The Spine Journal 16 (2016) 1478–1485

Review Article

Guideline summary review: an evidence-based clinical guideline for the

diagnosis and treatment of adult isthmic spondylolisthesis
D. Scott Kreiner, MDa,*, Jamie Baisden, MD, FACSb, Daniel J. Mazanec, MDc,
Rakesh D. Patel, MDd, Robert S. Bess, MDe, Douglas Burton, MDf, Norman B. Chutkan, MDg,
Bernard A. Cohen, PhDh, Charles H. Crawford, III, MDi, Gary Ghiselli, MDj,
Amgad S. Hanna, MDk, Steven W. Hwang, MDl, Cumhur Kilincer, MD, PhDm,
Mark E. Myers, MDn, Paul Park, MDo, Karie A. Rosolowski, MPHp, Anil K. Sharma, MDq,
Christopher K. Taleghani, MDr, Terry R. Trammell, MDs, Andrew N. Vo, MDt,
Keith D. Williams, MDu
a
Ahwatukee Sports & Spine, 4530 E. Muirwood Dr, Ste. 110, Phoenix, AZ 85048-7693, USA
b
Department of Neurosurgery, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
c
Cleveland Clinic Center for Spine Health, 9500 Euclid Ave, Cleveland, OH 44195, USA
d
University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
e
Department of Orthopedic Surgery, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
f
University of Kansas Medical Center, 3901 Rainbow Blvd # 5013, Kansas City, KS 66103, USA
g
The CORE Institute, 18444 N 25th Ave, Phoenix, AZ 85023, USA
h
Neurological Monitoring Associates, LLC, 333 W Brown Deer Rd, Milwaukee, WI 53217, USA
i
Norton Leatherman Spine Center, Department of Orthopaedic Surgery, University of Louisville, 210 E Gray St, Louisville, KY 40202, USA
j
Denver Spine, 7800 E. Orchard Road, Greenwood Village, CO 80111, USA
k
Department of Neurological Surgery, University of Wisconsin, 20 S Park St, Madison, WI 53715, USA
l
Department of Neurosurgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
m
Department of Neurosurgery, Trakya University Faculty of Medicine, Edirne, Turkey 22030
n
Center for Diagnostic Imaging, 5775 Wayzata Blvd, Saint Louis Park, MN 55416, USA
o
Department of Neurosurgery, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
p
North American Spine Society, 7075 Veterans Blvd, Willowbrook, IL 60527, USA
q
Spine and Pain Medicine, 655 Shrewsbury Ave, Shrewsbury, NJ 07702, USA
r
Cumberland Brain & Spine, 5655 Frist Blvd, Hermitage, TN 37076, USA
s
OrthoIndy, 8450 Northwest Blvd, Indianapolis, IN 46278, USA
t
Rockford Health Physicians, 2350 N Rockton Ave, Rockford, IL 61103, USA
u
Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1400 S Germantown Rd, Germantown, TN 38138, USA
Received 9 March 2016; revised 13 July 2016; accepted 29 August 2016

Abstract BACKGROUND CONTEXT: The North American Spine Society’s (NASS) Evidence-Based Clin-
ical Guideline for the Diagnosis and Treatment of Adult Isthmic Spondylolisthesis features evidence-
based recommendations for diagnosing and treating adult patients with isthmic spondylolisthesis.
The guideline is intended to reflect contemporary treatment concepts for symptomatic isthmic spon-
dylolisthesis as reflected in the highest quality clinical literature available on this subject as of June
2013. NASS’ guideline on this topic is the only guideline on adult isthmic spondylolisthesis ac-
cepted in the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse.
PURPOSE: The purpose of the guideline is to provide an evidence-based educational tool to assist
spine specialists when making clinical decisions for adult patients with isthmic spondylolisthesis.
This article provides a brief summary of the evidence-based guideline recommendations for diag-
nosing and treating patients with this condition.
STUDY DESIGN: This is a guideline summary review.
METHODS: This guideline is the product of the Adult Isthmic Spondylolisthesis Work Group of
NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop
this guideline are detailed in the complete guideline and technical report available on the NASS website.
In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions

http://dx.doi.org/10.1016/j.spinee.2016.08.034
1529-9430/© 2016 Elsevier Inc. All rights reserved.
 D.S. Kreiner et al. / The Spine Journal 16 (2016) 1478–1485 1479

to address in the guideline. The literature search strategy was developed in consultation
with medical librarians. Upon completion of the systematic literature search, evidence relevant
to the clinical questions posed in the guideline was reviewed. Work group members utilized
NASS evidentiary table templates to summarize study conclusions, identify study strengths
and weaknesses, and assign levels of evidence. Work group members participated in webcasts
and in-person recommendation meetings to update and formulate evidence-based
recommendations and incorporate expert opinion when necessary. The draft guidelines were
submitted to an internal peer review process and ultimately approved by the NASS Board
of Directors. Upon publication, the Adult Isthmic Spondylolisthesis guideline was accepted
into the National Guideline Clearinghouse and will be updated approximately every 5 years.
RESULTS: Thirty-one clinical questions were addressed, and the answers are summarized in this
article. The respective recommendations were graded according to the levels of evidence of the sup-
porting literature.
CONCLUSIONS: The evidence-based clinical guideline has been created using techniques of evidence-
based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult
patients with isthmic spondylolisthesis. The entire guideline document, including the evidentiary tables,
literature search parameters, literature attrition flowchart, suggestions for future research, and all of
the references, is available electronically on the NASS website at https://www.spine.org/
ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely
schedule. © 2016 Elsevier Inc. All rights reserved.

Keywords: Adult spondylolisthesis; Clinical practice guideline; Clinical practice recommendations; Evidence-based
guideline; Isthmic spondylolisthesis; Spondylolisthesis; Spondylolytic spondylolisthesis

FDA device/drug status: Not applicable.
Author disclosures: DSK: Stock Ownership: LDR Holdings (B, 33 shares,
1% of company, Own small amount of stock in personal portfolio, Does not
use any devices this company manufactures), outside the submitted work;
Trips/Travel: North American Spine Society: (A, Received a small stipend
and one-night lodging/travel reimbursement for teaching a course), outside
the submitted work; International Spine Intervention Society (Non-
financial, Received one-night lodging for teaching/presenting at the Annual
Meeting), outside the submitted work. JB: Nothing to disclose. DJM: Con-
sulting: First Consult (A), outside the submitted work; Trips/Travel: NASS
(Nonfinancial/Reimbursement for meeting attendance below Level A, outside
the submitted work. RDP: Consulting: Globus (C), outside the submitted
work. RSB: Royalties: Pioneer (B), outside the submitted work; Consult-
ing: K2M (B), AlloSource (B), outside the submitted work; Speaking
and/or Teaching Arrangements: K2M (B), outside the submitted work; Trips/
Travel: K2M (B), outside the submitted work; Scientific Advisory Board/
Other Office: AlloSource (B), outside the submitted work; Grants: DePuy
Spine (B, Paid to the institution), Medtronic (A, Paid to the institution),
K2Medical (A, Paid to the institution), Innovasis (E, Paid to the institu-
tion), Biomet (D, Paid to the institution), outside the submitted work. DB:
Royalties: DePuy Spine (C), outside the submitted work; Consulting: DePuy
Spine (B), outside the submitted work; Board of Directors: Kansas Univer-
sity Physicians Inc (Nonfinancial), International Spine Study Group (Non-
financial), outside the submitted work; Research Support (Investigator Salary,
Staff/Materials): DePuy Spine (B), outside the submitted work. NBC: Roy-
alties: Globus Medical (E), outside the submitted work; Speaking and/or
Teaching Arrangements: AO North America (Nonfinancial), outside the sub-
mitted work; Scientific Advisory Board/Other Office: AO Spine North America
(Nonfinancial), outside the submitted work. BAC: Stock Ownership: NuVasive
(E), Medtronic (E), General Electric (E), Synthes (C), Zimmer (C), Johnson
& Johnson (D), Hanson Medical (C), outside the submitted work; Consult-
ing: NuVasive (B), outside the submitted work; Scientific Advisory Board/
Other Office: Commission on Accreditation of Allied Health Education
Programs (Nonfinancial), outside the submitted work. CHC: Consulting:
Medtronic (C), Alphatec (C), outside the submitted work; Speaking and/or
Teaching Arrangements: DePuy-Synthes (B), Titan Spine (A), outside the
submitted work; Trips/Travel: NASS (A), SRS (A), outside the submitted
work; Scientific Advisory Board/Other Office: Scoliosis Research Society
(Nonfinancial), outside the submitted work. GG: Private Investments: DiFusion
(D, 100,000 shares, 9% of company, with stock ownership in DiFusion but
it does not return a profit), outside the submitted work; Consulting: Biomet
(B), outside the submitted work; Scientific Advisory Board/Other Office:
DiFusion (Nonfinancial position), outside the submitted work. ASH: Nothing
to disclose. SWH: Speaking and/or Teaching Arrangements: NASS (A, travel),
DePuy Spine (B, Paid to the institution), outside the submitted work. CK:
Nothing to disclose. MEM: Nothing to disclose. PP: Royalties: Globus
Medical (B), outside the submitted work; Consulting: Globus Medical (B),
Medtronic (B), Biomet (C), outside the submitted work; Scientific Advi-
sory Board/Other Office: Vertex (B), outside the submitted work; Grants:
StemCells (E, Paid to the institution), outside the submitted work. KAR: Staff
at the North American Spine Society. AKS: Third Eye Capital Partners LP
(Financial, managing, and general partner of “Third Eye Capital Partners”
onshore hedge fund), not relevant to submitted work. CKT: Royalties: SeaSpine
(D), Globus (A), outside the submitted work; Consulting: SeaSpine (B), outside
the submitted work. TRT: Consulting: Medtronic (D), Biomet (D), outside
the submitted work; Speaking and/or Teaching Arrangements: Biomet (D,
Financial amount is included with Biomet consulting income), outside the
submitted work. ANV: Nothing to disclose. KDW: Nothing to disclose.
The disclosure key can be found on the Table of Contents and at
www.TheSpineJournalOnline.com.
* Corresponding author. Ahwatukee Sports & Spine, 4530 E. Muirwood
Dr, Ste. 110, Phoenix, AZ 85048-7693, USA. Tel.: +1 (480) 763-5808; fax:
+1 (480) 759-0647.
E-mail address: skreiner@ahwatukeesportsandspine.com (D.S. Kreiner)
1480 D.S. Kreiner et al. / The Spine Journal 16 (2016) 1478–1485
Introduction
To improve the knowledge base concerning the diagno-
sis and treatment of isthmic spondylolisthesis in adult patients,
the Adult Isthmic Spondylolisthesis Work Group of the North
American Spine Society’s (NASS) Evidence-Based Clini-
cal Guideline Development Committee developed an evidence-
based clinical guideline on this topic. The Institute of Medicine
defines clinical practice guidelines as “statements that include
recommendations intended to optimize patient care. They are
informed by a systematic review of evidence and an assess-
ment of the benefits and harms of alternative care options”
[1]. The clinical literature is extensively searched to answer
specific clinical questions about a disease state or medical
condition. The literature, identified in the search, is rated ac-
cording to its scientific merit using NASS evidence analysis
criteria and the levels of evidence as determined by specific
rule sets that apply to human, clinical investigations. The ev-
idence with the highest possible levels of evidence obtained
from the searches is utilized to answer the specific clinical
questions. As a final step, the answers to clinical questions
are reformulated as recommendations. Recommendations are
then assigned a recommendation grade according to the level
of evidence for the best clinical evidence available at the time
Figure. Summary of the North American Spine Society’s guideline development process.
of answering each question. The intent of the grade of rec-
ommendation is to indicate the strength of evidence used by
the work group in answering the question asked.
Materials and methods
The methods used to develop this guideline and guide-
line development disclosure policies are detailed in the
complete guideline and technical report available on the NASS
website [2]. In brief (Figure), a multidisciplinary work group
of spine care specialists, including physiatrists, orthopedic sur-
geons, neurosurgeons, pain medicine physicians, and
chiropractors, convened to identify clinical questions to address
in the guideline. The literature search strategy was devel-
oped in consultation with medical librarians. Upon completion
of the systematic literature search, evidence relevant to the
clinical questions posed in the guideline was reviewed. Work
group members utilized NASS evidentiary table templates to
summarize study conclusions, identify study strengths and
weaknesses, and assign levels of evidence according to the
NASS Levels of Evidence for Primary Research Question scale
[3]. Work group members participated in webcasts and in-
person recommendation meetings to update and formulate
evidence-based recommendations and incorporate expert
 D.S. Kreiner et al. / The Spine Journal 16 (2016) 1478–1485
opinion when necessary. The draft guidelines were submit-
ted to an internal peer review process and ultimately approved
by the NASS Board of Directors. Upon publication, the Adult
Isthmic Spondylolisthesis guideline was accepted into the Na-
tional Guideline Clearinghouse and is the only guideline in
the clearinghouse on this topic. The National Guideline Clear-
inghouse inclusion criteria [4] were updated in June 2014 to
reflect the Institute of Medicine’s definition for clinical prac-
tice guideline [5]. NASS will convene a multidisciplinary work
group to review and update the guideline approximately every
5 years.
Results
Thirty-one clinical questions were addressed in this guide-
line, and a total of 488 articles were considered in the
evidentiary review process. Work group members engaged
in a two-step screening process to determine article eligibil-
ity, including title and abstract screening and evidentiary
review. The total number of articles retrieved, eligible for crit-
ical appraisal, and meeting inclusion criteria for each individual
clinical question can be accessed in the technical report. A
total of 28 recommendations were issued.
Definition and natural history
1. What is the best working definition of isthmic
spondylolisthesis?
Isthmic spondylolisthesis is the anterior translation of one
lumbar vertebra relative to the next caudal segment as a result
of an abnormality in the pars interarticularis. When symp-
tomatic, this causes a variable clinical syndrome of back and/
or lower extremity pain, and may include varying degrees of
neurologic deficits at or below the level of the injury.
Work Group Consensus Statement
2. What is the likelihood that spondylolysis (unilater-
al and/or bilateral, identified in adolescence or adulthood)
will progress to become a symptomatic spondylolisthesis?
Spondylolisthesis occurs in 40% to 66% of patients with
bilateral spondylolysis. Spondylolisthesis is unlikely to occur
in patients with unilateral spondylolysis [6–8].
Grade of Recommendation: B (Suggested)
Diagnosis and imaging
3. What are the most appropriate physical examina-
tion findings consistent with the diagnosis of isthmic
spondylolisthesis in adult patients?
There is insufficient evidence to make a recommenda-
tion for or against the use of palpation in the physical exam
diagnosis of adult patients with isthmic spondylolisthesis [9].
Grade of Recommendation: I (Insufficient Evidence)
Approximately half of adult patients with symptomatic
isthmic spondylolisthesis will have a positive straight leg test
on examination [10,11].
1481
Grade of Recommendation: B (Suggested)
4. In adult patients, what symptoms or clinical pre-
sentations are associated with the diagnosis of isthmic
spondylolisthesis?
In adult patients with symptomatic isthmic spondylolis-
thesis, most patients present with low back pain, and at least
half present radicular lower extremity pain [10,12].
Grade of Recommendation: B (Suggested)
5. What are the most appropriate diagnostic tests for
adult isthmic spondylolisthesis?
There is a relative paucity of high-quality studies on imaging
in adult patients with isthmic spondylolisthesis. It is the opinion
of the work group that in adult patients with history and phys-
ical examination findings consistent with isthmic
spondylolisthesis, standing plain radiographs, with or without
oblique views or dynamic radiographs, be considered as the
most appropriate, non-invasive test to confirm the presence of
isthmic spondylolisthesis. In the absence of a reliable diagno-
sis on plain radiographs, computed tomography scan is
considered the most reliable diagnostic test to diagnose a defect
of the pars interarticularis. In adult patients with radiculopathy,
magnetic resonance imaging should be considered.
Work Group Consensus Statement
Magnetic resonance imaging is suggested to identify
neuroforaminal stenosis in adult patients with isthmic spon-
dylolisthesis [13–15].
Grade of Recommendation: B (Suggested)
There is insufficient evidence to make a recommenda-
tion for or against the use of magnetic resonance imaging to
differentiate isthmic versus degenerative spondylolisthesis in
adult patients [15].
Grade of Recommendation: I (Insufficient Evidence)
There is insufficient evidence to make a recommenda-
tion for or against the use of discography to evaluate adult
patients with isthmic spondylolisthesis [16].
Grade of Recommendation: I (Insufficient Evidence)
Computed tomography may be considered as an option
to diagnose isthmic spondylolisthesis in adult patients [17,18].
Grade of Recommendation: C (May Be Considered;
Option)
There is insufficient evidence to make a recommendation
for or against the use of single-photon emission computed to-
mography (SPECT) in evaluating isthmic spondylolisthesis in
adult patients [19].
Grade of Recommendation: I (Insufficient Evidence)
6. In adult patients, what is the relationship between
the radiological grade of isthmic spondylolisthesis and ex-
pected clinical presentation?
A systematic review of the literature yielded no studies to
adequately address this question.
7. How frequently do adult patients with isthmic spon-
dylolisthesis have abnormal findings of their sagittal
spinopelvic alignment, sacral alignment, and spinopelvic
parameters?
Adult patients with a diagnosis of isthmic spondylolis-
thesis have a higher pelvic incidence, sacral slope, pelvic tilt,
1482 D.S. Kreiner et al. / The Spine Journal 16 (2016) 1478–1485
and lumbar lordosis compared to patients without isthmic spon-
dylolisthesis [20–25].
Grade of Recommendation: B (Suggested)
Outcome measures
8. What are the appropriate outcome measures for the
treatment of isthmic spondylolisthesis in adult patients?
NASS has a publication entitled Compendium of Outcome
Instruments for Assessment and Research of Spinal Disor-
ders. The compendium serves as a resource for spine care
providers when selecting the most clinically useful outcome
measurements for spinal conditions. These assessments include,
but are not limited to, the Oswestry Disability Index (ODI),
Short Form of the Medical Outcomes Study (SF-36), and
Visual Analog Scale (VAS). To purchase a copy of the com-
pendium, visit https://www.spine.org/Pages/ProductDetails
.aspx?productid=%7b68CDD1F4-C4AC-DB11-95B2
-001143EDB1C1%7d.
For additional information about the compendium, please
contact the NASS Research Department at nassresearch@spine
.org.
Medical or interventional treatment
9. What is the role of pharmacological treatment in the
management of isthmic spondylolisthesis?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
10. What is the role of manipulation in the treatment
of isthmic spondylolisthesis?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
11. What is the role of steroid injections for the treat-
ment of isthmic spondylolisthesis?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
12. What is the role of ancillary treatments such as
bracing, traction, electrical stimulation, and transcuta-
neous electrical stimulation (TENS) in the treatment of
isthmic spondylolisthesis?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
13. What is the role of physical therapy or exercise in
the treatment of isthmic spondylolisthesis?
There is insufficient evidence to make a recommenda-
tion for or against the use of physical therapy or exercise for
the treatment of isthmic spondylolisthesis [26,27].
Grade of Recommendation: I (Insufficient Evidence)
14. Does the degree of radiological grade, sagittal
spinopelvic alignment, sacral and spinopelvic param-
eters, or the presence of dynamic instability in patients
with isthmic spondylolisthesis affect the outcomes of pa-
tients treated with medical or interventional treatment?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
15. What is the long-term result of medical or
interventional management of isthmic spondylolisthesis?
There is insufficient evidence to make a recommenda-
tion for or against the use of medical or interventional treatment
for the long-term management of patients with isthmic spon-
dylolisthesis [27].
Grade of Recommendation: I (Insufficient Evidence)
Surgical treatment
16. In adult patients, is surgical treatment more effec-
tive than medical or interventional treatment alone for
the treatment of isthmic spondylolisthesis?
There is insufficient evidence to make a recommendation
for or against the efficacy of surgical treatment as com-
pared with medical or interventional alone for the management
of adult patients with isthmic spondylolisthesis [26–30].
Grade of Recommendation: I (Insufficient Evidence)
17. Does the addition of lumbar fusion, with or without
instrumentation, to surgical decompression improve sur-
gical outcomes in the treatment of adult patients with
isthmic spondylolisthesis compared with treatment by de-
compression alone?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
Although there was no literature evaluating the addition
of fusion to decompression versus decompression alone in
adult isthmic spondylolisthesis patients, the work group ob-
served the presence of literature evaluating the addition of
decompression to fusion versus fusion alone. Because the lit-
erature search was not specifically designed to address this
topic, the work group opted not to comment on findings. A
clinical question comparing the addition of decompression
to fusion versus fusion alone may be considered for a future
guideline on this topic.
18. Does the addition of instrumentation to decom-
pression and fusion for adult patients with isthmic
spondylolisthesis improve surgical outcomes compared with
decompression and fusion alone?
In patients with low-grade isthmic spondylolisthesis, the
addition of instrumentation may not improve outcomes in the
setting of posterolateral fusion, with or without decompres-
sion [26–30].
Grade of Recommendation: B (Suggested)
19. How do outcomes of decompression with postero-
lateral fusion compare with those for 360° fusion in the
treatment of adult patients with isthmic spondylolisthesis?
Posterolateral fusion and 360° fusion surgeries are rec-
ommended to improve the clinical outcomes in adult patients
with low-grade isthmic spondylolisthesis [31–36].
 D.S. Kreiner et al. / The Spine Journal 16 (2016) 1478–1485
Grade of Recommendation: A (Recommended)
360° fusion is recommended to provide higher radio-
graphic fusion rates compared with posterolateral fusion in
adult patients with low-grade isthmic spondylolisthesis
[31,34,35].
Grade of Recommendation: A (Recommended)
There is conflicting evidence whether 360° fusion pro-
vides better clinical outcomes than posterolateral fusion alone
[31–36].
Grade of Recommendation: I (Insufficient or Conflict-
ing Evidence)
20. Does reduction with fusion result in better out-
comes than fusion in situ in adult patients with isthmic
spondylolisthesis?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
21. What is the role of stand-alone interbody fusion,
for the purpose of indirect decompression, in the treat-
ment of adult patients with isthmic spondylolisthesis?
Anterior lumbar interbody fusion (ALIF) may be consid-
ered as an option to indirectly decompress foraminal stenosis
in adult patients with low-grade isthmic spondylolisthesis
[37–39].
Grade of Recommendation: C (May Be Considered;
Option)
22. How do outcomes from minimally invasive spinal
surgery (for decompression and/or fusion) for the man-
agement of adult patients with isthmic spondylolisthesis
compare with traditional/open techniques?
In adult patients undergoing ALIF, supplemental posteri-
or percutaneous pedicle screws lead to shorter hospital stays,
less operation room time, and less blood loss compared with
open posterior instrumentation [38,40].
Grade of Recommendation: B (Suggested)
There is conflicting evidence whether in adult patients un-
dergoing ALIF supplemental posterior percutaneous pedicle
screws lead to comparable clinical outcomes to those under-
going open posterior instrumentation [38,40].
Grade of Recommendation: I (Insufficient or Conflict-
ing Evidence)
23. How do outcomes of dynamic stabilization compare
with fusion for the treatment of isthmic spondylolisthe-
sis in adult patients?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
24. Does the degree of radiological grade, sagittal
spinopelvic alignment, sacral and spinopelvic param-
eters, or the presence of dynamic instability in adult
patients with isthmic spondylolisthesis affect the out-
comes of patients treated with surgery?
There is insufficient evidence to make a recommenda-
tion on the degree of radiological grade, sagittal spinopelvic
alignment, sacral and spinopelvic parameters, or the pres-
ence of dynamic instability on the outcomes of adult patients
1483
undergoing surgical treatment for isthmic spondylolisthesis
[41,42].
Grade of Recommendation: I (Insufficient Evidence)
25. Does the addition of fusion levels (cephalad, caudal,
or iliac) in the setting of a high-grade isthmic spondylo-
listhesis in adult patients improve outcomes?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
26. What is the long-term result (4+ years) of
surgical management of adult patients with isthmic
spondylolisthesis?
In adult patients undergoing surgical treatment for isthmic
spondylolisthesis, fusion is suggested to provide long-term
clinical improvements [27,30,43,44].
Grade of Recommendation: B (Suggested)
There is insufficient evidence to indicate that fusion leads
to improved long-term outcomes as compared with a di-
rected exercise program [27].
Grade of Recommendation: I (Insufficient Evidence)
There is insufficient evidence to recommend one surgi-
cal fusion technique over another to improve long-term
outcomes in adult patients undergoing surgical treatment for
isthmic spondylolisthesis [30,44].
Grade of Recommendation: I (Insufficient Evidence)
There is insufficient evidence to determine the clinical sig-
nificance of adjacent segment degeneration on the long-
term outcomes of fusion [43].
Grade of Recommendation: I (Insufficient Evidence)
27. Are the results of surgical management for adult
patients with isthmic spondylolisthesis affected by the pres-
ence of scoliosis or concurrent deformity?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
28. Which prognostic factors have been associated with
good or poor outcomes in the surgical management of adult
patients with isthmic spondylolisthesis?
There is insufficient evidence to make a recommenda-
tion on which prognostic factors have been associated with
good or poor outcomes [43].
Grade of Recommendation: I (Insufficient Evidence)
Value/cost-effectiveness of spine care
29. Which medical or interventional treatment method
of isthmic spondylolisthesis is the most cost-effective?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
30. Is the surgical treatment of isthmic spondylolisthe-
sis cost-effective compared with the medical and
interventional therapies?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
1484 D.S. Kreiner et al. / The Spine Journal 16 (2016) 1478–1485
31. Which surgical treatment method of isthmic spon-
dylolisthesis is the most cost-effective?
There was no evidence to address this clinical question.
Due to the paucity of literature addressing this question, the
work group was unable to generate a recommendation.
Discussion
This evidence-based clinical guideline for the diagnosis
and treatment of isthmic spondylolisthesis in adult patients
has several functions. It is an educational tool for both cli-
nicians and patients, and as such this particular guideline is
intended to assist practitioners who treat adult patients with
isthmic spondylolisthesis. This guideline also serves to focus
and rate the scientific data on this topic. An evidence-based
guideline such as this allows a clinician access to the best
and most current evidence and reduces the burden of “keeping
up with the literature” that spans innumerable journals from
a broad spectrum of disciplines. In addition, this evidence-
based clinical guideline has the potential to improve the
appropriateness and effectiveness of patient care by basing
decisions on the best evidence available.
Finally, this guideline serves to identify knowledge gaps
in the clinical literature on isthmic spondylolisthesis in adult
patients. High-quality clinical guidelines ideally identify and
suggest future research topics to improve guideline devel-
opment and thus patient care, as detailed in the current
guideline. The complete clinical guideline summarized in this
article, along with extensive descriptive narratives on each
topic outlining the evidence and the work group rationale for
the answers to each question, can be found on the NASS
website at https://www.spine.org/Pages/ResearchClinicalCare/
QualityImprovement/ClinicalGuidelines.aspx.
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