow-
patients in the OP-1 Putty group and 83% (p=0.001) of patients up. Outcome assessment was conducted via blinded radiograph-
in the autograft group. At 24 months, 74.5% of OP-1 subjects ic evaluation at 6 and 12 months after surgery. The radiologist
and 75.7% of autograft subjects had a >20% improvement from utilized 2 methods for reviewing the radiographs. Method A
baseline in ODI. At 36+ months, 68.6% of OP-1 subjects and involved viewing the posteroanterior radiograph with the lateral
radiograph as the reference for the presence of new bone mass. Korvessis et al4 conducted a randomized clinical trial and
If new bone was apparent, the mass on that side was compared radiological study to compare the surgical outcomes of instru-
with the mass on the other side. The side with the larger mass mented posterolateral lumbar and lumbosacral fusion using ei-
was noted and the side with the smaller mass was graded as a ther coralline hydroxyapatite (CH), Group A; or iliac bone graft
percentage of the larger side as follows: 0 to 24%, 25 to 49%, 50 (IBG), Group B; or both, Group C. A total of 57 patients who
to 74%, 75 to 100% or equal. Method B also involved comparing suffered from symptomatic degenerative lumbar spinal stenosis,
the sides for new bone mass. If new bone mass was apparent, including 19 in Group A, 18 in Group B and 20 in Group C, par-
the outline of this mass on either side was obtained and these ticipated in the study and underwent decompression and fusion
outlines provided area measurements, which were quantified by with bone graft, bone graft substitute or both. According to the
placing outlines over graph paper and totaling the 1mm2 areas documented technique, autologous IBG was applied bilaterally
within the outlines, allowing comparison between the lines. The in Group A; in Group B, IBG was applied on the left side and
authors considered the bone mass formation at the site of test hydroxyapatite mixed with local bone and bone marrow was ap-
material placement to be “equivalent” to the bone mass at the plied on the right side; and in Group C, hydroxyapatite mixed
control site if the test material bone mass was in the category of with local bone and bone marrow was applied bilaterally. Pa-
75% to 100% of, equal to, or better than the control side. Results tients were followed up to 4 years postoperatively, with a mini-
from Method A suggested that 88% of patients at 12 months mal observation of 3 years, and outcomes were evaluated with
produced bone formation at the test site graded as equivalent to the SF-36, Oswestry Disability Index (ODI), Roland-Morris (R-
the control site. Method B indicated that the bone mass forma- M) survey, Visual Analogue Scale (VAS) for pain severity, and
tion was equal for both graft sites. The test material increased plain roentgenograms and CT scan evaluated the evolution of
bone formation an average of 9.18 cm2 and the control mate- the fusion. Preoperative ODI scores improved postoperatively
rial increased bone formation an average of 6.44cm2 from 6-12 in all groups up to the 2-year follow-up with Group A improving
months after fusion surgery. The authors suggest that the use of 41±27%, Group B improving 47±39% and Group C improving
calcium sulfate pellets plus decompression bone provides equiv- 43±28%; however, there were no significant changes measured
alent bone formation to the use of autologous iliac crest bone. after 2 years. R-M scores were also improved up to the 2-year
Delawi et al3 conducted a multicenter prospective random- follow-up with Group A improving 47±43%, Group B improv-
ized controlled trial to evaluate the safety and feasibility of os- ing 60±46%, and Group C improving 55±28%. Thereafter, there
teogenic protein (OP-1) compared to iliac crest autograft in were no significant changes in any group. VAS scores were sig-
patients undergoing decompression and one level lumbar spine nificantly improved in all groups with a peak at 2 years postop-
instrumented posterolateral fusions for either degenerative or eratively. VAS scores improved from 8.1±1.2 to 4.7±3.6 in Group
isthmic spondylolisthesis. The OP-1 material consisted of 3.5 A; 8±1.7 to 3.5±3.1 in Group B, and 7±2 to 3.7±2.7 in Group C.
mg lyophilized rhOP-1 in 1 g of collagen type I combined with The authors suggest that the use of autologous IBG results in

locally obtained bone during laminectomy. Thirty-four patients superior fusion results when compared to fusion using CH.
were included in this study and completed follow-up, including McGuire et al5 conducted a systematic literature review of ar-
21 patients with a diagnosis of degenerative spondylolisthesis ticles published through January 2011, including the Alexander2
(10 OP-1 Group; 11 Autograft Group) and 13 with a diagnosis and Korvessis4 studies, to compare the fusion rate, functional
Spondylolisthesis
of isthmic spondylolisthesis (8 OP-1 Group; 5 Autograft Group). outcomes, and safety of local bone graft plus bone extender
The primary outcome measure was fusion rate one year after compared with iliac crest bone graft in posterolateral spinal fu-
surgery based on blinded computed tomography assessment sion procedures. After review of 20 potential citations, the au-
by a spinal surgeon and radiologist resident. Clinical assess- thors identified 3 articles meeting inclusion criteria, including 2
ments were conducted preoperatively and at 6 weeks and 3, 6 studies discussed above and provided as support in addressing
and 12 months postoperatively using the Visual Analog Scale this clinical question. All 3 randomized controlled trials includ-
(VAS) and Oswestry Disability Index (ODI). In addition, ad- ed patients with a diagnosis of degenerative disc disease, spon-
verse events, including any untoward medical occurrence in a dylolisthesis, spinal stenosis or deformity. Fusion rates were high
patient, were documented. Results indicated that fusion rates across studies and there were no significant differences between
were not statistically significantly different between the treat- treatment groups in fusion rates, functional outcomes, or quality
ment groups. Fusion rates of 63% were found in the OP-1 Group of life. This systematic review suggests that local bone graft plus
and 67% in the control/Autograft Group (p=0.95). ODI scores bone extender and iliac crest bone graft used in posterolateral
improved significantly in both groups compared to preoperative spinal fusion procedures have similar fusion rates, functional
assessment (p<0.001); however, there were no significant differ- outcomes, and quality of life scores.
ences in mean ODI scores between the groups at any study point
(p=0.52). VAS scores at the donor site were only measured in the
autograft group and therefore are unavailable for comparison. FDA Indications and Warnings
In addition, adverse events were experienced by 17 (50%) of pa- For informational purposes only, the work group has provided
tients; however, there were no statistically significant differences the following links to the FDA website to inform readers of the
in adverse event rates between the treatment groups (p=0.48). indications and warnings that may be associated with the use of
The authors suggest that OP-1 is a safe and effective alternative autograft and bone graft substitutes.
for iliac crest autograft in instrumented single-level posterolat-
eral fusions of the lumbar spine.
Autogenous Bone Graft sion using cage or auto graft as interbody construct in posterior
http://www.fda.gov/downloads/AdvisoryCommittees/Commit- lumbar interbody fusion in spondylolisthesis: Which is better?. J
teesMeetingMaterials/MedicalDevices/MedicalDevicesAdvi- Craniovertebr Junction Spine. 2011;2(1):12-6.
soryCommittee/OrthopaedicandRehabilitationDevicesPanel/ 3. Adogwa O, Parker SL, Bydon A, Cheng J, Mcgirt MJ. Compara-
tive effectiveness of minimally invasive versus open transfo-
UCM254662.pdf
raminal lumbar interbody fusion: 2-year assessment of narcotic
use, return to work, disability, and quality of life. J Spinal Disord
Recombinant Human Bone Morphogenetic Protein Tech. 2011;24(8):479-84.
http://www.fda.gov/MedicalDevices/safety/alertsandnotices/ 4. Adogwa O, Parker SL, Davis BJ, et al. Cost-effectiveness of
publichealthnotifications/ucm062000.htm transforaminal lumbar interbody fusion for Grade I degenera-
tive spondylolisthesis. J Neurosurg Spine. 2011;15(2):138-43.
Infuse Bone Graft 5. Agabegi SS, Majid K, Fischgrund JS, Vaccaro AR, Patel T. Can
http://www.accessdata.fda.gov/cdrh_docs/pdf/P000054c.pdf preoperative radiographic parameters be used to predict fusion
spondylolisthesis?. Spine. 2011;36(26):E1709-14.
Future Directions for Research 6. Albert TJ, Desai D, Mcintosh T, Lamb D, Balderston RA.
The work group identified the following suggestions for future Early versus late replacement of autotransfused blood in elec-
studies, which would generate meaningful evidence to assist in tive spinal surgery. A prospective randomized study. Spine.
further defining the role autogenous bone graft and bone graft 1993;18(8):1071-8.
substitutes in the surgical treatment of patients with degenera- 7. Alfieri, A., Gazzeri, R., Prell, J., Scheller, C., Rachinger, J.,
tive lumbar spondylolisthesis: Strauss, C., & Schwarz, A. (2012). Role of lumbar interspinous
distraction on the neural elements. Neurosurgical review, 35(4),
477-484. doi: 10.1007/s10143-012-0394-1
Recommendation #1:
8. Alfieri A, Gazzeri R, Prell J, et al. Role of lumbar interspi-
A multicenter registry database study evaluating the morbidity nous distraction on the neural elements. Neurosurg Rev.
of bone graft (and type of bone graft) versus autograft in patients 2012;35(4):477-84.
undergoing surgical treatment for degenerative lumbar spondy- 9. Alt V, Chhabra A, Franke J, Cuche M, Schnettler R, Le huec JC.
lolisthesis. An economic analysis of using rhBMP-2 for lumbar fusion in
Germany, France and UK from a societal perspective. Eur Spine
Recommendation #2: J. 2009;18(6):800-6.
A comparative cost-analysis study to evaluate the cost-effective- 10. Andersen T, Christensen FB, Høy KW, et al. The predictive
ness of bone graft (and type of bone graft) versus autograft in value of pain drawings in lumbar spinal fusion surgery. Spine J.
2010;10(5):372-9.
patients undergoing surgical treatment for degenerative lumbar
11. Aono H, Iwasaki M, Ohwada T, et al. Surgical outcome of
spondylolisthesis. drop foot caused by degenerative lumbar diseases. Spine.
2007;32(8):E262-6.
References 12. Aryan HE, Newman CB, Gold JJ, Acosta FL, Coover C, Ames
1. Vaccaro AR, Lawrence JP, Patel T, et al. The safety and efficacy CP. Percutaneous axial lumbar interbody fusion (AxiaLIF) of
of OP-1 (rhBMP-7) as a replacement for iliac crest autograft in the L5-S1 segment: initial clinical and radiographic experience.
Spondylolisthesis
posterolateral lumbar arthrodesis: a long-term (>4 years) pivotal Minim Invasive Neurosurg. 2008;51(4):225-30.
study. Spine. 2008;33(26):2850-62. 13. Asazuma T, Masuoka K, Motosuneya T, Tsuji T, Yasuoka H,
2. Alexander DI, Manson NA, Mitchell MJ. Efficacy of calcium Fujikawa K. Posterior lumbar interbody fusion using dense
sulfate plus decompression bone in lumbar and lumbosacral hydroxyapatite blocks and autogenous iliac bone: clinical and
spinal fusion: preliminary results in 40 patients. Can J Surg. radiographic examinations. J Spinal Disord Tech. 2005;18
2001;44(4):262-6. Suppl:S41-7.
3. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random- 14. Asghar FA, Hilibrand AS. The impact of the Spine Patient Out-
ized, controlled, multicenter study of osteogenic protein-1 in comes Research Trial (SPORT) results on orthopaedic practice. J
instrumented posterolateral fusions: report on safety and feasi- Am Acad Orthop Surg. 2012;20(3):160-6.
bility. Spine. 2010;35(12):1185-91. 15. Bagaria V. Re: Vaccaro AR, Patel T, Fischgrund J, et al. A pilot
4. Korovessis P, Koureas G, Zacharatos S, Papazisis Z, Lambiris E. study evaluating safety and efficacy of OP-1 putty (rhBMP-7)
Correlative radiological, self-assessment and clinical analysis of as a replacement for iliac crest autograft in posterolateral
evolution in instrumented dorsal and lateral fusion for degener- lumbar arthrodesis for degenerative spondylolisthesis. Spine
ative lumbar spine disease. Autograft versus coralline hydroxy- 2004;29:1885-92. Spine. 2006;31(7):851.
apatite. Eur Spine J. 2005;14(7):630-8. 16. Barbagallo GM, Olindo G, Corbino L, Albanese V. Analysis of
5. Mcguire RA, Pilcher LE, Dettori JR. Lumbar posterolateral complications in patients treated with the X-Stop Interspinous
fusion with local bone graft plus bone extender compared with Process Decompression System: proposal for a novel anatomic
iliac crest bone graft: a systematic review. Evid Based Spine Care scoring system for patient selection and review of the literature.
J. 2011;2(2):35-40. Neurosurgery. 2009;65(1):111-19.
17. Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, Mcisaac
Bibliography WJ, Wright JG. Who’s in the driver’s seat? The influence of
1. Abbott AD, Tyni-lenné R, Hedlund R. Early rehabilitation patient and physician enthusiasm on regional variation in
targeting cognition, behavior, and motor function after lumbar degenerative lumbar spinal surgery: a population-based study.
fusion: a randomized controlled trial. Spine. 2010;35(8):848-57. Spine. 2011;36(6):481-489.
2. Abdul QR, Qayum MS, Saradhi MV, Panigrahi MK, Sreedhar 18. Blumenthal C, Curran J, Benzel EC, et al. Radiographic predic-
V. Clinico-radiological profile of indirect neural decompres- tors of delayed instability following decompression without
fusion for degenerative grade I lumbar spondylolisthesis. J Outcomes of Multi-Center Study. J Korean Neurosurg Soc.
Neurosurg Spine. 2013;18(4):340-6. 2012;51(6):343-9.
19. Blumenthal SL, Ohnmeiss DD. Intervertebral cages for degen- 39. Cole CD, Mccall TD, Schmidt MH, Dailey AT. Comparison of
erative spinal diseases. Spine J. 2003;3(4):301-9. low back fusion techniques: transforaminal lumbar interbody
20. Boden SD. Spinescope. Semin Spine Surg. 2011;23(2):151-156. fusion (TLIF) or posterior lumbar interbody fusion (PLIF) ap-
21. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2):133-137. proaches. Curr Rev Musculoskelet Med. 2009;2(2):118-26.
22. Booth KC, Bridwell KH, Eisenberg BA, Baldus CR, Lenke LG. 40. Crawford CH, Smail J, Carreon LY, Glassman SD. Health-related
Minimum 5-year results of degenerative spondylolisthesis quality of life after posterolateral lumbar arthrodesis in patients
treated with decompression and instrumented posterior fusion. seventy-five years of age and older. Spine. 2011;36(13):1065-8.
Spine. 1999;24(16):1721-7. 41. Csécsei G, Klekner A, Sikula J. Posterior lumbar interbody
23. Brantigan JW, Neidre A. Achievement of normal sagit- fusion (PLIF) using the bony elements of the dorsal spinal seg-
tal plane alignment using a wedged carbon fiber reinforced ment. Acta Chir Hung. 1997;36(1-4):54-6.
polymer fusion cage in treatment of spondylolisthesis. Spine J. 42. Cutler AR, Siddiqui S, Mohan AL, Hillard VH, Cerabona F,
2003;3(3):186-96. Das K. Comparison of polyetheretherketone cages with femoral
24. Bridwell KH, Sedgewick TA, O’brien MF, Lenke LG, Baldus cortical bone allograft as a single-piece interbody spacer in
C. The role of fusion and instrumentation in the treatment of transforaminal lumbar interbody fusion. J Neurosurg Spine.
degenerative spondylolisthesis with spinal stenosis. J Spinal 2006;5(6):534-9.
Disord. 1993;6(6):461-72. 43. Dai, F., Belfer, I., Schwartz, C. E., Banco, R., Martha, J. F.,
25. Brislin B, Vaccaro AR. Advances in posterior lumbar interbody Tighioughart, H., Kim, D. H. (2010). Association of catechol-
fusion. Orthop Clin North Am. 2002;33(2):367-74. O-methyltransferase genetic variants with outcome in pa-
26. Burkus JK, Dryer RF, Peloza JH. Retrograde ejaculation fol- tients undergoing surgical treatment for lumbar degenerative
lowing single-level anterior lumbar surgery with or without disc disease. Spine Journal, 10(11), 949-957. doi: 10.1016/j.
recombinant human bone morphogenetic protein-2 in 5 spinee.2010.07.387
randomized controlled trials: clinical article. J Neurosurg Spine. 44. Dai F, Belfer I, Schwartz CE, et al. Association of catechol-O-
2013;18(2):112-21. methyltransferase genetic variants with outcome in patients
27. Burkus JK, Gornet MF, Schuler TC, Kleeman TJ, Zdeblick TA. undergoing surgical treatment for lumbar degenerative disc
Six-year outcomes of anterior lumbar interbody arthrodesis disease. Spine J. 2010;10(11):949-57.
with use of interbody fusion cages and recombinant hu- 45. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH.
man bone morphogenetic protein-2. J Bone Joint Surg Am. Degenerative spondylolisthesis of the cervical spine: analysis of
2009;91(5):1181-9. 58 patients treated with anterior cervical decompression and
28. Burkus JK, Sandhu HS, Gornet MF. Influence of rhBMP-2 on fusion. Spine J. 2009;9(6):439-46.
the healing patterns associated with allograft interbody con- 46. Desai A, Ball PA, Bekelis K, et al. Surgery for lumbar degen-
structs in comparison with autograft. Spine. 2006;31(7):775-81. erative spondylolisthesis in Spine Patient Outcomes Research
29. Carreon LY, Djurasovic M, Canan CE, Burke LO, Glassman SD. Trial: does incidental durotomy affect outcome?. Spine.
SF-6D values stratified by specific diagnostic indication. Spine. 2012;37(5):406-13.

2012;37(13):E804-8. 47. Dimar JR II, Djurasovic M, Carreon LY. Surgical management
30. Carreon LY, Puno RM, Dimar JR, Glassman SD, Johnson JR. of degenerative and postsurgical spondylolisthesis. Semin Spine
Perioperative complications of posterior lumbar decompression Surg. 2005;17(3 SPEC. ISS.):186-194.
and arthrodesis in older adults. J Bone Joint Surg Am. 2003;85- 48. Dimar JR, Glassman SD, Burkus JK, Pryor PW, Hardacker JW,
Spondylolisthesis
A(11):2089-92. Carreon LY. Clinical and radiographic analysis of an opti-
31. Cavagna R, Daculsi G, Bouler JM. Macroporous calcium phos- mized rhBMP-2 formulation as an autograft replacement in
phate ceramic: a prospective study of 106 cases in lumbar spinal posterolateral lumbar spine arthrodesis. J Bone Joint Surg Am.
fusion. J Long Term Eff Med Implants. 1999;9(4):403-12. 2009;91(6):1377-86.
32. Cavuşoğlu H, Türkmenoğlu O, Kaya RA, et al. Efficacy of unilat- 49. Djurasovic M, Glassman SD, Dimar JR, Crawford CH, Bratcher
eral laminectomy for bilateral decompression in lumbar spinal KR, Carreon LY. Changes in the Oswestry Disability Index that
stenosis. Turk Neurosurg. 2007;17(2):100-8. predict improvement after lumbar fusion. J Neurosurg Spine.
33. Chad, D. A. (2007). Lumbar Spinal Stenosis. Neurologic clinics, 2012;17(5):486-90.
25(2), 407-418. doi: 10.1016/j.ncl.2007.01.003 50. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec-
34. Chaloupka R, Krbec M, Cienciala J, et al. Two year clinical re- tive randomised study on the long-term effect of lumbar fusion
sults of 360 degree fusion of lumbar spondylolisthesis managed on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86.
by transpedicular fixation and PLIF or ALIF technique. Eur 51. Eliyas JK, Karahalios D. Surgery for degenerative lumbar spine
Spine J. 2006;15(Suppl 4):S506-s507. disease. Dis Mon. 2011;57(10):592-606.
35. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, 52. Epstein NE. An analysis of noninstrumented posterolateral
Loeser JD. Surgery for low back pain: a review of the evidence lumbar fusions performed in predominantly geriatric patients
for an American Pain Society Clinical Practice Guideline. Spine. using lamina autograft and beta tricalcium phosphate. Spine J.
2009;34(10):1094-109. 2008;8(6):882-7.
36. Chu G, Aikenmu K, He ZS. Unilateral versus bilateral instru- 53. Escobar E, Transfeldt E, Garvey T, Ogilvie J, Graber J, Schultz
mented posterolateral lumbar fusion in degenerative spondy- L. Video-assisted versus open anterior lumbar spine fusion
lolisthesis: A randomized controlled trial. J Clin Rehabil Tissue surgery: a comparison of four techniques and complications in
Eng Res. 2011;15(35):6540-6545. 135 patients. Spine. 2003;28(7):729-32.
37. Cloyd JM, Acosta FL, Ames CP. Complications and outcomes of 54. Etame AB, Wang AC, Than KD, Park P. Clinical and radio-
lumbar spine surgery in elderly people: a review of the literature. graphic outcomes after minimally invasive transforaminal
J Am Geriatr Soc. 2008;56(7):1318-27. lumbar interbody fusion. SAS J. 2010;4(2):47-53.
38. Coe JD, Kitchel SH, Meisel HJ, Wingo CH, Lee SE, Jahng 55. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D,
TA. NFlex Dynamic Stabilization System : Two-Year Clinical Giannini S. Surgical treatment of symptomatic degenerative
lumbar spondylolisthesis by decompression and instrumented osteogenic protein 1: results from a prospective, randomized,
fusion. J Orthop Traumatol. 2007;8(3):128-133. controlled, multicenter pivotal study of uninstrumented lumbar
56. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective posterolateral fusion. J Neurosurg Spine. 2010;13(4):484-93.
randomized study of unilateral versus bilateral instrumented 76. Ibrahimi DM, Beaty NB, Crandall KM, Hamilton DK, Sansur
posterolateral lumbar fusion in degenerative spondylolisthesis. CA. A review of lumbar spondylolisthesis. Eur Musculoskel Rev.
Spine. 2007;32(4):395-401. 2011;6(2):110-113.
57. Fischgrund JS. The argument for instrumented decompressive 77. Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with au-
posterolateral fusion for patients with degenerative spondylolis- tologous iliac bone versus local bone graft in posterior lumbar
thesis and spinal stenosis. Spine. 2004;29(2):173-4. interbody fusion. Spine. 2010;35(21):E1101-5.
58. Flynn JC, Hoque MA. Anterior fusion of the lumbar spine. End- 78. Jenis LG, Banco RJ, Kwon B. A prospective study of Autologous
result study with long-term follow-up. J Bone Joint Surg Am. Growth Factors (AGF) in lumbar interbody fusion. Spine J.
1979;61(8):1143-50. 2006;6(1):14-20.
59. Fu KM, Rhagavan P, Shaffrey CI, Chernavvsky DR, Smith JS. 79. Jo DJ, Jun JK, Kim KT, Kim SM. Lumbar Interbody Fusion Out-
Prevalence, severity, and impact of foraminal and canal stenosis comes in Degenerative Lumbar Disease : Comparison of Results
among adults with degenerative scoliosis. Neurosurgery. between Patients Over and Under 65 Years of Age. J Korean
2011;69(6):1181-7. Neurosurg Soc. 2010;48(5):412-8.
60. Fujimoto K, Yamazaki M, Hayashi K, et al. Posterior decom- 80. Kai Y, Oyama M, Morooka M. Posterior lumbar interbody fu-
pression with instrumented fusion in a patient with cervical sion using local facet joint autograft and pedicle screw fixation.
myelopathy thirty years after cadaveric renal transplantation. Spine. 2004;29(1):41-6.
Chiba Med J. 2011;87(1):11-15. 81. Kakiuchi M, Ono K. Defatted, gas-sterilised cortical bone
61. Gavaskar AS, Achimuthu R. Transfacetal fusion for low-grade allograft for posterior lumbar interbody vertebral fusion. Int
degenerative spondylolisthesis of the lumbar spine: results Orthop. 1998;22(2):69-76.
of a prospective single center study. J Spinal Disord Tech. 82. Kalanithi PS, Patil CG, Boakye M. National complication rates
2010;23(3):162-5. and disposition after posterior lumbar fusion for acquired spon-
62. Gelalis ID, Arnaoutoglou C, Christoforou G, Lykissas MG, dylolisthesis. Spine. 2009;34(18):1963-9.
Batsilas I, Xenakis T. Prospective analysis of surgical outcomes 83. Kalichman L, Hunter DJ. Degenerative lumbar spondylolisthe-
in patients undergoing decompressive laminectomy and pos- sis: Anatomy, biomechanics and risk factors. J Back Musculoskel
terior instrumentation for degenerative lumbar spinal stenosis. Rehabil. 2008;21(1):1-12.
Acta Orthop Traumatol Turc. 2010;44(3):235-40. 84. Kanayama M, Hashimoto T, Shigenobu K, Yamane S, Bauer TW,
63. Gilbert JW, Wheeler GR, Kreft MP, et al. Repeat upright posi- Togawa D. A prospective randomized study of posterolateral
tional magnetic resonance imaging for diagnosis of disorders lumbar fusion using osteogenic protein-1 (OP-1) versus local
underlying chronic noncancer lumbar pain. J Manipulative autograft with ceramic bone substitute: emphasis of surgical
Physiol Ther. 2008;31(8):627-31. exploration and histologic assessment. Spine. 2006;31(10):1067-
64. Gillet P, Petit M. Direct repair of spondylolysis without spondy- 74.
lolisthesis, using a rod-screw construct and bone grafting of the 85. Kasliwal MK, Deutsch H. Clinical and radiographic outcomes
pars defect. Spine. 1999;24(12):1252-6. using local bone shavings as autograft in minimally invasive
65. Glaser JA, Bernhardt M, Found EM, McDowell GS, Wetzel FT. transforaminal lumbar interbody fusion. World Neurosurg.
Lumbar arthrodesis for degenerative conditions. Instr Course 2012;78(1-2):185-90.
Lect. 2004;53:325-340. 86. Katonis P, Christoforakis J, Kontakis G, et al. Complications
66. Glassman SD, Carreon LY, Dimar JR, Campbell MJ, Puno RM, and problems related to pedicle screw fixation of the spine. Clin
Johnson JR. Clinical outcomes in older patients after posterolat- Orthop Relat Res. 2003;(411):86-94.
eral lumbar fusion. Spine J. 2007;7(5):547-51. 87. Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Suc-
67. Grob D. Surgery for degenerative lumbar disease: transforami- cess and failure of minimally invasive decompression for focal
nal lumbar interbody fusion. Eur Spine J. 2009;18(12):1991-2. lumbar spinal stenosis in patients with and without deformity.
68. Hasegawa K, Shimoda H, Kitahara K, Sasaki K, Homma T. Spine. 2010;35(19):E981-7.
What are the reliable radiological indicators of lumbar segmen- 88. Kim DH, Jeong ST, Lee SS. Posterior lumbar interbody fusion
tal instability?. J Bone Joint Surg Br. 2011;93(5):650-7. using a unilateral single cage and a local morselized bone
69. Hashimoto T, Shigenobu K, Kanayama M, et al. Clinical results graft in the degenerative lumbar spine. Clin Orthop Surg.
of single-level posterior lumbar interbody fusion using the Bran- 2009;1(4):214-21.
tigan I/F carbon cage filled with a mixture of local morselized 89. Kim KW, Ha KY, Moon MS, Kim YS, Kwon SY, Woo YK.
bone and bioactive ceramic granules. Spine. 2002;27(3):258-62. Volumetric change of the graft bone after intertransverse fusion.
70. Herron LD, Newman MH. The failure of ethylene oxide gas- Spine. 1999;24(5):428-33.
sterilized freeze-dried bone graft for thoracic and lumbar spinal 90. Kim MK, Lee SH, Kim ES, Eoh W, Chung SS, Lee CS. The
fusion. Spine. 1989;14(5):496-500. impact of sagittal balance on clinical results after posterior inter-
71. Hilibrand AS, Rand N. Degenerative lumbar stenosis: diagnosis body fusion for patients with degenerative spondylolisthesis: a
and management. J Am Acad Orthop Surg. 1999;7(4):239-49. pilot study. BMC Musculoskelet Disord. 2011;12:69.
72. Hitchon PW, Taggard DA. Lumbar spine fusion enhanced by 91. Kim S, Mortaz hedjri S, Coyte PC, Rampersaud YR. Cost-utility
pedicle screw fixation. Tech Neurosurg. 1998;4(3):211-215. of lumbar decompression with or without fusion for patients
73. Houten JK, Post NH, Dryer JW, Errico TJ. Clinical and radio- with symptomatic degenerative lumbar spondylolisthesis. Spine
graphically/neuroimaging documented outcome in transforami- J. 2012;12(1):44-54.
nal lumbar interbody fusion. Neurosurg Focus. 2006;20(3):E8. 92. Kleinstueck FS, Fekete TF, Mannion AF, et al. To fuse or
74. Hunt T, Shen FH, Shaffrey CI, Arlet V. Contralateral radiculopa- not to fuse in lumbar degenerative spondylolisthesis: do
thy after transforaminal lumbar interbody fusion. Eur Spine J. baseline symptoms help provide the answer?. Eur Spine J.
2007;16 Suppl 3:311-4. 2012;21(2):268-75.
75. Hwang CJ, Vaccaro AR, Hong J, et al. Immunogenicity of 93. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari-
son of surgical and conservative treatment for degenerative O. N. (2012). Implications of spinopelvic alignment for the
lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5. spine surgeon. Neurosurgery, 70(3), 707-721.
94. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, 113. Mirovsky Y, Halperin N, Anekstein Y, Neuwirth MG. Good re-
Berkower DL, Ditkoff JS. Degenerative lumbar spondylolisthesis sults of circumferential spine fusion in smokers, using autograft
with spinal stenosis: a prospective long-term study comparing and allograft. Cell Tissue Bank. 2002;3(3):169-73.
fusion and pseudarthrosis. Spine. 2004;29(7):726-33. 114. Miyamoto H, Sumi M, Uno K, Tadokoro K, Mizuno K. Clinical
95. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid- outcome of nonoperative treatment for lumbar spinal stenosis,
term clinical results of minimally invasive decompression and and predictive factors relating to prognosis, in a 5-year mini-
posterolateral fusion with percutaneous pedicle screws versus mum follow-up. J Spinal Disord Tech. 2008;21(8):563-8.
conventional approach for degenerative spondylolisthesis with 115. Mochida J, Suzuki K, Chiba M. How to stabilize a single level
spinal stenosis. Eur Spine J. 2012;21(6):1171-7. lesion of degenerative lumbar spondylolisthesis. Clin Orthop
96. Krishna M, Pollock RD, Bhatia C. Incidence, etiology, clas- Relat Res. 1999;(368):126-34.
sification, and management of neuralgia after posterior lumbar 116. Mokhtar SA, Mccombe PF, Williamson OD, Morgan MK, White
interbody fusion surgery in 226 patients. Spine J. 2008;8(2):374- GJ, Sears WR. Health-related quality of life: a comparison of
9. outcomes after lumbar fusion for degenerative spondylolisthesis
97. Lee JW, Myung JS, Park KW, et al. Fluoroscopically guided with large joint replacement surgery and population norms.
caudal epidural steroid injection for management of degenera- Spine J. 2010;10(4):306-12.
tive lumbar spinal stenosis: short-term and long-term results. 117. Molina M, Wagner P, Campos M. [Spinal lumbar stenosis: an
Skeletal Radiol. 2010;39(7):691-9. update]. Rev Med Chil. 2011;139(11):1488-95.
98. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- 118. Molinari RW, Bridwell KH, Klepps SJ, Baldus C. Minimum
strumented lower lumbar or lumbosacral posterolateral fusion. J 5-year follow-up of anterior column structural allografts in the
Clin Neurosci. 2009;16(1):37-43. thoracic and lumbar spine. Spine. 1999;24(10):967-72.
99. Lee SH, Lee JH, Hong SW, Chung SE, Yoo SH, Lee HY. Spi- 119. Molinari RW, Hunter JG, Mcassey RW. In-hospital postopera-
nopelvic alignment after interspinous soft stabilization with a tive radiographs for instrumented single-level degenerative
tension band system in grade 1 degenerative lumbar spondylo- spinal fusions: utility after intraoperative fluoroscopy. Spine J.
listhesis. Spine. 2010;35(15):E691-701. 2012;12(7):559-67.
100. Lee SH, Lee JH, Hong SW, et al. Factors affecting clinical out- 120. Möller J, Wittenberg RH, Nolte LP, Jergas M, Willburger R,
comes in treating patients with grade 1 degenerative spondylo- Krämer J. Results of lumbosacral distraction spondylodesis for
listhesis using interspinous soft stabilization with a tension band the treatment of spondylolisthesis, failed-back syndrome, and
system: a minimum 5-year follow-up. Spine. 2012;37(7):563-72. lumbar instability. Eur Spine J. 1992;1(2):117-24
101. Lekovic GP, Han PP, Kenny KJ, Dickman CA. Bone dowels 121. Monticone M, Giovanazzi E. Usefulness of a cognitive be-
in anterior lumbar interbody fusion. J Spinal Disord Tech. havioural and rehabilitative approach to enhance long lasting
2007;20(5):374-9. benefit after lumbar spinal stenosis and degenerative spon-
102. Lewandrowski KU, Nanson C, Calderon R. Vertebral osteolysis dylolisthesis surgery. A case report. Eur J Phys Rehabil Med.
after posterior interbody lumbar fusion with recombinant hu- 2008;44(4):467-71.
man bone morphogenetic protein 2: a report of five cases. Spine 122. Moon MS, Kim SS, Sun DH, Moon YW. Anterior spondylodesis
J. 2007;7(5):609-14. for spondylolisthesis: isthmic and degenerative types. Eur Spine
103. Lindley EM, Mccullough MA, Burger EL, Brown CW, Patel VV. J. 1994;3(3):172-6.
Complications of axial lumbar interbody fusion. J Neurosurg 123. Mummaneni PV, Pan J, Haid RW, Rodts GE. Contribution of
Spine. 2011;15(3):273-9. recombinant human bone morphogenetic protein-2 to the
104. Long H, Kazunasa U, Liu S, Akio S, Taito I. Preliminary ap- rapid creation of interbody fusion when used in transforaminal
plication of one-level posterior lumbar interbody fusion with lumbar interbody fusion: a preliminary report. Invited sub-
prospace and facet fusion using local autograft. Zhongguo Xiu mission from the Joint Section Meeting on Disorders of the
Fu Chong Jian Wai Ke Za Zhi. 2007;21(11):1155-9. Spine and Peripheral Nerves, March 2004. J Neurosurg Spine.
105. Majid K, Fischgrund JS. Degenerative lumbar spondylo- 2004;1(1):19-23.
listhesis: trends in management. J Am Acad Orthop Surg. 124. Nasca RJ. Lumbar spinal stenosis: surgical considerations. J
2008;16(4):208-15. South Orthop Assoc. 2002;11(3):127-34.
106. Marchesi DG, Thalgott JS, Aebi M. Application and results of 125. Nelson LD, Montgomery SP, Dameron TB, Nelson RB. Deep
the AO internal fixation system in nontraumatic indications. vein thrombosis in lumbar spinal fusion: a prospective study
Spine. 1991;16(3 Suppl):S162-9. of antiembolic and pneumatic compression stockings. J South
107. Markwalder TM, Reulen HJ. Translaminar screw fixation in Orthop Assoc. 1996;5(3):181-4.
lumbar spine pathology. Technical note. Acta Neurochir (Wien). 126. Ohmori K, Suzuki K, Ishida Y. Translamino-pedicular screw
1989;99(1-2):58-60. fixation with bone grafting for symptomatic isthmic lumbar
108. Matgé G, Leclercq TA. Rationale for interbody fusion with spondylolysis. Neurosurgery. 1992;30(3):379-84.
threaded titanium cages at cervical and lumbar levels. Results 127. Okuyama K, Kido T, Unoki E, Chiba M. PLIF with a titanium
on 357 cases. Acta Neurochir (Wien). 2000;142(4):425-33. cage and excised facet joint bone for degenerative spondylolis-
109. Maus T. Imaging the back pain patient. Phys Med Rehabil Clin thesis--in augmentation with a pedicle screw. J Spinal Disord
N Am. 2010;21(4):725-66. Tech. 2007;20(1):53-9.
110. Mayer HM, Wiechert K. Microsurgical anterior approaches to 128. Osman SG. Endoscopic transforaminal decompression,
the lumbar spine for interbody fusion and total disc replace- interbody fusion, and percutaneous pedicle screw implanta-
ment. Neurosurgery. 2002;51(5 Suppl):S159-65. tion of the lumbar spine: A case series report. Int J Spine Surg.
111. Mcafee PC, Devine JG, Chaput CD, et al. The indications for 2012;6(1):157-166.
interbody fusion cages in the treatment of spondylolisthesis: 129. Ozgur BM, Agarwal V, Nail E, Pimenta L. Two-year clinical and
analysis of 120 cases. Spine. 2005;30(6 Suppl):S60-5. radiographic success of minimally invasive lateral transpsoas
112. Mehta, V. A., Amin, A., Omeis, I., Gokaslan, Z. L., & Gottfried, approach for the treatment of degenerative lumbar conditions.
SAS J. 2010;4(2):41-46. 2008;33(18):E636-42.

130. Panagiotis ZE, Athanasios K, Panagiotis D, Minos T, Charis M, 147. Schiffman M, Brau SA, Henderson R, Gimmestad G. Bilateral
Elias L. Functional outcome of surgical treatment for multilevel implantation of low-profile interbody fusion cages: subsidence,
lumbar spinal stenosis. Acta Orthop. 2006;77(4):670-676. lordosis, and fusion analysis. Spine J. 2003;3(5):377-87.
131. Pao JL, Chen WC, Chen PQ. Clinical outcomes of microen- 148. Schnake KJ, Schaeren S, Jeanneret B. Dynamic stabilization
doscopic decompressive laminotomy for degenerative lumbar in addition to decompression for lumbar spinal stenosis with
spinal stenosis. Eur Spine J. 2009;18(5):672-8. degenerative spondylolisthesis. Spine. 2006;31(4):442-449.
132. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno- 149. Schnee CL, Freese A, Ansell LV. Outcome analysis for adults
sis lead to poorer outcomes?: a subanalysis of the Spine Patient with spondylolisthesis treated with posterolateral fusion and
Outcomes Research Trial (SPORT) lumbar stenosis study. Spine. transpedicular screw fixation. J Neurosurg. 1997;86(1):56-63.
2010;35(4):439-46. 150. Schulte TL, Leistra F, Bullmann V, et al. Disc height reduction
133. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost- in adjacent segments and clinical outcome 10 years after lumbar
effectiveness of minimally invasive versus open transforaminal 360 degrees fusion. Eur Spine J. 2007;16(12):2152-8.
lumbar interbody fusion for degenerative spondylolisthesis 151. Schwender JD, Holly LT, Rouben DP, Foley KT. Minimally
associated low-back and leg pain over two years. World Neuro- invasive transforaminal lumbar interbody fusion (TLIF): techni-
surg. 2012;78(1-2):178-84. cal feasibility and initial results. J Spinal Disord Tech. 2005;18
134. Parker SL, Mcgirt MJ. Determination of the minimum im- Suppl:S1-6.
provement in pain, disability, and health state associated with 152. Sears W. Posterior lumbar interbody fusion for degenerative
cost-effectiveness: introduction of the concept of minimum spondylolisthesis: restoration of sagittal balance using insert-
cost-effective difference. Neurosurgery. 2012;71(6):1149-55. and-rotate interbody spacers. Spine J. 2005;5(2):170-9.
135. Pelton MA, Phillips FM, Singh K. A comparison of peri- 153. Shen M, Razi A, Lurie JD, Hanscom B, Weinstein J. Retrolis-
operative costs and outcomes in patients with and without thesis and lumbar disc herniation: a preoperative assessment of
workers’ compensation claims treated with minimally inva- patient function. Spine J. 2007;7(4):406-13.
sive or open transforaminal lumbar interbody fusion. Spine. 154. Siewe J, Otto C, Knoell P, et al. Comparison of standard fusion
2012;37(22):1914-9. with a “topping off ” system in lumbar spine surgery: a protocol
136. Radcliff K, Hwang R, Hilibrand A, et al. The effect of iliac crest for a randomized controlled trial. BMC Musculoskelet Disord.
autograft on the outcome of fusion in the setting of degenera- 2011;12:239.
tive spondylolisthesis: a subgroup analysis of the Spine Patient 155. Singh K, Smucker JD, Gill S, Boden SD. Use of recombinant hu-
Outcomes Research Trial (SPORT). J Bone Joint Surg Am. man bone morphogenetic protein-2 as an adjunct in posterolat-
2012;94(18):1685-92. eral lumbar spine fusion: a prospective CT-scan analysis at one
137. Radcliff KE, Rihn J, Hilibrand A, et al. Does the duration of and two years. J Spinal Disord Tech. 2006;19(6):416-23.
symptoms in patients with spinal stenosis and degenerative 156. Snider RK, Krumwiede NK, Snider LJ, Jurist JM, Lew RA, Katz
spondylolisthesis affect outcomes?: analysis of the Spine Out- JN. Factors affecting lumbar spinal fusion. J Spinal Disord.
comes Research Trial. Spine. 2011;36(25):2197-210. 1999;12(2):107-14.
138. Rampersaud R, Macwan K, Mahomed NN. Spinal Care in a 157. Soegaard R, Bünger CE, Christiansen T, Høy K, Eiskjaer SP,
Single-Payer System: The Canadian Example. Semin Spine Surg. Christensen FB. Circumferential fusion is dominant over pos-
2012;24(2):117-122. terolateral fusion in a long-term perspective: cost-utility evalua-
139. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings tion of a randomized controlled trial in severe, chronic low back
MG. Cost-utility analysis of posterior minimally invasive fusion pain. Spine. 2007;32(22):2405-14.
compared with conventional open fusion for lumbar spondylo- 158. Stovall R, Halliday A. Degenerative lumbar spondylolisthesis:
listhesis. SAS J. 2011;5(2):29-35. Treatment strategies. Seminars in Neurosurgery. 2000;11(2):193-
140. Rechtine GR, Sutterlin CE, Wood GW, Boyd RJ, Mansfield FL. 205.
The efficacy of pedicle screw/plate fixation on lumbar/lumbosa- 159. Tajima N, Chosa E, Watanabe S. Posterolateral lumbar fusion. J
cral autogenous bone graft fusion in adult patients with degen- Orthop Sci. 2004;9(3):327-333.
erative spondylolisthesis. J Spinal Disord. 1996;9(5):382-91. 160. Taylor JA, Bussières A. Diagnostic imaging for spinal disor-
141. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect ders in the elderly: a narrative review. Chiropr Man Therap.
outcomes of treatment for lumbar stenosis and degenerative 2012;20(1):16.
spondylolisthesis? Analysis of the Spine Patient Outcomes Re- 161. Templin CR, Garfin SR. Surgical Management of Scoliosis and/
search Trial (SPORT). Spine. 2012;37(23):1933-46. or Spondylolisthesis Associated with Spinal Stenosis. Semin
142. Robertson PA, Plank LD. Prospective cohort analysis of disabil- Spine Surg. 2007;19(3):187-199.
ity reduction with lumbar spinal fusion surgery in community 162. Tokuhashi Y, Ajiro Y, Umezawa N. Follow-up of patients with
practice. J Spinal Disord Tech. 2008;21(4):235-40. delayed union after posterior fusion with pedicle screw fixation.
143. Rouben D, Casnellie M, Ferguson M. Long-term durability of Spine. 2008;33(7):786-91.
minimal invasive posterior transforaminal lumbar interbody fu- 163. Truumees E. The Role of Fusion in Degenerative Lumbar Dis-
sion: a clinical and radiographic follow-up. J Spinal Disord Tech. ease. Semin Spine Surg. 2004;15(4):430-459.
2011;24(5):288-96. 164. Vaccaro A. Unilateral approach for microsurgical decompres-
144. Rousseau MA, Lazennec JY, Bass EC, Saillant G. Predictors of sion. J Neurosurg Spine. 2008;9(6):552-3.
outcomes after posterior decompression and fusion in degenera- 165. Vaccaro AR, Anderson DG, Patel T, et al. Comparison of OP-1
tive spondylolisthesis. Eur Spine J. 2005;14(1):55-60. Putty (rhBMP-7) to iliac crest autograft for posterolateral lum-
145. Savvidou C, Chatziioannou SN, Pilichou A, Pneumaticos SG. bar arthrodesis: a minimum 2-year follow-up pilot study. Spine.
Efficacy and cost-effectiveness of cell saving blood autotransfu- 2005;30(24):2709-16.
sion in adult lumbar fusion. Transfus Med. 2009;19(4):202-6. 166. Vaccaro AR, Garfin SR. Internal fixation (pedicle screw fixation)
146. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow- for fusions of the lumbar spine. Spine. 1995;20(24 Suppl):157S-
up of spinal stenosis with degenerative spondylolisthesis 165S.
treated with decompression and dynamic stabilization. Spine. 167. Vaccaro AR, Patel T, Fischgrund J, et al. A pilot safety and
efficacy study of OP-1 putty (rhBMP-7) as an adjunct to iliac 178. Willems P. Decision making in surgical treatment of chronic low
crest autograft in posterolateral lumbar fusions. Eur Spine J. back pain: the performance of prognostic tests to select patients
2003;12(5):495-500. for lumbar spinal fusion. Acta Orthop Suppl. 2013;84(349):1-35.
168. Vaccaro AR, Patel T, Fischgrund J, et al. A pilot safety and 179. Wood GW, Boyd RJ, Carothers TA, et al. The effect of pedicle
efficacy study of OP-1 putty (rhBMP-7) as an adjunct to iliac screw/plate fixation on lumbar/lumbosacral autogenous bone
crest autograft in posterolateral lumbar fusions. Eur Spine J. graft fusions in patients with degenerative disc disease. Spine.
2003;12(5):495-500. 1995;20(7):819-30.
169. Vaccaro AR, Patel T, Fischgrund J, et al. A pilot study evaluating 180. Xiao YX, Chen QX, Li FC. Unilateral transforaminal lumbar in-
the safety and efficacy of OP-1 Putty (rhBMP-7) as a replace- terbody fusion: a review of the technique, indications and graft
ment for iliac crest autograft in posterolateral lumbar arthrod- materials. J Int Med Res. 2009;37(3):908-17.
esis for degenerative spondylolisthesis. Spine (Phila Pa 1976). 181. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz
2004;29(17):1885-1892. TE. The utility of repeated postoperative radiographs after lum-
170. Vaccaro AR, Stubbs HA, Block JE. Demineralized bone matrix bar instrumented fusion for degenerative lumbar spine. Spine.
composite grafting for posterolateral spinal fusion. Orthopedics. 2011;36(23):1955-60.
2007;30(7):567-70. 182. Yan DL, Pei FX, Li J, Soo CL. Comparative study of PILF and
171. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy TLIF treatment in adult degenerative spondylolisthesis. Eur
of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for Spine J. 2008;17(10):1311-6.
posterolateral lumbar arthrodesis: minimum 4-year follow-up of 183. Yao N, Wang W, Liu Y. Percutaneous endoscopic lumbar dis-
a pilot study. Spine J. 2008;8(3):457-65. cectomy and interbody fusion with B-Twin expandable spinal
172. Virk S, Sandhu HS, Khan SN. Cost effectiveness analysis of graft spacer. Arch Orthop Trauma Surg. 2011;131(6):791-6.
options in spinal fusion surgery using a Markov model. J Spinal 184. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
Disord Tech. 2012;25(7):E204-10. results of pediculo-body fixation and posterolateral fusion for
173. Watters WC III. If, when, and how to fuse when treating lumbar lumbar spondylolisthesis. Eur Spine J. 2009;18 Suppl 1:151-5.
degenerative stenosis. Semin Spine Surg. 2011;23(4):218-221. 185. Zdeblick TA. A prospective, randomized study of lumbar fu-
174. Weiner BK, Walker M. Efficacy of autologous growth fac- sion. Preliminary results. Spine. 1993;18(8):983-991.
tors in lumbar intertransverse fusions. Spine (Phila Pa 1976). 186. Zhang YF, Yang HL, Tang TS, Shi Y. Mobilization range of the
2003;28(17):1968-1970; discussion 1971. vertebral bodies after treatment of lumbar instability with tita-
175. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non- nium-coated fusion cage. Chin J Clin Rehabil. 2005;9(10):204-
surgical treatment for lumbar degenerative spondylolisthesis. N 205.
Engl J Med. 2007;356(22):2257-70. 187. Zhao Y, Wang YP, Qiu GX, Zhao H, Zhang JG, Zhou X. Ef-
176. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared ficacy of the Dynamic Interspinous Assisted Motion system in
with nonoperative treatment for lumbar degenerative spon- clinical treatment of degenerative lumbar disease. Chin Med J.
dylolisthesis. four-year results in the Spine Patient Outcomes 2010;123(21):2974-7.
Research Trial (SPORT) randomized and observational cohorts. 188. Zhou J, Wang B, Dong J, et al. Instrumented transforaminal
J Bone Joint Surg Am. 2009;91(6):1295-304. lumbar interbody fusion with single cage for the treatment
177. Whitecloud TS, Castro FP, Brinker MR, Hartzog CW, Ricciardi of degenerative lumbar disease. Arch Orthop Trauma Surg.
JE, Hill C. Degenerative conditions of the lumbar spine treated 2011;131(9):1239-45.
with intervertebral titanium cages and posterior instrumenta-
tion for circumferential fusion. J Spinal Disord. 1998;11(6):479-
86.


Do minimally invasive surgical treatments
improve outcomes in the treatment of
degenerative lumbar spondylolisthesis
compared to:
a. conventional open decompression
(laminectomy)?
b. conventional (open) lumbar decompression
and fusion, with or without instrumentation?
No evidence was found to assess the efficacy of minimally invasive surgical techniques versus open
decompression alone in the surgical treatment of degenerative lumbar spondylolisthesis.
While both minimally invasive techniques and open decompression

and fusion, with or without instrumentation, demonstrate significantly
improved clinical outcomes for the surgical treatment of degenerative
lumbar spondylolisthesis, there is conflicting evidence which technique
leads to better outcomes.
Grade of Recommendation: I (Insufficient/Conflicting Evidence)
Harris et al1 conducted a retrospective comparative study of 51 mini-open group. Similar to pain scores, the improvement in
total patients undergoing 2 types of fusion surgeries with bilat- disability at 3 months and one year after surgery was statistically
eral decompression for the treatment of degenerative spondylo- significant (p<0.05); however, there were no statistically signifi-
listhesis with spinal stenosis. Patients underwent either fusion cant differences in improvement between the groups at either
using a standard, midline open technique (open group, n=21) follow-up periods (p=0.19). Radiological review found only 2
or fusion using a mini-open technique, with a small, central fusion failures. In the open group, one patient showed isolated
incision for the decompression and bilateral paramedian inci- radiolucency around one of the L4 pedicle screws, as well as lack
sions for the posterolateral fusion and placement of cannulated of bridging posterolateral bone graft on the AP radiograph. In
pedicle screws (mini-open group, n=30). All patients in this ret- the mini-open group, one patient showed radiolucency around
rospective review had documented preoperative and postopera- one of the L5 screws, as well as lack of bridging bone between
tive Visual Analog Scale (VAS) and Oswestry Disability Index the L4 and L5 transverse processes. The authors conclude that
(ODI) scores. Postoperative anteroposterior (AP) fluoroscopic the standard open fusion and decompression and less invasive
images and lateral radiographs were also taken at 12 month after fusion techniques are equally effective in providing statistically
surgery. The mean preoperative VAS score was 7.58 in the open significant improvement in leg pain (VAS scores) and function
group and 7.78 in the mini-open group (P = .74). By 3-month (ODI scores) at 3-month and one-year follow-ups. This study
follow-up, mean VAS score had improved to 2.68 in the open provides Level III therapeutic evidence that open exposure de-
group and 2.89 in the mini-open group. By one-year follow-up, compression and fusion (traditional midline incision) and mini-
this score had improved to 2.38 in the open group and 2.32 in mally invasive mini-open exposure (3 small incisions) are effec-
the mini-open group. The improvement at 3 months and one tive surgical treatment options with equivalent short-term and
year after surgery was statistically significant (p<0.05); however, medium-term outcomes for patients with degenerative lumbar
there were no statistically significant differences in improvement spondylolisthesis.
between the groups at either follow-up periods (p =0.95). Both In a prospective comparative study, Kotani et al2 compared
group’s mean preoperative ODI score was 45.7 (consistent with the clinical outcomes of degenerative spondylolisthesis with
severe disability). By 3-month follow-up, mean ODI score had spinal stenosis patients undergoing MIS posterolateral fusion
improved to 27.2 (moderate disability) in the mini-open group (PLF), n=43, to patients undergoing conventional PLF, n=37.
and 19.0 (minimal disability) in the open group. By one-year fol- There were no statistically significant differences in gender,
low-up, mean ODI score had improved further, to 6.4 (minimal age, vertebral level and degree of spondylolisthesis between
disability) in the open group and 13.9 (minimal disability) in the the groups. Patients were evaluated over a period of at least 2
years using the Japanese Orthopaedic Association (JOA) score, were no statistically significant differences between the groups
Oswestry-Disability Index (ODI), Roland-Morris Questionnaire for JOA, RDQ, or VAS scores for low back pain and low back
(RMQ), the visual analogue scale of low back pain (LBP VAS), discomfort at follow-up. However, one year after the surgery, the
and the surgical complication rate. Fusion status was evaluated average VAS score for low back pain in the SPS open PSF group
by radiograph studies and CT scans at the final follow-up visit. was significantly lower than that in the conventional open PSF
Results indicated that the average operation time was statisti- group (1.5 ± 1.6 and 2.8 ± 2.3, respectively, p<0.05). The average
cally equivalent between the 2 groups. Intraoperative blood loss multifidus atrophy ratios at the fusion level in the SPS open PSF
was significantly less (p<0.01) in the MIS-PLF group (181 ml) group were significantly greater than those in the conventional
when compared to the open-PLF group (453 ml). The postoper- open PSF group at one and 3 years after surgery (0.98 ± 0.08 vs
ative bleeding on day one was also significantly less (p<0.01) in 0.87 ± 0.07 and 0.96 ± 0.11 vs 0.84 ± 0.07, respectively, p<0.01).
the MIS-PLF group (210 ml) when compared to the open-PLF At the one-year postoperative follow-up, the multifidus atrophy
group (406 ml). There were no statistically significant differences ratio significantly correlated with the VAS score for discomfort
between the average preoperative and follow-up JOA scores in in the low back (p<0.05). The authors suggest that SPS open
the MIS-PLF Group, 11.1 and 23.5 vs Open-PLF Group, 12.6 PSF was less damaging to the paraspinal muscle than the con-
and 22.8. The recovery rates of the JOA score were 63.1 and ventional open PSF and resulted in improved clinical outcomes
59.9% in each group, respectively. The average preoperative ODI and less low back discomfort at one year after the surgery. This
values were statistically equivalent, 52.0 and 48.9 for each group, study provides Level III therapeutic evidence that the minimally
respectively. Two weeks after surgery, the MIS-PLF group’s ODI invasive SPS and PSF surgical technique may result in better sur-
value reduced significantly. There was a statistically significant gical outcomes when compared to the conventional open PSF
difference in ODI values between the 2 groups at 2 weeks post- technique.
operatively (p<0.01). At 3 months, the MIS-PLF group dem- Adogwa et al4 conducted a retrospective study to compare
onstrated a further decrease to an average of 13.2; however, the surgical and functional outcomes of patients undergoing either
average score for the open-PLF group remained 32.1. This differ- minimally invasive (MIS) or open transforaminal lumbar inter-
ence was statistically significant (p<0.001) and was maintained body fusion (TLIF) for Grade I degenerative spondylolisthesis.
at 6, 12 and 24 months postoperatively (p<0.01). There was a Patients were excluded if they were above 70 years of age. Thirty
statistical difference of RMQ value at 2 weeks between the 2 patients were included in the analysis, including 15 in the MIS-
groups, 12.2 in the MIS-PLF group and 13.7 in the Open-PLF TLIF and 15 in the open TLIF. Outcomes were assessed at 2 years
group (p<0.01). At 3 months, MIS-PLF group showed a further via visual analog scale (VAS), low-back disability (ODI), Euro-
decrease to 5.1; however, the Open-PLF group remained at 10.9 Qol-5D, occupational disability, and narcotic use. No patients
(p<0.01). This difference was maintained until 6, 12 and 24 within the analysis were excluded or lost to follow-up. Overall,
months postoperatively (p<0.01). The LBP VAS on day 3 in the the mean age was 50±9.6 years and included 18 women and 12
MIS-PLF group was statistically lower than that in the open-PLF men. Interbody fusion was performed at L4 to L5 in 19 (63%)
group (p<0.02). Radiological evaluation via x-ray films and CT patients and L5 to S1 in 11 (37%) patients. All cases were single-
scans demonstrated that solid fusion was achieved in 42 out of level fusions. Results indicated that the median interquartile
43 cases (98%) in the MIS-PLF group and in all 37 cases (100%) range (IQR) length of surgery was shorter for open-TLIF cases
in the open-PLF group. Statistically, there was no difference in versus MIS-TLIF procedures, 210 versus 300 minutes (p=0.008).
fusion success between the groups. The authors suggest that the The median (IQR) estimated blood loss during surgery was
MIS-PLF utilizing percutaneous pedicle screw fixation serves as greater for open-TLIF versus MIS-TLIF procedures, 295 versus
an alternative technique to the conventional open approach. In 200 mL (p=0.09). Median (IQR) length of hospitalization after
critique, the number of patients who completed follow-up was surgery was significantly less for MIS-TLIF versus open-TLIF,
not addressed and patients had the option to choose their treat- 3.0 versus 5.0 days (p=0.001). For all patients, the median IQR
ment; thus, adding potential bias to the study. Due to these rea- of the duration of postoperative narcotic use was 3 (1.4 to 4.6)
sons, this potential Level II study has been downgraded to a Lev- weeks and median (IQR) time to return to work was 13.9 (2.2
el III. This study provides Level III therapeutic evidence that the to 25.5) weeks. MIS-TLIF patients used narcotics for about 2
MIS-PLF procedure is demonstrated to have better short-term weeks compared to 4 weeks for patients in the open-TLIF group
and medium-term clinical outcomes when compared to conven- (p=0.008). Return to work time was also shorter for MIS-TLIF
tional open-PLF in patients undergoing surgical treatment for versus open-TLIF, 8.5 weeks versus 17.1 weeks (p=0.02). MIS-
degenerative spondylolisthesis with spinal stenosis. TLIF versus open TLIF patients showed similar 2-year improve-
In a retrospective comparative study, Mori et al3 evaluated ment in VAS for back pain, VAS for leg pain, Oswestry disability
53 patients with degenerative lumbar spondylolisthesis who index, and EuroQol-5D scores. The authors suggest that MIS-
underwent either spinous process-splitting (SPS) open pedicle TLIF may allow for shorter hospital stays, reduced postopera-
screw fusion (PSF) (n=27) or conventional open PSF (n=26) for tive narcotic use, and accelerated return to work resulting in less
a single-level instrumented posterior lumbar decompression direct medical costs and indirect costs of lost work productiv-
and fusion. Radiographic and clinical outcomes were assessed ity associated with TLIF procedures. This study provides Level
using MRI, the Japanese Orthopedic Association (JOA) score, III therapeutic evidence that both minimally invasive and open
the Roland-Morris disability questionnaire (RDQ), and the vi- TLIF provide long-term improvement in pain and disability and
sual analog scale (VAS) for low back pain and low back discom- the minimally invasive technique may allow for an accelerated
fort at one to 3 years after surgery. Results indicated that there recovery and return to work time.
Future Directions For Research 7. Lee HY, Ahn Y, Kim DY, Shin SW, Lee SH. Percutaneous ventral
The work group recommends the undertaking of randomized decompression for L4-L5 degenerative spondylolisthesis in
medically compromised elderly patients: technical case report.
controlled trials or prospective studies comparing the efficacy
Neurosurgery. 2004;55(2):435.
and durability of minimally invasive (MIS) to open techniques. 8. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar de-
It is important to note that MIS recommendations are compli- compression for degenerative lumbar spinal stenosis. J Neuro-
cated by the lack of a consistent definition of what constitutes surg Spine. 2006;4(5):359-64.
MIS; therefore, the work group recommends that MIS is clearly 9. Markwalder TM. Surgical management of neurogenic claudica-
and consistently defined in any future studies evaluating the ef- tion in 100 patients with lumbar spinal stenosis due to degen-
ficacy of MIS surgical techniques. erative spondylolisthesis. Acta Neurochir (Wien). 1993;120(3-
4):136-42.
10. Mcculloch JA. Microdecompression and uninstrumented single-
References level fusion for spinal canal stenosis with degenerative spondy-
1. Harris EB, Sayadipour A, Massey P, Duplantier NL, Anderson
lolisthesis. Spine. 1998;23(20):2243-52.
DG. Mini-open versus open decompression and fusion for lum-
11. Müslüman AM, Cansever T, Yılmaz A, Çavuşoğlu H, Yüce İ,
bar degenerative spondylolisthesis with stenosis. Am J Orthop.
Aydın Y. Midterm outcome after a microsurgical unilateral
2011;40(12):E257-61.
approach for bilateral decompression of lumbar degenerative
2. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid-
spondylolisthesis. J Neurosurg Spine. 2012;16(1):68-76.
term clinical results of minimally invasive decompression and
12. Osman SG. Endoscopic transforaminal decompression,
posterolateral fusion with percutaneous pedicle screws versus
interbody fusion, and percutaneous pedicle screw implanta-
conventional approach for degenerative spondylolisthesis with
tion of the lumbar spine: A case series report. Int J Spine Surg.
spinal stenosis. Eur Spine J. 2012;21(6):1171-7.
2012;6(1):157-166.
3. Mori E, Okada S, Ueta T, et al. Spinous process-splitting open
13. Palmer S, Turner R, Palmer R. Bilateral decompression of
pedicle screw fusion provides favorable results in patients with
lumbar spinal stenosis involving a unilateral approach with mi-
low back discomfort and pain compared to conventional open
croscope and tubular retractor system. J Neurosurg. 2002;97(2
pedicle screw fixation over 1 year after surgery. Eur Spine J.
Suppl):213-7. .
2012;21(4):745-53.
14. Pao JL, Chen WC, Chen PQ. Clinical outcomes of microen-
4. Adogwa O, Parker SL, Bydon A, Cheng J, Mcgirt MJ. Compara-
doscopic decompressive laminotomy for degenerative lumbar
spinal stenosis. Eur Spine J. 2009;18(5):672-8.
raminal lumbar interbody fusion: 2-year assessment of narcotic
15. Podichetty VK, Spears J, Isaacs RE, Booher J, Biscup RS. Com-
use, return to work, disability, and quality of life. J Spinal Disord
plications associated with minimally invasive decompression for
Tech. 2011;24(8):479-84.
lumbar spinal stenosis. J Spinal Disord Tech. 2006;19(3):161-6.
16. Rouben D, Casnellie M, Ferguson M. Long-term durability of
Bibliography minimal invasive posterior transforaminal lumbar interbody fu-
1. Hatta Y, Shiraishi T, Sakamoto A, et al. Muscle-preserving sion: a clinical and radiographic follow-up. J Spinal Disord Tech.
interlaminar decompression for the lumbar spine: a minimally 2011;24(5):288-96.
invasive new procedure for lumbar spinal canal stenosis. Spine. 17. Sasai K, Umeda M, Maruyama T, Wakabayashi E, Iida H. Mi-
2009;34(8):E276-80. crosurgical bilateral decompression via a unilateral approach for
2. Ikuta K, Tono O, Oga M. Clinical outcome of microendoscopic lumbar spinal canal stenosis including degenerative spondylolis-
posterior decompression for spinal stenosis associated with thesis. J Neurosurg Spine. 2008;9(6):554-9.
degenerative spondylolisthesis--minimum 2-year outcome of 37 18. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous
patients. Minim Invasive Neurosurg. 2008;51(5):267-71. transforaminal lumbar interbody fusion for the treatment of de-
3. Ikuta K, Tono O, Oga M. Prevalence and clinical features of generative lumbar instability. Neurosurgery. 2007;60(4 SUPPL.
intraspinal facet cysts after decompression surgery for lumbar 2):203- 212.
spinal stenosis. J Neurosurg Spine. 2009;10(6):617-22. 19. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Matsu-
4. Kantelhardt SR, Török E, Gempt J, et al. Safety and efficacy of da H. Clinical outcome of microsurgical bilateral decompression
a new percutaneously implantable interspinous process device. via unilateral approach for lumbar canal stenosis: minimum
Acta Neurochir (Wien). 2010;152(11):1961-7. five-year follow-up. Spine. 2011;36(5):410-5.
5. Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Suc- 20. Vaccaro A. Unilateral approach for microsurgical decompres-
cess and failure of minimally invasive decompression for focal sion. J Neurosurg Spine. 2008;9(6):552-3.
lumbar spinal stenosis in patients with and without deformity. 21. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure
Spine. 2010;35(19):E981-7. rate of the interspinous distraction device (X-Stop) for the treat-
6. Kinoshita T, Ohki I, Roth KR, Amano K, Moriya H. Results of ment of lumbar spinal stenosis caused by degenerative spondy-
degenerative spondylolisthesis treated with posterior de- lolisthesis. Eur Spine J. 2008;17(2):188-92.
compression alone via a new surgical approach. J Neurosurg.

2001;95(1 Suppl):11-6.

What is the long-term result (4 or more years)
of surgical management of degenerative lumbar
spondylolisthesis?
Decompression and fusion may be considered as a means to provide

satisfactory long-term results for the treatment of patients with
symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.
Maintained from original guideline with minor word modifications
Studies obtained from updated literature search: reoperation due to complications including 2 degenerative
Schaeren et al1 conducted a prospective case-series of 26 con- spondylolisthesis and 2 degenerative lumbar scoliosis patients.
secutive patients with symptomatic spinal stenosis and degen- For patients with degenerative spondylolisthesis, the mean rate
erative spondylolisthesis to evaluate whether posterior dynamic of improvement at 3 months was 72.3% and 64.1% at the last
stabilization in situ with the Dynesys System can maintain follow-up. The preoperative percentages of slippage in patients
enough stability to prevent progression of spondylolisthesis. Pa- degenerative spondylolisthesis was 13.2% ± 5.9%, whereas the
tients were followed-up at a mean of 52 months using VAS and degrees of progression of slippage at latest follow-up was 2.4%
radiographic measurements. At 2 and 4 years follow-up, pain ± 4.7%. This study provides Level IV therapeutic evidence that
according to VAS assessment and walking distance significantly MIS decompression yields satisfactory outcomes at 5 years.
improved (p<0.001). Plain and functional radiographs showed In a retrospective case-series study, Tsutsuminmoto et al3
that spondylolisthesis did not progress and the motion segments evaluated the long-term surgical outcomes of patients with lum-
remained stable. At 2 year follow-up, anterior and posterior disc bar canal stenosis and Grade I degenerative spondylolisthesis
height had significantly increased from 2.9 to 3.5mm (p=0.02). undergoing uninstrumented posterolateral lumbar fusion (PLF)
At 4 years follow-up, anterior and posterior disc height did not to determine whether the fusion status influences the long-term
show significant alteration (p=0.02 and 0.05). Some degenera- operative results of PLF. Nine patients were lost to follow-up;
tion at adjacent levels was seen in 47% of patients at 4 years therefore, the final analysis included 42 patients. Fusion status
follow-up. Patient satisfaction was high and 95% responded that was assessed via plain radiographs and clinical outcomes were
they would undergo the same procedure again. This study pro- evaluated using Japanese Orthopaedic Association (JOA) scores.
vides level IV therapeutic evidence that dynamic stabilization The average preoperative JOA score was 13.2 (range 3-20 points)
with Dynesys may be associated with satisfactory clinical and and 23.5 (range 11-29 points) at the final follow-up. At the fi-
radiographic outcomes after 4 years in patients undergoing sur- nal follow-up, the percent recovery was greater than 3 in 69.0%
gery for degenerative spondylolisthesis. (29/42) of the patients. Nonunion developed in 26.2% (11/42)
In a retrospective case-series study, Toyoda et al2 evaluated of the patients. At one and 3-year follow-up, there was no sta-
clinical and radiologic outcomes in patients who underwent mi- tistically significant difference in the overall percent recovery
crosurgical bilateral decompression using a unilateral approach. between the union and nonunion groups (3.5 ± 0.8 vs 3.4 ± 0.7,
A total of 57 patients were included in the analysis, including p = 0.515, and 3.4 ± 0.8 vs 3.1 ± 1.2, P = 0.508, respectively).
27 with lumbar spinal stenosis, 20 with degenerative spondy- However, the union group’s percent recovery was significantly
lolisthesis, and 10 with degenerative lumbar scoliosis. Patients better at 5-year and final follow up compared to that of the non-
were followed for a minimum of 5 years and the mean follow-up union group (3.5 ± 0.7 vs 2.5 ± 1.0, p = 0.006 and 3.3 ± 0.9 vs 2.2
time was 6 years. Clinical outcomes were evaluated by the Japa- ± 1.2, P = 0.008, respectively). The overall fusion rate achieved
nese Orthopedic Association (JOA) score. Complications, rate by PLF was 74%. Regression analysis revealed that fusion sta-
of reoperation, and radiographic changes after surgery on plain tus and the presence of comorbidity were significant risk factors
radiograph were also evaluated. The mean blood loss per level for percent recovery at follow-up. This study provides Level IV
was 113.4±74.8 mL, and the mean operative time per level was therapeutic evidence that fusion status following PLF influences
134.2±28.7 minutes. The mean JOA score was 13.8±3.6 points the long-term but not short-term operative results and that im-
before surgery, but improved to 24.9±3.1 points at 3 months, proved clinical outcomes are sustained long term in the treat-
25.6±2.5 points at 1 year, and 22.6±4.7 points at latest follow-up. ment of patients with lumbar canal stenosis with degenerative
The mean rate of improvement was 71.5% at 3 months, 73.5% at spondylolisthesis.
one year, and 57.9% at latest follow-up. Four patients required
In a retrospective review, Turunen et al4 assessed the long- up) evidence that laminectomy and attempted fusion results in
term clinical outcome (at least 10 years), late complications, longstanding symptom improvement for spinal stenosis from
reoperations and postoperative patient satisfaction in patients degenerative spondylolisthesis. Furthermore, this study suggests
with different indications for posterolateral fusion. A total of that those patients who achieved solid fusion have statistically
106 patients were included in the study, including 31 with de- better long-term outcomes than those with pseudarthroses for
generative spondylolisthesis (Group 1), 33 with isthmic spon- noninstrumented fusions.
dylolisthesis (Group 2), 22 with postdiscectomy syndrome
(Group 3), and 20 with postlaminectomy syndrome (Group 4). Future Directions for Research
Clinical outcomes were evaluated by an independent orthope- The work group identified the following suggestions for future
dic surgeon, the Oswestry Disability Index (ODI) and the Visual studies, which would generate meaningful evidence to assist in
Analog Scale (VAS) questionnaires. The degenerative spondylo- further defining the role of surgical treatment for degenerative
listhesis patients (Group 1) showed the greatest improvements lumbar spondylolisthesis:
in ODI and VAS values compared to the other groups (47.0 vs.
26.4, p<0.001 and 6.3 vs. 4.1, p<0.001, respectively). In addition, Recommendation #1:
28 of 31 patients reported experiencing either excellent or good Future long-term studies of the effects of surgical interventions
long term results. This study provides Level IV therapeutic evi- for patients with symptomatic spinal stenosis and degenerative
dence that posterolateral fusion provides satisfactory long term lumbar spondylolisthesis should include a comparison group
outcomes in patients suffering from degenerative lumbar spon- undergoing best current medical management techniques, when
dylolisthesis. ethically feasible. Continued follow-up of patients already en-
rolled in ongoing prospective comparative studies will yield
Studies included in original guideline: higher quality data regarding the relative efficacy of surgery
Booth et al5 described a presumably retrospective study of 41 compared to medical/interventional treatments.
patients with neurogenic claudication from spinal stenosis and
spondylolisthesis who were followed for a minimum of 5 years Recommendation #2:
after a laminectomy and instrumented fusion. At final follow-up, Future long-term outcome studies, such as multicenter registry
there were no new neurological deficits, no recurrent stenosis at database studies, are necessary to compare different surgical
the level of surgery and no symptomatic pseudarthroses. Three techniques for the treatment of patients with symptomatic spinal
patients underwent surgery for adjacent level stenosis, which stenosis and degenerative lumbar spondylolisthesis.
took place 4 to 12 years after the index procedure. Clinical out-
comes were available in 36 patients: 83% reported high satisfac- References
tion, 86% reported reduced back and leg pain, and 46% had in- 1. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow-
creased function at follow-up that ranged from 5 to 10.7 years. up of spinal stenosis with degenerative spondylolisthesis
In critique of this study, it had small patient numbers and there treated with decompression and dynamic stabilization. Spine.
was a considerable amount of attrition (less than 80% follow- 2008;33(18):E636-42.
up). Of 49 consecutive patients operated during the study inter- 2. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Matsu-
val, 41 were available for follow-up (8 patients died) and only 36 da H. Clinical outcome of microsurgical bilateral decompression
had clinical outcomes measured. Attrition from death, however, via unilateral approach for lumbar canal stenosis: minimum
five-year follow-up. Spine. 2011;36(5):410-5.
is expected in the affected population. This retrospective case
3. Tsutsumimoto T, Shimogata M, Yoshimura Y, Misawa H. Union
series provides Level IV therapeutic evidence that laminectomy versus nonunion after posterolateral lumbar fusion: a compari-
and instrumented fusion for stenosis from degenerative spondy- son of long-term surgical outcomes in patients with degenera-
lolisthesis provides a high rate of satisfaction and pain relief and tive lumbar spondylolisthesis. Eur Spine J. 2008;17(8):1107-12.
moderately increased function at long-term follow-up. 4. Turunen V, Nyyssönen T, Miettinen H, et al. Lumbar instru-
Kornblum et al6 conducted a follow-up study on 47 of 58 mented posterolateral fusion in spondylolisthetic and failed
patients who had originally been part of a randomized con- back patients: a long-term follow-up study spanning 11-13
trolled trial comparing instrumented versus noninstrumented years. Eur Spine J. 2012;21(11):2140-8.
fusion for spinal stenosis and degenerative spondylolisthesis. 5. Booth KC, Bridwell KH, Eisenberg BA, Baldus CR, Lenke LG.
Minimum 5-year results of degenerative spondylolisthesis
This study’s cohort consisted only of the noninstrumented cases,
treated with decompression and instrumented posterior fusion.
which were followed for a minimum of 5 years. Clinical out-
Spine. 1999;24(16):1721-7.
comes were analyzed based on the presence of solid fusion (22 6. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA,
patients) or a pseudarthrosis (25 patients). A statistically greater Berkower DL, Ditkoff JS. Degenerative lumbar spondylolisthesis
percentage of patients had good or excellent results in patients with spinal stenosis: a prospective long-term study comparing
with solid fusion (86%) versus pseudarthrosis (56%). Important- fusion and pseudarthrosis. Spine. 2004;29(7):726-33.
ly, 5 of the pseudarthrosis patients and 2 of the fusion patients
had undergone a second procedure. In critique of this study, the Bibliography from updated literature search
authors used a less frequently implemented outcomes instru- 1. Acosta FL Jr, Christensen FB, Coe JD, et al. Early Clinical &
ment, the Swiss Spinal Stenosis (SSS) Questionnaire, making it Radiographic Results of NFix II Posterior Dynamic Stabilization
difficult to compare directly to other studies in which the ODI or System. SAS J. 2008;2(2):69-75.
ZCQ were used. Despite these minor limitations, as a prospec- 2. Adogwa O, Parker SL, Bydon A, Cheng J, Mcgirt MJ. Compara-
tive case series, the data offer Level IV therapeutic (>80% follow-
raminal lumbar interbody fusion: 2-year assessment of narcotic lumbar fusion with pedicle screw instrumentation--a minimum
use, return to work, disability, and quality of life. J Spinal Disord 4-year follow-up. Fukuoka Igaku Zasshi. 2008;99(5):107-13.
Tech. 2011;24(8):479-84. 20. Helenius I, Remes V, Poussa M. Uninstrumented in situ fusion
3. Azzazi A, Elhawary Y. Dynamic stabilization using X-stop for high-grade childhood and adolescent isthmic spondylolis-
versus transpedicular screw fixation in the treatment of lumbar thesis: long-term outcome. Surgical technique. J Bone Joint Surg
canal stenosis: comparative study of the clinical outcome. Neu- Am. 2008;90 Suppl 2 Pt 1:145-52.
rosurg Quart. 2010;20(3):165-169. 21. Hsieh PC, Koski TR, O’shaughnessy BA, et al. Anterior lumbar
4. Bae JS, Lee SH, Kim JS, Jung B, Choi G. Adjacent segment interbody fusion in comparison with transforaminal lumbar
degeneration after lumbar interbody fusion with percutane- interbody fusion: implications for the restoration of foraminal
ous pedicle screw fixation for adult low-grade isthmic spon- height, local disc angle, lumbar lordosis, and sagittal balance. J
dylolisthesis: minimum 3 years of follow-up. Neurosurgery. Neurosurg Spine. 2007;7(4):379-86.
2010;67(6):1600-7. 22. Ikuta K, Tono O, Oga M. Clinical outcome of microendoscopic
5. Bashir el F, Ajani O. Management of lumbar spine juxtafacet posterior decompression for spinal stenosis associated with
cysts. World Neurosurg. 2012;77(1):141-6. degenerative spondylolisthesis--minimum 2-year outcome of 37
6. Blondel B, Adetchessi T, Pech-gourg G, Métellus P, Dufour H, patients. Minim Invasive Neurosurg. 2008;51(5):267-71.
Fuentes S. Minimally invasive transforaminal lumbar interbody 23. Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with au-
fusion through a unilateral approach and percutaneous osteo- tologous iliac bone versus local bone graft in posterior lumbar
synthesis. Orthop Traumatol Surg Res. 2011;97(6):595-601. interbody fusion. Spine. 2010;35(21):E1101-5.
7. Cansever T, Civelek E, Kabatas S, Yılmaz C, Caner H, Altinörs 24. Jagannathan J, Sansur CA, Oskouian RJ, Fu KM, Shaffrey CI.
MN. Dysfunctional segmental motion treated with dynamic Radiographic restoration of lumbar alignment after transforam-
stabilization in the lumbar spine. World Neurosurg. 2011;75(5- inal lumbar interbody fusion. Neurosurgery. 2009;64(5):955-63.
6):743-9. 25. Jiya TU, Smit T, Van royen BJ, Mullender M. Posterior lumbar
8. Cavuşoğlu H, Türkmenoğlu O, Kaya RA, et al. Efficacy of unilat- interbody fusion using non resorbable poly-ether-ether-ketone
eral laminectomy for bilateral decompression in lumbar spinal versus resorbable poly-L-lactide-co-D,L-lactide fusion devices.
stenosis. Turk Neurosurg. 2007;17(2):100-8. Clinical outcome at a minimum of 2-year follow-up. Eur Spine J.
9. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, 2011;20(4):618-22.
Loeser JD. Surgery for low back pain: a review of the evidence 26. Kantelhardt SR, Török E, Gempt J, et al. Safety and efficacy of
for an American Pain Society Clinical Practice Guideline. Spine. a new percutaneously implantable interspinous process device.
2009;34(10):1094-109. Acta Neurochir (Wien). 2010;152(11):1961-7.
10. De iure F, Bosco G, Cappuccio M, Paderni S, Amendola L. 27. Kroppenstedt S, Gulde M, Schönmayr R. Radiological compari-
Posterior lumbar fusion by peek rods in degenerative spine: pre- son of instrumented posterior lumbar interbody fusion with one
liminary report on 30 cases. Eur Spine J. 2012;21 Suppl 1:S50-4. or two closed-box plasmapore coated titanium cages: follow-up
11. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH. study over more than seven years. Spine. 2008;33(19):2083-8.
Degenerative spondylolisthesis of the cervical spine: analysis of 28. Lamberg T, Remes V, Helenius I, Schlenzka D, Seitsalo S, Poussa
58 patients treated with anterior cervical decompression and M. Uninstrumented in situ fusion for high-grade childhood
fusion. Spine J. 2009;9(6):439-46. and adolescent isthmic spondylolisthesis: Long-term outcome. J
12. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random- Bone Joint Surg Am. 2007;89(3):512-518.
ized, controlled, multicenter study of osteogenic protein-1 in 29. Lee DY, Lee SH, Shim CS, Lee HY. Decompression and inter-
instrumented posterolateral fusions: report on safety and feasi- spinous dynamic stabilization using the locker for lumbar canal
bility. Spine. 2010;35(12):1185-91. stenosis associated with low-grade degenerative spondylolisthe-
13. Dhall SS, Wang MY, Mummaneni PV. Clinical and radiographic sis. Minim Invasive Neurosurg. 2010;53(3):117-21.
comparison of mini-open transforaminal lumbar interbody 30. Lindley EM, Mccullough MA, Burger EL, Brown CW, Patel VV.
fusion with open transforaminal lumbar interbody fusion Complications of axial lumbar interbody fusion. J Neurosurg
in 42 patients with long-term follow-up. J Neurosurg Spine. Spine. 2011;15(3):273-9.
2008;9(6):560-5. 31. Majid K, Fischgrund JS. Degenerative lumbar spondylo-
14. Disch AC, Schmoelz W, Matziolis G, Schneider SV, Knop C, listhesis: trends in management. J Am Acad Orthop Surg.
Putzier M. Higher risk of adjacent segment degeneration after 2008;16(4):208-15.
floating fusions: long-term outcome after low lumbar spine fu- 32. McAfee, P. C., Cunningham, B. W., Tortolani, P. J., Fedder, I. L.,
sions. J Spinal Disord Tech. 2008;21(2):79-85. Sefter, J. C., & Davis, C. (2009). 100 Consecutive Cases of De-
15. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- generative Lumbar Conditions Using a Non-Threaded Locking
tive randomised study on the long-term effect of lumbar fusion Screw System With a 90-Degree Locking Cap. SAS Journal, 3(1),
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. 1-11.
16. Elhawary Y, Azzazi A. Dynamic stabilization using X-stop vs. 33. Ozgur BM, Agarwal V, Nail E, Pimenta L. Two-year clinical and
trans-pedicular screw fixation in the treatment of lumbar canal radiographic success of minimally invasive lateral transpsoas
stenosis: Comparative study of the clinical outcome. Spine J. approach for the treatment of degenerative lumbar conditions.
2010;10(9)Supplement, S130. SAS J. 2010;4(2):41-46.
17. Etame AB, Wang AC, Than KD, Park P. Clinical and radio- 34. Park SC, Yoon SH, Hong YP, Kim KJ, Chung SK, Kim HJ. Mini-
graphic outcomes after minimally invasive transforaminal mum 2-year follow-up result of degenerative spinal stenosis
lumbar interbody fusion. SAS J. 2010;4(2):47-53. treated with interspinous u (coflex). J Korean Neurosurg Soc.
18. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective 2009;46(4):292-9.
randomized study of unilateral versus bilateral instrumented 35. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost-
posterolateral lumbar fusion in degenerative spondylolisthesis. effectiveness of minimally invasive versus open transforaminal
Spine. 2007;32(4):395-401. lumbar interbody fusion for degenerative spondylolisthesis
19. Hayashi T, Arizono T, Fujimoto T, et al. Degenerative change associated low-back and leg pain over two years. World Neuro-
in the adjacent segments to the fusion site after posterolateral surg. 2012;78(1-2):178-84.
36. Radcliff K, Hwang R, Hilibrand A, et al. The effect of iliac crest delayed union after posterior fusion with pedicle screw fixation.
autograft on the outcome of fusion in the setting of degenera- Spine. 2008;33(7):786-91.
tive spondylolisthesis: a subgroup analysis of the Spine Patient 46. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy
Outcomes Research Trial (SPORT). J Bone Joint Surg Am. of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
2012;94(18):1685-92. posterolateral lumbar arthrodesis: minimum 4-year follow-up of
37. Rouben D, Casnellie M, Ferguson M. Long-term durability of a pilot study. Spine J. 2008;8(3):457-65.
minimal invasive posterior transforaminal lumbar interbody fu- 47. Wang HL, Lü FZ, Jiang JY, Ma X, Xia XL, Wang LX. Minimally
sion: a clinical and radiographic follow-up. J Spinal Disord Tech. invasive lumbar interbody fusion via MAST Quadrant retrac-
2011;24(5):288-96. tor versus open surgery: a prospective randomized clinical trial.
38. Sapkas GS, Mavrogenis AF, Themistocleous GS, Zachos VC, Chin Med J. 2011;124(23):3868-74.
Kelalis G, Papagelopoulos PJ. Posterior lumbar interbody fusion 48. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non-
versus circumferential fusion using the B-Twin expandable spi- surgical treatment for lumbar degenerative spondylolisthesis. N
nal system. J Long Term Eff Med Implants. 2007;17(3):217-27. Engl J Med. 2007;356(22):2257-70.
39. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous 49. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared
transforaminal lumbar interbody fusion for the treatment of with nonoperative treatment for lumbar degenerative spon-
degenerative lumbar instability. Neurosurgery. 2007;60(4 Suppl dylolisthesis. four-year results in the Spine Patient Outcomes
2):203-212. Research Trial (SPORT) randomized and observational cohorts.
40. Schulte TL, Leistra F, Bullmann V, et al. Disc height reduction J Bone Joint Surg Am. 2009;91(6):1295-304.
in adjacent segments and clinical outcome 10 years after lumbar 50. Welch WC, Cheng BC, Awad TE, et al. Clinical outcomes of
360 degrees fusion. Eur Spine J. 2007;16(12):2152-8. the Dynesys dynamic neutralization system: 1-year preliminary
41. Schulte TL, Leistra F, Bullmann V, et al. Disc height reduction results. Neurosurg Focus. 2007;22(1):E8.
in adjacent segments and clinical outcome 10 years after lumbar 51. Willems P. Decision making in surgical treatment of chronic low
360 degrees fusion. Eur Spine J. 2007;16(12):2152-8. back pain: the performance of prognostic tests to select patients
42. Sharma AK, Kepler CK, Girardi FP, Cammisa FP, Huang RC, for lumbar spinal fusion. Acta Orthop Suppl. 2013;84(349):1-
Sama AA. Lateral lumbar interbody fusion: clinical and radio- 35. Xu H, Tang H, Li Z. Surgical treatment of adult degenera-
graphic outcomes at 1 year: a preliminary report. J Spinal Disord tive spondylolisthesis by instrumented transforaminal lumbar
Tech. 2011;24(4):242-50. interbody fusion in the Han nationality. J Neurosurg Spine.
43. Skowroński J, Wojnar J, Bielecki M. Interbody fusion and trans- 2009;10(5):496-9. Zagra A, Giudici F, Minoia L, Corriero AS,
pedicular fixation in the treatment of spondylolisthesis. Ortop Zagra L. Long-term results of pediculo-body fixation and
Traumatol Rehabil. 2007;9(2):149-55. posterolateral fusion for lumbar spondylolisthesis. Eur Spine J.
44. Soegaard R, Bünger CE, Christiansen T, Høy K, Eiskjaer SP, 2009;18 Suppl 1:151-5.
Christensen FB. Circumferential fusion is dominant over pos- 52. Zhao Y, Wang YP, Qiu GX, Zhao H, Zhang JG, Zhou X. Ef-
terolateral fusion in a long-term perspective: cost-utility evalua- ficacy of the Dynamic Interspinous Assisted Motion system in
tion of a randomized controlled trial in severe, chronic low back clinical treatment of degenerative lumbar disease. Chin Med J.
pain. Spine. 2007;32(22):2405-14. 2010;123(21):2974-7.
45. Tokuhashi Y, Ajiro Y, Umezawa N. Follow-up of patients with

Which patient-specific characteristics influence
outcomes (and prognosis) in the treatment
(surgical or any) of degenerative lumbar
spondylolisthesis?

the influence of a nonorganic pain drawing on the outcomes/prognosis of
treatments for patients with degenerative lumbar spondylolisthesis.
Andersen et al1 investigated whether pain drawings predicted There is insufficient evidence to make a
outcome in patients undergoing lumbar spinal fusion. The study recommendation regarding the influence of
also assessed the differences between spondylolisthesis patients
and patients with degenerative disease as well as between pa-
age and three or more comorbidities on the
tients with or without radicular pain. Patients over the age of outcomes of patients undergoing treatment
60 were excluded to make the patient population more compa- for degenerative lumbar spondylolisthesis.
rable to other studies. One hundred thirty-five patients, includ-
ing 28 spondylolisthesis patients, undergoing lumbar spinal fu- Grade of Recommendation: I (Insufficient
sion were followed for at least one year and evaluated using the
Dallas Pain Questionnaire (DPQ), Low Back Pain Rating Scale
Evidence)
(LBPRS) pain index and patient satisfaction. Pain drawings were
Kalanthi et al2 conducted a retrospective study of degenera-
composed by outling each patient’s front, back and area under
tive spondylolisthesis patients undergoing posterior lumbar fu-
feet. Patients were asked to indicate where their pain was oc-
sion to determine rates of in-patient complications and complex
curring on the drawing. Six different symbols denoting different
disposition for and evalaute the association of demographic
levels of pain were used for the following: dull/aching, burning,
variables. The Nationwide Inpatient Sample (NIS) administra-
numbness, pins and needles, stabbing/cutting and muscular
tive data was used to retrieve data from 66,601 patients with
cramps. Based on visual results, pain drawings were classified
diagnostic and procedure codes specifying posterior lumbar fu-
as organic or nonorganic. Pain drawings were correlated to
sion for acquired spondylolisthesis. Variables assessed included
outcomes to determine their predictive value. Results indicat-
age, sex, race, number of comorbidities, hospital size and time
ed that 90 pain drawings were deemed organic (67%) and 45
period of procedure. Multivariate analysis revealed an associa-
were deemed nonorganic pain drawings (33%). In the sub-set of
tion between age and complex disposition. The reference group
spondylolisthesis patients, patients with an organic pain draw-
was defined as the age Group 45 to 64 years. The likelihood of
ing had a greater improvement in all outcome scores, including
complex disposition was significantly higher for patients in the
DPQ daily activity, work/leisure, anxiety/depression, social in-
age Group 65 to 84 (OR: 5.8, p<0.0001), but less likely in young-
terest and LBPRS, compared with those with a nonorganic pain
er groups. Patients with 3 or more comorbidities were twice as
drawing; however, this difference was not observed to the same
likely to have complex disposition, regardless of age, when com-
extent in patients operated for degenerative disease. Nonorganic
pared with those with no comorbidities (p<0.0001). This study
pain drawings were associated with poorer outcomes in patients
provides Level II prognostic evidence that increasing age and the
with low back pain and radicular symptoms, however, not in

presence of three or more comorbidities may increase the risk of
patients without radicular symptoms. This study provides Level

a postoperative complex disposition in patients with degenera-
IV prognostic evidence that spondylolisthesis patients with an
tive spondylolisthesis.
organic pain drawing had a greater improvement in outcome
scores compared with those with a nonorganic pain drawing.
There is insufficient evidence to make a There is insufficient evidence to make a

recommendation regarding the influence recommendation regarding the influence
of symptom duration on the treatment of obesity (BMI >30) and its impact on
outcomes of patients with degenerative treatment outcomes in patients with
lumbar spondylolisthesis. degenerative lumbar spondylolisthesis.

Grade of Recommendation: I (Insufficient Grade of Recommendation: I (Insufficient
Evidence) Evidence)
Radcliff et al3 retrospectively reviewed data from the Spine In another post hoc retrospective subgroup analysis of
Outcomes Research Trial (SPORT) study to determine whether SPORT, Rihn et al4 evaluated the impact of obesity on the treat-
the duration of symptoms affects outcomes after the treatment of ment outcomes for lumbar stenosis and degenerative spondylo-
spinal stenosis (SS) or degenerative spondylolisthesis (DS). The listhesis patients. In the cohort of degenerative spondylolisthe-
SPORT study compared the surgical and nonsurgical outcomes sis patients, there were 376 patients with a BMI of less than 30
in patients enrolled in either a randomized or observational co- (non-obese) and 225 patients with a BMI more than 30 (obese).
hort. All patients in the trial had neurogenic claudication or ra- It is important to note that in addition to obesity, obese patients
dicular leg pain with associated neurologic signs, spinal stenosis had a significantly higher incidence of comorbidities, includ-
shown on cross-sectional imaging, and degenerative spondylo- ing hypertension, diabetes and stomach problems (p<0.001). A
listhesis shown on lateral radiographs obtained with the patient higher proportion of obese patients underwent instrumented
in a standing position. Treatment was standard decompressive fusion and less underwent decompression alone compared to
laminectomy, with or without fusion, or usual nonsurgical care, non-obese patients. The incidence of intraoperative complica-
which included at least physical therapy, education or counseling tions was significantly lower in the obese patient group; how-
on home exercises, and nonsteroidal anti-inflammatory agents, ever, there was a trend toward increase rate of wound infection
if tolerated. Investigators enrolled 304 patients in the random- in the obese patients compared to nonobese patients (5% vs. 1%,
ized cohort and 303 in the observational cohort. In the random- p=0.051). At 4 year follow-up, there was a significantly higher
ized cohort, 159 patients were assigned to surgery and 145 were rate of reoperation in the obese patient group compared to the
assigned to nonsurgical treatment. Of the 145 patients assigned nonobese group (20% vs. 11%, p=0.013). At 4 year follow-up
to receive nonoperative care, 54% underwent surgery by 4 years. in the nonoperative group, obese patients had SF-36 physical
In the observational cohort, 173 initially chose surgery and 130 function scores that worsened from baseline by a mean of 3.5
initially chose nonsurgical care. Of the 130 patients who ini- compared to a mean improvement of 13.9 points in the non-
tially chose nonoperative treatment, 33% underwent surgery by obese group (p<0.001). The treatment effect for the SF-36 Physi-
four years. Patients were evaluated over 4 years using the SF-36 cal Function score was significantly higher for the obese surgical
for bodily pain and physical function scores and the modified patient group compared to nonoperative obese patient group
Oswestry Disability Index. An as-treated analysis comparison (25.6 vs. 14, p=0.004) suggesting that surgery has a significantly
was made between patients with SS with 12 or fewer months’ greater benefit over nonsurgical treatment of degenerative spon-
(n = 405) and those with more than 12 months’ (n = 227) du- dylolisthesis in obese patients. This study provides Level II prog-
ration of symptoms. A comparison was also made between pa- nostic evidence the risk of infection and reoperation 4 years after
tients with DS with 12 or fewer months’ (n = 397) and those surgical treatment is greater in obese patients compared to non-
with more than 12 months’ (n = 204) duration of symptoms. Pri- obese surgical patients.
mary and secondary outcomes were measured at baseline and
at regular follow-up time intervals up to 4 years. The difference Future Directions for Research
in improvement among patients whose surgical or nonsurgical The work group recommends the undertaking of population-
treatment began less than or greater than 12 months after the based observational studies, such as a multicenter registry data
onset of symptoms was measured. In addition, the difference in studies, to examine the clinical characteristics associated with
improvement with surgical versus nonsurgical treatment (treat- poor medical/interventional or surgical treatment in patients
ment effect) was determined at each follow-up period for each with degenerative lumbar spondylolisthesis.
group. Results indicated that the primary and secondary out-

come measures within the DS group did not differ according to References
symptom duration and suggests that there was no difference in 1. Andersen T, Christensen FB, Høy KW, et al. The predictive
the treatment outcome of patients with degenerative spondylo- value of pain drawings in lumbar spinal fusion surgery. Spine J.
listhesis according to symptom duration. This study provides 2010;10(5):372-9.
Level II prognostic evidence that suggests that symptom dura- 2. Kalanithi PS, Patil CG, Boakye M. National complication rates
tion does not impact nonoperative or surgical treatment success and disposition after posterior lumbar fusion for acquired spon-
dylolisthesis. Spine. 2009;34(18):1963-9.
for patients with degenerative lumbar spondylolisthesis.
3. Radcliff KE, Rihn J, Hilibrand A, et al. Does the duration of
symptoms in patients with spinal stenosis and degenerative
spondylolisthesis affect outcomes?: analysis of the Spine Out-
comes Research Trial. Spine. 2011;36(25):2197-210.
4. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect eral lumbar fusion. Spine J. 2007;7(5):547-51.
outcomes of treatment for lumbar stenosis and degenerative 17. Hasegawa K, Shimoda H, Kitahara K, Sasaki K, Homma T.
spondylolisthesis? Analysis of the Spine Patient Outcomes What are the reliable radiological indicators of lumbar segmen-
Research Trial (SPORT). Spine. 2012;37(23):1933-46. tal instability?. J Bone Joint Surg Br. 2011;93(5):650-7.
18. Hee HT, Wong HK. The long-term results of surgical treat-
Bibliography ment for spinal stenosis in the elderly. Singapore Med J.
1. Alexander DI, Manson NA, Mitchell MJ. Efficacy of calcium 2003;44(4):175-80.
sulfate plus decompression bone in lumbar and lumbosacral 19. Jo DJ, Jun JK, Kim KT, Kim SM. Lumbar Interbody Fusion Out-
spinal fusion: preliminary results in 40 patients. Can J Surg. comes in Degenerative Lumbar Disease: Comparison of Results
2001;44(4):262-6. between Patients Over and Under 65 Years of Age. J Korean
2. Aono H, Iwasaki M, Ohwada T, et al. Surgical outcome of Neurosurg Soc. 2010;48(5):412-8.
drop foot caused by degenerative lumbar diseases. Spine. 20. Kalichman L, Hunter DJ. Degenerative lumbar spondylolisthe-
2007;32(8):E262-6. sis: Anatomy, biomechanics and risk factors. J Back Musculoskel
3. Barbagallo GM, Olindo G, Corbino L, Albanese V. Analysis of Rehabil. 2008;21(1):1-12.
complications in patients treated with the X-Stop Interspinous 21. Kawakami M, Tamaki T, Ando M, Yamada H, Hashizume H,
Process Decompression System: proposal for a novel anatomic Yoshida M. Lumbar sagittal balance influences the clinical out-
scoring system for patient selection and review of the literature. come after decompression and posterolateral spinal fusion for
Neurosurgery. 2009;65(1):111-19. degenerative lumbar spondylolisthesis. Spine. 2002;27(1):59-64.
4. Benoist M. The natural history of lumbar degenerative spinal 22. Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Suc-
stenosis. Joint Bone Spine. 2002;69(5):450-7. cess and failure of minimally invasive decompression for focal
5. Blumenthal C, Curran J, Benzel EC, et al. Radiographic predic- lumbar spinal stenosis in patients with and without deformity.
tors of delayed instability following decompression without Spine. 2010;35(19):E981-7.
fusion for degenerative grade I lumbar spondylolisthesis. J 23. Kim DH, Albert TJ. Update on use of instrumentation in
Neurosurg Spine. 2013;18(4):340-6. lumbar spine disorders. Best Pract Res Clin Rheumatol.
6. Bono CM, Lee CK. The influence of subdiagnosis on radio- 2002;16(1):123-40.
graphic and clinical outcomes after lumbar fusion for degen- 24. Kim MK, Lee SH, Kim ES, Eoh W, Chung SS, Lee CS. The
erative disc disorders: an analysis of the literature from two impact of sagittal balance on clinical results after posterior in-
decades. Spine. 2005;30(2):227-34. terbody fusion for patients with degenerative spondylolisthesis:
7. Coe JD, Kitchel SH, Meisel HJ, Wingo CH, Lee SE, Jahng a pilot study. BMC Musculoskelet Disord. 2011;12:69.
TA. NFlex Dynamic Stabilization System : Two-Year Clinical 25. Kleinstueck FS, Fekete TF, Mannion AF, et al. To fuse or
Outcomes of Multi-Center Study. J Korean Neurosurg Soc. not to fuse in lumbar degenerative spondylolisthesis: do
2012;51(6):343-9. baseline symptoms help provide the answer?. Eur Spine J.
8. Crawford CH, Smail J, Carreon LY, Glassman SD. Health-related 2012;21(2):268-75.
quality of life after posterolateral lumbar arthrodesis in patients 26. Lee JW, Myung JS, Park KW, et al. Fluoroscopically guided
seventy-five years of age and older. Spine. 2011;36(13):1065-8. caudal epidural steroid injection for management of degenera-
9. Dai F, Belfer I, Schwartz CE, et al. Association of catechol-O- tive lumbar spinal stenosis: short-term and long-term results.
methyltransferase genetic variants with outcome in patients Skeletal Radiol. 2010;39(7):691-9.
undergoing surgical treatment for lumbar degenerative disc 27. Lee SH, Lee JH, Hong SW, Chung SE, Yoo SH, Lee HY. Spi-
disease. Spine J. 2010;10(11):949-57. nopelvic alignment after interspinous soft stabilization with a
10. Desai A, Ball PA, Bekelis K, et al. Surgery for lumbar degen- tension band system in grade 1 degenerative lumbar spondylo-
erative spondylolisthesis in Spine Patient Outcomes Research listhesis. Spine. 2010;35(15):E691-701.
Trial: does incidental durotomy affect outcome?. Spine. 28. Lee SH, Lee JH, Hong SW, et al. Factors affecting clinical out-
2012;37(5):406-13. comes in treating patients with grade 1 degenerative spondylo-
11. Djurasovic M, Glassman SD, Dimar JR, Crawford CH, Bratcher listhesis using interspinous soft stabilization with a tension band
KR, Carreon LY. Changes in the Oswestry Disability Index that system: a minimum 5-year follow-up. Spine. 2012;37(7):563-72.
predict improvement after lumbar fusion. J Neurosurg Spine. 29. Lindley EM, Mccullough MA, Burger EL, Brown CW, Patel VV.
2012;17(5):486-90. Complications of axial lumbar interbody fusion. J Neurosurg
12. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- Spine. 2011;15(3):273-9.
tive randomised study on the long-term effect of lumbar fusion 30. Maus T. Imaging the back pain patient. Phys Med Rehabil Clin
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. N Am. 2010;21(4):725-66.
13. Etame AB, Wang AC, Than KD, Park P. Clinical and radio- 31. Mehta VA, Amin A, Omeis I, Gokaslan ZL, Gottfried ON.
graphic outcomes after minimally invasive transforaminal Implications of spinopelvic alignment for the spine surgeon.
Neurosurgery. 2012;70(3):707-21.
lumbar interbody fusion. SAS J. 2010;4(2):47-53.
32. Miyamoto H, Sumi M, Uno K, Tadokoro K, Mizuno K. Clinical
14. Fu KM, Rhagavan P, Shaffrey CI, Chernavvsky DR, Smith JS.

Prevalence, severity, and impact of foraminal and canal stenosis outcome of nonoperative treatment for lumbar spinal stenosis,
among adults with degenerative scoliosis. Neurosurgery. and predictive factors relating to prognosis, in a 5-year mini-
2011;69(6):1181-7. mum follow-up. J Spinal Disord Tech. 2008;21(8):563-8.
15. Gehrchen PM, Dahl B, Katonis P, Blyme P, Tøndevold E, Kiaer 33. Mokhtar SA, Mccombe PF, Williamson OD, Morgan MK, White
T. No difference in clinical outcome after posterolateral lumbar GJ, Sears WR. Health-related quality of life: a comparison of
fusion between patients with isthmic spondylolisthesis and outcomes after lumbar fusion for degenerative spondylolisthesis
those with degenerative disc disease using pedicle screw instru- with large joint replacement surgery and population norms.
mentation: a comparative study of 112 patients with 4 years of Spine J. 2010;10(4):306-12.
follow-up. Eur Spine J. 2002;11(5):423-7. 34. Molina M, Wagner P, Campos M. [Spinal lumbar stenosis: an
16. Glassman SD, Carreon LY, Dimar JR, Campbell MJ, Puno RM, update]. Rev Med Chil. 2011;139(11):1488-95.
Johnson JR. Clinical outcomes in older patients after posterolat- 35. Ozgur BM, Agarwal V, Nai, E, & Pimenta L. Two-year clinical
and radiographic success of minimally invasive lateral trans- 42. Schulte TL, Leistra F, Bullmann V, et al. Disc height reduction
psoas approach for the treatment of degenerative lumbar condi- in adjacent segments and clinical outcome 10 years after lumbar
tions. SAS J. 2010;4(2):41-46. 360 degrees fusion. Eur Spine J. 2007;16(12):2152-8.
36. Pao JL, Chen WC, Chen PQ. Clinical outcomes of microen- 43. Shen M, Razi A, Lurie JD, Hanscom B, Weinstein J. Retrolis-
doscopic decompressive laminotomy for degenerative lumbar thesis and lumbar disc herniation: a preoperative assessment of
spinal stenosis. Eur Spine J. 2009;18(5):672-8. patient function. Spine J. 2007;7(4):406-13.
37. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno- 44. Vaccaro A. Unilateral approach for microsurgical decompres-
sis lead to poorer outcomes?: a subanalysis of the Spine Patient sion. J Neurosurg Spine. 2008;9(6):552-553.
Outcomes Research Trial (SPORT) lumbar stenosis study. Spine. 45. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared
2010;35(4):439-46. with nonoperative treatment for lumbar degenerative spon-
38. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings dylolisthesis. four-year results in the Spine Patient Outcomes
MG. Cost-utility analysis of posterior minimally invasive fusion Research Trial (SPORT) randomized and observational cohorts.
compared with conventional open fusion for lumbar spondylo- J Bone Joint Surg Am. 2009;91(6):1295-304.
listhesis. SAS J. 2011;5(2):29-35. 46. Willems P. Decision making in surgical treatment of chronic low
39. Rouben D, Casnellie M, Ferguson M. Long-term durability of back pain: the performance of prognostic tests to select patients
minimal invasive posterior transforaminal lumbar interbody fu- for lumbar spinal fusion. Acta Orthop Suppl. 2013;84(349):1-35.
sion: a clinical and radiographic follow-up. J Spinal Disord Tech. 47. Yan DL, Pei FX, Li J, Soo CL. Comparative study of PILF and
2011;24(5):288-96. TLIF treatment in adult degenerative spondylolisthesis. Eur
40. Rousseau MA, Lazennec JY, Bass EC, Saillant G. Predictors of Spine J. 2008;17(10):1311-6.
outcomes after posterior decompression and fusion in degenera- 48. Zhao Y, Wang YP, Qiu GX, Zhao H, Zhang JG, Zhou X. Ef-
tive spondylolisthesis. Eur Spine J. 2005;14(1):55-60. ficacy of the Dynamic Interspinous Assisted Motion system in
41. Schnee CL, Freese A, Ansell LV. Outcome analysis for adults clinical treatment of degenerative lumbar disease. Chin Med J.
with spondylolisthesis treated with posterolateral fusion and 2010;123(21):2974-7.
transpedicular screw fixation. J Neurosurg. 1997;86(1):56-63.

What is the effect of postsurgical rehabilitation
including exercise, spinal mobilization/
manipulation or psychosocial interventions on
outcomes in the management of degenerative
lumbar spondylolisthesis (compared to
patients who do not undergo postsurgical
rehabilitation)?
There was no evidence found to address this question. Due to the paucity
of evidence, a recommendation cannot be made regarding the effect of
postsurgical rehabilitation the outcomes of patients undergoing surgical
treatment for degenerative lumbar spondylolisthesis.
Future Directions For Research 12. Gilbert JW, Wheeler GR, Kreft MP, et al. Repeat upright posi-
The work group recommends the undertaking of observational tional magnetic resonance imaging for diagnosis of disorders
underlying chronic noncancer lumbar pain. J Manipulative
studies to evaluate the effect of various postsurgical rehabilita-
Physiol Ther. 2008;31(8):627-31.
tion strategies on patients with degenerative lumbar spondylo- 13. Grob D. Surgery for degenerative lumbar disease: transforami-
listhesis. nal lumbar interbody fusion. Eur Spine J. 2009;18(12):1991-2.
14. Ibrahimi DM, Beaty NB, Crandall KM, Hamilton DK, Sansur C.
Bibliography A. A review of lumbar spondylolisthesis. Eur Musculoskel Rev.
1. Abbott AD, Tyni-lenné R, Hedlund R. Early rehabilitation 2011;6(2):110-113.
targeting cognition, behavior, and motor function after lumbar 15. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari-
fusion: a randomized controlled trial. Spine. 2010;35(8):848-57. son of surgical and conservative treatment for degenerative
2. Aliabadi H, Isaacs R. Lumbar spinal stenosis: A brief review. lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5.
Neurosurg Quart. 2009;19(3):200-206. 16. Majid K, Fischgrund JS. Degenerative lumbar spondylo-
3. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2):133-137. listhesis: trends in management. J Am Acad Orthop Surg.
4. Cavuşoğlu H, Türkmenoğlu O, Kaya RA, et al. Efficacy of 2008;16(4):208-15.
unilateral laminectomy for bilateral decompression in lumbar 17. Monticone M, Giovanazzi E. Usefulness of a cognitive be-
spinal stenosis. Turk Neurosurg. 2007;17(2):100-8. havioural and rehabilitative approach to enhance long lasting
5. Chad DA. Lumbar spinal stenosis. Neurol Clin. 2007;25(2):407- benefit after lumbar spinal stenosis and degenerative spon-
18. dylolisthesis surgery. A case report. Eur J Phys Rehabil Med.
6. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, 2008;44(4):467-71.
Loeser JD. Surgery for low back pain: a review of the evidence 18. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect
for an American Pain Society Clinical Practice Guideline. Spine. outcomes of treatment for lumbar stenosis and degenerative
2009;34(10):1094-109. spondylolisthesis? Analysis of the Spine Patient Outcomes
7. Cloyd JM, Acosta FL, Ames CP. Complications and outcomes Research Trial (SPORT). Spine. 2012;37(23):1933-46.
of lumbar spine surgery in elderly people: a review of the litera- 19. Templin CR, Garfin SR. (2007). Surgical Management of Sco-
ture. J Am Geriatr Soc. 2008;56(7):1318-27. liosis and/or Spondylolisthesis Associated with Spinal Stenosis.
8. Dai F, Belfer I, Schwartz CE, et al. Association of catechol-O- Seminars in Spine Surgery, 19(3), 187-199.
methyltransferase genetic variants with outcome in patients 20. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non-
undergoing surgical treatment for lumbar degenerative disc surgical treatment for lumbar degenerative spondylolisthesis. N
disease. Spine J. 2010;10(11):949-57. Engl J Med. 2007;356(22):2257-70.
9. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec- 21. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared
tive randomised study on the long-term effect of lumbar fusion with nonoperative treatment for lumbar degenerative spon-
on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86. dylolisthesis. four-year results in the Spine Patient Outcomes
10. Eliyas JK, Karahalios D. Surgery for degenerative lumbar spine Research Trial (SPORT) randomized and observational cohorts.
disease. Dis Mon. 2011;57(10):592-606. J Bone Joint Surg Am. 2009;91(6):1295-304.
11. Faldini C, Pagkrati S, Acri F, Miscione MT, Francesconi D, 22. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz
Giannini S. Surgical treatment of symptomatic degenerative TE. The utility of repeated postoperative radiographs after lum-
lumbar spondylolisthesis by decompression and instrumented bar instrumented fusion for degenerative lumbar spine. Spine.
fusion. J Orthop Traumatol. 2007;8(3):128-133. 2011;36(23):1955-60.
E. Value of Spine Care

What is the cost-effectiveness of the
surgical treatment of degenerative lumbar
spondylolisthesis compared to medical/
interventional treatment (consider with and
without fusion separately)?
There was no evidence found to address this question. Due to the paucity
of evidence, a recommendation cannot be made regarding the cost-
effectiveness of surgical treatment compared to medical/interventional
treatment for the management of patients with degenerative lumbar
spondylolisthesis.
Future Directions For Research 9. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective

The work group recommends the undertaking of cost-analysis randomized study of unilateral versus bilateral instrumented pos-
terolateral lumbar fusion in degenerative spondylolisthesis. Spine.
studies evaluating the long term cost-effectiveness of surgical
2007;32(4):395-401.
treatments versus medical/interventional treatment in patients 10. Kalanithi PS, Patil CG, Boakye M. National complication rates
undergoing treatment for degenerative lumbar spondylolisthe- and disposition after posterior lumbar fusion for acquired spon-
sis. dylolisthesis. Spine. 2009;34(18):1963-9.
11. Katz JN, Lipson SJ, Lew RA, et al. Lumbar laminectomy alone or
Bibliography with instrumented or noninstrumented arthrodesis in degenera-
1. Adogwa O, Parker SL, Bydon A, Cheng J, Mcgirt MJ. Compara- tive lumbar spinal stenosis. Patient selection, costs, and surgical
tive effectiveness of minimally invasive versus open transforami- outcomes. Spine (Phila Pa 1976). 1997;22(10):1123-1131.
nal lumbar interbody fusion: 2-year assessment of narcotic use, 12. Kim S, Mortaz hedjri S, Coyte PC, Rampersaud YR. Cost-utility
return to work, disability, and quality of life. J Spinal Disord Tech. of lumbar decompression with or without fusion for patients
2011;24(8):479-84. with symptomatic degenerative lumbar spondylolisthesis. Spine J.
2. Adogwa O, Parker SL, Davis BJ, et al. Cost-effectiveness of 2012;12(1):44-54.
transforaminal lumbar interbody fusion for Grade I degenerative 13. Kuntz KM, Snider RK, Weinstein JN, Pope MH, Katz JN. Cost-
spondylolisthesis. J Neurosurg Spine. 2011;15(2):138-43. effectiveness of fusion with and without instrumentation for
3. Alfieri A, Gazzeri R, Prell J, et al. Role of lumbar interspinous dis- patients with degenerative spondylolisthesis and spinal stenosis.
traction on the neural elements. Neurosurg Rev. 2012;35(4):477- Spine. 2000;25(9):1132-9.
84. 14. Maus T. Imaging the back pain patient. Phys Med Rehabil Clin N
4. Alt V, Chhabra A, Franke J, Cuche M, Schnettler R, Le huec JC. Am. 2010;21(4):725-66.
An economic analysis of using rhBMP-2 for lumbar fusion in 15. Molinari RW, Hunter JG, Mcassey RW. In-hospital postopera-
Germany, France and UK from a societal perspective. Eur Spine J. tive radiographs for instrumented single-level degenerative
2009;18(6):800-6. spinal fusions: utility after intraoperative fluoroscopy. Spine J.
5. Asghar FA, Hilibrand AS. The impact of the Spine Patient Out- 2012;12(7):559-67.
comes Research Trial (SPORT) results on orthopaedic practice. J 16. Osman SG. Endoscopic transforaminal decompression, inter-
Am Acad Orthop Surg. 2012;20(3):160-6. body fusion, and percutaneous pedicle screw implantation of the
6. Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, Mcisaac WJ, lumbar spine: A case series report. Int J Spine Surg. 2012;6(1):157-
Wright JG. Who’s in the driver’s seat? The influence of patient 166.
and physician enthusiasm on regional variation in degenera- 17. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost-
tive lumbar spinal surgery: a population-based study. Spine. effectiveness of minimally invasive versus open transforaminal
2011;36(6):481-489. lumbar interbody fusion for degenerative spondylolisthesis as-
7. Carreon LY, Djurasovic M, Canan CE, Burke LO, Glassman SD. sociated low-back and leg pain over two years. World Neurosurg.
SF-6D values stratified by specific diagnostic indication. Spine. 2012;78(1-2):178-84.
2012;37(13):E804-8. 18. Parker SL, Mcgirt MJ. Determination of the minimum improve-
8. Chu G, Aikenmu K, He ZS. Unilateral versus bilateral instrument- ment in pain, disability, and health state associated with cost-
ed posterolateral lumbar fusion in degenerative spondylolisthesis: effectiveness: introduction of the concept of minimum cost-effec-
A randomized controlled trial. J Clin Rehabil Tissue Eng Res. tive difference. Neurosurgery. 2012;71(6):1149-55.
2011;15(35):6540-6545.
19. Pelton MA, Phillips FM, Singh K. A comparison of periopera- Christensen FB. Circumferential fusion is dominant over postero-
tive costs and outcomes in patients with and without workers’ lateral fusion in a long-term perspective: cost-utility evaluation
compensation claims treated with minimally invasive or open of a randomized controlled trial in severe, chronic low back pain.
transforaminal lumbar interbody fusion. Spine. 2012;37(22):1914- Spine. 2007;32(22):2405-14.
1919. 26. Soegaard R, Christensen FB. Health economic evaluation in lum-
20. Rampersaud R, Macwan K, Mahomed NN. Spinal Care in a bar spinal fusion: a systematic literature review anno 2005. Eur
Single-Payer System: The Canadian Example. Semin Spine Surg. Spine J. 2006;15(8):1165-1173.
2012;24(2):117-122. 27. Taylor JA, Bussières A. Diagnostic imaging for spinal disor-
21. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings ders in the elderly: a narrative review. Chiropr Man Therap.
MG. Cost-utility analysis of posterior minimally invasive fusion 2012;20(1):16.
compared with conventional open fusion for lumbar spondylolis- 28. Virk S, Sandhu HS, Khan SN. Cost effectiveness analysis of graft
thesis. SAS J. 2011;5(2):29-35. options in spinal fusion surgery using a Markov model. J Spinal
22. Robertson PA, Plank LD. Prospective cohort analysis of disabil- Disord Tech. 2012;25(7):E204-10.
ity reduction with lumbar spinal fusion surgery in community 29. Watters WC. If, when, and how to fuse when treating lumbar
practice. J Spinal Disord Tech. 2008;21(4):235-40. degenerative stenosis. Semin Spine Surg. 2011;23(4):218-221.
23. Savvidou C, Chatziioannou SN, Pilichou A, Pneumaticos SG. Ef- 30. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz TE.
ficacy and cost-effectiveness of cell saving blood autotransfusion The utility of repeated postoperative radiographs after lum-
in adult lumbar fusion. Transfus Med. 2009;19(4):202-6. bar instrumented fusion for degenerative lumbar spine. Spine.
24. Siewe J, Otto C, Knoell P, et al. Comparison of standard fusion 2011;36(23):1955-60.
with a “topping off ” system in lumbar spine surgery: a protocol 31. Zhou J, Wang B, Dong J, et al. Instrumented transforaminal
for a randomized controlled trial. BMC Musculoskelet Disord. lumbar interbody fusion with single cage for the treatment
2011;12:239. of degenerative lumbar disease. Arch Orthop Trauma Surg.
25. Soegaard R, Bünger CE, Christiansen T, Høy K, Eiskjaer SP, 2011;131(9):1239-45.

What is the cost-effectiveness of minimal access-
based surgical treatments of degenerative
lumbar spondylolisthesis compared to
traditional open surgical treatments?

the cost-effectiveness of minimal access-based surgical treatments
compared to traditional open surgical treatments for degenerative lumbar
spondylolisthesis.
In a retrospective cost-effectiveness comparative study of pa- lated by the difference in the mean total costs between cohorts,
tients undergoing surgical treatment for Grade 1 degenerative divided by the difference in mean QALYs. The analysis indicat-
spondylolisthesis, Parker et al1 assessed the cost and cost util- ed that the MIS-TLIF versus the open-TLIF cohorts were similar
ity of minimally invasive transforaminal lumbar interbody fu- at baseline. Mean preoperative health state values significantly
sion (MIS-TLIF) vs open-TLIF. Fifteen patients received surgi- improved for both the MIS-TLIF and open-TLIF cohorts by two
cal treatment with MIS-TLIF and 15 other patients underwent years after surgery. The total mean QALYs gained for MIS-TLIF
open-TLIF. Independent investigators not involved in the pa- patients was 0.50 (95% CI, 0.37-0.63) and 0.41 (95% CI, 0.14-
tients’ care conducted phone interviews to assess preoperative 0.68) for open-TLIF patients. The total two year mean costs were
and 2-year postoperative pain, disability and quality of life. At 2 $35,996 for the MIS-TLIF treated patients and $44,727 for the
years postsurgery, information on duration of narcotic use and open-TLIF treated patients (p=0.18). Treatment groups were
time to return to work was collected via phone interview as part similar in use of oral steroids (33% MIS vs. 20% open, p=0.68)
of a standard of care protocol. Patient-assessed questionnaires but differed significantly in the mean duration of narcotics (MIS:
included Visual Analog Scale (VAS) for low back pain and leg 2.6 weeks vs. open: 6.5 weeks, p=0.008). MIS-TLIF patients had
pain, the Oswestry Disability Index (ODI), and EuroQuol-5D accelerated return to work times versus open-TLIF patients (8.3
(EQ-5D). QALY was used to measure the treatment effectiveness vs.16.3 weeks, p=0.02). During the 2-year study period, indirect
and the incremental cost-effectiveness ratio (ICER) was calcu- costs accounted for a substantial proportion of total costs in both
groups (32.8% of cost for MIS-TLIF patients and 41.2% of costs respectively. Compared with decompression alone, decompres-
for open-TLIF patients). When all costs were considered, MIS- sion plus instrumented fusion was associated with an improve-
TLIF versus open-TLIF was associated with a nonsignificant ment in quality of life at value of $185,878 per QALY. Because
trend of mean 2-year cost savings of $8,731 per patient while this study does not directly answer this comparative question,
providing similar QALYs gained (ICER). Two-year cost and util- the work group did not assign it a level of evidence. However, it
ity gained were similar for both techniques. The authors suggest does provide background information on the cost of open surgi-
that MIS-TLIF is a cost reducing surgical treatment for patients cal techniques and has been included for educational reference.
with Grade I degenerative lumbar spondylolisthesis. In critique, The authors suggest that for a specific subpopulation of degen-
this study may have been too small to show a difference. In ad- erative lumbar spondylolisthesis patients, decompression alone
dition, open surgery can be done with posterolateral fusion only and decompression and fusion are almost similar in clinical ef-
with similar results to TLIF, but for reduced cost, whereas MIS is fectiveness with a slight advantage for fusion.
more dependent on TLIF to accomplish goals of decompression
and fusion. This study provides Level III economic and decision Future Directions for Research
analysis evidence that there is no statistical difference in the cost The work group recommends the undertaking of cost-analysis
of MIS-TLIF compared to open-TLIF. studies evaluating the long term cost-effectiveness of minimally
In a follow-up analysis using the same 30 patients as above, invasive surgeries vs conventional surgery in patients with de-
Parker et al2 evaluated 100 patients undergoing TLIF for degen- generative lumbar spondylolisthesis. It is important to note that
erative lumbar spondylolisthesis were evaluated. Fifty patients MIS recommendations are complicated by the lack of a con-
underwent MIS-TLIF and the other 50 patients underwent sistent definition of what constitutes MIS; therefore, the work
open-TLIF. Preoperative, 3-month and 2-year postoperative group recommends that MIS is clearly and consistently defined
pain, disability and quality of life were assessed via phone in- in any future studies evaluating the role and cost-effectiveness of
terview by an independent investigator not involved in care. MIS surgical techniques.
Patient-assessed questionnaires included Visual Analog Scale
(VAS) for low back pain and leg pain, Oswestry Disability Index References
(ODI), Short-Form (SF)-12 health survey with mental (MCS) 1. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost-
and physical (PCS) component scores, Zung depression index effectiveness of minimally invasive versus open transforaminal
and EuroQol-5D (EQ-5D). Cost-effectiveness metrics evaluated lumbar interbody fusion for degenerative spondylolisthesis
included QALY, direct hospital costs, two year resource use and associated low-back and leg pain over two years. World Neuro-
direct costs, indirect costs and incremental cost-effectiveness surg. 2012;78(1-2):178-84.
ratio (ICER). Length of hospitalization and time to return to 2. Parker SL, Mendenhall SK, Shau DN, et al. Minimally Invasive
Versus Open Transforaminal Lumbar Interbody Fusion for
work were less for MIS-TLIF versus open TLIF (p=0.006 and
Degenerative Spondylolisthesis: Comparative Effectiveness and
p=0.03, respectively). MIS-TLIF versus open TLIF demonstrat- Cost-Utility Analysis. World Neurosurg. 2014;82(1-2):230-238.
ed similar improvement in patient-reported outcomes assessed. 3. Kim S, Mortaz hedjri S, Coyte PC, Rampersaud YR. Cost-utility
MIS-TLIF was associated with a reduced total 2-year cost versus of lumbar decompression with or without fusion for patients
open-TLIF, $38,563 versus $47,858 (p=0.03). MIS vs open TLIF with symptomatic degenerative lumbar spondylolisthesis. Spine
was associated with a reduction in mean hospital cost of $1758, J. 2012;12(1):44-54.
indirect cost of $8474, and total 2-year societal cost of $9295
(p=0.03) but similar 2-year direct health care cost and quality- Bibliography
adjusted life years gained. In critique, open surgery can be done 1. Adogwa O, Parker SL, Bydon A, Cheng J, Mcgirt MJ. Compara-
with posterolateral fusion only with similar results to TLIF, but tive effectiveness of minimally invasive versus open transfo-
for reduced cost, whereas MIS is more dependent on TLIF to raminal lumbar interbody fusion: 2-year assessment of narcotic
accomplish goals of decompression and fusion. This choice of use, return to work, disability, and quality of life. J Spinal Disord
Tech. 2011;24(8):479-84.
comparison could affect final analysis. This study provides Level
2. Adogwa O, Parker SL, Davis BJ, et al. Cost-effectiveness of
III economic and decision analysis evidence that MIS-TLIF ver- transforaminal lumbar interbody fusion for Grade I degenera-
sus open-TLIF was associated with reduced costs over 2 years tive spondylolisthesis. J Neurosurg Spine. 2011;15(2):138-43.
while providing equivalent improvement in clinical outcomes. 3. Alfieri A, Gazzeri R, Prell J, et al. Role of lumbar interspi-
Kim et al3 conducted a comparative cost-effectiveness study nous distraction on the neural elements. Neurosurg Rev.
to determine the relative cost-utility of decompression with and
2012;35(4):477-84.
without concomitant instrumented fusion for patients with de- 4. Alt V, Chhabra A, Franke J, Cuche M, Schnettler R, Le huec JC.
generative lumbar spondylolisthesis. All consecutive patients An economic analysis of using rhBMP-2 for lumbar fusion in
(n=150) with a primary diagnosis of degenerative lumbar spon- Germany, France and UK from a societal perspective. Eur Spine
J. 2009;18(6):800-6.
dylolisthesis were assessed. The primary outcome was the incre-
5. Asghar FA, Hilibrand AS. The impact of the Spine Patient Out-
mental cost/utility ratio (ICUR) expressed as the differential cost comes Research Trial (SPORT) results on orthopaedic practice. J
per relative gain in quality-adjusted life-year (QALY). A Markov Am Acad Orthop Surg. 2012;20(3):160-6
model with 10-year follow-up was also developed to compare 6. Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, Mcisaac
costs and outcomes of the two operative strategies. The cost- WJ, Wright JG. Who’s in the driver’s seat? The influence of
utility of decompression with fusion and decompression alone at patient and physician enthusiasm on regional variation in
10 years post-intervention was $3,281/QALY and $1,040/QALY, degenerative lumbar spinal surgery: a population-based study.
Spine. 2011;36(6):481-489.
7. Carreon LY, Djurasovic M, Canan CE, Burke LO, Glassman SD. 18. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings
SF-6D values stratified by specific diagnostic indication. Spine. MG. Cost-utility analysis of posterior minimally invasive fusion
2012;37(13):E804-8. compared with conventional open fusion for lumbar spondylo-
8. Chu G, Aikenmu K, He ZS. Unilateral versus bilateral instru- listhesis. SAS J. 2011;5(2):29-35.
mented posterolateral lumbar fusion in degenerative spondy- 19. Robertson PA, Plank LD. Prospective cohort analysis of disabil-
lolisthesis: A randomized controlled trial. J Clin Rehabil Tissue ity reduction with lumbar spinal fusion surgery in community
Eng Res. 2011;15(35):6540-6545. practice. J Spinal Disord Tech. 2008;21(4):235-40.
9. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective 20. Savvidou C, Chatziioannou SN, Pilichou A, Pneumaticos SG.
randomized study of unilateral versus bilateral instrumented Efficacy and cost-effectiveness of cell saving blood autotransfu-
posterolateral lumbar fusion in degenerative spondylolisthesis. sion in adult lumbar fusion. Transfus Med. 2009;19(4):202-6.
Spine. 2007;32(4):395-401. 21. Siewe J, Otto C, Knoell P, et al. Comparison of standard fusion
10. Kalanithi PS, Patil CG, Boakye M. National complication rates with a “topping off ” system in lumbar spine surgery: a protocol
and disposition after posterior lumbar fusion for acquired spon- for a randomized controlled trial. BMC Musculoskelet Disord.
dylolisthesis. Spine. 2009;34(18):1963-9 2011;12:239.
11. Kuntz KM, Snider RK, Weinstein JN, Pope MH, Katz JN. Cost- 22. Soegaard R, Bünger CE, Christiansen T, Høy K, Eiskjaer SP,
effectiveness of fusion with and without instrumentation for Christensen FB. Circumferential fusion is dominant over pos-
patients with degenerative spondylolisthesis and spinal stenosis. terolateral fusion in a long-term perspective: cost-utility evalua-
Spine. 2000;25(9):1132-9. tion of a randomized controlled trial in severe, chronic low back
12. Maus T. Imaging the Back Pain Patient. Phys Med Rehabil Clin pain. Spine. 2007;32(22):2405-14.
N Am. 2010;21(4):725-766. 23. Soegaard R, Christensen FB. Health economic evaluation in
13. Molinari RW, Hunter JG, Mcassey RW. In-hospital postopera- lumbar spinal fusion: A systematic literature review anno 2005.
tive radiographs for instrumented single-level degenerative Eur Spine J. 2006;15(8):1165-1173.
spinal fusions: utility after intraoperative fluoroscopy. Spine J. 24. Taylor JA, Bussières A. Diagnostic imaging for spinal disor-
2012;12(7):559-67. ders in the elderly: a narrative review. Chiropr Man Therap.
14. Osman SG. Endoscopic transforaminal decompression, 2012;20(1):16.
interbody fusion, and percutaneous pedicle screw implanta- 25. Virk S, Sandhu HS, Khan SN. Cost effectiveness analysis of graft
tion of the lumbar spine: A case series report. Int J Spine Surg. options in spinal fusion surgery using a Markov model. J Spinal
2012;6(1):157-166. Disord Tech. 2012;25(7):E204-10.
15. Parker SL, Mcgirt MJ. Determination of the minimum im- 26. Watters WC. If, when, and how to fuse when treating lumbar
provement in pain, disability, and health state associated with degenerative stenosis. Semin Spine Surg. 2011;23(4):218-221.
cost-effectiveness: introduction of the concept of minimum 27. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz
cost-effective difference. Neurosurgery. 2012;71(6):1149-55. TE. The utility of repeated postoperative radiographs after lum-
16. Pelton MA, Phillips FM, Singh K. A comparison of peri- bar instrumented fusion for degenerative lumbar spine. Spine.
operative costs and outcomes in patients with and without 2011;36(23):1955-60.
workers’ compensation claims treated with minimally inva- 28. Zhou J, Wang B, Dong J, et al. Instrumented transforaminal
sive or open transforaminal lumbar interbody fusion. Spine. lumbar interbody fusion with single cage for the treatment
2012;37(22):1914-1919. of degenerative lumbar disease. Arch Orthop Trauma Surg.
17. Rampersaud R, Macwan K, Mahomed NN. Spinal Care in a 2011;131(9):1239-45.
Single-Payer System: The Canadian Example. Semin Spine Surg.
2012;24(2):117-122.

VI. Appendices
Appendices
A. Acronyms
CI confidence interval
COS clinical outcome score
CT computed tomography
DCSA dural sac cross sectional area
DH disc height
EBM evidence-based medicine
EMG electromyelography
ESI epidural steroid injection
GROC Global Rating of Change
JOA Japanese Orthopaedic Association
LLA lumbar lordotic angles
LR likelihood ratio
MED Microendoscopic decompression
MR magnetic resonance
MRI magnetic resonance imaging
NASS North American Spine Society
NCOS Neurogenic Claudication Outcome Score
NSAIDs nonsteroidal anti-inflammatory drugs
ODI Oswestry Disability Index
PDS pain and disability score
PLIF Posterior lumbar interbody fusion
PLF Posterolateral fusion
PPV positive predictive value
QALY quality adjusted life years
QST quantitative sensory testing
RDQ Roland-Morris Disability Questionairre
RCT randomized controlled trial
SR sagittal rotation
ST sagittal translation
SLFE standing lateral flexion-extension radiograph
SLR straight leg raise
SEP somatosensory evoked potentials
SNRB selective nerve root block
TENS transcutaneous electrical nerve stimulation
VAS visual analog scale
Appendices
B. Levels of Evidence for Primary Research Question1
Types of Studies
Therapeutic Studies – Prognostic Studies – Diagnostic Studies – Economic and Decision
Investigating the results of Investigating the effect of Investigating a diagnostic Analyses –
treatment a patient characteristic on test Developing an economic or
the outcome of disease decision model
Level I • High quality • High quality • Testing of previously • Sensible costs and
randomized trial with prospective study4 (all developed diagnostic alternatives; values
statistically significant patients were enrolled criteria on consecutive obtained from many
difference or no at the same point in patients (with studies; with multiway
statistically significant their disease with universally applied sensitivity analyses
difference but narrow ≥ 80% follow-up of reference “gold” • Systematic review2 of
confidence intervals enrolled patients) standard) Level I studies
• Systematic review2 • Systematic review2 of • Systematic review2 of
of Level I RCTs (and Level I studies Level I studies
study results were
homogenous3)
Level II • Lesser quality RCT • Retrospective6 study • Development of • Sensible costs and
(eg, < 80% follow- • Untreated controls diagnostic criteria on alternatives; values
up, no blinding, from an RCT consecutive patients obtained from limited
or improper • Lesser quality (with universally studies; with multiway
randomization) prospective study applied reference sensitivity analyses
• Prospective4 (eg, patients enrolled “gold” standard) • Systematic review2 of
comparative study5 at different points in • Systematic review2 of Level II studies
• Systematic review2 their disease or <80% Level II studies
of Level II studies or follow-up)
Level 1 studies with • Systematic review2 of
inconsistent results Level II studies
Level III • Case control study7 Case control study7 • Study of non- • Analyses based on
• Retrospective6 consecutive patients; limited alternatives
comparative study5 without consistently and costs; and poor
• Systematic review2 of applied reference estimates
Level III studies “gold” standard • Systematic review2 of
• Systematic review2 of Level III studies
Level III studies
Level IV Case series8 Case series • Case-control study Analyses with no sensitivity
• Poor reference analyses
standard
Level V Expert Opinion Expert Opinion Expert Opinion Expert Opinion
1. A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
2. A combination of results from two or more prior studies.
3. Studies provided consistent results.
4. Study was started before the first patient enrolled.
5. Patients treated one way (eg, cemented hip arthroplasty) compared with a group of patients treated in another way (eg, unce-
mented hip arthroplasty) at the same institution.
6. The study was started after the first patient enrolled.
7. Patients identified for the study based on their outcome, called “cases” (eg, failed total arthroplasty) are compared to those
who did not have outcome, called “controls” (eg, successful total hip arthroplasty).
8. Patients treated one way with no comparison group of patients treated in another way.
C. Grades of Recommendations for Summaries or Reviews

of Studies
Appendices
A: Good evidence (Level I Studies with consistent finding) for or against recommending intervention.
B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.
C: Poor quality evidence (Level IV or V Studies) for or against recommending intervention.
I: Insufficient or conflicting evidence not allowing a recommendation for or against intervention.
D. Linking Levels of Evidence to Grades of

Recommendation
Appendices
Grade of Standard Language Levels of Evidence
Recommendation
A Recommended Two or more consistent Level I
studies
B Suggested One Level I study with additional Two or more consistent Level II
supporting Level II or III studies or III studies
C May be considered; is an option One Level I, II or III study with Two or more consistent Level IV
supporting Level IV studies studies
I (Insufficient Insufficient evidence to make A single Level I, II, III or IV More than one study with
or Conflicting recommendation for or against study without other supporting inconsistent findings*
Evidence) evidence
*Note that in the presence of multiple consistent studies, and a single outlying, inconsistent study, the Grade of Recommendation
will be based on the level of consistent studies.
E. Protocol for NASS Literature Searches

Appendices
One of the most crucial elements of evidence analysis to sup- 2. Search results with abstracts will be compiled by the medi-
port development of recommendations for appropriate clinical cal librarian in Endnote software. The medical librarian typically
care or use of new technologies is the comprehensive literature responds to requests and completes the searches within two
search. Thorough assessment of the literature is the basis for the to five business days. Results will be forwarded to the research
review of existing evidence, which will be instrumental to these staff, who will share it with the appropriate NASS staff member
activities. It is important that all searches conducted at NASS or requesting party(ies). (Research staff has access to EndNote
employ a solid search strategy, regardless of the source of the re- software and will maintain a database of search results for future
quest. To this end, this protocol has been developed and NASS- use/documentation.)
wide implementation is recommended.
3. NASS staff shares the search results with an appropriate con-
NASS research staff will work with the requesting parties and tent expert (NASS Committee member or other) to assess rel-
the NASS-contracted medical librarian to run a comprehensive evance of articles and identify appropriate articles to review.
search employing at a minimum the following search techniques:
4. NASS research staff will work with LoansomeDoc library to
1. A comprehensive search of the evidence will be conducted obtain requested full-text articles for review.
using the following clearly defined search parameters (as deter-
mined by the content experts). The following parameters are to 5. NASS members reviewing full-text articles should also review
be provided to research staff to facilitate this search. the references at the end of each article to identify additional
articles which should be reviewed, but may have been missed in
• Time frames for search the search.
• Foreign and/or English language
• Order of results (chronological, by journal, etc.) Following this protocol will help ensure that NASS recommen-
• Key search terms and connectors, with or without MeSH dations are (1) based on a thorough review of relevant literature;
terms to be employed (2) are truly based on a uniform, comprehensive search strategy;
• Age range and (3) represent the current best research evidence available.
• Answers to the following questions: Research staff will maintain a search history in EndNote for fu-
o Should duplicates be eliminated between searches? ture use or reference.
o Should searches be separated by term or as one large pack-
age?
o Should human studies, animal studies or cadaver studies
be included?
This search will encompass, at minimum, a search of Medline/

PubMed, EMBASE, and Cochrane Library. Additional databas-
es may be searched depending upon the topic.
VII. Bibliography
(All citations from 2008 and 2013 literature searches)
1. Abbott AD, Tyni-lenné R, Hedlund R. Early rehabilitation 18. Andersen T, Christensen FB, Høy KW, et al. The predictive
targeting cognition, behavior, and motor function after lumbar value of pain drawings in lumbar spinal fusion surgery. Spine J.
fusion: a randomized controlled trial. Spine. 2010;35(8):848-57. 2010;10(5):372-9.
2. Abdul QR, Qayum MS, Saradhi MV, Panigrahi MK, Sreedhar 19. Anderson PA, Tribus CB, Kitchel SH. Treatment of neurogenic
V. Clinico-radiological profile of indirect neural decompres- claudication by interspinous decompression: application of the
sion using cage or auto graft as interbody construct in posterior X STOP device in patients with lumbar degenerative spondylo-
lumbar interbody fusion in spondylolisthesis: Which is better?. J listhesis. J Neurosurg Spine. 2006;4(6):463-71.
Craniovertebr Junction Spine. 2011;2(1):12-6. 20. Aoki Y, Yamagata M, Nakajima F, Ikeda Y, Takahashi K. Poste-
3. Acosta FL Jr, Christensen FB, Coe JD, et al. Early Clinical & rior migration of fusion cages in degenerative lumbar disease
Radiographic Results of NFix II Posterior Dynamic Stabilization treated with transforaminal lumbar interbody fusion: a report of
System. SAS J. 2008;2(2):69-75. three patients. Spine. 2009;34(1):E54-8.
4. Acosta FL, Thompson TL, Campbell S, Weinstein PR, Ames 21. Aono H, Iwasaki M, Ohwada T, et al. Surgical outcome of
CP. Use of intraoperative isocentric C-arm 3D fluoroscopy for drop foot caused by degenerative lumbar diseases. Spine.
sextant percutaneous pedicle screw placement: case report and 2007;32(8):E262-6.
review of the literature. Spine J. 2005;5(3):339-43. 22. Apel DM, Lorenz MA, Zindrick MR. Symptomatic spondylolis-
5. Adachi K, Futami T, Ebihara A, et al. Spinal canal enlargement thesis in adults: four decades later. Spine. 1989;14(3):345-8.
Bibliography
procedure by restorative laminoplasty for the treatment of lum- 23. Aryan HE, Newman CB, Gold JJ, Acosta FL, Coover C, Ames
bar canal stenosis. Spine J. 2003;3(6):471-8. CP. Percutaneous axial lumbar interbody fusion (AxiaLIF) of
6. Adogwa O, Parker SL, Bydon A, Cheng J, McGirt MJ. Compara- the L5-S1 segment: initial clinical and radiographic experience.
tive effectiveness of minimally invasive versus open transfo- Minim Invasive Neurosurg. 2008;51(4):225-30.
raminal lumbar interbody fusion: 2-year assessment of narcotic 24. Asazuma T, Masuoka K, Motosuneya T, Tsuji T, Yasuoka H,
use, return to work, disability, and quality of life. J Spinal Disord Fujikawa K. Posterior lumbar interbody fusion using dense
Tech. 2011;24(8):479-484. hydroxyapatite blocks and autogenous iliac bone: clinical and
7. Adogwa O, Parker SL, Davis BJ, et al. Cost-effectiveness of radiographic examinations. J Spinal Disord Tech. 2005;18
transforaminal lumbar interbody fusion for Grade I degenera- Suppl:S41-7.
tive spondylolisthesis. J Neurosurg Spine. 2011;15(2):138-43. 25. Asghar FA, Hilibrand AS. The impact of the Spine Patient Out-
8. Agabegi SS, Majid K, Fischgrund JS, Vaccaro AR, Patel T. Can comes Research Trial (SPORT) results on orthopaedic practice.
preoperative radiographic parameters be used to predict fusion J Am Acad Orthop Surg. 2012;20(3):160-6.
in non-instrumented posterolateral fusion for degenerative 26. Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical
spondylolisthesis?. Spine. 2011;36(26):E1709-14. treatment. Clin Orthop Relat Res. 2006;443:198-207.
9. Aihara T, Toyone T, Aoki Y, et al. Surgical management of 27. Austin RC, Branch CL, Alexander JT. Novel bioabsorbable
degenerative lumbar spondylolisthesis. J Musculoskel Res. interbody fusion spacer-assisted fusion for correction of spinal
2012;15(4). deformity. Neurosurg Focus. 2003;14(1):e11.
10. Aiki H, Ohwada O, Kobayashi H, et al. Adjacent segment steno- 28. Axelsson P, Johnsson R, Strömqvist B. Is there increased inter-
sis after lumbar fusion requiring second operation. J Orthop Sci. vertebral mobility in isthmic adult spondylolisthesis? A matched
2005;10(5):490-5. comparative study using roentgen stereophotogrammetry.
11. Albert TJ, Desai D, Mcintosh T, Lamb D, Balderston RA. Spine. 2000;25(13):1701-3.
Early versus late replacement of autotransfused blood in elec- 29. Azzazi A, Elhawary Y. Dynamic stabilization using X-stop
tive spinal surgery. A prospective randomized study. Spine. versus transpedicular screw fixation in the treatment of lumbar
1993;18(8):1071-8. canal stenosis: comparative study of the clinical outcome. Neu-
12. Alexander DI, Manson NA, Mitchell MJ. Efficacy of calcium rosurg Quart., 2010;20(3):165-169.
sulfate plus decompression bone in lumbar and lumbosacral 30. Bae JS, Lee SH, Kim JS, Jung B, Choi G. Adjacent segment
spinal fusion: preliminary results in 40 patients. Can J Surg. degeneration after lumbar interbody fusion with percutane-
2001;44(4):262-6. ous pedicle screw fixation for adult low-grade isthmic spon-
13. Alexander E, Kelly DL, Davis CH, Mcwhorter JM, Brown W. dylolisthesis: minimum 3 years of follow-up. Neurosurgery.
Intact arch spondylolisthesis. A review of 50 cases and descrip- 2010;67(6):1600-7.
tion of surgical treatment. J Neurosurg. 1985;63(6):840-4. 31. Bagaria V. Re: Vaccaro AR, Patel T, Fischgrund J, et al. A pilot
14. Alfieri A, Gazzeri R, Prell J, et al. Role of lumbar interspi- study evaluating safety and efficacy of OP-1 putty (rhBMP-7)
nous distraction on the neural elements. Neurosurg Rev. as a replacement for iliac crest autograft in posterolateral
2012;35(4):477-84. lumbar arthrodesis for degenerative spondylolisthesis. Spine
15. Aliabadi H, Isaacs R. Lumbar spinal stenosis: A brief review. 2004;29:1885-92. Spine. 2006;31(7):851.
Neurosurg Quart. 2009;19(3):200-206. 32. Bagheri MH, Hosseini MM, Foroughi AA. Pseudolisthesis
16. Allen RT, Rihn JA, Glassman SD, Currier B, Albert TJ, Phillips secondary to small L5. Eur J Radiol. 2011;80(3):802-4.
FM. An evidence-based approach to spine surgery. Am J Med 33. Baker AD, Sanderson P. Spinal surgery in older people:
Qual. 2009;24(6 Suppl):15S-24S. Indications, techniques and outcomes. Rev Clin Geront.
17. Alt V, Chhabra A, Franke J, Cuche M, Schnettler R, Le huec JC. 2011;21(4):277-285.
An economic analysis of using rhBMP-2 for lumbar fusion in 34. Barbagallo GM, Olindo G, Corbino L, Albanese V. Analysis of
Germany, France and UK from a societal perspective. Eur Spine complications in patients treated with the X-Stop Interspinous
J. 2009;18(6):800-6. Process Decompression System: proposal for a novel anatomic
scoring system for patient selection and review of the literature. synthesis. Orthop Traumatol Surg Res. 2011;97(6):595-601.
Neurosurgery. 2009;65(1):111-19. 54. Blumenthal C, Curran J, Benzel EC, et al. Radiographic predic-
35. Barrey C, Jund J, Perrin G, Roussouly P. Spinopelvic alignment tors of delayed instability following decompression without
of patients with degenerative spondylolisthesis. Neurosurgery. fusion for degenerative grade I lumbar spondylolisthesis. J
2007;61(5):981-6. Neurosurg Spine. 2013;18(4):340-6.
36. Bartynski WS, Petropoulou KA. The MR imaging features and 55. Blumenthal SL, Ohnmeiss DD. Intervertebral cages for degen-
clinical correlates in low back pain-related syndromes. Magn erative spinal diseases. Spine J. 2003;3(4):301-9.
Reson Imaging Clin N Am. 2007;15(2):137-54, v. 56. Boden SD. Spinescope. Semin Spine Surg. 2011;23(2):151-156.
37. Bashir el F, Ajani O. Management of lumbar spine juxtafacet 57. Boden SD. Spinescope. Semin Spine Surg. 2012;24(2):133-137.
cysts. World Neurosurg. 2012;77(1):141-6. 58. Boden SD, Riew KD, Yamaguchi K, Branch TP, Schellinger
38. Bassewitz H, Herkowitz H. Lumbar stenosis with spondylolis- D, Wiesel SW. Orientation of the lumbar facet joints: associa-
thesis: current concepts of surgical treatment. Clin Orthop Relat tion with degenerative disc disease. J Bone Joint Surg Am.
Res. 2001;(384):54-60. 1996;78(3):403-11.
39. Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, Mcisaac 59. Bolesta MJ, Bohlman HH. Degenerative spondylolisthesis.
WJ, Wright JG. Who’s in the driver’s seat? The influence of Instruct Course Lect. 1989;38:157-165.
patient and physician enthusiasm on regional variation in 60. Bolesta MJ, Winslow L, Gill K. A comparison of film and
degenerative lumbar spinal surgery: a population-based study. computer workstation measurements of degenerative spondy-
Spine. 2011;36(6):481-489. lolisthesis: intraobserver and interobserver reliability. Spine.
40. Bednar DA. Surgical management of lumbar degenerative spinal 2010;35(13):1300-3.
stenosis with spondylolisthesis via posterior reduction with 61. Bono CM, Kadaba M, Vaccaro AR. Posterior pedicle fixation-
minimal laminectomy. J Spinal Disord Tech. 2002;15(2):105-9. based dynamic stabilization devices for the treatment of
41. Been E, Li L, Hunter DJ, Kalichman L. Geometry of the ver- degenerative diseases of the lumbar spine. J Spinal Disord Tech.
Bibliography
tebral bodies and the intervertebral discs in lumbar segments 2009;22(5):376-83.

adjacent to spondylolysis and spondylolisthesis: pilot study. Eur 62. Bono CM, Lee CK. The influence of subdiagnosis on radio-
Spine J. 2011;20(7):1159-65. graphic and clinical outcomes after lumbar fusion for degen-
42. Belfi LM, Ortiz AO, Katz DS. Computed tomography evaluation erative disc disorders: an analysis of the literature from two
of spondylolysis and spondylolisthesis in asymptomatic patients. decades. Spine. 2005;30(2):227-34.
Spine. 2006;31(24):E907-10. 63. Booth KC, Bridwell KH, Eisenberg BA, Baldus CR, Lenke LG.
43. Bendo JA, Ong B. Importance of correlating static and dynamic Minimum 5-year results of degenerative spondylolisthesis
imaging studies in diagnosing degenerative lumbar spondylolis- treated with decompression and instrumented posterior fusion.
thesis. Am J Orthop. 2001;30(3):247-50. Spine. 1999;24(16):1721-7.
44. Ben-galim P, Reitman CA. The distended facet sign: an indicator 64. Bose B. Fracture of S1-2 after L4-S1 decompression and fusion.
of position-dependent spinal stenosis and degenerative spondy- Case report and review of the literature. J Neurosurg. 2003;99(3
lolisthesis. Spine J. 2007;7(2):245-8. Suppl):310-2.
45. Benini A, Plötz G. Reduction and stabilization without laminec- 65. Bourassa-moreau E, Mac-thiong JM, Labelle H. Redefining the
tomy for unstable degenerative spondylolisthesis: a preliminary technique for the radiologic measurement of slip in spondylolis-
report. Neurosurgery. 1995;37(4):843-4. thesis. Spine. 2010;35(14):1401-5.
46. Benoist M. The natural history of lumbar degenerative spinal 66. Brantigan JW, Neidre A. Achievement of normal sagit-
stenosis. Joint Bone Spine. 2002;69(5):450-7. tal plane alignment using a wedged carbon fiber reinforced
47. Berlemann U, Jeszenszky DJ, Bühler DW, Harms J. Facet joint polymer fusion cage in treatment of spondylolisthesis. Spine J.
remodeling in degenerative spondylolisthesis: an investigation 2003;3(3):186-96.
of joint orientation and tropism. Eur Spine J. 1998;7(5):376-80. 67. Bridwell KH, Sedgewick TA, O’brien MF, Lenke LG, Baldus
48. Berlemann U, Jeszenszky DJ, Bühler DW, Harms J. Mechanisms C. The role of fusion and instrumentation in the treatment of
of retrolisthesis in the lower lumbar spine. A radiographic study. degenerative spondylolisthesis with spinal stenosis. J Spinal
Acta Orthop Belg. 1999;65(4):472-7. Disord. 1993;6(6):461-72.
49. Berlemann U, Jeszenszky DJ, Bühler DW, Harms J. The role of 68. Brislin B, Vaccaro AR. Advances in posterior lumbar interbody
lumbar lordosis, vertebral end-plate inclination, disc height, fusion. Orthop Clin North Am. 2002;33(2):367-74.
and facet orientation in degenerative spondylolisthesis. J Spinal 69. Brotis AG, Paterakis KN, Tsiamalou PM, Fountas KN, Hahji-
Disord. 1999;12(1):68-73. georgiou GM, Karavelis A. Instrumented posterior lumbar
50. Berven S, Tay BB, Colman W, Hu SS. The lumbar zygapophy- fusion outcomes for lumbar degenerative disorders in a
seal (facet) joints: a role in the pathogenesis of spinal pain southern European, semirural population. J Spinal Disord Tech.
syndromes and degenerative spondylolisthesis. Semin Neurol. 2010;23(7):444-50.
2002;22(2):187-96. 70. Brower RS, Vickroy NM. A case of psoas ossification from
51. Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, the use of BMP-2 for posterolateral fusion at L4-L5. Spine.
Grant WD, Baker D. The natural history of spondylolysis 2008;33(18):E653-5.
and spondylolisthesis: 45-year follow-up evaluation. Spine. 71. Brown, MD, Lockwood, JM. Degenerative spondylolisthesis.
2003;28(10):1027-35. Instruct Course Lect. 1983;32:162-169.
52. Bjarke christensen F, Stender hansen E, Laursen M, Thomsen 72. Brown MD, Wehman KF, Heiner AD. The clinical useful-
K, Bünger CE. Long-term functional outcome of pedicle screw ness of intraoperative spinal stiffness measurements. Spine.
instrumentation as a support for posterolateral spinal fusion: 2002;27(9):959-61.
randomized clinical study with a 5-year follow-up. Spine. 73. Burkus JK, Dryer RF, Peloza JH. Retrograde ejaculation fol-
2002;27(12):1269-77. lowing single-level anterior lumbar surgery with or without
53. Blondel B, Adetchessi T, Pech-gourg G, Métellus P, Dufour H, recombinant human bone morphogenetic protein-2 in 5
Fuentes S. Minimally invasive transforaminal lumbar interbody randomized controlled trials: clinical article. J Neurosurg Spine.
fusion through a unilateral approach and percutaneous osteo- 2013;18(2):112-21.
74. Burkus JK, Gornet MF, Schuler TC, Kleeman TJ, Zdeblick TA. women with low back pain. Spine. 2009;34(13):1402-9.
Six-year outcomes of anterior lumbar interbody arthrodesis 94. Chen KX, Yang QY, Liu XC, Li HJ. [Treatment of degenerative
with use of interbody fusion cages and recombinant hu- lumbar spondylolisthesis through posterolateral fusion and fixa-
man bone morphogenetic protein-2. J Bone Joint Surg Am. tion with pedicle screws]. Zhongguo Gu Shang. 2010;23(4):254-
2009;91(5):1181-9. 6. http://onlinelibrary.wiley.com/o/cochrane/clcentral/ar-
75. Burkus JK, Sandhu HS, Gornet MF. Influence of rhBMP-2 on ticles/900/CN-00766900/frame.html
the healing patterns associated with allograft interbody con- 95. Cho BY, Murovic JA, Park J. Imaging correlation of the degree
structs in comparison with autograft. Spine. 2006;31:775-81. of degenerative L4-5 spondylolisthesis with the corresponding
76. Buttermann GR, Garvey TA, Hunt AF, et al. Lumbar fusion amount of facet fluid. J Neurosurg Spine. 2009;11(5):614-9.
results related to diagnosis. Spine. 1998;23(1):116-27. 96. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO,
77. Cansever T, Civelek E, Kabatas S, Yılmaz C, Caner H, Altinörs Loeser JD. Surgery for low back pain: a review of the evidence
MN. Dysfunctional segmental motion treated with dynamic for an American Pain Society Clinical Practice Guideline. Spine.
stabilization in the lumbar spine. World Neurosurg. 2011;75(5- 2009;34(10):1094-109.
6):743-9. 97. Chu G, Aikenmu K, He ZS. Unilateral versus bilateral instru-
78. Cansever T, Civelek E, Sencer A, Karasu A, Turantan I. Inter- mented posterolateral lumbar fusion in degenerative spondy-
mittent priapism in degenerative lumbar spinal stenosis: case lolisthesis: A randomized controlled trial. J Clin Rehabil Tissue
report. Turk Neurosurg. 2007;17(4):260-3. Eng Res. 2011;15(35):6540-6545.
79. Carreon LY, Djurasovic M, Canan CE, Burke LO, Glassman SD. 98. Chung-Ting MW, Pak-Ho, AC, Cheung KK. A Prospective
SF-6D values stratified by specific diagnostic indication. Spine. Study on the Outcome of Degenerative Lumbar Spinal Stenosis
2012;37(13):E804-8. Treated With Open Laminotomy. J Orthop Trauma Rehabil.
80. Carreon LY, Glassman SD, Howard J. Fusion and nonsurgi- 2012;16(2):62-65.
cal treatment for symptomatic lumbar degenerative disease: a 99. Cinotti G, Postacchini F, Fassari F, Urso S. Predisposing factors
Bibliography
systematic review of Oswestry Disability Index and MOS Short in degenerative spondylolisthesis. A radiographic and CT study.
Form-36 outcomes. Spine J. 2008;8(5):747-55. Int Orthop. 1997;21(5):337-42.
81. Carreon LY, Puno RM, Dimar JR, Glassman SD, Johnson JR. 100. Clarke JA, Van tulder MW, Blomberg SE, et al. Traction for low-
Perioperative complications of posterior lumbar decompression back pain with or without sciatica. Cochrane Database Syst Rev.
and arthrodesis in older adults. J Bone Joint Surg Am. 2003;85- 2007;(2):CD003010.
A(11):2089-92. 101. Cloyd JM, Acosta FL, Ames CP. Complications and outcomes of
82. Carrino JA, Lurie JD, Tosteson AN, et al. Lumbar spine: reli- lumbar spine surgery in elderly people: a review of the literature.
ability of MR imaging findings. Radiology. 2009;250(1):161-70. J Am Geriatr Soc. 2008;56(7):1318-27.
83. Caserta S, La maida GA, Misaggi B, et al. Elastic stabilization 102. Coe JD, Kitchel SH, Meisel HJ, Wingo CH, Lee SE, Jahng
alone or combined with rigid fusion in spinal surgery: a biome- TA. NFlex Dynamic Stabilization System : Two-Year Clinical
chanical study and clinical experience based on 82 cases. Eur Outcomes of Multi-Center Study. J Korean Neurosurg Soc.
Spine J. 2002;11 Suppl 2:S192-7. 2012;51(6):343-9.
84. Caterini R, Mancini F, Bisicchia S, Maglione P, Farsetti P. The 103. Cole CD, Mccall TD, Schmidt MH, Dailey AT. Comparison of
correlation between exaggerated fluid in lumbar facet joints and low back fusion techniques: transforaminal lumbar interbody
degenerative spondylolisthesis: prospective study of 52 patients. fusion (TLIF) or posterior lumbar interbody fusion (PLIF) ap-
J Orthop Traumatol. 2011;12(2):87-91. proaches. Curr Rev Musculoskelet Med. 2009;2(2):118-26.
85. Cauchoix J, Benoist M, Chassaing V. Degenerative spondylolis- 104. Crawford CH, Smail J, Carreon LY, Glassman SD. Health-related
thesis. Clin Orthop Relat Res. 1976;115:122-129. quality of life after posterolateral lumbar arthrodesis in patients
86. Cavagna R, Daculsi G, Bouler JM. Macroporous calcium phos- seventy-five years of age and older. Spine. 2011;36(13):1065-8.
phate ceramic: a prospective study of 106 cases in lumbar spinal 105. Crawford NR, Cagli S, Sonntag VK, Dickman CA. Biomechan-
fusion. J Long Term Eff Med Implants. 1999;9(4):403-12. ics of grade I degenerative lumbar spondylolisthesis. Part 1: in
87. Cavuşoğlu H, Türkmenoğlu O, Kaya RA, et al. Efficacy of unilat- vitro model. J Neurosurg. 2001;94(1 Suppl):45-50.
eral laminectomy for bilateral decompression in lumbar spinal 106. Csécsei G, Klekner A, Sikula J. Posterior lumbar interbody
stenosis. Turk Neurosurg. 2007;17(2):100-8. fusion (PLIF) using the bony elements of the dorsal spinal seg-
88. Chad DA. Lumbar spinal stenosis. Neurol Clin. 2007;25(2):407- ment. Acta Chir Hung. 1997;36(1-4):54-6.
18. 107. Cummins J, Lurie JD, Tosteson TD, et al. Descriptive epidemi-
89. Chaloupka R, Krbec M, Cienciala J, et al. TWO YEAR CLINI- ology and prior healthcare utilization of patients in the Spine
CAL RESULTS OF 360 DEGREE FUSION OF LUMBAR Patient Outcomes Research Trial’s (SPORT) three observational
SPONDYLOLISTHESIS MANAGED BY TRANSPEDICULAR cohorts: disc herniation, spinal stenosis, and degenerative spon-
FIXATION AND PLIF OR ALIF TECHNIQUE. Eur Spine J. dylolisthesis. Spine. 2006;31(7):806-14.
2006;15(Suppl 4):S506-s507. 108. Cutler AR, Siddiqui S, Mohan AL, Hillard VH, Cerabona F,
90. Chang P, Seow KH, Tan SK. Comparison of the results of spinal Das K. Comparison of polyetheretherketone cages with femoral
fusion for spondylolisthesis in patients who are instrumented cortical bone allograft as a single-piece interbody spacer in
with patients who are not. Singapore Med J. 1993;34(6):511-4. transforaminal lumbar interbody fusion. J Neurosurg Spine.
91. Chaput C, Padon D, Rush J, Lenehan E, Rahm M. The signifi- 2006;5(6):534-9.
cance of increased fluid signal on magnetic resonance imaging 109. Dai F, Belfer I, Schwartz CE, et al. Association of catechol-O-
in lumbar facets in relationship to degenerative spondylolisthe- methyltransferase genetic variants with outcome in patients
sis. Spine. 2007;32(17):1883-7. undergoing surgical treatment for lumbar degenerative disc
92. Chaudhary KS, Groff MW. Minimally invasive transforaminal disease. Spine J. 2010;10(11):949-57.
lumbar interbody fusion for degenerative spine. Tech Orthop. 110. Dai LY. Orientation and tropism of lumbar facet joints in degen-
2011;26(3):146-155. erative spondylolisthesis. Int Orthop. 2001;25(1):40-2.
93. Chen IR, Wei TS. Disc height and lumbar index as independent 111. Dai LY, Jia LS, Yuan W, Ni B, Zhu HB. Direct repair of defect
predictors of degenerative spondylolisthesis in middle-aged in lumbar spondylolysis and mild isthmic spondylolisthesis by
bone grafting, with or without facet joint fusion. Eur Spine J. KR, Carreon LY. Changes in the Oswestry Disability Index that
2001;10(1):78-83. predict improvement after lumbar fusion. J Neurosurg Spine.
112. Dai LY, Jiang LS. Single-level instrumented posterolateral fusion 2012;17(5):486-90.
of lumbar spine with beta-tricalcium phosphate versus auto- 130. Don AS, Robertson PA. Facet joint orientation in spondy-
graft: a prospective, randomized study with 3-year follow-up. lolysis and isthmic spondylolisthesis. J Spinal Disord Tech.
Spine. 2008;33(12):1299-304. 2008;21(2):112-5.
113. Dall BE, Rowe DE. Degenerative spondylolisthesis. Its surgical 131. Dupuis PR, Yong-hing K, Cassidy JD, Kirkaldy-willis WH.
management. Spine. 1985;10(7):668-672. Radiologic diagnosis of degenerative lumbar spinal instability.
114. D’andrea G, Ferrante L, Dinia L, Caroli E, Orlando ER. “Supine- Spine. 1985;10(3):262-76.
prone” dynamic X-ray examination: new method to evaluate 132. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospec-
low-grade lumbar spondylolisthesis. J Spinal Disord Tech. tive randomised study on the long-term effect of lumbar fusion
2005;18(1):80-3. on adjacent disc degeneration. Eur Spine J. 2009;18(8):1175-86.
115. Dantas FL, Prandini MN, Ferreira MA. Comparison between 133. Elhawary Y, Azzazi A. Dynamic stabilization using X-stop vs.
posterior lumbar fusion with pedicle screws and posterior trans-pedicular screw fixation in the treatment of lumbar canal
lumbar interbody fusion with pedicle screws in adult spondylo- stenosis: Comparative study of the clinical outcome. Spine J.
listhesis. Arq Neuropsiquiatr. 2007;65(3B):764-70. 2010; 10(9 suppl. 1):S130.
116. De iure F, Bosco G, Cappuccio M, Paderni S, Amendola L. 134. Eliyas JK, Karahalios D. Surgery for Degenerative Lumbar Spine
Posterior lumbar fusion by peek rods in degenerative spine: pre- Disease. Dis Mon. 2011;57(10):592-606.
liminary report on 30 cases. Eur Spine J. 2012;21 Suppl 1:S50-4. 135. Elster AD, Jensen KM. Computed tomography of spondylo-
117. Dean CL, Gabriel JP, Cassinelli EH, Bolesta MJ, Bohlman HH. listhesis: patterns of associated pathology. J Comput Assist
Degenerative spondylolisthesis of the cervical spine: analysis of Tomogr. 1985;9(5):867-74.
58 patients treated with anterior cervical decompression and 136. Epstein JA, Epstein BS, Lavine LS, Carras R, Rosenthal AD. De-
Bibliography
fusion. Spine J. 2009;9(6):439-46. generative lumbar spondylolisthesis with an intact neural arch
118. Debusscher F, Troussel S. Direct repair of defects in lumbar (pseudospondylolisthesis). J Neurosurg. 1976;44(2):139-47.
spondylolysis with a new pedicle screw hook fixation: clinical, 137. Epstein JA, Epstein BS, Lavine LS, Rosenthal AD, Decker RE,
functional and Ct-assessed study. Eur Spine J. 2007;16(10):1650- Carras R. Obliterative arachnoiditis complicating lumbar spinal
8. stenosis. J Neurosurg. 1978;48(2):252-8.
119. Deinsberger R, Kinn E, Ungersböck K. Microsurgical treatment 138. Epstein NE. Evaluation of varied surgical approaches used in the
of juxta facet cysts of the lumbar spine. J Spinal Disord Tech. management of 170 far-lateral lumbar disc herniations: indica-
2006;19(3):155-60. tions and results. J Neurosurg. 1995;83(4):648-56.
120. Delawi D, Dhert WJ, Rillardon L, et al. A prospective, random- 139. Epstein NE. Primary fusion for the management of ‘unstable’
ized, controlled, multicenter study of osteogenic protein-1 in degenerative spondylolisthesis. Neuro Orthop. 1998;23(1-2):45-
instrumented posterolateral fusions: report on safety and feasi- 52.
bility. Spine. 2010;35(12):1185-91. 140. Epstein NE. Lumbar laminectomy for the resection of synovial
121. Desai A, Ball PA, Bekelis K, et al. Surgery for lumbar degen- cysts and coexisting lumbar spinal stenosis or degenerative
erative spondylolisthesis in Spine Patient Outcomes Research spondylolisthesis: an outcome study. Spine. 2004;29(9):1049-55.
Trial: does incidental durotomy affect outcome?. Spine. 141. Epstein NE. An analysis of noninstrumented posterolateral
2012;37(5):406-13. lumbar fusions performed in predominantly geriatric patients
122. Detwiler PW, Porter RW, Han PP, et al. Surgical treatment using lamina autograft and beta tricalcium phosphate. Spine J.
of lumbar spondylolisthesis. Adv Tech Stand Neurosurg. 2008;8(6):882-7.
2000;26:331-346. 142. Epstein NE. X-Stop: foot drop. Spine J. 2009;9(5):e6-9.
123. Dewald CJ, Vartabedian JE, Rodts MF, Hammerberg KW. 143. Epstein NE, Epstein JA, Carras R, Lavine LS. Degenerative spon-
Evaluation and management of high-grade spondylolisthesis in dylolisthesis with an intact neural arch: a review of 60 cases with
adults. Spine. 2005;30(6 Suppl):S49-59. an analysis of clinical findings and the development of surgical
124. Dhall SS, Wang MY, Mummaneni PV. Clinical and radiographic management. Neurosurgery. 1983;13(5):555-61.
comparison of mini-open transforaminal lumbar interbody 144. Escobar E, Transfeldt E, Garvey T, Ogilvie J, Graber J, Schultz
fusion with open transforaminal lumbar interbody fusion L. Video-assisted versus open anterior lumbar spine fusion
in 42 patients with long-term follow-up. J Neurosurg Spine. surgery: a comparison of four techniques and complications in
2008;9(6):560-5. 135 patients. Spine. 2003;28(7):729-32.
125. Di silvestre M, Lolli F, Bakaloudis G. Degenerative lumbar sco- 145. Eskander MS, Eskander JP, Drew JM, Pelow-aidlen JL, Eslami
liosis in elderly patients: dynamic stabilization without fusion MH, Connolly PJ. A modified technique for dowel fibular strut
versus posterior instrumented fusion. Spine J. 2014;14(1):1-10. graft placement and circumferential fusion in the setting of
126. Dimar JR II, Djurasovic M, Carreon LY. Surgical management L5-S1 spondylolisthesis and multilevel degenerative disc disease.
of degenerative and postsurgical spondylolisthesis. Semin Spine Neurosurgery. 2010;67(3 Suppl Operative):ons91-5.
Surg. 2005;17(3 SPEC. ISS.):186-194. 146. Etame AB, Wang AC, Than KD, Park P. Clinical and radiograph-
127. Dimar JR, Glassman SD, Burkus JK, Pryor PW, Hardacker JW, ic outcomes after minimally invasive transforaminal lumbar
Carreon LY. Clinical and radiographic analysis of an opti- interbody fusion. SAS J. 2010;4(2):47-53.
mized rhBMP-2 formulation as an autograft replacement in 147. Excoffon SG, Wallace H. Chiropractic and rehabilitative
posterolateral lumbar spine arthrodesis. J Bone Joint Surg Am. management of a patient with progressive lumbar disk injury,
2009;91(6):1377-86. spondylolisthesis, and spondyloptosis. J Manipulative Physiol
128. Disch AC, Schmoelz W, Matziolis G, Schneider SV, Knop C, Ther. 2006;29(1):66-71.
Putzier M. Higher risk of adjacent segment degeneration after 148. Faldini C, Pagkrati S, Acri F, et al. Surgical treatment of
floating fusions: long-term outcome after low lumbar spine fu- symptomatic degenerative lumbar spondylolisthesis by de-
sions. J Spinal Disord Tech. 2008;21(2):79-85. compression and instrumented fusion. J Orthop Traumatol.
129. Djurasovic M, Glassman SD, Dimar JR, Crawford CH, Bratcher 2007;8(3):128-133.
149. Fayyazi AH, Ordway NR, Park SA, Fredrickson BE, Yonemura myelopathy thirty years after cadaveric renal transplantation.
K, Yuan HA. Radiostereometric analysis of postoperative mo- Chiba Med J. 2011;87(1):11-15.
tion after application of dynesys dynamic posterior stabilization 167. Fujiya M, Saita M, Kaneda K, Abumi K. Clinical study on
system for treatment of degenerative spondylolisthesis. J Spinal stability of combined distraction and compression rod instru-
Disord Tech. 2010;23(4):236-41. mentation with posterolateral fusion for unstable degenerative
150. Feffer HL, Wiesel SW, Cuckler JM, Rothman RH. Degenerative spondylolisthesis. Spine. 1990;15(11):1216-22.
spondylolisthesis: To fuse or not to fuse. Spine. 1985;10(3):287- 168. Furlan AF, Yazdi F, Tsertsvadze A, et al. Acupuncture for (sub)
289. acute non-specific low-back pain. Cochrane Database Syst Rev.
151. Fernández-fairen M, Sala P, Ramírez H, Gil J. A prospective 2011;(8):CD009265.
randomized study of unilateral versus bilateral instrumented 169. Gaetani P, Aimar E, Panella L, et al. Functional disability after
posterolateral lumbar fusion in degenerative spondylolisthesis. instrumented stabilization in lumbar degenerative spondylolis-
Spine. 2007;32(4):395-401. thesis: a follow-up study. Funct Neurol. 2006;21(1):31-7.
152. Ferrari S, Costa F, Fornari M. Conservative treatment with 170. Gavaskar AS, Achimuthu R. Transfacetal fusion for low-grade
spontaneous stabilization of Grade II isthmic spondylolisthesis degenerative spondylolisthesis of the lumbar spine: results
L5/S1 in a forty-four-year old woman, with a six-year follow-up: of a prospective single center study. J Spinal Disord Tech.
a case report. Eur J Phys Rehabil Med. 2012;48(2):275-81. 2010;23(3):162-5.
153. Ferreiro perez A, Garcia isidro M, Ayerbe E, Castedo J, Jinkins 171. Gehrchen PM, Dahl B, Katonis P, Blyme P, Tøndevold E, Kiaer
JR. Evaluation of intervertebral disc herniation and hypermobile T. No difference in clinical outcome after posterolateral lumbar
intersegmental instability in symptomatic adult patients under- fusion between patients with isthmic spondylolisthesis and
going recumbent and upright MRI of the cervical or lumbosa- those with degenerative disc disease using pedicle screw instru-
cral spines. Eur J Radiol. 2007;62(3):444-8. mentation: a comparative study of 112 patients with 4 years of
154. Fersum KV, Dankaerts W, O’sullivan PB, et al. Integration of follow-up. Eur Spine J. 2002;11(5):423-7.
Bibliography
subclassification strategies in randomised controlled clinical 172. Gelalis ID, Arnaoutoglou C, Christoforou G, Lykissas MG,
trials evaluating manual therapy treatment and exercise therapy Batsilas I, Xenakis T. Prospective analysis of surgical outcomes
for non-specific chronic low back pain: a systematic review. Br J in patients undergoing decompressive laminectomy and pos-
Sports Med. 2010;44(14):1054-62. terior instrumentation for degenerative lumbar spinal stenosis.
155. Fischgrund JS. The argument for instrumented decompressive Acta Orthop Traumatol Turc. 2010;44(3):235-40.
posterolateral fusion for patients with degenerative spondylolis- 173. Gelalis ID, Kang JD. Thoracic and lumbar fusions for degenera-
thesis and spinal stenosis. Spine. 2004;29(2):173-4. tive disorders: rationale for selecting the appropriate fusion
156. Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgom- techniques. Orthop Clin North Am. 1998;29(4):829-42.
ery DM, Kurz LT. 1997 Volvo Award winner in clinical studies. 174. Gertzbein SD, Seligman J, Holtby R, et al. Centrode patterns
Degenerative lumbar spondylolisthesis with spinal stenosis: a and segmental instability in degenerative disc disease. Spine.
prospective, randomized study comparing decompressive lami- 1985;10(3):257-61.
nectomy and arthrodesis with and without spinal instrumenta- 175. Ghiselli G, Wang JC, Hsu WK, Dawson EG. L5-S1 segment
tion. Spine. 1997;22(24):2807-12. survivorship and clinical outcome analysis after L4-L5 isolated
157. Fitzgerald JA., Newman PH. Degenerative spondylolisthesis. J fusion. Spine. 2003;28(12):1275-80.
Bone Joint Surg Br. 1976;58(2):184-192. 176. Ghogawala Z, Benzel EC, Amin-Hanjani S, et al. Prospective
158. Flynn JC, Hoque MA. Anterior fusion of the lumbar spine. End- outcomes evaluation after decompression with or without in-
result study with long-term follow-up. J Bone Joint Surg Am. strumented fusion for lumbar stenosis and degenerative Grade I
1979;61(8):1143-50. spondylolisthesis. J Neurosurg Spine. 2004;1(3):267-272.
159. France JC, Yaszemski MJ, Lauerman WC, et al. A random- 177. Gibson JN, Waddell G. Surgery for degenerative lumbar spon-
ized prospective study of posterolateral lumbar fusion. Out- dylosis. Cochrane Database Syst Rev. 2005;(4):CD001352.
comes with and without pedicle screw instrumentation. Spine. 178. Gibson JN, Grant IC, Waddell G. The Cochrane review of
1999;24(6):553-60. surgery for lumbar disc prolapse and degenerative lumbar spon-
160. Fransen P. Increasing pedicle screw anchoring in the os- dylosis. Spine. 1999;24(17):1820-32.
teoporotic spine by cement injection through the implant. 179. Gibson JN, Waddell G, Grant IC. Surgery for degen-
Technical note and report of three cases. J Neurosurg Spine. erative lumbar spondylosis. Cochrane Database Syst Rev.
2007;7(3):366-9. 2000;(2):CD001352.
161. Fraser J, Gebhard H, Irie D, Parikh K, Härtl R. Iso-C/3-dimen- 180. Gibson JN, Waddell G. Surgery for degenerative lumbar spon-
sional neuronavigation versus conventional fluoroscopy for dylosis: updated Cochrane Review. Spine. 2005;30(20):2312-20.
minimally invasive pedicle screw placement in lumbar fusion. 181. Gilbert JW, Wheeler GR, Kreft MP, et al. Repeat upright posi-
Minim Invasive Neurosurg. 2010;53(4):184-90. tional magnetic resonance imaging for diagnosis of disorders
162. Frazier DD, Lipson SJ, Fossel AH, Katz JN. Associations be- underlying chronic noncancer lumbar pain. J Manipulative
tween spinal deformity and outcomes after decompression for Physiol Ther. 2008;31(8):627-31.
spinal stenosis. Spine. 1997;22(17):2025-9. 182. Gillet P, Petit M. Direct repair of spondylolysis without spondy-
163. Friberg O. Lumbar instability: a dynamic approach by traction- lolisthesis, using a rod-screw construct and bone grafting of the
compression radiography. Spine. 1987;12(2):119-29. pars defect. Spine. 1999;24(12):1252-6.
164. Frymoyer JW, Selby DK. Segmental instability. Rationale for 183. Glaser JA, Bernhardt M, Found EM, McDowell GS, Wetzel
treatment. Spine. 1985;10(3):280-6. FT. Lumbar arthrodesis for degenerative conditions. Instruct
165. Fu KM, Rhagavan P, Shaffrey CI, Chernavvsky DR, Smith JS. Course Lect. 2004;53:325-340.
Prevalence, severity, and impact of foraminal and canal stenosis 184. Glassman SD, Carreon LY, Dimar JR, Campbell MJ, Puno RM,
among adults with degenerative scoliosis. Neurosurgery. Johnson JR. Clinical outcomes in older patients after posterolat-
2011;69(6):1181-7. eral lumbar fusion. Spine J. 2007;7(5):547-51.
166. Fujimoto K, Yamazaki M, Hayashi K, et al. Posterior decom- 185. Glassman SD, Carreon LY, Djurasovic M, et al. Lumbar fusion
pression with instrumented fusion in a patient with cervical outcomes stratified by specific diagnostic indication. Spine J.
2009;9(1):13-21. 206. Hasegawa K, Kitahara K, Hara T, Takano K, Shimoda H, Hom-

186. Graham N, Gross A, Goldsmith CH, et al. Mechanical traction ma T. Evaluation of lumbar segmental instability in degenerative
for neck pain with or without radiculopathy. Cochrane Database diseases by using a new intraoperative measurement system. J
Syst Rev. 2008;(3):CD006408. Neurosurg Spine. 2008;8(3):255-62.
187. Grob D. Surgery for degenerative lumbar disease: Transforami- 207. Hasegawa K, Kitahara K, Shimoda H, Hara T. Facet joint
nal lumbar interbody fusion. Eur Spine J. 2009;18(12):1991- opening in lumbar degenerative diseases indicating segmental
1992. instability. J Neurosurg Spine. 2010;12(6):687-93.
188. Grob D, Humke T, Dvorak J. Direct pediculo-body fixation in 208. Hasegawa K, Shimoda H, Kitahara K, Sasaki K, Homma T.
cases of spondylolisthesis with advanced intervertebral disc What are the reliable radiological indicators of lumbar segmen-
degeneration. Eur Spine J. 1996;5(4):281-5. tal instability?. J Bone Joint Surg Br. 2011;93(5):650-7.
189. Grobler LJ, Robertson PA, Novotny JE, Ahern JW. Decom- 209. Hashimoto T, Oha F, Shigenobu K, et al. Mid-term clinical
pression for degenerative spondylolisthesis and spinal ste- results of Graf stabilization for lumbar degenerative pathologies.
nosis at L4-5. The effects on facet joint morphology. Spine. a minimum 2-year follow-up. Spine J. 2001;1(4):283-9.
1993;18(11):1475-82. 210. Hashimoto T, Shigenobu K, Kanayama M, et al. Clinical results
190. Grobler LJ, Robertson PA, Novotny JE, Pope MH. Etiology of of single-level posterior lumbar interbody fusion using the Bran-
spondylolisthesis. Assessment of the role played by lumbar facet tigan I/F carbon cage filled with a mixture of local morselized
joint morphology. Spine. 1993;18(1):80-91. bone and bioactive ceramic granules. Spine. 2002;27(3):258-62.
191. Gross A, Forget M, St George K, et al. Patient education for neck 211. Hatta Y, Shiraishi T, Sakamoto A, et al. Muscle-preserving
pain. Cochrane Database Syst Rev. 2012;3:CD005106. interlaminar decompression for the lumbar spine: a minimally
192. Ha KY, Na KH, Shin JH, Kim KW. Comparison of posterolateral invasive new procedure for lumbar spinal canal stenosis. Spine.
fusion with and without additional posterior lumbar interbody 2009;34(8):E276-80.
fusion for degenerative lumbar spondylolisthesis. J Spinal Dis- 212. Hayashi T, Arizono T, Fujimoto T, et al. Degenerative change
Bibliography
ord Tech. 2008;21(4):229-34. in the adjacent segments to the fusion site after posterolateral
193. Haberl H, Cripton PA, Orr TE, et al. Kinematic response of lumbar fusion with pedicle screw instrumentation--a minimum
lumbar functional spinal units to axial torsion with and without 4-year follow-up. Fukuoka Igaku Zasshi. 2008;99(5):107-13.
superimposed compression and flexion/extension. Eur Spine J. 213. Hayeri MR, Tehranzadeh J. Diagnostic imaging of spinal fusion
2004;13(6):560-6. and complications. Appl Radiol. 2009;38(7-8):14-28.
194. Hackenberg L, Halm H, Bullmann V, Vieth V, Schneider M, 214. Hee HT, Wong HK. The long-term results of surgical treat-
Liljenqvist U. Transforaminal lumbar interbody fusion: a safe ment for spinal stenosis in the elderly. Singapore Med J.
technique with satisfactory three to five year results. Eur Spine J. 2003;44(4):175-80.
2005;14(6):551-8. 215. Helenius I, Remes V, Poussa M. Uninstrumented in situ fusion
195. Hahn F, Kissling R, Weishaupt D, Boos N. The extremes of for high-grade childhood and adolescent isthmic spondylolis-
spinal motion: a kinematic study of a contortionist in an open- thesis: long-term outcome. Surgical technique. J Bone Joint Surg
configuration magnetic resonance scanner: case report. Spine. Am. 2008;90 Suppl 2 Pt 1:145-52.
2006;31(16):E565-7. 216. Heo DH, Cho YJ, Cho SM, Choi HC, Kang SH. Adjacent seg-
196. Hambly MF, Wiltse LL, Raghavan N, Schneiderman G, Koenig ment degeneration after lumbar dynamic stabilization using
C. The transition zone above a lumbosacral fusion. Spine. pedicle screws and a nitinol spring rod system with 2-year
1998;23(16):1785-92. minimum follow-up. J Spinal Disord Tech. 2012;25(8):409-14.
197. Hammouri QM, Haims AH, Simpson AK, Alqaqa A, Grauer 217. Herkowitz HN. Spine update degenerative lumbar spondylolis-
JN. The utility of dynamic flexion-extension radiographs in thesis. Spine. 1995;20(9):1084-1090.
the initial evaluation of the degenerative lumbar spine. Spine. 218. Herkowitz HN. Degenerative lumbar spondylolisthesis: evolu-
2007;32(21):2361-4. tion of surgical management. Spine J. 2009;9(7):605-6.
198. Hanley EN. Decompression and distraction-derotation arthrod- 219. Herkowitz HN. Degenerative lumbar spondylolisthe-
esis for degenerative spondylolisthesis. Spine. 1986;11(3):269-76. sis: a surgeon’s perspective of 30 years in practice. Spine J.
199. Hanley EN. The indications for lumbar spinal fusion with and 2010;10(10):916-7.
without instrumentation. Spine. 1995;20(24 Suppl):143S-153S. 220. Herkowitz HN, Abraham DJ, Albert TJ. Management of degen-
200. Hanley EN. Indications for fusion in the lumbar spine. Bull erative disc disease above an L5-S1 segment requiring arthrod-
Hosp Jt Dis. 1996;55(3):154-157. esis. Spine. 1999;24(12):1268-70.
201. Hansraj KK, O’leary PF, Cammisa FP, et al. Decompression, 221. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis
fusion, and instrumentation surgery for complex lumbar spinal with spinal stenosis: A prospective study comparing decompres-
stenosis. Clin Orthop Relat Res. 2001;(384):18-25. sion with decompression and intertransverse process arthrod-
202. Hara M, Nishimura Y, Takemoto M, Nakamura S, Wakabayashi esis. J Bone Jt Surg Am. 1991;73(6):802-808.
T. Posterior fixation for lumbar degenerative spondylosis: Mini- 222. Herno A, Partanen K, Talaslahti T, et al. Long-term clini-
open TLIF. Neurol Med Chir (Tokyo). 2012;21(2):118-127. cal and magnetic resonance imaging follow-up assessment of
203. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical patients with lumbar spinal stenosis after laminectomy. Spine.
evaluation and self-assessment by patients after decompres- 1999;24(15):1533-7.
sion surgery for degenerative lumbar canal stenosis. Spine J. 223. Herron LD, Newman MH. The failure of ethylene oxide gas-
2008;8(2):380-4. sterilized freeze-dried bone graft for thoracic and lumbar spinal
204. Harris EB, Sayadipour A, Massey P, Duplantier NL, Anderson fusion. Spine. 1989;14(5):496-500.
DG. Mini-open versus open decompression and fusion for lum- 224. Herron LD, Trippi AC. L4-5 degenerative spondylolisthesis. The
bar degenerative spondylolisthesis with stenosis. Am J Orthop. results of treatment by decompressive laminectomy without fu-
2011;40(12):E257-61. sion. Spine. 1989;14(5):534-8.
205. Hart RA, Prendergast MA. Spine surgery for lumbar degenera- 225. Hilibrand AS, Rand N. Degenerative lumbar stenosis: diagnosis
tive disease in elderly and osteoporotic patients. Instr Course and management. J Am Acad Orthop Surg. 1999;7(4):239-49.
Lect. 2007;56:257-72. 226. Hirabayashi S, Kumano K, Kuroki T. Cotrel-Dubousset pedicle
screw system for various spinal disorders. Merits and problems. Degenerative spondylolisthesis. Pathophysiology and results of
Spine. 1991;16(11):1298-304. anterior interbody fusion. Clin Orthop Relat Res. 1988;227:90-8.
227. Hitchon PW, Taggard DA. Lumbar spine fusion enhanced by 246. Irwin ZN, Hilibrand A, Gustavel M, et al. Variation in surgi-
pedicle screw fixation. Tech Neurosurg. 1998;4(3):211-215. cal decision making for degenerative spinal disorders. Part I:
228. Hong SW, Lee HY, Kim KH, Lee SH. Interspinous ligamen- lumbar spine. Spine. 2005;30(19):2208-13.
toplasty in the treatment of degenerative spondylolisthesis: 247. Ito K. Reviewer’s comments concerning “Biomechanical evalua-
midterm clinical results. J Neurosurg Spine. 2010;13(1):27-35. tion of segmental instability in degenerative lumbar spondylolis-
229. Houten JK, Post NH, Dryer JW, Errico TJ. Clinical and radio- thesis” by K. Hasegawa et al. (ESJO-D-08-00441R1). Eur Spine J.
graphically/neuroimaging documented outcome in transforami- 2009;18(4):471-2.
nal lumbar interbody fusion. Neurosurg Focus. 2006;20(3):E8. 248. Ito S, Yamada Y, Tuboi S, Yamada Y, Muro T. Specific pattern of
230. Hrabálek L, Wanek T, Adamus M. [Treatment of degenerative ruptured annulus fibrosus in lumbar degenerative spondylolis-
spondylolisthesis of the lumbosacral spine by decompression thesis. Neuroradiology. 1990;32(6):460-3.
and dynamic transpedicular stabilisation]. Acta Chir Orthop 249. Ito Y, Oda H, Taguchi T, Inoue H, Kawai S. Results of surgical
Traumatol Cech. 2011;78(5):431-6. treatment for lumbar canal stenosis due to degenerative spondy-
231. Hsieh PC, Koski TR, O’shaughnessy BA, et al. Anterior lumbar lolisthesis: enlargement of the lumbar spinal canal. J Orthop Sci.
interbody fusion in comparison with transforaminal lumbar 2003;8(5):648-56.
interbody fusion: implications for the restoration of foraminal 250. Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with au-
height, local disc angle, lumbar lordosis, and sagittal balance. J tologous iliac bone versus local bone graft in posterior lumbar
Neurosurg Spine. 2007;7(4):379-86. interbody fusion. Spine. 2010;35(21):E1101-5.
232. Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and 251. Iwamoto J, Takeda T. Effect of surgical treatment on physical ac-
spondylolysis. Instr Course Lect. 2008;57:431-445. tivity and bone resorption in patients with neurogenic intermit-
233. Hu Y, Gu YJ, Xu RM, Zhou LJ, Ma WH. Short-term clinical ob- tent claudication. J Orthop Sci. 2002;7(1):84-90.
Bibliography
servation of the Dynesys neutralization system for the treatment 252. Peloso P, Gross A, Haines T, et al. Medicinal and injection thera-
of degenerative disease of the lumbar vertebrae. Orthop Surg. pies for mechanical neck disorders. Cochrane Database Syst
2011;3(3):167-75. Rev. 2007;(3):CD000319.
234. Huang KF, Chen TY. Clinical results of a single central inter- 253. Jackson A, Isherwood I. Does degenerative disease of the lum-
body fusion cage and transpedicle screws fixation for recurrent bar spine cause arachnoiditis? A magnetic resonance study and
herniated lumbar disc and low-grade spondylolisthesis. Chang review of the literature. Br J Radiol. 1994;67(801):840-7.
Gung Med J. 2003;26(3):170-7. 254. Jackson RK, Boston DA, Edge AJ. Lateral mass fusion. A pro-
235. Huang KY, Lin RM, Lee YL, Li JD. Factors affecting disability spective study of a consecutive series with long-term follow-up.
and physical function in degenerative lumbar spondylolisthe- Spine. 1985;10(9):828-32.
sis of L4-5: evaluation with axially loaded MRI. Eur Spine J. 255. Jacobs W, Van der gaag NA, Tuschel A, et al. Total disc replace-
2009;18(12):1851-7. ment for chronic back pain in the presence of disc degeneration.
236. Huang TY, Lee KS, Tsai TH, Su YF, Hwang SL. Posterior epidur- Cochrane Database Syst Rev. 2012;9:CD008326.
al migration of sequestrated lumbar disc fragments into the bi- 256. Jacobsen S, Sonne-holm S, Rovsing H, Monrad H, Gebuhr
lateral facet joints: case report. Neurosurgery. 2011;69(5):E1148- P. Degenerative lumbar spondylolisthesis: an epidemiologi-
51. cal perspective: the Copenhagen Osteoarthritis Study. Spine.
237. Hunt T, Shen FH, Shaffrey CI, Arlet V. Contralateral radiculopa- 2007;32(1):120-5.
thy after transforaminal lumbar interbody fusion. Eur Spine J. 257. Jagannathan J, Sansur CA, Oskouian RJ, Fu KM, Shaffrey CI.
2007;16 Suppl 3:311-314. Radiographic restoration of lumbar alignment after transforam-
238. Hussain NS, Hanscom D, Oskouian RJ. Chyloretroperito- inal lumbar interbody fusion. Neurosurgery. 2009;64(5):955-63.
neum following anterior spinal surgery. J Neurosurg Spine. 258. Jaovisidha S, Techatipakorn S, Apiyasawat P, Laohacharoensom-
2012;17(5):415-21. bat W, Poramathikul M, Siriwongpairat P. Degenerative disk
239. Hwang CJ, Vaccaro AR, Hong J, et al. Immunogenicity of disease at lumbosacral junction: plain film findings and related
osteogenic protein 1: results from a prospective, randomized, MRI abnormalities. J Med Assoc Thai. 2000;83(8):865-71.
controlled, multicenter pivotal study of uninstrumented lumbar 259. Jayakumar P, Nnadi C, Saifuddin A, Macsweeney E, Casey
posterolateral fusion. J Neurosurg Spine. 2010;13(4):484-93. A. Dynamic degenerative lumbar spondylolisthesis: diag-
240. Ibrahimi DM, Beaty NB, Crandall KM, Hamilton DK, Sansur nosis with axial loaded magnetic resonance imaging. Spine.
CA. A review of lumbar spondylolisthesis. Eur Musculoskel Rev. 2006;31(10):E298-301..
2011;6(2):110-113. 260. Jenis LG, Banco RJ, Kwon B. A prospective study of Autologous
241. Ido K, Urushidani H. Radiographic evaluation of posterolateral Growth Factors (AGF) in lumbar interbody fusion. Spine J.
lumbar fusion for degenerative spondylolisthesis: long-term 2006;6(1):14-20.
follow-up of more than 10 years vs. midterm follow-up of 2-5 261. Jiang SD, Jiang LS, Dai LY. Degenerative cervical spondylolisthe-
years. Neurosurg Rev. 2001;24(4):195-9. sis: a systematic review. Int Orthop. 2011;35(6):869-75.
242. Ikuta K, Tono O, Oga M. Clinical outcome of microendoscopic 262. Jin J, Jianxiong S, Guixing Q, Hong Z, Xisheng W, Yipeng W.
posterior decompression for spinal stenosis associated with Surgical treatment of spondylolisthesis with SOCON instru-
degenerative spondylolisthesis--minimum 2-year outcome of 37 mentation. Chin Med Sci J. 2000;15(2):111-4.
patients. Minim Invasive Neurosurg. 2008;51(5):267-71. 263. Jinkins JR. Acquired degenerative changes of the intervertebral
243. Ikuta K, Tono O, Oga M. Prevalence and clinical features of segments at and supradjacent to the lumbosacral junction: A
intraspinal facet cysts after decompression surgery for lumbar radioanatomic analysis of the discal and nondiscal structures
spinal stenosis. J Neurosurg Spine. 2009;10(6):617-22. of the spinal column and perispinal soft tissues. Neuroradiol J.
244. Indar R, Tsiridis E, Morgan M, Aldham CH, Hussein AA. In- 2002;15(4):359-392.
traspinal lumbar synovial cysts: diagnosis and surgical manage- 264. Jiya TU, Smit T, Van royen BJ, Mullender M. Posterior lumbar
ment. Surgeon. 2004;2(3):141-4. interbody fusion using non resorbable poly-ether-ether-ketone
245. Inoue S, Watanabe T, Goto S, Takahashi K, Takata K, Sho E. versus resorbable poly-L-lactide-co-D,L-lactide fusion devices.
Clinical outcome at a minimum of 2-year follow-up. Eur Spine J. 283. Kantelhardt SR, Török E, Gempt J, et al. Safety and efficacy of
2011;20(4):618-22. a new percutaneously implantable interspinous process device.
265. Jo DJ, Jun JK, Kim KT, Kim SM. Lumbar Interbody Fusion Out- Acta Neurochir (Wien). 2010;152(11):1961-7.
comes in Degenerative Lumbar Disease : Comparison of Results 284. Karabekir HS, Atar EK, Yaycioglu S, Yildizhan A. Comparison
between Patients Over and Under 65 Years of Age. J Korean of unilateral posterior lumbar interbody fusion and bilateral
Neurosurg Soc. 2010;48(5):412-8. posterior interbody fusion with simple discectomy at degenera-
266. Johnson JR, Kirwan EO. The long-term results of fusion in situ tive disc herniations. Neurosciences (Riyadh). 2008;13(3):248-
for severe spondylolisthesis. J Bone Joint Surg Br. 1983;65(1):43- 52.
6. 285. Kasliwal MK, Deutsch H. Clinical and radiographic outcomes
267. Johnsson KE, Willner S, Johnsson K. Postoperative instabil- using local bone shavings as autograft in minimally invasive
ity after decompression for lumbar spinal stenosis. Spine. transforaminal lumbar interbody fusion. World Neurosurg.
1986;11(2):107-110. 2012;78(1-2):185-90.
268. Jones TR, Rao RD. Adult isthmic spondylolisthesis. J Am Acad 286. Katonis P, Christoforakis J, Kontakis G, et al. Complications
Orthop Surg. 2009;17(10):609-617. and problems related to pedicle screw fixation of the spine. Clin
269. Kai Y, Oyama M, Morooka M. Posterior lumbar interbody fu- Orthop Relat Res. 2003;(411):86-94.
sion using local facet joint autograft and pedicle screw fixation. 287. Katz JN, Lipson SJ, Lew RA, et al. Lumbar laminectomy alone or
Spine. 2004;29(1):41-6. with instrumented or noninstrumented arthrodesis in degenera-
270. Kakiuchi M, Ono K. Defatted, gas-sterilised cortical bone tive lumbar spinal stenosis. Patient selection, costs, and surgical
allograft for posterior lumbar interbody vertebral fusion. Int outcomes. Spine. 1997;22(10):1123-1131.
Orthop. 1998;22(2):69-76. 288. Kauppila LI, Eustace S, Kiel DP, Felson DT, Wright AM. Degen-
271. Kalanithi PS, Patil CG, Boakye M. National complication rates erative displacement of lumbar vertebrae. A 25-year follow-up
and disposition after posterior lumbar fusion for acquired spon- study in Framingham. Spine. 1998;23(17):1868-73.
Bibliography
dylolisthesis. Spine. 2009;34(18):1963-9. 289. Kawakami M, Tamaki T, Ando M, Yamada H, Hashizume H,

272. Kalichman L, Hunter DJ. Degenerative lumbar spondylolisthe- Yoshida M. Lumbar sagittal balance influences the clinical out-
sis: Anatomy, biomechanics and risk factors. J Back Musculoskel come after decompression and posterolateral spinal fusion for
Rehabil. 2008;21(1):1-12. degenerative lumbar spondylolisthesis. Spine. 2002;27(1):59-64.
273. Kalichman L, Hunter DJ. Diagnosis and conservative manage- 290. Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical
ment of degenerative lumbar spondylolisthesis. Eur Spine J. neck disorders. Cochrane Database Syst Rev. 2012;8:CD004250.
2008;17(3):327-35. 291. Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Suc-
274. Kalpakcioglu B, Altinbilek T, Senel K. Determination of spon- cess and failure of minimally invasive decompression for focal
dylolisthesis in low back pain by clinical evaluation. J Back lumbar spinal stenosis in patients with and without deformity.
Musculoskelet Rehabil. 2009;22(1):27-32. Spine. 2010;35(19):E981-7.
275. Kamioka Y, Yamamoto H. Lumbar trapezoid plate for lumbar 292. Kepler CK, Rihn JA, Radcliff KE, et al. Restoration of lordosis
spondylolisthesis. A clinical study on preoperative and postop- and disk height after single-level transforaminal lumbar inter-
erative instability. Spine. 1990;15(11):1198-203. body fusion. Orthop Surg. 2012;4(1):15-20.
276. Kanayama M, Hashimoto T, Shigenobu K, et al. Adjacent-seg- 293. Khan AM, Girardi F. Spinal lumbar synovial cysts. Diagnosis
ment morbidity after Graf ligamentoplasty compared with pos- and management challenge. Eur Spine J. 2006;15(8):1176-82.
terolateral lumbar fusion. J Neurosurg. 2001;95(1 Suppl):5-10. 294. Khan AM, Synnot K, Cammisa FP, Girardi FP. Lumbar synovial
277. Kanayama M, Hashimoto T, Shigenobu K, Oha F, Ishida T, cysts of the spine: an evaluation of surgical outcome. J Spinal
Yamane S. Intraoperative biomechanical assessment of lumbar Disord Tech. 2005;18(2):127-31.
spinal instability: validation of radiographic parameters indicat- 295. Khan JA, Bajracharya AR. Surgical treatment of isthmic spon-
ing anterior column support in lumbar spinal fusion. Spine. dylolisthesis with radicular pain in adults. JNMA J Nepal Med
2003;28(20):2368-72. Assoc. 2007;46(168):170-4.
278. Kanayama M, Hashimoto T, Shigenobu K, Togawa D, Oha F. A 296. Kim DH, Albert TJ. Update on use of instrumentation in lumbar
minimum 10-year follow-up of posterior dynamic stabilization spine disorders. Best Pract Res Clin Rheumatol. 2002;16(1):123-
using Graf artificial ligament. Spine. 2007;32(18):1992-6. 40.
279. Kanayama M, Hashimoto T, Shigenobu K, Yamane S, Bauer TW, 297. Kim DH, Jeong ST, Lee SS. Posterior lumbar interbody fusion
Togawa D. A prospective randomized study of posterolateral using a unilateral single cage and a local morselized bone
lumbar fusion using osteogenic protein-1 (OP-1) versus local graft in the degenerative lumbar spine. Clin Orthop Surg.
autograft with ceramic bone substitute: emphasis of surgical 2009;1(4):214-21.
exploration and histologic assessment. Spine. 2006;31(10):1067- 298. Kim DH, Shanti N, Tantorski ME, et al. Association between
74. degenerative spondylolisthesis and spinous process fracture after
280. Kaner T, Dalbayrak S, Oktenoglu T, Sasani M, Aydin AL, Ozer interspinous process spacer surgery. Spine J. 2012;12(6):466-72.
AF. Comparison of posterior dynamic and posterior rigid 299. Kim KS, Chin DK, Park JY. Herniated nucleus pulposus in isth-
transpedicular stabilization with fusion to treat degenerative mic spondylolisthesis: higher incidence of foraminal and extra-
spondylolisthesis. Orthopedics. 2010;33(5) foraminal types. Acta Neurochir (Wien). 2009;151(11):1445-50.
281. Kang BU, Choi WC, Lee SH, et al. An analysis of general 300. Kim KW, Ha KY, Moon MS, Kim YS, Kwon SY, Woo YK.
surgery-related complications in a series of 412 minilaparo- Volumetric change of the graft bone after intertransverse fusion.
tomic anterior lumbosacral procedures. J Neurosurg Spine. Spine. 1999;24(5):428-33.
2009;10(1):60-5. 301. Kim MK, Lee SH, Kim ES, Eoh W, Chung SS, Lee CS. The
282. Kang, C. H., Shin, M. J., Kim, S. M., Lee, S. H., & Lee, C. impact of sagittal balance on clinical results after posterior inter-
S. (2007). MRI of paraspinal muscles in lumbar degenera- body fusion for patients with degenerative spondylolisthesis: a
tive kyphosis patients and control patients with chronic low pilot study. BMC Musculoskelet Disord. 2011;12:69.
back pain. Clinical radiology, 62(5), 479-486. doi: 10.1016/j. 302. Kim NH, Lee JW. The relationship between isthmic and degen-
crad.2006.12.002 erative spondylolisthesis and the configuration of the lamina
and facet joints. Eur Spine J. 1995;4(3):139-44. lumbosacral instrumented fusion?. Eur Spine J. 2009;18(6):830-
303. Kim S, Mortaz Hedjri S, Coyte PC, Rampersaud YR. Cost-utility 40.
of lumbar decompression with or without fusion for patients 322. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid-
with symptomatic degenerative lumbar spondylolisthesis. Spine term clinical results of minimally invasive decompression and
J. 2012;12(1):44-54. posterolateral fusion with percutaneous pedicle screws versus
304. Kim SY, Maeng DH, Lee SH, Jang JS. Anterior lumbar interbody conventional approach for degenerative spondylolisthesis with
fusion for lumbosacral junction in steep sacral slope. J Spinal spinal stenosis. Eur Spine J. 2012;21(6):1171-7.
Disord Tech. 2008;21(1):33-8. 323. Krishna M, Pollock RD, Bhatia C. Incidence, etiology, clas-
305. Kimura I, Shingu H, Murata M, Hashiguchi H. Lumbar sification, and management of neuralgia after posterior lumbar
posterolateral fusion alone or with transpedicular instrumenta- interbody fusion surgery in 226 patients. Spine J. 2008;8(2):374-
tion in L4--L5 degenerative spondylolisthesis. J Spinal Disord. 9.
2001;14(4):301-310. 324. Kristof RA, Aliashkevich AF, Schuster M, Meyer B, Urbach H,
306. Kinoshita T, Ohki I, Roth KR, Amano K, Moriya H. Results of Schramm J. Degenerative lumbar spondylolisthesis-induced
degenerative spondylolisthesis treated with posterior de- radicular compression: nonfusion-related decompression in
compression alone via a new surgical approach. J Neurosurg. selected patients without hypermobility on flexion-extension
2001;95(1 Suppl):11-6. radiographs. J Neurosurg. 2002;97(3 Suppl):281-6.
307. Kirkaldy-willis WH, Wedge JH, Yong-hing K, Reilly J. Pathol- 325. Kroppenstedt S, Gulde M, Schönmayr R. Radiological compari-
ogy and pathogenesis of lumbar spondylosis and stenosis. Spine. son of instrumented posterior lumbar interbody fusion with one
1978;3(4):319-28. or two closed-box plasmapore coated titanium cages: follow-up
308. Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra study over more than seven years. Spine. 2008;33(19):2083-8.
in spinal tuberculosis. Eur Spine J. 2011;20(1):1-5. 326. Kuntz KM, Snider RK, Weinstein JN, Pope MH, Katz JN. Cost-
309. Kizilkilic O, Yalcin O, Sen O, Aydin MV, Yildirim T, Hurcan C. effectiveness of fusion with and without instrumentation for
Bibliography
The role of standing flexion-extension radiographs for spon- patients with degenerative spondylolisthesis and spinal stenosis.
dylolisthesis following single level disk surgery. Neurol Res. Spine. 2000;25(9):1132-9.
2007;29(6):540-3. 327. Kuroki H, Tajima N, Kubo S. Clinical results of posterolateral
310. Kleeman TJ, Hiscoe AC, Berg EE. Patient outcomes after mini- fusion for degenerative lumbar spinal diseases: a follow-up
mally destabilizing lumbar stenosis decompression: the “Port- study of more than 10 years. J Orthop Sci. 2002;7(3):317-24.
Hole” technique. Spine. 2000;25(7):865-70. 328. Kurz LT, Garfin SR, Unger AS, Thorne RP, Rothman RH.
311. Kleinstueck FS, Fekete TF, Mannion AF, et al. To fuse or Intraspinal synovial cyst causing sciatica. J Bone Joint Surg Am.
not to fuse in lumbar degenerative spondylolisthesis: do 1985;67(6):865-71.
baseline symptoms help provide the answer?. Eur Spine J. 329. Kwon BK, Albert TJ. Adult low-grade acquired spondylolytic
2012;21(2):268-75. spondylolisthesis: evaluation and management. Spine. 2005;30(6
312. Klopfenstein JD, Kim LJ, Feiz-erfan I, Dickman CA. Retroperi- Suppl):S35-41.
toneal approach for lumbar interbody fusion with anterolateral 330. Lakdawala RH, Rahmat R, Tan L, Wong HK. Aortic flap valve
instrumentation for treatment of spondylolisthesis and degen- presenting as neurogenic claudication: a case report. Spine.
erative foraminal stenosis. Surg Neurol. 2006;65(2):111-6. 2004;29(4):E79-81.
313. Kluba T, Dikmenli G, Dietz K, Giehl JP, Niemeyer T. Compari- 331. Lamberg T, Remes V, Helenius I, et al. Uninstrumented in
son of surgical and conservative treatment for degenerative situ fusion for high-grade childhood and adolescent isthmic
lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):1-5. spondylolisthesis: long-term outcome. J Bone Jt Surg Am.
314. Knaub MA, Won DS, Mcguire R, Herkowitz HN. Lumbar spinal 2007;89(3):512-518.
stenosis: indications for arthrodesis and spinal instrumentation. 332. Langerak NG, Vaughan CL, Hoffman EB, Figaji AA, Fieggen
Instr Course Lect. 2005;54:313-9. AG, Peter JC. Incidence of spinal abnormalities in patients with
315. Knox BD, Harvell JC, Nelson PB, Hanley EN. Decompression spastic diplegia 17 to 26 years after selective dorsal rhizotomy.
and luque rectangle fusion for degenerative spondylolisthesis. J Childs Nerv Syst. 2009;25(12):1593-1603.
Spinal Disord. 1989;2(4):223-8. 333. Lattig F, Fekete TF, Grob D, Kleinstück FS, Jeszenszky D, Man-
316. Knuttson F. The instability associated with disc degeneration in nion AF. Lumbar facet joint effusion in MRI: a sign of instability
the lumbar spine. Acta Radiol. 1944;25:593-609. in degenerative spondylolisthesis?. Eur Spine J. 2012;21(2):276-
317. Konno S, Kikuchi S. Prospective study of surgical treatment of 81.
degenerative spondylolisthesis: comparison between decom- 334. Lauber S, Schulte TL, Liljenqvist U, Halm H, Hackenberg
pression alone and decompression with graf system stabiliza- L. Clinical and radiologic 2-4-year results of transforaminal
tion. Spine. 2000;25(12):1533-7. lumbar interbody fusion in degenerative and isthmic spondylo-
318. Konno S, Kikuchi S, Tanaka Y, et al. A diagnostic support tool listhesis grades 1 and 2. Spine. 2006;31(15):1693-8.
for lumbar spinal stenosis: a self-administered, self-reported 335. Lauryssen C. Appropriate selection of patients with lumbar
history questionnaire. BMC Musculoskelet Disord. 2007;8:102. spinal stenosis for interspinous process decompression with the
319. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, X STOP device. Neurosurg Focus. 2007;22(1):E5.
Berkower DL, Ditkoff JS. Degenerative lumbar spondylolisthesis 336. Laus M, Tigani D, Alfonso C, Giunti A. Degenerative spondy-
with spinal stenosis: a prospective long-term study comparing lolisthesis: lumbar stenosis and instability. Chir Organi Mov.
fusion and pseudarthrosis. Spine. 2004;29(7):726-33. 1992;77(1):39-49.
320. Korovessis P, Koureas G, Zacharatos S, Papazisis Z, Lambiris E. 337. Laus M, Tigani D, Pignatti G, et al. Posterolateral spinal fusion:
Correlative radiological, self-assessment and clinical analy- a study of 123 cases with a long-term follow-up. Chir Organi
sis of evolution in instrumented dorsal and lateral fusion for Mov. 1994;79(1):69-79.
degenerative lumbar spine disease. Autograft versus coralline 338. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP.
hydroxyapatite. Eur Spine J. 2005;14(7):630-8. Treatment of degenerative spondylolisthesis: potential impact
321. Korovessis P, Repantis T, Zacharatos S, Zafiropoulos A. Does of dynamic stabilization based on imaging analysis. Eur Spine J.
Wallis implant reduce adjacent segment degeneration above 2009;18(6):815-22.
339. Lawhorne TW, Girardi FP, Mina CA, Pappou I, Cammisa FP. J. 2007;7(5):609-14.
Treatment of degenerative spondylolisthesis: potential impact 358. Liao JC, Chen WJ, Chen LH, Niu CC. Outcome of the L5-S1
of dynamic stabilization based on imaging analysis. Eur Spine J. segment after posterior instrumented spinal surgery in degen-
2009;18(6):815-22. erative lumbar diseases. Chang Gung Med J. 2009;32(1):81-8.
340. Lee DY, Jung TG, Lee SH. Single-level instrumented mini-open 359. Liao JC, Chen WJ, Chen LH, Niu CC, Keorochana G. Surgi-
transforaminal lumbar interbody fusion in elderly patients. J cal outcomes of degenerative spondylolisthesis with L5-S1 disc
Neurosurg Spine. 2008;9(2):137-44. degeneration: comparison between lumbar floating fusion and
341. Lee DY, Lee SH. L2 radicular compression caused by a fo- lumbosacral fusion at a minimum 5-year follow-up. Spine.
raminal extradural gas pseudocyst. J Korean Neurosurg Soc. 2011;36(19):1600-7.
2010;47(3):232-4. 360. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar de-
342. Lee DY, Lee SH, Shim CS, Lee HY. Decompression and inter- compression for degenerative lumbar spinal stenosis. J Neuro-
spinous dynamic stabilization using the locker for lumbar canal surg Spine. 2006;4(5):359-64.
stenosis associated with low-grade degenerative spondylolisthe- 361. Lindley EM, McCullough MA, Burger EL, Brown CW, Patel VV.
sis. Minim Invasive Neurosurg. 2010;53(3):117-21. Complications of axial lumbar interbody fusion. J Neurosurg
343. Lee HY, Ahn Y, Kim DY, Shin SW, Lee SH. Percutaneous ventral Spine. 2011;15(3):273-9.
decompression for L4-L5 degenerative spondylolisthesis in 362. Lindley EM, Sherman B, Ohnmeiss D, et al. The positive predic-
medically compromised elderly patients: technical case report. tive value of provocative discography in artificial disc replace-
Neurosurgery. 2004;55(2):435. ment. Spine J. 2010;10:(9 Suppl. 1):68S-69S.
344. Lee JC, Jang HD, Shin BJ. Learning curve and clinical outcomes 363. Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer
of minimally invasive transforaminal lumbar interbody fusion: C 3rd. Treatment of degenerative spondylolisthesis. Spine.
our experience in 86 consecutive cases. Spine. 2012;37(18):1548- 1985;10(9):821-827.
57. 364. Long H, Kazunasa U, Liu S, Akio S, Taito I. Preliminary ap-
Bibliography
345. Lee JW, Myung JS, Park KW, et al. Fluoroscopically guided plication of one-level posterior lumbar interbody fusion with
caudal epidural steroid injection for management of degenera- prospace and facet fusion using local autograft. Zhongguo Xiu
tive lumbar spinal stenosis: short-term and long-term results. Fu Chong Jian Wai Ke Za Zhi. 2007;21(11):1155-9.
Skeletal Radiol. 2010;39(7):691-9. 365. Lorenz R. Lumbar spondylolisthesis. Clinical syndrome and
346. Lee JY, Hohl JB, Fedorka CJ, et al. Surgeons agree to disagree on operative experience with Cloward’s technique. Acta Neurochir
surgical options for degenerative conditions of the cervical and (Wien). 1982;60(3-4):223-44.
lumbar spine. Spine. 2011;36(3):E203-12. 366. Lowe RW, Hayes TD, Kaye J, Bagg RJ, Luekens CA. Standing
347. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for in- roentgenograms in spondylolisthesis. Clin Orthop Relat Res.
strumented lower lumbar or lumbosacral posterolateral fusion. J 1976;(117):80-4.
Clin Neurosci. 2009;16(1):37-43. 367. Ly JQ. Systematic approach to interpretation of the lumbar spine
348. Lee SE, Park SB, Jahng TA, Chung CK, Kim HJ. Clinical experi- MR imaging examination. Magn Reson Imaging Clin N Am.
ence of the dynamic stabilization system for the degenerative 2007;15(2):155-66, v.
spine disease. J Korean Neurosurg Soc. 2008;43(5):221-6. 368. Maheshwaran S, Davies AM, Evans N, Broadley P, Cassar-
349. Lee SH, Kang BU, Jeon SH, et al. Revision surgery of the lumbar pullicino VN. Sciatica in degenerative spondylolisthesis of the
spine: anterior lumbar interbody fusion followed by percutane- lumbar spine. Ann Rheum Dis. 1995;54(7):539-43.
ous pedicle screw fixation. J Neurosurg Spine. 2006;5(3):228-33. 369. Mahmud T, Basu D, Dyson PH. Crystal arthropathy of the
350. Lee SH, Lee JH, Hong SW, Chung SE, Yoo SH, Lee HY. Spi- lumbar spine: a series of six cases and a review of the literature. J
nopelvic alignment after interspinous soft stabilization with a Bone Joint Surg Br. 2005;87(4):513-7.
tension band system in grade 1 degenerative lumbar spondylo- 370. Majid K, Fischgrund JS. Degenerative lumbar spondylo-
listhesis. Spine. 2010;35(15):E691-701. listhesis: trends in management. J Am Acad Orthop Surg.
351. Lee SH, Lee JH, Hong SW, et al. Factors affecting clinical out- 2008;16(4):208-15.
comes in treating patients with grade 1 degenerative spondylo- 371. Malter AD, Mcneney B, Loeser JD, Deyo RA. 5-year reopera-
listhesis using interspinous soft stabilization with a tension band tion rates after different types of lumbar spine surgery. Spine.
system: a minimum 5-year follow-up. Spine. 2012;37(7):563-72. 1998;23(7):814-20.
352. Lee TC. Reduction and stabilization without laminectomy for 372. Manchikanti L, Cash KA, Mcmanus CD, Pampati V, Abdi S.
unstable degenerative spondylolisthesis: a preliminary report. Preliminary results of a randomized, equivalence trial of fluoro-
Neurosurgery. 1994;35(6):1072-1076. scopic caudal epidural injections in managing chronic low back
353. Lefkowitz DM, Quencer RM. Vacuum facet phenomenon: a pain: Part 4--Spinal stenosis. Pain Physician. 2008;11(6):833-48.
computed tomographic sign of degenerative spondylolisthesis. 373. Manenti G, Liccardo G, Sergiacomi G, et al. Axial loading MRI
Radiology. 1982;144(3):562. of the lumbar spine. In Vivo. 2003;17(5):413-20.
354. Lekovic GP, Han PP, Kenny KJ, Dickman CA. Bone dowels 374. Marchesi DG, Thalgott JS, Aebi M. Application and results of
in anterior lumbar interbody fusion. J Spinal Disord Tech. the AO internal fixation system in nontraumatic indications.
2007;20(5):374-9. Spine. 1991;16(3 Suppl):S162-9.
355. Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lum- 375. Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spon-
bar spondylolysis: a review. Skeletal Radiol. 2011;40(6):683-700. dylolisthesis: A meta-analysis of literature 1970- 1993. Spine.
356. Lerner T, Frobin W, Bullmann V, Schulte T, Brinckmann P, 1994;19(20 Suppl.):2256S-2265S.
Liljenqvist U. Changes in disc height and posteroanterior 376. Margulies JY, Seimon LP. Clinical efficacy of lumbar and lumbo-
displacement after fusion in patients with idiopathic scoliosis: sacral fusion using the Boucher facet screw fixation technique.
a 9-year follow-up study. J Spinal Disord Tech. 2007;20(3):195- Bull Hosp Jt Dis. 2000;59(1):33-9.
202. 377. Mariconda M, Fava R, Gatto A, Longo C, Milano C. Unilateral
357. Lewandrowski KU, Nanson C, Calderon R. Vertebral osteolysis laminectomy for bilateral decompression of lumbar spinal
after posterior interbody lumbar fusion with recombinant hu- stenosis: a prospective comparative study with conservatively
man bone morphogenetic protein 2: a report of five cases. Spine treated patients. J Spinal Disord Tech. 2002;15(1):39-46.
378. Mariconda M, Galasso O, Imbimbo L, Lotti G, Milano C. Rela- 397. McGregor AH, Probyn K, Cro S, et al. Rehabilitation following
tionship between alterations of the lumbar spine, visualized with surgery for lumbar spinal stenosis. Cochrane Database Syst Rev.
magnetic resonance imaging, and occupational variables. Eur 2013 Dec 9;12:CD009644.
Spine J. 2007;16(2):255-66. 398. McGregor AH, Anderton L, Gedroyc WM, Johnson J, Hughes
379. Markwalder TM. Surgical management of neurogenic claudica- SP. The use of interventional open MRI to assess the kinematics
tion in 100 patients with lumbar spinal stenosis due to degen- of the lumbar spine in patients with spondylolisthesis. Spine.
erative spondylolisthesis. Acta Neurochir (Wien). 1993;120(3- 2002;27(14):1582-6.
4):136-42. 399. Mcgregor AH, Cattermole HR, Hughes SP. Global spinal motion
380. Markwalder TM, Reulen HJ. Translaminar screw fixation in in subjects with lumbar spondylolysis and spondylolisthesis:
lumbar spine pathology. Technical note. Acta Neurochir (Wien). does the grade or type of slip affect global spinal motion?. Spine.
1989;99(1-2):58-60. 2001;26(3):282-6.
381. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo 400. Mcguire RA, Pilcher LE, Dettori JR. Lumbar posterolateral
RA. Are lumbar spine reoperation rates falling with greater fusion with local bone graft plus bone extender compared with
use of fusion surgery and new surgical technology?. Spine. iliac crest bone graft: a systematic review. Evid Based Spine Care
2007;32(19):2119-26. J. 2011;2(2):35-40.
382. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo 401. Mehta VA, Amin A, Omeis I, Gokaslan ZL, Gottfried ON.
RA. Reoperation rates following lumbar spine surgery and the Implications of spinopelvic alignment for the spine surgeon.
influence of spinal fusion procedures. Spine. 2007;32(3):382-7. Neurosurgery. 2012;70(3):707-21.
383. Martin BI, Mirza SK, Franklin GM, Lurie JD, Mackenzie TA, 402. Mehta VA, Mcgirt MJ, Garcés ambrossi GL, et al. Trans-foram-
Deyo RA. Hospital and surgeon variation in complications and inal versus posterior lumbar interbody fusion: comparison of
repeat surgery following incident lumbar fusion for common surgical morbidity. Neurol Res. 2011;33(1):38-42.
degenerative diagnoses. Health Serv Res. 2013;48(1):1-25. 403. Mercaitis OP, Dropkin BM, Kaufman EL, Carl AL. Epidural
Bibliography
384. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah granuloma arising from epidural catheter placement. Orthope-
SM, O’neil J, Wai EK. The surgical management of degen- dics. 2009;32(4)
erative lumbar spondylolisthesis: a systematic review. Spine. 404. Métellus P, Fuentes S, Adetchessi T, et al. Retrospective study of
2007;32(16):1791-8. 77 patients harbouring lumbar synovial cysts: functional and
385. Matgé G, Leclercq TA. Rationale for interbody fusion with neurological outcome. Acta Neurochir (Wien). 2006;148(1):47-
threaded titanium cages at cervical and lumbar levels. Results 54.
on 357 cases. Acta Neurochir (Wien). 2000;142(4):425-33. 405. Min JH, Jang JS, Kim SK, Maeng DH, Lee SH. The ligamen-
386. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal stenosis in totactic effect on a herniated disc at the level adjacent to the
grade I degenerative lumbar spondylolisthesis: a comparative anterior lumbar interbody fusion : report of two cases. J Korean
study of outcomes following laminoplasty and laminectomy Neurosurg Soc. 2009;46(1):65-7.
with instrumented spinal fusion. J Orthop Sci. 2005;10(3):270-6. 406. Mirovsky Y, Halperin N, Anekstein Y, Neuwirth MG. Good re-
387. Matsunaga S, Ijiri K, Hayashi K. Nonsurgically managed sults of circumferential spine fusion in smokers, using autograft
patients with degenerative spondylolisthesis: a 10- to 18-year and allograft. Cell Tissue Bank. 2002;3(3):169-73.
follow-up study. J Neurosurg. 2000;93(2 Suppl):194-8. 407. Miscusi M, Petrozza V, Polli FM, Forcato S, Rocca CD, Raco
388. Matsunaga S, Sakou T, Morizono Y, Masuda A, Demirtas AM. A. Symptomatic ganglion cyst of ligamentum flavum as a
Natural history of degenerative spondylolisthesis. Pathogenesis late complication of lumbar fixation. Neurol Neurochir Pol.
and natural course of the slippage. Spine. 1990;15(11):1204-10. 2012;46(1):82-6.
389. Maus T. Imaging the back pain patient. Phys Med Rehabil Clin 408. Miyamoto H, Sumi M, Uno K, Tadokoro K, Mizuno K. Clinical
N Am. 2010;21(4):725-66. outcome of nonoperative treatment for lumbar spinal stenosis,
390. Mayer HM, Wiechert K. Microsurgical anterior approaches to and predictive factors relating to prognosis, in a 5-year mini-
the lumbar spine for interbody fusion and total disc replace- mum follow-up. J Spinal Disord Tech. 2008;21(8):563-8.
ment. Neurosurgery. 2002;51(5 Suppl):S159-65. 409. Miyazaki M, Morishita Y, Takita C, Yoshiiwa T, Wang JC, Tsu-
391. Mazzocchio R, Scarfò GB, Cartolari R, et al. Abnormalities mura H. Analysis of the relationship between facet joint angle
of the soleus H-reflex in lumbar spondylolisthesis: a possible orientation and lumbar spine canal diameter with respect to
early sign of bilateral S1 root dysfunction. J Spinal Disord. the kinematics of the lumbar spinal unit. J Spinal Disord Tech.
2000;13(6):487-95. 2010;23(4):242-8.
392. McAfee P, Khoo LT, Pimenta L, et al. Treatment of lumbar spinal 410. Mochida J, Suzuki K, Chiba M. How to stabilize a single level
stenosis with a total posterior arthroplasty prosthesis: implant lesion of degenerative lumbar spondylolisthesis. Clin Orthop
description, surgical technique, and a prospective report on 29 Relat Res. 1999;(368):126-34.
patients. Neurosurg Focus. 2007;22(1):E13. 411. Moke L, Debeer P, Moens P. Spondylolisthesis in twins: mul-
393. McAfee PC, Cunningham BW, Tortolani PJ, Fedder IL, Sefter tifactorial etiology: a case report and review of the literature.
JC, Davis C. 100 Consecutive Cases of Degenerative Lumbar Spine. 2011;36(11):E741-6.
Conditions Using a Non-Threaded Locking Screw System With 412. Mokhtar SA, Mccombe PF, Williamson OD, Morgan MK, White
a 90-Degree Locking Cap. SAS J. 2009;3(1):1-11. GJ, Sears WR. Health-related quality of life: a comparison of
394. Mcafee PC, Devine JG, Chaput CD, et al. The indications for outcomes after lumbar fusion for degenerative spondylolisthesis
interbody fusion cages in the treatment of spondylolisthesis: with large joint replacement surgery and population norms.
analysis of 120 cases. Spine. 2005;30(6 Suppl):S60-5. Spine J. 2010;10(4):306-12.
395. McAfee PC, Ullrich CG, Yuan HA, Sherry RG, Lockwood RC. 413. Molina M, Wagner P, Campos M. [Spinal lumbar stenosis: an
Computed tomography in degenerative spinal stenosis. Clin update]. Rev Med Chil. 2011;139(11):1488-95.
Orthop Relat Res. 1981;(161):221-34. 414. Molinari RW, Bridwell KH, Klepps SJ, Baldus C. Minimum
396. McCulloch JA. Microdecompression and uninstrumented 5-year follow-up of anterior column structural allografts in the
single-level fusion for spinal canal stenosis with degenerative thoracic and lumbar spine. Spine. 1999;24(10):967-72.
spondylolisthesis. Spine. 1998;23(20):2243-52. 415. Molinari RW, Hunter JG, Mcassey RW. In-hospital postopera-
tive radiographs for instrumented single-level degenerative Database Syst Rev. 2003;(1):CD004058.
spinal fusions: utility after intraoperative fluoroscopy. Spine J. 433. Niggemann P, Simons P, Kuchta J, Beyer HK, Frey H,
2012;12(7):559-67. Grosskurth D. Spondylolisthesis and posterior instability. Acta
416. Möller J, Wittenberg RH, Nolte LP, Jergas M, Willburger R, Radiol. 2009;50(3):301-5.
Krämer J. Results of lumbosacral distraction spondylodesis for 434. Nizard RS, Wybier M, Laredo JD. Radiologic assessment of lum-
the treatment of spondylolisthesis, failed-back syndrome, and bar intervertebral instability and degenerative spondylolisthesis.
lumbar instability. Eur Spine J. 1992;1(2):117-24. Radiol Clin North Am. 2001;39(1):55-71, v-vi.
417. Monticone M, Giovanazzi E. Usefulness of a cognitive be- 435. Nojiri K, Matsumoto M, Chiba K, Toyama Y, Momoshima S.
havioural and rehabilitative approach to enhance long lasting Comparative assessment of pedicle morphology of the lum-
benefit after lumbar spinal stenosis and degenerative spon- bar spine in various degenerative diseases. Surg Radiol Anat.
dylolisthesis surgery. A case report. Eur J Phys Rehabil Med. 2005;27(4):317-21.
2008;44(4):467-71. 436. Oh IS, Ha KY. Matrix metalloproteinase-3 on ligamentum
418. Moon MS, Kim SS, Sun DH, Moon YW. Anterior spondylodesis flavum in degenerative lumbar spondylolisthesis. Spine.
for spondylolisthesis: isthmic and degenerative types. Eur Spine 2009;34(16):E552-7.
J. 1994;3(3):172-6. 437. Ohmori K, Suzuki K, Ishida Y. Translamino-pedicular screw
419. Mori E, Okada S, Ueta T, et al. Spinous process-splitting open fixation with bone grafting for symptomatic isthmic lumbar
pedicle screw fusion provides favorable results in patients with spondylolysis. Neurosurgery. 1992;30(3):379-84.
low back discomfort and pain compared to conventional open 438. Ohta H, Matsumoto Y, Morishita Y, et al. Surgical results of
pedicle screw fixation over 1 year after surgery. Eur Spine J. dynamic nonfusion stabilization with the Segmental Spinal
2012;21(4):745-53. Correction System for degenerative lumbar spinal diseases with
420. Morishita Y, Ohta H, Naito M, et al. Kinematic evaluation of the instability: Minimum 2-year follow-up. SAS J. 2011;5(3):69-74.
adjacent segments after lumbar instrumented surgery: a com- 439. Ohtori S, Inoue G, Orita S, et al. Teriparatide accelerates lumbar
Bibliography
parison between rigid fusion and dynamic non-fusion stabiliza- posterolateral fusion in women with postmenopausal osteopo-
tion. Eur Spine J. 2011;20(9):1480-5. rosis: prospective study. Spine. 2012;37(23):E1464-8.
421. Mummaneni PV, Pan J, Haid RW, Rodts GE. Contribution of 440. Ohtori S, Yamashita M, Inoue G, et al. Rotational hypermobil-
recombinant human bone morphogenetic protein-2 to the ity of disc wedging using kinematic CT: preliminary study to
rapid creation of interbody fusion when used in transforaminal investigate the instability of discs in degenerated scoliosis in the
lumbar interbody fusion: a preliminary report. Invited sub- lumbar spine. Eur Spine J. 2010;19(6):989-94.
mission from the Joint Section Meeting on Disorders of the 441. Oishi Y, Murase M, Hayashi Y, Ogawa T, Hamawaki J. Smaller
Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. facet effusion in association with restabilization at the time of
2004;1(1):19-23. operation in Japanese patients with lumbar degenerative spon-
422. Murtagh RD, Quencer RM, Castellvi AE, Yue JJ. New techniques dylolisthesis. J Neurosurg Spine. 2010;12(1):88-95.
in lumbar spinal instrumentation: what the radiologist needs to 442. Okawa A, Shinomiya K, Komori H, Muneta T, Arai Y, Nakai O.
know. Radiology. 2011;260(2):317-30. Dynamic motion study of the whole lumbar spine by videofluo-
423. Müslüman AM, Cansever T, Yılmaz A, Çavuşoğlu H, Yüce İ, roscopy. Spine. 1998;23(16):1743-9.
Aydın Y. Midterm outcome after a microsurgical unilateral 443. Okuda S, Oda T, Miyauchi A, Haku T, Yamamoto T, Iwasaki
approach for bilateral decompression of lumbar degenerative M. Surgical outcomes of posterior lumbar interbody fusion
spondylolisthesis. J Neurosurg Spine. 2012;16(1):68-76. in elderly patients. Surgical technique. J Bone Joint Surg Am.
424. Naderi S, Manisali M, Acar F, Ozaksoy D, Mertol T, Arda MN. 2007;89 Suppl 2 Pt.2:310-20.
Factors affecting reduction in low-grade lumbosacral spondylo- 444. Okuda T, Baba I, Fujimoto Y, et al. The pathology of ligamentum
listhesis. J Neurosurg. 2003;99(2 Suppl):151-6. flavum in degenerative lumbar disease. Spine. 2004;29(15):1689-
425. Nagaosa Y, Kikuchi S, Hasue M, Sato S. Pathoanatomic mecha- 97.
nisms of degenerative spondylolisthesis. A radiographic study. 445. Okuyama K, Kido T, Unoki E, Chiba M. PLIF with a titanium
Spine. 1998;23(13):1447-51. cage and excised facet joint bone for degenerative spondylolis-
426. Nakashima H, Sato K, Ando T, Inoh H, Nakamura H. Compari- thesis--in augmentation with a pedicle screw. J Spinal Disord
son of the percutaneous screw placement precision of isocentric Tech. 2007;20(1):53-9.
C-arm 3-dimensional fluoroscopy-navigated pedicle screw 446. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic
implantation and conventional fluoroscopy method with mini- assessment of the ability of the extreme lateral interbody fusion
mally invasive surgery. J Spinal Disord Tech. 2009;22(7):468-72. procedure to indirectly decompress the neural elements. Spine.
427. Nasca RJ. Rationale for spinal fusion in lumbar spinal stenosis. 2010;35(26 Suppl):S331-7.
Spine. 1989;14(4):451-454. 447. Onda A, Otani K, Konno S, Kikuchi S. Mid-term and long-
428. Nasca RJ. Lumbar spinal stenosis: surgical considerations. J term follow-up data after placement of the Graf stabilization
South Orthop Assoc. 2002;11(3):127-34. system for lumbar degenerative disorders. J Neurosurg Spine.
429. Nathan M, Keller TS. Measurement and analysis of the in 2006;5(1):26-32.
vivo posteroanterior impulse response of the human thoraco- 448. Osman SG. Endoscopic transforaminal decompression,
lumbar spine: a feasibility study. J Manipulative Physiol Ther. interbody fusion, and percutaneous pedicle screw implanta-
1994;17(7):431-41.. tion of the lumbar spine: A case series report. Int J Spine Surg.
430. Nelson LD, Montgomery SP, Dameron TB, Nelson RB. Deep 2012;6(1):157-166.
vein thrombosis in lumbar spinal fusion: a prospective study 449. Ozawa H, Kanno H, Koizumi Y, et al. Dynamic changes in the
of antiembolic and pneumatic compression stockings. J South dural sac cross-sectional area on axial loaded MR imaging: is
Orthop Assoc. 1996;5(3):181-4. there a difference between degenerative spondylolisthesis and
431. Newman PH. Degenerative spondylolisthesis. Orthop Clin N spinal stenosis?. AJNR Am J Neuroradiol. 2012;33(6):1191-7.
Am. 1975;6(1):197-198. 450. Ozgur BM, Agarwal V, Nail E, Pimenta L. Two-year clinical and
432. Niemisto L, Kalso E, Malmivaara A, Seitsalo S, Hurri H. radiographic success of minimally invasive lateral transpsoas
Radiofrequency denervation for neck and back pain Cochrane approach for the treatment of degenerative lumbar conditions.
SAS J. 2010;4(2):41-46. of baseline characteristics and outcomes (SPORT). Spine.

451. Ozkan N, Sandalcioglu IE, Petr O, et al. Minimally invasive 2010;35(3):298-305.
transpedicular dorsal stabilization of the thoracolumbar and 468. Peloso P, Gross A, Haines T, et al. Medicinal and injection thera-
lumbar spine using the minimal access non-traumatic insertion pies for mechanical neck disorders. Cochrane Database Syst
system (MANTIS): preliminary clinical results in 52 patients. J Rev. 2007;(3):CD000319.
Neurol Surg A Cent Eur Neurosurg. 2012;73(6):369-76. 469. Pelton MA, Phillips FM, Singh K. A comparison of peri-
452. Paajanen H, Tertti M. Association of incipient disc degeneration operative costs and outcomes in patients with and without
and instability in spondylolisthesis. A magnetic resonance and workers’ compensation claims treated with minimally inva-
flexion-extension radiographic study of 20-year-old low back sive or open transforaminal lumbar interbody fusion. Spine.
pain patients. Arch Orthop Trauma Surg. 1991;111(1):16-9. 2012;37(22):1914-9.
453. Palmer S, Turner R, Palmer R. Bilateral decompression of 470. Penning L, Blickman JR. Instability in lumbar spondylolisthesis:
lumbar spinal stenosis involving a unilateral approach with mi- a radiologic study of several concepts. AJR Am J Roentgenol.
croscope and tubular retractor system. J Neurosurg. 2002;97(2 1980;134(2):293-301.
Suppl):213-7. 471. Piñera AR, Duran C, Lopez B, Saez I, Correia E, Alvarez L. In-
454. Pao JL, Chen WC, Chen PQ. Clinical outcomes of microen- strumented lumbar arthrodesis in elderly patients: prospective
doscopic decompressive laminotomy for degenerative lumbar study using cannulated cemented pedicle screw instrumenta-
spinal stenosis. Eur Spine J. 2009;18(5):672-8. tion. Eur Spine J. 2011;20 Suppl 3:408-14.
455. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar steno- 472. Plötz GM, Benini A. Surgical treatment of degenerative spon-
sis lead to poorer outcomes?: a subanalysis of the Spine Patient dylolisthesis in the lumbar spine: no reposition without prior
Outcomes Research Trial (SPORT) lumbar stenosis study. Spine. decompression. Acta Neurochir (Wien). 1995;137(3-4):188-91.
2010;35(4):439-46. 473. Ploumis A, Transfeldt EE, Gilbert TJ, Mehbod AA, Dykes DC,
456. Park H, Zhang HY, Cho BY, Park JY. Change of lumbar mo- Perra JE. Degenerative lumbar scoliosis: radiographic correla-
Bibliography
tion after multi-level posterior dynamic stabilization with tion of lateral rotatory olisthesis with neural canal dimensions.
bioflex system : 1 year follow up. J Korean Neurosurg Soc. Spine. 2006;31(20):2353-8.
2009;46(4):285-91. 474. Podichetty VK, Spears J, Isaacs RE, Booher J, Biscup RS. Com-
457. Park JH, Hyun SJ, Roh SW, Rhim SC. A comparison of unilater- plications associated with minimally invasive decompression for
al laminectomy with bilateral decompression and fusion surgery lumbar spinal stenosis. J Spinal Disord Tech. 2006;19(3):161-6.
in the treatment of grade I lumbar degenerative spondylolisthe- 475. Posner I, White AA, Edwards WT, Hayes WC. A biomechanical
sis. Acta Neurochir (Wien). 2012;154(7):1205-12. analysis of the clinical stability of the lumbar and lumbosacral
458. Park JY, Chin DK, Cho YE. Accelerated L5-S1 Segment spine. Spine. 1982;7(4):374-89.
Degeneration after Spinal Fusion on and above L4-5 : Mini- 476. Postacchini F, Cinotti G. Bone regrowth after surgical de-
mum 4-Year Follow-Up Results. J Korean Neurosurg Soc. compression for lumbar spinal stenosis. J Bone Joint Surg Br.
2009;45(2):81-4. 1992;74(6):862-9.
459. Park P, Foley KT. Minimally invasive transforaminal lumbar 477. Postacchini F, Cinotti G, Perugia D. Degenerative lumbar spon-
interbody fusion with reduction of spondylolisthesis: technique dylolisthesis. II. Surgical treatment. Ital J Orthop Traumatol.
and outcomes after a minimum of 2 years’ follow-up. Neurosurg 1991;17(4):467-77.
Focus. 2008;25(2):E16. 478. Postacchini F, Cinotti G, Perugia D, Gumina S. The surgical
460. Park SC, Yoon SH, Hong YP, Kim KJ, Chung SK, Kim HJ. Mini- treatment of central lumbar stenosis. Multiple laminotomy
mum 2-year follow-up result of degenerative spinal stenosis compared with total laminectomy. J Bone Joint Surg Br.
treated with interspinous u (coflex). J Korean Neurosurg Soc. 1993;75(3):386-92.
2009;46(4):292-9. 479. Postacchini F, Perugia D. Degenerative lumbar spondylolisthe-
461. Park Y, Ha JW, Lee YT, Sung NY. The effect of a radiographic sis. Part I: Etiology, pathogenesis, pathomorphology, and clini-
solid fusion on clinical outcomes after minimally invasive trans- cal features. Ital J Orthop Traumatol. 1991;17(2):165-73.
foraminal lumbar interbody fusion. Spine J. 2011;11(3):205-12. 480. Potter BK, Freedman BA, Verwiebe EG, Hall JM, Polly DW,
462. Park YK, Chung HS. Instrumented facet fusion for the Kuklo TR. Transforaminal lumbar interbody fusion: clinical
degenerative lumbar disorders. Acta Neurochir (Wien). and radiographic results and complications in 100 consecutive
1999;141(9):915-20. patients. J Spinal Disord Tech. 2005;18(4):337-46.
463. Parker SL, Adogwa O, Bydon A, Cheng J, Mcgirt MJ. Cost- 481. Pratt RK, Fairbank JC, Virr A. The reliability of the Shuttle
effectiveness of minimally invasive versus open transforaminal Walking Test, the Swiss Spinal Stenosis Questionnaire, the
lumbar interbody fusion for degenerative spondylolisthesis Oxford Spinal Stenosis Score, and the Oswestry Disability Index
associated low-back and leg pain over two years. World Neuro- in the assessment of patients with lumbar spinal stenosis. Spine.
surg. 2012;78(1-2):178-84. 2002;27(1):84-91.
464. Parker SL, Mcgirt MJ. Determination of the minimum im- 482. Prolo DJ, Oklund SA, Butcher M. Toward uniformity in evaluat-
provement in pain, disability, and health state associated with ing results of lumbar spine operations. A paradigm applied to
cost-effectiveness: introduction of the concept of minimum posterior lumbar interbody fusions. Spine. 1986;11(6):601-6.
cost-effective difference. Neurosurgery. 2012;71(6):1149-55. 483. Quraishi NA, Lewis SJ, Kelleher MO, Sarjeant R, Rampersaud
465. Parker SL, Mendenhall SK, Shau DN, et al. Minimally Invasive YR, Fehlings MG. Intraoperative multimodality monitoring
versus Open Transforaminal Lumbar Interbody Fusion for in adult spinal deformity: analysis of a prospective series of
Degenerative Spondylolisthesis: Comparative Effectiveness and one hundred two cases with independent evaluation. Spine.
Cost-Utility Analysis. World Neurosurg. 2014;82(1-2):230-238. 2009;34(14):1504-12.
466. Pateder DB, Benzel E. Noninstrumented facet fusion in patients 484. Radcliff K, Hwang R, Hilibrand A, et al. The effect of iliac crest
undergoing lumbar laminectomy for degenerative spondylolis- autograft on the outcome of fusion in the setting of degenera-
thesis. J Surg Orthop Adv. 2010;19(3):153-8. tive spondylolisthesis: a subgroup analysis of the Spine Patient
467. Pearson A, Blood E, Lurie J, et al. Degenerative spondylolis- Outcomes Research Trial (SPORT). J Bone Joint Surg Am.
thesis versus spinal stenosis: does a slip matter? Comparison 2012;94(18):1685-92.
485. Radcliff KE, Rihn J, Hilibrand A, et al. Does the duration of 503. Rosenberg WS, Mummaneni PV. Transforaminal lumbar
symptoms in patients with spinal stenosis and degenerative interbody fusion: technique, complications, and early results.
spondylolisthesis affect outcomes?: analysis of the Spine Out- Neurosurgery. 2001;48(3):569-74.
comes Research Trial. Spine. 2011;36(25):2197-210. 504. Rothman SL, Glenn WV, Kerber CW. Multiplanar CT in the
486. Radu AS, Menkès CJ. Update on lumbar spinal stenosis. Ret- evaluation of degenerative spondylolisthesis. A review of 150
rospective study of 62 patients and review of the literature. Rev cases. Comput Radiol. 1985;9(4):223-32.
Rhum Engl Ed. 1998;65(5):337-45. 505. Rouben D, Casnellie M, Ferguson M. Long-term durability of
487. Raley DA, Mobbs RJ. Retrospective computed tomography scan minimal invasive posterior transforaminal lumbar interbody fu-
analysis of percutaneously inserted pedicle screws for posterior sion: a clinical and radiographic follow-up. J Spinal Disord Tech.
transpedicular stabilization of the thoracic and lumbar spine: 2011;24(5):288-96.
accuracy and complication rates. Spine. 2012;37(12):1092-100. 506. Rousseau MA, Lazennec JY, Bass EC, Saillant G. Predictors of
488. Rampersaud R, Macwan K, Mahomed NN. Spinal Care in a outcomes after posterior decompression and fusion in degenera-
Single-Payer System: The Canadian Example. Semin Spine Surg. tive spondylolisthesis. Eur Spine J. 2005;14(1):55-60.
2012;24(2):117-122. 507. Roy C. Does the diagnosis of spondylolisthesis matter? Pain
489. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings Physician. 2012;15(2).
MG. Cost-utility analysis of posterior minimally invasive fusion 508. Rubery PT. Degenerative spondylolisthesis. Current Opin Or-
compared with conventional open fusion for lumbar spondylo- thop. 2001;12(3):183-188.
listhesis. SAS J. 2011;5(2):29-35. 509. Sachs BL, Zindrick MR, Beasley RD. Reflex sympathetic dystro-
490. Rampersaud YR, Wai EK, Fisher CG, et al. Postoperative phy after operative procedures on the lumbar spine. J Bone Joint
improvement in health-related quality of life: a national Surg Am. 1993;75(5):721-725.
comparison of surgical treatment for focal (one- to two-level) 510. Sanderson PL, Wood PL. Surgery for lumbar spinal stenosis in
lumbar spinal stenosis compared with total joint arthroplasty for old people. J Bone Joint Surg Br. 1993;75(3):393-7.
Bibliography
osteoarthritis. Spine J. 2011;11(11):1033-41. 511. Sandu N, Schaller B, Arasho B, Orabi M. Wallis interspinous im-
491. Ranjith RK, Mullett JH, Burke TE. Hangman’s fracture caused plantation to treat degenerative spinal disease: description of the
by suspected child abuse. A case report. J Pediatr Orthop B. method and case series. Expert Rev Neurother. 2011;11(6):799-
2002;11(4):329-32. 807.
492. Rechtine GR, Sutterlin CE, Wood GW, Boyd RJ, Mansfield FL. 512. Sapkas GS, Mavrogenis AF, Themistocleous GS, Zachos VC,
The efficacy of pedicle screw/plate fixation on lumbar/lumbosa- Kelalis G, Papagelopoulos PJ. Posterior lumbar interbody fusion
cral autogenous bone graft fusion in adult patients with degen- versus circumferential fusion using the B-Twin expandable spi-
erative spondylolisthesis. J Spinal Disord. 1996;9(5):382-91. nal system. J Long Term Eff Med Implants. 2007;17(3):217-27.
493. Reddy SJ, Al-holou WN, Leveque JC, La marca F, Park P. 513. Sasai K, Umeda M, Maruyama T, Wakabayashi E, Iida H. Mi-
Traumatic lateral spondylolisthesis of the lumbar spine with crosurgical bilateral decompression via a unilateral approach for
a unilateral locked facet: description of an unusual injury, lumbar spinal canal stenosis including degenerative spondylolis-
probable mechanism, and management. J Neurosurg Spine. thesis. J Neurosurg Spine. 2008;9(6):554-9.
2008;9(6):576-80. 514. Sato K, Kikuchi S. Clinical analysis of two-level compression
494. Remes V, Lamberg T, Tervahartiala P, et al. Long-term outcome of the cauda equina and the nerve roots in lumbar spinal canal
after posterolateral, anterior, and circumferential fusion for stenosis. Spine. 1997;22(16):1898-903.
high-grade isthmic spondylolisthesis in children and adoles- 515. Sato K, Wakamatsu E, Yoshizumi A, Watanabe N, Irei O.
cents: magnetic resonance imaging findings after average of The configuration of the laminas and facet joints in degen-
17-year follow-up. Spine. 2006;31(21):2491-9. erative spondylolisthesis. A clinicoradiologic study. Spine.
495. Resnick D. Degenerative diseases of the vertebral column. Radi- 1989;14(11):1265-71.
ology. 1985;156(1):3-14. 516. Satomi K, Hirabayashi K, Toyama Y, Fujimura Y. A clinical study
496. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the of degenerative spondylolisthesis. Radiographic analysis and
performance of fusion procedures for degenerative disease of choice of treatment. Spine. 1992;17(11):1329-36.
the lumbar spine. Part 12: pedicle screw fixation as an adjunct 517. Savvidou C, Chatziioannou SN, Pilichou A, Pneumaticos SG.
to posterolateral fusion for low-back pain. J Neurosurg Spine. Efficacy and cost-effectiveness of cell saving blood autotransfu-
2005;2(6):700-6. sion in adult lumbar fusion. Transfus Med. 2009;19(4):202-6.
497. Rihn JA, Radcliff K, Hilibrand AS, et al. Does obesity affect 518. Schaeren S, Broger I, Jeanneret B. Minimum four-year follow-
outcomes of treatment for lumbar stenosis and degenerative up of spinal stenosis with degenerative spondylolisthesis
spondylolisthesis? Analysis of the Spine Patient Outcomes Re- treated with decompression and dynamic stabilization. Spine.
search Trial (SPORT). Spine. 2012;37(23):1933-46. 2008;33(18):E636-42.
498. Robertson PA, Grobler LJ, Novotny JE, Katz JN. Postoperative 519. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous
spondylolisthesis at L4-5. The role of facet joint morphology. transforaminal lumbar interbody fusion for the treatment of
Spine. 1993;18(11):1483-90. degenerative lumbar instability. Neurosurgery. 2007;60(4 Suppl.
499. Robertson PA, Plank LD. Prospective cohort analysis of disabil- 2):203- 212.
ity reduction with lumbar spinal fusion surgery in community 520. Schiffman M, Brau SA, Henderson R, Gimmestad G. Bilateral
practice. J Spinal Disord Tech. 2008;21(4):235-40. implantation of low-profile interbody fusion cages: subsidence,
500. Rodgers WB, Lehmen JA, Gerber EJ, Rodgers JA. Grade 2 lordosis, and fusion analysis. Spine J. 2003;3(5):377-87.
spondylolisthesis at L4-5 treated by XLIF: safety and midterm 521. Schizas C, Tzinieris N, Tsiridis E, Kosmopoulos V. Minimally
results in the “worst case scenario”. ScientificWorldJournal. invasive versus open transforaminal lumbar interbody fusion:
2012;2012:356712. evaluating initial experience. Int Orthop. 2009;33(6):1683-8.
501. Rosenberg NJ. Degenerative spondylolisthesis. Predisposing fac- 522. Schlenzka D, Remes V, Helenius I, et al. Direct repair for treat-
tors. J Bone Joint Surg Am. 1975;57(4):467-474. ment of symptomatic spondylolysis and low-grade isthmic
502. Rosenberg NJ. Degenerative spondylolisthesis: surgical treat- spondylolisthesis in young patients: no benefit in comparison to
ment. Clin Orthop Relat Res. 1976;(117):112-120. segmental fusion after a mean follow-up of 14.8 years. Eur Spine
J. 2006;15(10):1437-47. and two years. J Spinal Disord Tech. 2006;19(6):416-23.

523. Schlenzka D, Seitsalo S, Poussa M, Osterman K. Operative treat- 543. Sirvanci M, Ulusoy L, Duran C. Pedicular stress fracture in
ment of symptomatic lumbar spondylolysis and mild isthmic lumbar spine. Clin Imaging. 2002;26(3):187-93.
spondylolisthesis in young patients: direct repair of the defect or 544. Skowroński J, Wojnar J, Bielecki M. Interbody fusion and trans-
segmental spinal fusion? Eur Spine J. 1993;2(2):104-112. pedicular fixation in the treatment of spondylolisthesis. Ortop
524. Schnake KJ, Schaeren S, Jeanneret B. Dynamic stabilization Traumatol Rehabil. 2007;9(2):149-55.
in addition to decompression for lumbar spinal stenosis with 545. Snider RK, Krumwiede NK, Snider LJ, Jurist JM, Lew RA, Katz
degenerative spondylolisthesis. Spine. 2006;31(4):442-449. JN. Factors affecting lumbar spinal fusion. J Spinal Disord.
525. Schnee CL, Freese A, Ansell LV. Outcome analysis for adults 1999;12(2):107-14.
with spondylolisthesis treated with posterolateral fusion and 546. Soegaard R, Bünger CE, Christiansen T, Høy K, Eiskjaer SP,
transpedicular screw fixation. J Neurosurg. 1997;86(1):56-63. Christensen FB. Circumferential fusion is dominant over pos-
526. Schuller S, Charles YP, Steib JP. Sagittal spinopelvic alignment terolateral fusion in a long-term perspective: cost-utility evalua-
and body mass index in patients with degenerative spondylolis- tion of a randomized controlled trial in severe, chronic low back
thesis. Eur Spine J. 2011;20(5):713-9. pain. Spine. 2007;32(22):2405-14.
527. Schulte TL, Leistra F, Bullmann V, et al. Disc height reduction 547. Soegaard R, Christensen FB. Health economic evaluation in
in adjacent segments and clinical outcome 10 years after lumbar lumbar spinal fusion: A systematic literature review anno 2005.
360 degrees fusion. Eur Spine J. 2007;16(12):2152-8. Eur Spine J. 2006;15(8):1165-1173.
528. Schulte TL, Schubert T, Winter C, et al. Step activity monitoring 548. Soini J, Slätis P, Kannisto M, Sandelin J. External transpe-
in lumbar stenosis patients undergoing decompressive surgery. dicular fixation test of the lumbar spine correlates with the
Eur Spine J. 2010;19(11):1855-64. outcome of subsequent lumbar fusion. Clin Orthop Relat Res.
529. Schwender JD, Holly LT, Rouben DP, Foley KT. Minimally 1993;(293):89-96.
invasive transforaminal lumbar interbody fusion (TLIF): techni- 549. Song KJ, Lee KB. Spontaneous fusion of L5-S1 isthmic spondy-
Bibliography
cal feasibility and initial results. J Spinal Disord Tech. 2005;18 lolisthesis. J Back Musculoskel Rehabil. 2007;20(4):177-179.
Suppl:S1-6. 550. Sonntag VK, Marciano FF. Is fusion indicated for lumbar spinal
530. Sears W. Posterior lumbar interbody fusion for degenerative disorders?. Spine. 1995;20(24 Suppl):138S-142S.
spondylolisthesis: restoration of sagittal balance using insert- 551. Soren A, Waugh TR. Spondylolisthesis and related disorders.
and-rotate interbody spacers. Spine J. 2005;5(2):170-9. A correlative study of 105 patients. Clin Orthop Relat Res.
531. Sengupta DK. Point of view: Dynamic stabilization in addition 1985;(193):171-7.
to decompression for lumbar spinal stenosis with degenerative 552. St Clair S, Tan JS, Lieberman I. Oblique lumbar interbody fixa-
spondylolisthesis. Spine. 2006;31(4):450. tion: a biomechanical study in human spines. J Spinal Disord
532. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis. Treat- Tech. 2012;25(4):183-9. Stoll, T. M., Dubois, G., & Schwar-
ment strategies and indications for surgery. Orthop Clin North zenbach, O. (2002). The dynamic neutralization system for
Am. 2003;34(2):281-95. the spine: a multi-center study of a novel non-fusion system.
533. Sengupta DK, Herkowitz HN. Degenerative spondylolisthesis: European Spine Journal, 11 Suppl 2, S170-178.
review of current trends and controversies. Spine. 2005;30(6 553. Stone AT, Tribus CB. Acute progression of spondylolysis to isth-
Suppl):S71-81. mic spondylolisthesis in an adult. Spine. 2002;27(16):E370-2.
534. Sharma AK, Kepler CK, Girardi FP, Cammisa FP, Huang 554. Stovall R, Halliday A. Degenerative lumbar spondylolisthesis:
RC, Sama AA. Lateral lumbar interbody fusion: clinical and Treatment strategies. Semin Neurosurg. 2000;11(2):193-205.
radiographic outcomes at 1 year: a preliminary report. J Spinal 555. Stucki G, Daltroy L, Liang MH, Lipson SJ, Fossel AH, Katz JN.
Disord Tech. 2011;24(4):242-50. Measurement properties of a self-administered outcome mea-
535. Sheehan JM, Shaffrey CI, Jane JA. Degenerative lumbar ste- sure in lumbar spinal stenosis. Spine. 1996;21(7):796-803.
nosis: the neurosurgical perspective. Clin Orthop Relat Res. 556. Sugawara A, Isu T, Kim K, et al. (2012). Surgical results using
2001;(384):61-74. only posterior decompression for lumbar canal stenosis with
536. Shen M, Razi A, Lurie JD, Hanscom B, Weinstein J. Retrolis- lumbar degenerative spondylolisthesis. Japanese J Neurosurg.
thesis and lumbar disc herniation: a preoperative assessment of 2012;21(2) 111-117.
patient function. Spine J. 2007;7(4):406-13. 557. Surace MF, Fagetti A, Fozzato S, Cherubino P. Lumbar spinal
537. Shen NJ, Lin MX, Lin QB, Wang XA, Chen J, Wang GJ. Do- stenosis treatment with Aperius perclid interspinous system.
mestic vertebral internal fixation system for treating lumbar Eur Spine J. 2012;21 Suppl 1:S69-74.
spondylolisthesis in 55 cases. A follow-up study. J Clin Rehabil 558. Tajima N, Chosa E, Watanabe S. Posterolateral lumbar fusion. J
Tissue Eng Res. 2009;13(9):1793-1796. Orthop Sci. 2004;9(3):327-333.
538. Sienkiewicz PJ, Flatley TJ. Postoperative spondylolisthesis. Clin 559. Takahashi K, Kitahara H, Yamagata M, et al. Long-term results
Orthop Relat Res. 1987;(221):172-180. of anterior interbody fusion for treatment of degenerative spon-
539. Siewe J, Otto C, Knoell P, et al. Comparison of standard fusion dylolisthesis. Spine. 1990;15(11):1211-1215.
with a “topping off ” system in lumbar spine surgery: a protocol 560. Takahashi T, Hanakita J, Minami M, et al. Clinical outcomes
for a randomized controlled trial. BMC Musculoskelet Disord. and adverse events following transforaminal interbody fusion
2011;12:239. for lumbar degenerative spondylolisthesis in elderly patients.
540. Silvers HR, Lewis PJ, Asch HL. Decompressive lumbar laminec- Neurol Med Chir (Tokyo). 2011;51(12):829-35.
tomy for spinal stenosis. J Neurosurg. 1993;78(5):695-701. 561. Takayanagi K, Takahashi K, Yamagata M, Moriya H, Kitahara H,
541. Sinaki M, Lutness MP, Ilstrup DM, Chu CP, Gramse RR. Lum- Tamaki T. Using cineradiography for continuous dynamic-mo-
bar spondylolisthesis: retrospective comparison and three-year tion analysis of the lumbar spine. Spine. 2001;26(17):1858-65.
follow-up of two conservative treatment programs. Arch Phys 562. Tanaka M, Shimizu H, Yato Y, Asazuma T, Nemoto K. Acute
Med Rehabil. 1989;70(8):594-8. pyogenic discitis in a degenerative intervertebral disc in an
542. Singh K, Smucker JD, Gill S, Boden SD. Use of recombinant hu- adult. Int Med Case Rep J. 2010;3:77-80.
man bone morphogenetic protein-2 as an adjunct in posterolat- 563. Tarantino U, Fanucci E, Iundusi R, et al. Lumbar spine MRI
eral lumbar spine fusion: a prospective CT-scan analysis at one in upright position for diagnosing acute and chronic low back
pain: statistical analysis of morphological changes. J Orthop 584. Vaccaro AR, Garfin SR. Degenerative lumbar spondylolisthesis
Traumatol. 2013;14(1):15-22. with spinal stenosis, a prospective study comparing decompres-
564. Taylor JA, Bussières A. Diagnostic imaging for spinal disor- sion with decompression and intertransverse process arthrod-
ders in the elderly: a narrative review. Chiropr Man Therap. esis: a critical analysis. Spine. 1997;22(4):368-9.
2012;20(1):16. 585. Vaccaro AR, Lawrence JP, Patel T, et al. The safety and efficacy
565. Templin CR, Garfin SR. Surgical Management of Scoliosis and/ of OP-1 (rhBMP-7) as a replacement for iliac crest autograft in
or Spondylolisthesis Associated with Spinal Stenosis. Sem Spine posterolateral lumbar arthrodesis: a long-term (>4 years) pivotal
Surg. 2007;19(3):187-199. study. Spine. 2008;33(26):2850-62.
566. Teplick JG, Laffey PA, Berman A, Haskin ME. Diagnosis and 586. Vaccaro AR, Patel T, Fischgrund J, et al. A pilot safety and
evaluation of spondylolisthesis and/or spondylolysis on axial efficacy study of OP-1 putty (rhBMP-7) as an adjunct to iliac
CT. AJNR Am J Neuroradiol. 1986;7(3):479-491. crest autograft in posterolateral lumbar fusions. Eur Spine J.
567. Terao T, Ishii T, Tani S, Abe T. Combination therapy of radiofre- 2003;12(5):495-500.
quency lumbar facet joint denervation and epidural spinal cord 587. Vaccaro AR, Patel T, Fischgrund J, et al. A 2-year follow-up pilot
stimulation for failed back surgery syndrome. Neurol Med Chir study evaluating the safety and efficacy of op-1 putty (rhbmp-7)
(Tokyo). 2011;51(11):805-9. as an adjunct to iliac crest autograft in posterolateral lumbar
568. Tile M, McNeil SR, Zarins RK, Pennal GF, Garside SH. fusions. Eur Spine J. 2005;14(7):623-9.
Spinal stenosis. Results of treatment. Clin Orthop Relat Res. 588. Vaccaro AR, Patel T, Fischgrund J, et al. A pilot study evaluating
1976;115:104-108. safety and efficacy of OP-1 putty (rhBMP-7) as a replacement
569. Tillich M, Trummer M, Lindbichler F, Flaschka G. Symptomatic for iliac crest autograft in posterolateral lumbar arthrodesis for
intraspinal synovial cysts of the lumbar spine: correlation of MR degenerative spondylolisthesis. Spine 2004;29:1885-92.
and surgical findings. Neuroradiology. 2001;43(12):1070-5. 589. Vaccaro AR, Stubbs HA, Block JE. Demineralized bone matrix
570. Tokuhashi Y, Ajiro Y, Umezawa N. Follow-up of patients with composite grafting for posterolateral spinal fusion. Orthopedics.
Bibliography
delayed union after posterior fusion with pedicle screw fixation. 2007;30(7):567-70.
Spine. 2008;33(7):786-91. 590. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy
571. Tokuhashi Y, Ajiro Y, Umezawa N. Subsidence of metal inter- of OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
body cage after posterior lumbar interbody fusion with pedicle posterolateral lumbar arthrodesis: minimum 4-year follow-up of
screw fixation. Orthopedics. 2009;32(4):259. a pilot study. Spine J. 2008;8(3):457-65.
572. Tokuhashi Y, Matsuzaki H, Sano S. Evaluation of clinical lumbar 591. Vamvanij V, Ferrara LA, Hai Y, Zhao J, Kolata R, Yuan HA.
instability using the treadmill. Spine. 1993;18(15):2321-4. Quantitative changes in spinal canal dimensions using interbody
573. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Matsu- distraction for spondylolisthesis. Spine. 2001;26(3):E13-8.
da H. Clinical outcome of microsurgical bilateral decompression 592. Van den heuvel R, Hertel M, Gallagher J, Naidoo V. A toddler
via unilateral approach for lumbar canal stenosis: minimum who refused to stand or walk: lumbar spondylodiscitis. BMJ
five-year follow-up. Spine. 2011;36(5):410-5. Case Rep. 2012;2012
574. Trayneli, VC. Comments. Neurosurgery. 2009;64(5):963-964. 593. Van oostrom SH, Driessen MT, De vet HC, et al. Workplace
575. Truumees E. The Role of Fusion in Degenerative Lumbar Dis- interventions for preventing work disability. Cochrane Database
ease. Semin Spine Surg. 2003;15(4):430-459. Syst Rev. 2009;(2):CD006955.
576. Tsai KH, Chang GL, Lin HT, Kuo DC, Chang LT, Lin RM. Dif- 594. Vanek P, Saur K. Transforaminal lumbar interbody fusion
ferences of lumbosacral kinematics between degenerative and (TLIF) and instruments. Prospective study with the minimum
induced spondylolisthetic spine. Clin Biomech (Bristol, Avon). of 20-month follow-up. Cesk Neurol Neurochir. 2007;70(5):552-
2003;18(6):S10-6. 557.
577. Tsutsumimoto T, Shimogata M, Ohta H, Misawa H. Mini-open 595. Verhoof OJ, Bron JL, Wapstra FH, Van royen BJ. High failure
versus conventional open posterior lumbar interbody fusion for rate of the interspinous distraction device (X-Stop) for the treat-
the treatment of lumbar degenerative spondylolisthesis: comment of lumbar spinal stenosis caused by degenerative spondy-
parison of paraspinal muscle damage and slip reduction. Spine. lolisthesis. Eur Spine J. 2008;17(2):188-92.
2009;34(18):1923-8. 596. Vibert BT, Sliva CD, Herkowitz HN. Treatment of instability and
578. Tsutsumimoto T, Shimogata M, Yoshimura Y, Misawa H. Union spondylolisthesis: surgical versus nonsurgical treatment. Clin
versus nonunion after posterolateral lumbar fusion: a compari- Orthop Relat Res. 2006;443:222-7.
son of long-term surgical outcomes in patients with degenera- 597. Virk S, Sandhu HS, Khan SN. Cost effectiveness analysis of graft
tive lumbar spondylolisthesis. Eur Spine J. 2008;17(8):1107-12. options in spinal fusion surgery using a Markov model. J Spinal
579. Turunen V, Nyyssönen T, Miettinen H, et al. Lumbar instru- Disord Tech. 2012;25(7):E204-10.
mented posterolateral fusion in spondylolisthetic and failed 598. Vital JM, Gille O, Pointillart V, et al. Course of Modic 1
back patients: a long-term follow-up study spanning 11-13 six months after lumbar posterior osteosynthesis. Spine.
years. Eur Spine J. 2012;21(11):2140-8. 2003;28(7):715-20.
580. Unnanantana A. Posterolateral lumbar fusion for degenerative 599. Vitzthum HE, König A, Seifert V. Dynamic examination of the
spondylolisthesis: experiences of a modified technique without lumbar spine by using vertical, open magnetic resonance imag-
instrumentation. J Med Assoc Thai. 1997;80(9):570-4. ing. J Neurosurg. 2000;93(1 Suppl):58-64.
581. Vaccaro A. Unilateral approach for microsurgical decompres- 600. Vogt MT, Rubin D, Valentin RS, et al. Lumbar olisthesis and
sion. J Neurosurg Spine. 2008;9(6):552-3. lower back symptoms in elderly white women. The Study of
582. Vaccaro AR, Anderson DG, Patel T, et al. Comparison of OP-1 Osteoporotic Fractures. Spine. 1998;23(23):2640-7.
Putty (rhBMP-7) to iliac crest autograft for posterolateral lum- 601. Wang HL, Lü FZ, Jiang JY, Ma X, Xia XL, Wang LX. Minimally
bar arthrodesis: a minimum 2-year follow-up pilot study. Spine. invasive lumbar interbody fusion via MAST Quadrant retrac-
2005;30(24):2709-16. tor versus open surgery: a prospective randomized clinical trial.
583. Vaccaro AR, Garfin SR. Internal fixation (pedicle screw fixation) Chin Med J. 2011;124(23):3868-74.
for fusions of the lumbar spine. Spine. 1995;20(24 Suppl):157S- 602. Wang J, Yang X. Age-related changes in the orientation of lum-
165S. bar facet joints. Spine. 2009;34(17):E596-8.
603. Watters WC. If, when, and how to fuse when treating lumbar spacer. Arch Orthop Trauma Surg. 2011;131(6):791-6.
degenerative stenosis. Semin Spine Surg. 2011;23(4):218-221. 620. Yao Q, Wang S, Shin JH, Li G, Wood KB. Lumbar facet joint
604. Watters WC, Bono CM, Gilbert TJ, et al. An evidence-based motion in patients with degenerative spondylolisthesis. J Spinal
clinical guideline for the diagnosis and treatment of degenera- Disord Tech. 2013;26(1):E19-27.
tive lumbar spondylolisthesis. Spine J. 2009;9(7):609-14. 621. Yee AJ, Yoo JU, Marsolais EB, et al. Use of a postoperative
605. Weiner BK, Walker M. Efficacy of autologous growth factors in lumbar corset after lumbar spinal arthrodesis for degenerative
lumbar intertransverse fusions. Spine. 2003;28:1968-1971. conditions of the spine. A prospective randomized trial. J Bone
606. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non- Joint Surg Am. 2008;90(10):2062-8.
surgical treatment for lumbar degenerative spondylolisthesis. N 622. Yone K, Sakou T, Kawauchi Y, Yamaguchi M, Yanase M. Indica-
Engl J Med. 2007;356(22):2257-70. tion of fusion for lumbar spinal stenosis in elderly patients and
607. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared its significance. Spine. 1996;21(2):242-8.
with nonoperative treatment for lumbar degenerative spon- 623. Yong-hing K. Pathophysiology and rationale for treatment
dylolisthesis. four-year results in the Spine Patient Outcomes in lumbar spondylosis and instability. Chir Organi Mov.
Research Trial (SPORT) randomized and observational cohorts. 1994;79(1):3-10.
J Bone Joint Surg Am. 2009;91(6):1295-304. 624. Yoshimoto H, Sato S, Nakagawa I, et al. Deep vein thrombosis
608. Welch WC, Cheng BC, Awad TE, et al. Clinical outcomes of due to migrated graft bone after posterior lumbosacral inter-
the Dynesys dynamic neutralization system: 1-year preliminary body fusion. Case report. J Neurosurg Spine. 2007;6(1):47-51.
results. Neurosurg Focus. 2007;22(1):E8. 625. Yue WM, Tan SB. Distant skip level discitis and vertebral osteo-
609. Whitecloud TS, Castro FP, Brinker MR, Hartzog CW, Ricciardi myelitis after caudal epidural injection: a case report of a rare
JE, Hill C. Degenerative conditions of the lumbar spine treated complication of epidural injections. Spine. 2003;28(11):E209-11.
with intervertebral titanium cages and posterior instrumenta- 626. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
tion for circumferential fusion. J Spinal Disord. 1998;11(6):479- results of pediculo-body fixation and posterolateral fusion for
Bibliography
86. lumbar spondylolisthesis. Eur Spine J. 2009;18 Suppl 1:151-5.
610. Wildermuth S, Zanetti M, Duewell S, et al. Lumbar spine: 627. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
quantitative and qualitative assessment of positional (upright non-surgical treatment for lumbar spinal stenosis. Cochrane
flexion and extension) MR imaging and myelography. Radiol- Database Syst Rev. 2012;(12):CD010264.
ogy. 1998;207(2):391-8. 628. Zdeblick TA. A prospective, randomized study of lumbar fu-
611. Willems P. Decision making in surgical treatment of chronic low sion. Preliminary results. Spine. 1993;18(8):983-991.
back pain: the performance of prognostic tests to select patients 629. Zhang HY, Park JY, Cho BY. The BioFlex System as a Dynamic
for lumbar spinal fusion. Acta Orthop Suppl. 2013;84(349):1-35. Stabilization Device : Does It Preserve Lumbar Motion?. J Ko-
612. Wiltse LL, Guyer RD, Spencer CW, Glenn WV, Porter IS. Alar rean Neurosurg Soc. 2009;46(5):431-6.
transverse process impingement of the L5 spinal nerve: the far- 630. Zhang YF, Yang HL, Tang TS, Shi Y. Mobilization range of the
out syndrome. Spine. 1984;9(1):31-41. vertebral bodies after treatment of lumbar instability with tita-
613. Wood GW, Boyd RJ, Carothers TA, et al. The effect of pedicle nium-coated fusion cage. Chin J Clin Rehabil. 2005;9(10):204-
screw/plate fixation on lumbar/lumbosacral autogenous bone 205.
graft fusions in patients with degenerative disc disease. Spine. 631. Zhang ZM, Jin DD, Chen JT. [Comparative study of dynamic
1995;20(7):819-30. fixation with rigid fixation in the management of degenerative
614. Wood KB, Popp CA, Transfeldt EE, Geissele AE. Radio- lumbar spondylosis]. Zhonghua Wai Ke Za Zhi. 2008;46(5):346-
graphic evaluation of instability in spondylolisthesis. Spine. 9.
1994;19(15):1697-1703. 632. Zhao J, Hou T, Wang X, Ma S. Posterior lumbar interbody fu-
615. Xiao YX, Chen QX, Li FC. Unilateral transforaminal lumbar in- sion using one diagonal fusion cage with transpedicular screw/
terbody fusion: a review of the technique, indications and graft rod fixation. Eur Spine J. 2003;12(2):173-7.
materials. J Int Med Res. 2009;37(3):908-17. 633. Zhao J, Wang X, Hou T, He S. One versus two BAK fusion
616. Xu H, Tang H, Li Z. Surgical treatment of adult degenerative cages in posterior lumbar interbody fusion to L4-L5 degenera-
spondylolisthesis by instrumented transforaminal lumbar inter- tive spondylolisthesis: a randomized, controlled prospective
body fusion in the Han nationality: Clinical article. J Neurosurg study in 25 patients with minimum two-year follow-up. Spine.
Spine. 2009;10(5):496-499. 2002;27(24):2753-7.
617. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz 634. Zhao Y, Wang YP, Qiu GX, Zhao H, Zhang JG, Zhou X. Ef-
TE. The utility of repeated postoperative radiographs after lum- ficacy of the Dynamic Interspinous Assisted Motion system in
bar instrumented fusion for degenerative lumbar spine. Spine. clinical treatment of degenerative lumbar disease. Chin Med J.
2011;36(23):1955-60. 2010;123(21):2974-7.
618. Yan DL, Pei FX, Li J, Soo CL. Comparative study of PILF and 635. Zhou J, Wang B, Dong J, et al. Instrumented transforaminal
TLIF treatment in adult degenerative spondylolisthesis. Eur lumbar interbody fusion with single cage for the treatment
Spine J. 2008;17(10):1311-6. of degenerative lumbar disease. Arch Orthop Trauma Surg.
619. Yao N, Wang W, Liu Y. Percutaneous endoscopic lumbar dis- 2011;131(9):1239-45.
cectomy and interbody fusion with B-Twin expandable spinal 636. Zouboulis P, Panagiotis ZE, Karageorgos A, et al. Functional
outcome of surgical treatment for multilevel lumbar spinal
stenosis. Acta Orthop. 2006;77(4):670-6

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Introduction/Guideline Methodology

Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis | NASS Clinical Guidelines 1

Evidence-Based Clinical Guidelines for Multidisciplinary

Diagnosis and Treatment of

NASS Evidence-Based Clinical Guidelines Committee

North American Spine Society

II. Guideline Development Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III. Recommendation Summary: Comparison of 2008 and Current Recommendations . . . . . . . . . . 8

IV. Definition for Degenerative Lumbar Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

V. Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis . . 16

II. Guideline Development Methodology

Consensus Development Process

III. Recommendation Summary

present with sensory changes, muscle eliminated from this guideline.

Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation

Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation

There is no universally accepted standard to

Grade of Recommendation: I (Insufficient

The Shuttle Walking Test (SWT), Oxford

Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation

Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation

interventional treatment. Evidence)

Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation

Clinical Question 2008 Guideline Recommendation Current Guideline Reccomendation

of patients undergoing treatment for degenerative

IV. Definition of Degenerative Lumbar

An acquired anterior displacement of one vertebra over the subjacent

Definition for Degenerative Lumbar

V. Recommendations for Diagnosis and

In the absence of evidence to address this question, it is the work group’s

In patients with imaging evidence of degenerative lumbar

Original Guideline Question:

The lateral radiograph is the most appropriate, noninvasive test for

Level II diagnostic evidence that an effusion >1.5 mm is predic-

tive of degenerative spondylolisthesis and the increasing size of

erative spondylolisthesis than those with spinal stenosis without

spondylolisthesis. In critique, use of a 15mm2 criterion as sig-

regular joint was noted in 91 patients. Severe canal stenosis was

els was present in 92% of these patients. The authors concluded

CLJ, Vaccaro AR. Surgeons agree to disagree on surgical options

New Guideline Question:

There is insufficient evidence to make a recommendation on the most

There is no universally accepted standard to diagnose fixed versus

J Orthop Traumatol. 2011;12(2):87-91.

2004;29(9):1049-1055. ing in lumbar degenerative diseases indicating segmental insta-

C. The transition zone above a lumbosacral fusion. Spine. 2006;31(10):E298-301.

Spine J. 2009;18(6):815-822. 102. Molina M, Wagner P, Campos M Spinal lumbar stenosis. An

New Guideline Question:

sis. Spine 2007;32(17):1883-1887.

B. Outcome Measures for Medical/Interventional and

Original Guideline Question:

Recommendations for Diagnosis and Treatment

C. Medical and Interventional Treatment

An updated systematic review of the literature yielded no studies to adequately

• What is the role of pharmacological treatment in the management of degenerative lumbar

Original Guideline Question:

Medical/interventional treatment for degenerative lumbar

Treatment recommendations and the supporting evidence are Recommendation #1:

tient symptomatology (eg, axial back pain only, combination of

3. Aliabadi H, Isaacs R. Lumbar spinal stenosis: A brief review.

Original Guideline Question:

Direct surgical decompression may be considered for the treatment of

There is insufficient evidence to make a comparing surgical to medical/interventional treatment in the