Summary of Guidelines for

t h e Tre a t m e n t o f L u m b a r
Spondylolisthesis
Andrew K. Chan, MD*, Viraj Sharma,
Leslie C. Robinson, MD, PharmD, MBA,
Praveen V. Mummaneni, MD

KEYWORDS
 Degenerative lumbar spondylolisthesis  Spinal laminectomy  Spinal fusion
 Spinal decompression  Clinical guidelines  Interbody  Minimally invasive surgery

KEY POINTS
 Despite the prevalence of the condition, controversy exists regarding the optimal management
strategy for patients with degenerative lumbar spondylolisthesis.
 Surgical treatment of degenerative lumbar spondylolisthesis results in superior clinical outcomes
compared with nonsurgical treatment.
 The addition of fusion to decompression for surgical treatment of lumbar spondylolisthesis may
result in superior clinical outcomes and lower reoperation rates, although this is not consistent
through all available research.
 Research has shown MIS to have comparable clinical outcomes with open fusion, at a reduced
cost, shorter time, decreased blood loss, and shorter length of stay in the hospital.
 Aside from anatomic and clinical considerations, there is no clear evidence supporting the use of
one interbody technique over another. There is inconsistent evidence with regard to patient-re-
ported outcomes and further comparative study is required.

INTRODUCTION Despite the prevalence of the condition, contro-

Degenerative lumbar spondylolisthesis is a com-
mon cause of low back pain, affecting about
11.5% of the United States population1 (Fig. 1A).
Patients with symptomatic lumbar spondylolisthe-
sis may first be treated with conservative manage-
ment strategies including but not limited to non-
narcotic and narcotic pain medications, epidural
steroid injections, transforaminal injections, and
physical therapy.2,3 For well-selected patients
who fail conservative management strategies, sur-
gical management is appropriate.
versy exists regarding the optimal management
strategy for patients with spondylolisthesis. This
point is highlighted by the differing findings in 2
recent randomized controlled trials (RCTs) investi-
gating the benefit of the addition of arthrodesis to
decompression for spondylolisthesis surgery.4,5
Even among surgeons proceeding with fusion,
multiple considerations exist including (1) the inva-
siveness of surgery, (2) the direction of approach,
and (3) whether to use one or a combination
of segmental instrumentation, posterolateral
fusion, and/or interbody fusion. Nonetheless,
neurosurgery.theclinics.com

Disclosures: Dr. A.K. Chan: research support for non-related study from Orthofix. Dr P.V. Mummaneni: consul-
tant for DePuy Spine, Globus, and Stryker; direct stock ownership in Spinicity/ISD; clinical/research support for
non-related study from NREF; royalties from DePuy Spine, Thieme Publishers, and Springer Publishers; grant
from AOSpine; and honoraria from Spineart.
Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue M779, San
Francisco, CA 94143, USA
* Corresponding author.
E-mail address: andrew.chan@ucsf.edu

Neurosurg Clin N Am 30 (2019) 353–364

https://doi.org/10.1016/j.nec.2019.02.009
1042-3680/19/Ó 2019 Elsevier Inc. All rights reserved.
354 Chan et al
evidence-based guidelines are incompletely
defined because of the relative paucity of high-
quality, comparative investigation within the perti-
nent study population. Indeed, in a recent expert
panel survey in 2016, 34 clinical questions were
posed on the diagnosis and treatment of degener-
ative lumbar spondylolisthesis, of which no ques-
tions had consistent Level I evidence to support
a recommendation, and of which 17 questions
had insufficient or conflicting evidence.6,7
In this context, this article summarizes the cur-
rent literature on the surgical management of lum-
bar spondylolisthesis and synthesizes the
evidence into recommendations and guidelines.
METHODS
A systematic literature review was conducted on-
line through the PubMed database. The following
search terms were used to find relevant literature
specific to lumbar spondylolisthesis: (“lumbar
spondylolisthesis” OR “degenerative lumbar
spondylolisthesis” OR “lumbar degenerative
spondylolisthesis”). These results were filtered to
include only clinical trials, retrospective and pro-
spective analyses, and meta-analytical studies in
English and with human subjects, yielding 365 re-
sults. Manuscripts involving basic science, case
reports, editorials, and nonstructured reviews
were excluded. Titles and abstracts were reviewed
to identify studies that held (1) comparative data
Fig. 1. (A) Preoperative and (B) postop-
erative lateral 36-inch radiographs of a
75-year-old woman who presented
with low back pain radiating into her
legs from grade 1 L4-5 degenerative
lumbar spondylolisthesis with severe
stenosis. Her symptoms were addressed
with L4-5 transforaminal lumbar inter-
body fusion surgery.
and (2) a population of patients with degenerative
lumbar spondylolisthesis. A total of 63 studies
were deemed relevant by title and abstract alone.
After full text reviews and searching the refer-
ence sections of these studies, a total of 46 studies
were included in the present review, 37 of which
were used for evidence-based recommendations
(Fig. 2). Levels of recommendation are summa-
rized in Table 1.
SURGICAL VERSUS CONSERVATIVE
MANAGEMENT
Recommendation: Grade A
Evidence shows superior results for patients
receiving surgical treatment compared with
nonsurgical treatment of degenerative lumbar
spondylolisthesis.2
Evidence
In the randomized controlled Spine Patient Out-
comes Research Trial (SPORT), Weinstein and col-
leagues2 followed 324 patients receiving surgical
treatment and 187 patients receiving nonsurgical
treatment for degenerative lumbar spondylolisthe-
sis over a 2-year period. Surgical treatments per-
formed included decompression, fusion without
instrumentation, or fusion with instrumentation. Pa-
tients receiving surgical treatment had significantly
greater improvements in Short Form-36 (SF-36)

and Oswestry Disability Index (ODI) outcomes at
3 months than those receiving nonsurgical treat-
ment. This improvement gap was maintained
throughout the 2-year follow-up, with an 18.1-point
difference in SF-36 and a 16.7-point difference in
ODI in favor of the surgery group. Furthermore,
74.1% of the surgery patients noted major
improvement in their symptoms, whereas only
24.1% of the nonsurgical treatment patients noted
similar improvement. Therefore, SPORT provides
Level I evidence that surgery is effective at treating
degenerative lumbar spondylolisthesis. Note-
worthy is that SPORT patients additionally had
lumbar stenosis, and 86% had grade 1 slippage
with the remainder having grade 2 slippage. Those
receiving decompression only and those receiving
fusions were not directly compared, and the vast
majority (94%) of patients in the surgical cohort
were treated with decompression and fusion.
Other studies4,8–10 show moderate to excellent
rates of satisfactory results for surgical treatment
of degenerative spondylolisthesis with spinal steno-
sis, ranging from 66%4 to 96%.8 Considering avail-
able evidence, a majority of patients should expect
Table 1
Grades of recommendation
Grade A Good evidence (Level I evidence
with consistent findings)
Grade B Fair evidence (Level II or III
evidence with consistent
findings)
Grade C Conflicting or poor-quality
evidence (less than Level III
evidence)
Grade I Insufficient evidence to make
a recommendation
Treatment of Lumbar Spondylolisthesis 355
Fig. 2. Flow chart summarizing study
selection.
clinical improvement when given surgical treatment
appropriate for their individual conditions.
THE ADDITION OF FUSION TO
DECOMPRESSION
Recommendation: Grade C
Although there is randomized (Level I) and pro-
spective (Level II) evidence favoring the addition
of fusion for spondylolisthesis surgery,5,8,10,11
there is also Level I evidence demonstrating non-
superiority of the addition of fusion.4 Therefore,
there is conflicting evidence not allowing for a
recommendation for or against the addition of
fusion. More long-term, high-quality (RCT, pro-
spective registry) research is needed.
Evidence
The Spinal Laminectomy versus Instrumented
Pedicle Screw (SLIP) trial conducted by Ghoga-
wala and colleagues5 provides evidence as to
whether laminectomy with the addition of fusion
is superior to laminectomy alone. The study
included 66 patients with grade 1 spondylolisthe-
sis with lumbar stenosis; patients with lumbar
instability and previous lumbar surgery were
excluded. Results showed significant differences
in change from baseline at the 3-month through
4-year follow-ups for SF-36 scores, in favor of
the fusion group. At 3 months, the fusion group
had SF-36 scores 4.5 points higher than the
decompression-alone group, on average. This
increased to a 6.7-point advantage at 4 years.
The fusion group also had a greater improvement
in ODI scores at 3 months through 4 years,
although the differences were not significant. Of
note, SF-36 and ODI scores tended to decline after
1-year follow-up for the decompression-alone
group, although this was statistically insignificant
as well. Overall, the SLIP trial provides Level I
356 Chan et al
evidence that decompression with fusion yields
greater improvement in quality of life and is asso-
ciated with lower reoperation rates than decom-
pression alone (14% vs 34%).
The results of the SLIP trial somewhat differ from
a similar RCT by Försth and colleagues4 (Swedish
Spinal Stenosis Study [SSSS]), but ultimately the 2
studies are not directly comparable. Indeed, the 2
studies consist of heterogeneous populations, use
different outcome measures, and contain nonuni-
form surgical techniques. The study by Försth
and colleagues4 included patients with stenosis
and separated them into subgroups with and
without degenerative spondylolisthesis. However,
dynamic lumbar radiographs were not included,
so this study could not differentiate between pa-
tients with and without radiographic instability
and mobile listhesis. In other words, instability
was not an exclusion factor.12 Furthermore, a het-
erogeneous population was present because pa-
tients with both 1 and 2 levels of disease were
included (the SLIP trial contained a homogeneous
population of patients with nonmobile, single-level
spondylolisthesis). In the SSSS, a total of 247 pa-
tients were randomized into either a decompres-
sion with fusion group or decompression-alone
group. Two years after surgery, there was no sig-
nificant difference between the 2 groups in terms
of ODI score, the primary outcome measure. Of
note, the study was likely underpowered to detect
differences in ODI for patients with single-level ste-
nosis and spondylolisthesis.8,13 EuroQoL-5D (EQ-
5D) scores and patient satisfaction rates were also
similar. Försth and colleagues4 provide Level I
evidence that suggest clinical outcomes do not
differ significantly in a heterogeneous population
receiving various lengths of fusion compared
with those receiving decompression alone, but it
is unclear how many patients had mobile spondy-
lolisthesis with associated preoperative back pain
(owing to lack of dynamic radiographs).
Herkowitz and Kurz8 conducted a similar study of
a heterogeneous sample of 50 patients with
lumbar stenosis and degenerative spondylolisthe-
sis. Severity of disease varied among the patients,
and the patients were divided evenly into a
decompression-alone cohort (n 5 25) and a decom-
pression with posterolateral fusion (PLF) cohort
(n 5 25). During 3-year follow-up, all but one patient
(96%; 24/25) in the fusion group had satisfactory re-
sults, compared with only 11 (44%; 11/25) satisfac-
tory results in the decompression-alone group.
A multicenter, retrospective study by
Rampersaud and colleagues14 included 46
decompression-alone patients and 133 decom-
pression with fusion (PLF and/or interbody fusion)
patients, all of whom were receiving treatment at 1
or 2 levels of stenosis with degenerative lumbar
spondylolisthesis. Of note, the decompression-
alone group contained patients with grade I spon-
dylolisthesis only, while the fusion group also
included patients who had grade II or higher listhe-
sis. Two years postoperatively both groups
improved in SF-36 scores, but no significant differ-
ences were found between the 2 groups. Sixty-
eight percent of decompression-alone patients
and 73% of fusion patients reached minimum clin-
ically important difference (MCID) in the SF-36
Physical Component Summary score. Overall,
Rampersaud and colleagues14 reached a conclu-
sion similar to that of the SSSS.4 Namely, fusion
in addition to decompression was not associated
with better clinical outcomes when compared
with those receiving decompression alone.
In a prospective registry effort by the Quality Out-
comes Database Spondylolisthesis Study Group,
Chan and colleagues11 analyzed 426 patients (342
fusion with or without decompression and 84
decompression-alone) with grade I lumbar spondy-
lolisthesis receiving single-segment treatment with
a posterior approach. Twelve months following sur-
gery, fusion was linked to superior ODI scores in
adjusted analyses, correcting for baseline cohort
differences. Fusion patients also had lower reoper-
ation rates (4.4% vs 6.0%), Numeric Rating Scale
(NRS) back pain, NRS leg pain, and EQ-5D out-
comes, but these were not statistically significant.
Extended follow-up of this prospective registry will
be critical to assess whether the results at 1 year
are maintained. However, this initial experience
suggests that fusion surgery may be superior
when surgeons select the type of surgery (laminec-
tomy alone versus fusion) they deem most appro-
priate for patients in a nonrandomized fashion.
INSTRUMENTED VERSUS
NONINSTRUMENTED FUSION
Recommendation: Grade C
Supplementing fusions with pedicle screw fixation
has not led to significantly different outcomes
compared with noninstrumented surgeries in the
limited and underpowered studies that have
been published.15–17
Some studies report significant differences in
successful fusion rates in favor of instrumentation,
but this is not associated with superior clinical
outcomes.15,16
Evidence for pedicle screw fixation may be
strongest for patients with instability or kyphosis.17
Evidence
Fischgrund and colleagues16 completed follow-
ups with 67 patients 2 years after surgery in a

prospective randomized study. The patients were
divided into 2 groups, laminectomy and single-
level autogenous bilateral lateral intertransverse
process arthrodesis with or without pedicle screw
instrumentation. In the instrumentation group, the
fusion rate was 82% and satisfactory clinical out-
comes were found in 76% of patients. The fusion
rate was lower in the noninstrumented group at
45%, but satisfactory clinical outcomes were
slightly higher at 85%. Although the proportion to
achieve fusion was significantly higher in the instru-
mented group, fusion rate was not linked to clinical
outcomes. However, the study was underpowered.
A larger study was conducted by Thomsen and
colleagues,15 which investigated 130 patients un-
dergoing PLF for grade 1 or 2 spondylolisthesis.
Of these, 64 patients were in the instrumented
(Cotrel-Dubousset instrumentation) group and 66
in the noninstrumented group. The patient satis-
faction rate was 82% in the instrumented group
and 74% in the noninstrumented group, a statisti-
cally insignificant difference. Fusion rates and Dal-
las Pain Questionnaire outcomes were also
similar, but the instrumented group had longer op-
erations, more blood loss, and more early reoper-
ations. The investigators concluded that the
difference between the 2 groups was not large
enough to make a recommendation for instrumen-
tation. Moreover, at 130 patients the study was un-
derpowered to detect such a difference.
Similarly, a retrospective study by Kimura and
colleagues17 on 57 patients with L4-5 degenera-
tive spondylolisthesis showed similar results with
regard to patient satisfaction (72.4% [noninstru-
mented] vs 82.8% [instrumented]) and fusion
rates (82.1% [noninstrumented] vs 92.8% [instru-
mented]) between an instrumented group
(transpedicular screw fixation) and a noninstru-
mentation group (PLF only), at a minimum follow-
up of 2 years. However, screw instrumentation
was associated with a reduction in postoperative
back pain. Of note, in the subset of patients with
greater than or equal to 3 mm of translational mo-
tion with flexion-extension radiographs, flexion
angulation of 5 or less, and a slip angle of 5
or less at the level of spondylolisthesis, the
kyphotic slip angle (L4-5) tended to increase after
surgery. Thus, the investigators note that instru-
mentation may still be beneficial for treating these
patients with significant (>3 mm) motion at the site
of spondylolisthesis and kyphosis.9,17 As with the
prior 2 studies, the study was underpowered.
Chang and colleagues18 also conducted a
retrospective comparative study of 57 patients
who underwent fusion surgery for degenerative
spondylolisthesis using both instrumented and
noninstrumented techniques. Instrumentation
Treatment of Lumbar Spondylolisthesis 357
was variable, consisting of either AO (Arbeitsge-
meinschaft für Osteosynthesefragen) plating,
Luque rectangle and Wisconsin wiring, or Roy
Camille plate and pedicle screws. Ten patients
with degenerative spondylolisthesis underwent
instrumentation, of whom 9 had grade 1 or 2 slip-
page and 1 had grade 3 slippage. The noninstru-
mented group had 43 patients with grade 1
slippage and 4 with grade 2 slippage. The instru-
mented group had superior results, with 60% hav-
ing complete pain relief. Only 34% had complete
pain relief in the noninstrumented group while
61.7% had partial relief. However, when consid-
ering these results it is important to note the differ-
ence in group sizes, the small sample size of the
instrumented group limiting the study’s power,
and the variability of instrumentation techniques.
OPEN VERSUS MINIMALLY INVASIVE
SURGERY
Grade B
Research has shown minimally invasive surgery
(MIS) to have clinical outcomes similar to those
for open fusion, at a reduced cost and shorter
time required to return to work.19–21 MIS is associ-
ated with less blood loss and shorter length of stay
in hospital, but the patient-reported outcomes are
comparable. MIS may be especially advantageous
in patients needing a 2-level fusion surgery.20
However, anatomic factors (eg, morbid obesity)
and surgical considerations (eg, requirement for
wide bilateral decompression) may preclude the
use of MIS techniques. More high-quality, long-
term investigations are required.
Evidence
In efforts to better understand clinical outcomes for
MIS, Mummaneni and colleagues20 completed a
retrospective analysis of the prospective Quality
Outcomes Database (QOD) registry sponsored by
the American Association of Neurologic Surgeons
(AANS), the AANS/Congress of Neurologic Sur-
geons Joint Section on Disorders of the Spine
and Peripheral Nerves, and the NeuroPoint Alli-
ance. In the study, patient-reported outcomes
(PRO) for MIS and open fusion patients were
compared. The study excluded spondylolisthesis
patients with grade II or higher spondylolisthesis,
more than 2 levels of fusion, and nonposterior
approach surgery. The study compared fusions
for 1 and 2 levels separately. For the 1-level fusion
group analysis, 181 open fusion patients and 76
MIS patients were compared. For the 2-level fusion
group, 73 open fusion patients and 15 MIS patients
were compared. Both open and MIS cohorts, in
both analyses, achieved significant improvement
358 Chan et al
in all PROs at 12 months (ODI, NRS back pain, NRS
leg pain, EQ-5D). MIS was associated with signifi-
cantly lower blood loss. Twelve-month PROs,
length of stay (LOS), and 90-day return to work in
the 1-level fusion group were comparable. In the
2-level fusion group, MIS patients had significantly
superior results for leg pain at 12 months (NRS
leg pain 12-month change of 4.9 vs 2.8 for
MIS and open fusion, respectively). Multivariate
analysis did not reveal a risk-adjusted association
of MIS surgery with 12-month ODI, EQ-5D, NRS
back pain, NRS leg pain, patient satisfaction,
LOS, and 90-day return to work.
Parker and colleagues22 analyzed a cohort of 100
patients with grade I spondylolisthesis who were
suitable candidates for both MIS and open fusion
surgery. The cohort was split evenly into an MIS-
transforaminal lumbar interbody fusion (TLIF) group
(n 5 50) and an open TLIF group (n 5 50) (Fig. 1B).
Similar readmission rates, complication rates, and
improvements in visual analog scale (VAS)-back/
leg pain, ODI, and SF-36 outcomes were seen in
both groups at 3-month and 2-year follow-ups.
However, MIS did have a few advantages. MIS pa-
tients had less blood loss, shorter LOS, as well as
a 4-week reduction in return-to-work time.
Narcotic use lasted an average of 3 weeks in the
MIS group versus 9 weeks in the open TLIF group,
although the high variation in each group resulted
in an insignificant difference. Of note, MIS-TLIF
was associated with a significant reduction in 2-
year total cost versus open TLIF ($38,563 vs
$47,858, P 5 .03).
Kotani and colleagues21 conducted a compara-
tive study on single-level degenerative lumbar
Fig. 3. Algorithm containing both anatomic and clinical considerations influencing the choice of interbody.
spondylolisthesis that included 43 patients
receiving MIS-posterior lumbar interbody fusions
(PLIF) with percutaneous pedicle screw fixation
and 37 patients receiving an open PLIF. MIS pro-
cedures were associated with less intraoperative
and postoperative day 1 blood loss and superior
ODI and Roland-Morris Questionnaire scores from
2 weeks postoperatively through 24-month follow-
up. There were no differences in operative time,
fusion rates (98% and 100% for the MIS and
open groups, respectively), and complication rates.
WHICH INTERBODY APPROACH TO USE?
The surgeon may make use of an interbody graft to
augment a fusion construct anteriorly, increase
disc space height, improve alignment, and in-
crease indirect decompression of nerve roots.
TLIF is commonly used for fusion for lumbar spon-
dylolisthesis, but PLIF, lateral lumbar interbody
fusion (LLIF; prepsoas or transpsoas), and anterior
lumbar interbody fusion (ALIF) alone or part of a 2-
stage procedure are also used for interbody place-
ment. Fig. 3 demonstrates the algorithm of the se-
nior author (P.V.M.), which contains both anatomic
and clinical considerations influencing the choice
of interbody. The variety of fusion options, limited
comparative investigation, and often conflicting
conclusions limit the ability to synthesize
recommendations.
Interbody Versus No Interbody
Grade B
Compared with posterolateral fusion alone, the
addition of interbody is associated with superior

radiographic fusion, improved disability, and
reduced back pain.23 However, further study is
needed to understand the long-term impact of
interbody placement on back pain and disability.
Interbody placement is associated with longer
operative times, and this perioperative issue
must be balanced with the improved fusion
rate.23,24
Evidence
In a meta-analysis of studies comparing PLF and
PLF 1 TLIF for spondylolisthesis, Levin and col-
leagues23 found superior pooled fusion success
rates in the TLIF group (n 5 123) compared with
the PLF group (n 5 118) (94.3% vs 84.7%, respec-
tively).25–31 In addition, TLIF patients had higher
odds of achieving solid arthrodesis (odds ra-
tio 5 3.0, P 5 .02). Clinically, TLIF was associated
with superior postoperative superior back pain
scores ( 0.27 difference) and ODI results (3.73-
point difference). However, TLIF was associated
with longer operative times (25.55 minutes longer).
There were no differences observed for leg pain,
health-related quality of life, blood loss, or infec-
tion rate. Of note, although the back pain and
ODI findings were statistically significant, the ef-
fect size is small and clinically insignificant.
Anterior Versus Lateral Interbody
The anterior and lateral approaches—ALIF, trans-
psoas interbody fusion, and prepsoas interbody
fusion—are potential techniques for well-selected
patients with grade 1 or 2 spondylolisthesis. It is
generally avoided for spondylolisthesis greater
than grade 2 because nerve roots are located
more anteriorly.32,33
There are additional anatomic considerations.
ALIF offers clearer access to L4 through S1, with
upper regions blocked by vascular structures.
LLIF (prepsoas or transpsoas) allows access to
T12 through L5; more inferior access is obstructed
by the iliac crest at the sacral level. However, the
prepsoas and modifications of LLIF may be
applied from L1 through S1.32
Prepsoas Lateral Interbody Fusion
Grade C
Prepsoas LLIF is associated with radiographic and
clinical improvement,34,35 although the literature
for its application to degenerative lumbar spondy-
lolisthesis is limited. Further larger and prospective
study is warranted.
Evidence
Sato and colleagues35 evaluated 20 patients
with degenerative lumbar spondylolisthesis who
received prepsoas LLIF with percutaneous pedicle
Treatment of Lumbar Spondylolisthesis 359
screw fixation without posterior laminectomy. MRI
and computed tomography images were obtained
before and 6 months after surgery to evaluate
radiographic parameters (spinal canal cross-
sectional area, foraminal area, disc height, degree
of slip). Clinical outcomes (VAS and ODI) were also
assessed preoperatively and at 6 months. Postop-
eratively, significant increases in both axial and
sagittal spinal canal diameters (12% and 32%),
spinal canal area (19%), disc height (61%), foram-
inal area (21%–39%), and a significant decrease in
slip ( 9%) were observed (all comparisons,
P<.05). Clinically, significant improvements were
observed following surgery in VAS back pain
(1.3  0.7 from 4.5  1.7), VAS leg pain
(1.5  0.8 from 8.2  2.7), and ODI (18  10
from 52  12). Of the 20 cases, there was a single
injury to a segmental artery intraoperatively. There
was no need to convert to open surgery. There
were 2 cases of graft subsidence in 2 patients
with osteoporosis. Otherwise there were no infec-
tions, major vessel injuries, peritoneal injury, uri-
nary injury, or spinal nerve injury. There was one
patient with significant thigh pain and numbness,
which diminished 2 weeks following surgery. An
additional study of 35 patients (20 of whom had
degenerative spondylolisthesis) investigating pre-
psoas LLIF was conducted by Ohtori and col-
leagues.34 Similarly, they found that pain scores
improved significantly 6 months following surgery.
There was 1 case of graft subsidence and 3 pa-
tients with thigh numbness, 1 with quadriceps
weakness, and 1 with thigh pain. There were no
cases requiring reoperation and no injuries to a
major vessel, the peritoneum, the urinary tract, or
a spinal nerve. These results are promising for pre-
psoas LLIF, but larger-scale and comparative
studies are still necessary.
Transpsoas Lateral Interbody Fusion
Grade C
In limited study, lateral (transpsoas) lumbar
interbody fusion for degenerative lumbar spondy-
lolisthesis is associated with significant clinical
benefit and a high rate of fusion.36,37 Without pos-
terior supplementation, however, there may be
higher rates of revision surgery although compara-
tive studies are lacking.37 Patients should be
warned about the relatively high rate of transient
anterior thigh numbness following surgery.36
Evidence
Ahmadian and colleagues36 completed a retro-
spective study including 31 patients receiving
MIS lateral retroperitoneal transpsoas interbody
fusion for grade I (n 5 26) and grade II (n 5 5)
L4-5 spondylolisthesis. Patients received
360 Chan et al
percutaneous pedicle screw fixation without
further manipulation of the posterior elements.
With mean follow-up of 18.2 months, significant
improvements in ODI (50.4–30.9), VAS (69.9–
38.7), and SF-36 (38.1–59.5) scores were
observed. In regard to complications, 22.5% of
patients experienced transient anterior thigh
numbness. No permanent neurologic deficits
were observed. Radiographic analysis revealed a
100% fusion rate and an 87.1% rate of complete
reduction of listhesis. There were no cases of
hardware failure or pseudarthrosis in this study.
Marchi and colleagues37 conducted a prospec-
tive, observational study on a consecutive series
of 52 patients undergoing stand-alone lateral inter-
body fusion for grade I or II degenerative lumbar
spondylolisthesis. These procedures were per-
formed without posterior screw supplementation.
Similarly to Ahmadian and colleagues,36 this study
found significant and durable changes to VAS and
ODI clinical outcomes (60% and 54.5% change,
respectively). At 24-month follow-up, solid fusion
was observed in 86.5% of levels treated. Listhesis
was improved in 90.4% of cases. However, 17%
had cage subsidence and 13% needed revision
surgery.
Anterior/Lateral Versus Posterior Interbody
Grade B
ALIF and LLIF are associated with greater im-
provements in disc and foraminal height.38–40
TLIF is associated with greater increases in spi-
nal canal cross-sectional area.38,39
Transpsoas LLIF, compared with TLIF/PLIF, re-
sults in less intraoperative blood loss39,41,42 and
muscle damage,41 but is associated with transient
neurologic deficits.39,41,42
All 3 methods result in similar fusion rates and
reduction in listhesis, although open TLIF/PLIF
may be associated with higher rates of adjacent-
segment disease40 and subsidence.42
Grade C
Aside from anatomic considerations, there is no
clear evidence supporting the use of one interbody
approach over another. There is inconsistent evi-
dence with regard to clinical outcomes (VAS,
ODI). Further comparative study is required.
ALIF is associated with greater improvements in
segmental lordosis and should be considered in
patients requiring larger lordotic corrections.40
PLIF has been associated with postoperative
loss of segmental lordosis.
Evidence
Lee and colleagues40 conducted a comparative
study of ALIF (n 5 27), LLIF (n 5 24), and PLIF
(n 5 31) in the treatment of 82 patients with L4-5
spondylolisthesis. Mean follow-up ranged from
32.8 to 38.4 months. No significant differences
were found with regard to length of hospital stay,
blood loss, operation times, complication rates,
or subsidence rates. There were no cases of pseu-
darthrosis requiring revision. Fusion rates were not
compared. VAS back pain, VAS leg pain, and ODI
clinical outcomes were similar across the 3 groups
postoperatively. Statistically significant improve-
ments in all clinical outcomes were observed at
the last postoperative follow-up. Preoperative
radiographic parameters did not differ among the
groups, but postoperatively ALIF was associated
with significantly greater improvement in
segmental lordosis. LLIF did not produce a signif-
icant difference in segmental lordosis and PLIF
was associated with a significant worsening of
segmental lordosis postoperatively (mean 12.1 –
10.3 , P 5 .04). Postoperatively, ALIF and LLIF—
but not PLIF—were associated with significant in-
creases in disc and foraminal height. In addition,
ALIF was associated with a significantly lower
rate of adjacent-segment disease compared with
PLIF (37.0% vs 64.5%, respectively). All 3 ap-
proaches resulted in significant reductions of lis-
thesis, but ALIF was associated with the best
ability to reduce the degree of spondylolisthesis.
A prospective, multicenter clinical study with
randomized and observational arms by Sembrano
and colleagues42 compared 2-year outcomes for
transpsoas LLIF (n 5 29) and MIS-TLIF (n 5 26) pa-
tients with low-grade degenerative lumbar spon-
dylolisthesis. Blood loss was lower in the
transpsoas LLIF group but hip flexion weakness
was more common in the transpsoas LLIF group
(31% vs 0%). Transient neurologic deficits were
observed in 4 transpsoas LLIF patients and 2
MIS-TLIF patients, all which resolved by
12 months. Similar improvements were observed
for back pain, leg pain, and ODI. Radiographi-
cally,38 both groups had significant improvements
in disc height. However, Transpsoas LLIF was
associated with less subsidence and greater in-
creases in ipsilateral foraminal height. Postopera-
tive change in cross-sectional spinal canal area
was statistically greater in the MIS-TLIF group. Us-
ing computed tomography fusion criteria, 100% of
transpsoas LLIF levels and 96% of MIS-TLIF levels
were solidly fused, a statistically insignificant
difference.
Similar results were observed in a retrospective
study by Kono and colleagues39 of 40 patients un-
dergoing transpsoas LLIF (n 5 20) and mini-open
TLIF (n 5 20) for degenerative lumbar spondylolis-
thesis. In the study, there were no differences in
LOS or operative time. transpsoas LLIF was
 361
Table 2
Recommendations for the treatment of degenerative lumbar spondylolisthesis

Recommendation Grade of Recommendation

Surgical vs nonoperative management
Surgical treatment of degenerative lumbar spondylolisthesis results in A2
superior clinical outcomes compared with nonsurgical treatment.
The addition of fusion to decompression
Addition of fusion to decompression for surgical treatment of lumbar C4,8,11,12
spondylolisthesis may result in superior clinical outcomes and lower
reoperation rates, although this is not consistent through all
available research.
Instrumented vs noninstrumented fusion
Supplementing fusions with instrumentation may increase fusion rates, C15–17
but this is not associated with superior clinical outcomes in the few
underpowered studies available.
Evidence for benefit from pedicle screw fixation may be strongest for C17
patients with instability or kyphosis.
Open vs minimally invasive surgery
Research has shown MIS to have comparable clinical outcomes with B19–21
open fusion, at a reduced cost, shorter time, decreased blood loss,
and shorter length of stay in hospital.
MIS may be especially advantageous in patients needing a 2-level fusion B20
surgery.
Interbody vs No Interbody
Compared with posterolateral fusion alone, the addition of an B23,24
interbody is associated with superior radiographic fusion, improved
disability, and reduced back pain. However, the magnitude of
improvement in disability and back pain may be small. Interbody
placement is associated with longer operative times, and this
perioperative risk must be balanced with the improved fusion rate.
ALIF vs LLIF vs PLIF/TLIF
Prepsoas LLIF is associated with radiographic and clinical improvement. C34,35
Transpsoas LLIF is associated with significant clinical benefit and a high C36,37
rate of fusion. Without posterior supplementation, however, there
may be higher rates of revision surgery, although comparative studies
are lacking. Patients should be informed about the relatively high
rate of transient anterior thigh numbness following surgery.
Aside from surgical goals and anatomic considerations, there is no clear C38–42
evidence supporting the use of one interbody approach over another.
There is inconsistent evidence with regard to clinical outcomes (VAS,
ODI).
ALIF is associated with greater improvements in segmental lordosis and C40
should be considered in patients requiring larger lordotic corrections.
PLIF has been associated with postoperative loss of segmental
lordosis.
ALIF and LLIF are associated with greater improvements in disc and B38–40
foraminal height than posterior approaches for interbody placement.
TLIF is associated with greater increases in spinal canal cross-sectional B38,39
area compared with transpsoas LLIF.
Transpsoas LLIF, compared with TLIF/PLIF, results in less intraoperative B39,41,42
blood loss and muscle damage, but is associated with a higher rate of
transient neurologic deficits.
All 3 methods result in similar fusion rates and reduction in listhesis, B40,42
although TLIF/PLIF may be associated with higher rates of adjacent-
segment disease and subsidence.

Abbreviations: ALIF, anterior lumbar interbody fusion; LLIF, lateral lumbar interbody fusion; MIS, minimally invasive sur-
gery; ODI, Oswestry Disability Index; PLIF, posterior lumbar interbody fusion; TLIF, transforaminal interbody fusion; VAS,
visual analog scale.
362 Chan et al
associated with significantly lower blood loss.
There were no serious complications in either
group. Clinical outcomes, as measured by the
Japanese Orthopedic Association Back Pain Eval-
uation Questionnaire, were similar in both groups,
although minor complications occurred in 50% of
the transpsoas LLIF group and 15% of the mini-
open TLIF group. Radiographically, greater
correction of disc height was observed in the
transpsoas LLIF group, but changes in disc angle
and magnitude of postoperative listhesis were
similar. Changes in cross-sectional spinal canal
area were significantly greater in the TLIF group.
Ohba and colleagues41 conducted a compari-
son of consecutive open PLIF (n 5 56) and
consecutive, single-staged transpsoas LLIF with
percutaneous pedicle screw placement (n 5 46)
for degenerative lumbar spondylolisthesis who
were followed for a minimum of 1 year. Compared
with PLIF, the transpsoas LLIF was associated
with less intraoperative blood loss and muscle
damage (as measured by serum markers C-reac-
tive protein, creatine kinase, and white blood cell
count postoperatively). This was associated with
an earlier recovery of daily activities and reduced
incidence of low back pain. Transpsoas LLIF was
associated with superior VAS lumbar scores
(1.5  2.6 vs 3.7  3.1) and ODI (9.2  7.4 vs
13.5  6.4) compared with PLIF 1 year following
surgery. Fusion rates were 100% in both groups
at 1 year. Minor complications were found in 6
transpsoas LLIF (13.0%) patients (5 with tempo-
rary thigh sensory change and 4 with temporary
hip flexion weakness) and 2 (3.6%) PLIF patients
(1 with superficial disturbance of wound healing
and 1 requiring repair of durotomy). There were
no reoperations for inadequate decompression
or postoperative instability.
DISCUSSION
Despite the present recommendations (summa-
rized in Table 2), there remains uncertainty in
many areas of degenerative lumbar spondylolis-
thesis treatment requiring further clarification.
Even with the recent RCTs4,5 and prospective reg-
istry effort11 investigating the utility of the addition
of fusion to spondylolisthesis surgery, there re-
mains a need to conduct further investigation.
Longer-term follow-up of the QOD prospective
registry and larger RCTs that include modern tech-
niques—including but not limited to use of mini-
mally invasive methods that may decrease
postoperative instability—are required and will be
of importance to multiple stakeholders including
patients, surgeons, and payers. Further clarifica-
tion, with class I evidence, will be required to
determine the role for minimally invasive tech-
niques and different instrumentation and grafts
for spondylolisthesis surgery.
With regard to clinical outcomes, further investi-
gations to define optimal clinical outcomes to be
used in comparative studies (eg, PRO versus
radiographic outcomes versus return to work) are
required. Although emphasis historically is placed
on radiographic corrections following spondylolis-
thesis surgery (eg, listhesis correction, radio-
graphic fusion, slip angle improvement), these
postoperative radiographic parameters may be
unrelated to patient-centered clinical outcomes.16
At other times, preoperative radiographic parame-
ters may be important predictors of who may have
the best outcomes with fusion surgeries, such as
patients with facet angles greater than 50 , disc
height greater than 6.5 mm, and motion at spondy-
lolisthesis site greater than 1.25 mm as suggested
by Blumenthal and colleagues43 Similarly, defining
optimal thresholds for realizing clinically meaning-
ful benefits following surgery are necessary.
Indeed, optimal thresholds for MCID for spondylo-
listhesis surgery may be unique to the pathology.44
As these outcomes are defined, it will become
increasingly possible to define subgroups of pa-
tients that may fare best (or worse) following spon-
dylolisthesis surgery, such as in studies
undertaken by the QOD Spondylolisthesis Study
Group45,46 and Spinal Laminectomy versus Instru-
mented Pedicle Screw Fusion II Registry (SLIP
II).47 Results from such studies should be shared
with patients and may help in the surgical
decision-making process.
In addition, in a value-based model of health
care delivery the cost-effectiveness of any surgical
treatment of degenerative lumbar spondylolisthe-
sis should be considered. The effect of select clin-
ical outcomes, such as reoperation rate, on cost
will also help to determine the comparative effec-
tiveness of treatment options. For instance, fusion
patients may have a higher upfront direct cost than
decompression patients, but may ultimately have
comparable long-term cost-effectiveness when
costs are adjusted for by quality-adjusted life
years gained.19 Further study on these topics is
required.
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