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The PDF of the article you requested follows this cover page. This is an enhanced PDF from The Journal of Bone and Joint Surgery 2008;90:656-671. J Bone Joint Surg Am. Serena S. Hu, Clifford B. Tribus, Mohammad Diab and Alexander J. Ghanayem Spondylolisthesis and Spondylolysis This information is current as of March 25, 2009 Reprints and Permissions Permissions] link. and click on the [Reprints and jbjs.org article, or locate the article citation on to use material from this order reprints or request permission Click here to Publisher Information www.jbjs.org 20 Pickering Street, Needham, MA 02492-3157 The Journal of Bone and Joint Surgery
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Page 1: Spondylolisthesis and Spondylolysis - Semantic Scholar · spondylolisthesis have a lower preva-lence of progression than those with high dysplastic spondylolisthesis. Pa-tients with

The PDF of the article you requested follows this cover page.  

This is an enhanced PDF from The Journal of Bone and Joint Surgery

2008;90:656-671. J Bone Joint Surg Am.Serena S. Hu, Clifford B. Tribus, Mohammad Diab and Alexander J. Ghanayem    

Spondylolisthesis and Spondylolysis

This information is current as of March 25, 2009

Reprints and Permissions

Permissions] link. and click on the [Reprints andjbjs.orgarticle, or locate the article citation on

to use material from thisorder reprints or request permissionClick here to

Publisher Information

www.jbjs.org20 Pickering Street, Needham, MA 02492-3157The Journal of Bone and Joint Surgery

Page 2: Spondylolisthesis and Spondylolysis - Semantic Scholar · spondylolisthesis have a lower preva-lence of progression than those with high dysplastic spondylolisthesis. Pa-tients with

Selected

Instructional

Course Lectures

The American Academy of Orthopaedic Surgeons

PAUL J. DUWELIUSEDITOR, VOL. 57

COMMITTEE

PAUL J. DUWELIUSCHAIRMAN

FREDERICK M. AZARKENNETH A. EGOLJ. LAWRENCE MARSHMARY I. O’CONNOR

EX-OFFICIO

DEMPSEY S. SPRINGFIELDDEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY

FOR INSTRUCTIONAL COURSE LECTURES

JAMES D. HECKMANEDITOR-IN-CHIEF,THE JOURNAL OF BONE AND JOINT SURGERY

Printed with permission of the American Academy ofOrthopaedic Surgeons. This article, as well as other lecturespresented at the Academy’s Annual Meeting, will be availablein March 2008 in Instructional Course Lectures, Volume 57.The complete volume can be ordered online at www.aaos.org,or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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Spondylolisthesis and SpondylolysisBy Serena S. Hu, MD, Clifford B. Tribus, MD, Mohammad Diab, MD, and Alexander J. Ghanayem, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The term ‘‘spondylolisthesis’’ refers toslipping, or olisthesis, of a vertebra(‘‘spondylos’’ in Greek) relative to anadjacent vertebra. The term ‘‘spondy-lolysis’’ refers to dissolution of, or adefect in, the pars interarticularis ofa vertebra. To these original terms hasbeen added ‘‘spondyloptosis,’’ fromthe Greek ‘‘ptosis’’ (falling off ordown) to indicate a vertebra that iscompletely or essentially completelydislocated.

There are five types of spondylo-listhesis: dysplastic, isthmic, degenera-tive, traumatic, and pathologic1. In thedysplastic type, facet joints allow ante-rior translation of one vertebra onanother. Because the neural arch of theolisthetic vertebra is intact, it can com-press the cauda equina as it translates.This type accounts for the only reportedcase of spondylolisthesis at birth2.‘‘Isthmic’’ is from the Greek, meaningnarrow. The isthmic type involves alesion of the pars interarticularis (thenarrow part of bone between the supe-rior and inferior articular processes)(Fig. 1). There are three subclasses: A,which is due to a stress fracture of thepars interarticularis; B, an elongation ofthe pars interarticularis; and C, which is

due to an acute fracture of the parsinterarticularis. Dysplastic and isthmicare the two subtypes found in children,with the latter accounting for approxi-mately 85% of cases.

Degenerative spondylolisthesis issecondary to osteoarthritis leading tofacet incompetence and disc degenera-tion. This condition allows anteriortranslation of one vertebra on another.Traumatic spondylolisthesis is due to afracture of the posterior elements,other than the pars interarticularis,leading to instability and olisthesis. Apathologic spondylolisthesis is due toa tumor or another primary disease ofbone affecting the pars interarticularisor the facet joints and leading to insta-bility and olisthesis.

The dysplastic and isthmic pat-terns can be classified as congenital,whereas the degenerative, traumatic,and pathologic patterns are consideredacquired3. The dysplastic type is con-sidered to be high if L5 is abnormal andlow if L5 is normal. The low types arehigher-grade deformities, with domed-shaped S1 end plates and a trapezoidalL5 vertebral body. The severity ofspondylolisthesis is graded on the basisof the percentage of translation of one

vertebra relative to the caudal vertebra4:grade I is translation of up to 25%;grade II, 26% to 50%; grade III, 51% to75%; grade IV, 76% to 100%; and gradeV, >100% (spondyloptosis). The ma-jority (75%) of the cases of spondylo-listhesis are grade I, and 20% aregrade II. A simpler classificationsystem divides spondylolisthesis intocases with translation of £50% (stable)and those with translation of >50%(unstable)5.

PathophysiologyWhen the lumbar spine extends, theinferior articular process of the cranialvertebra impacts the pars interarticula-ris of the caudal vertebra6,7. Repetitiveimpacts can produce a stress or fatiguefracture of the pars interarticularis.Lumbar hyperextension activities, suchas gymnastics and American football,and lumbar hyperextension secondaryto spinal deformity, such as Scheuer-mann disease, are associated withspondylolysis, findings that support thetraumatic mechanism8-10. This mecha-nism is consistent with the observationthat spondylolysis never has been re-ported in individuals who cannot walkand the fact that up to 40% of athletes

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of theauthors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitmentor agreement to provide such benefits from a commercial entity (ESM Technologies, LLC). Commercial entities (Medtronic, DePuy, and Synthes) paid ordirected in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, orother charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

J Bone Joint Surg Am. 2008;90:656-71

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with spondylolysis recall a specific backinjury11,12. This direct compression bymeans of a ‘‘nutcracker’’ mechanism isone explanation, but another is that thepars interarticularis fails in tensionthrough a traction mechanism13,14.Which of the two mechanisms is morelikely to be present in a given individualis thought to be determined by thelordosis of the spine and the lumbosa-cral relationship. More recently, reviewsof surgical and radiographic findings inpatients with high-grade spondylolis-thesis as well as biomechanical studieshave suggested that abnormalities of thesacral growth plate may be an etiologyof high-grade slippage. Yue et al.found that the only constant abnormalanatomic feature in twenty-seven pa-tients treated for spondyloptosis wasrounding of the proximal sacral endplate15. Biomechanical studies of imma-ture calf spines placed under shear loadsshowed the growth plate to be the site offailure in all cases16. These studies haveraised the question of which of theseabnormalities, the pars interarticularisdefect or the sacral growth plate, is theprimary cause of spondylolysis andspondylolisthesis.

GeneticsFamily history, gender, and race all areimplicated. Spondylolysis occurs in 15%to 70% of first-degree relatives of indi-viduals with the disorder17-19. Lysis is twoto three times more frequent in boysthan girls, but slippage affects girls twoto three times more often than boys20.The prevalence of spondylolysis is ap-proximately 6% in the white popula-tion, a rate that is two to three timeshigher than that in the black popula-tion21,22. In the Inuit population, the rateis as high as 25%23.

Natural HistoryThe prevalence of a defect in the parsinterarticularis is approximately 5% inthe general population. Fredricksonet al. started a prospective study of 500first-grade children in 195522. Theprevalence of spondylolysis was 4.4%at six years of age and 6% in adulthood.It was twice as common in males. Painwas not associated with the development

of the pars interarticularis defect. Ap-proximately 15% of individuals with apars interarticularis lesion had progres-sion to a spondylolisthesis. The slip wasseen predominately during the growthspurt, with minimal change after the ageof sixteen years. Progression to a slip didnot cause pain. After these individualshad been followed for forty-five years,thirty had a pars interarticularis defectand twenty-two of the thirty had finallumbar radiographs24. No slip was>40%. Slip progression also appeared toslow with each decade and, of particularnote, the results from a back painquestionnaire and a Short Form-36 (SF-36) survey were no different from thosefor an age-matched general populationcontrol group.

Patients with low dysplasticspondylolisthesis have a lower preva-lence of progression than those withhigh dysplastic spondylolisthesis. Pa-tients with higher grades of spondylo-listhesis and higher slip angles, ameasure of lumbosacral kyphosis, havea higher risk of progression25-27. Low-grade isthmic spondylolisthesis canprogress in an adult, but the progression

is thought to be secondary to progres-sive degeneration of the L5-S1 inter-vertebral disc28.

Clinical PresentationIn most children (75%) with back pain,the cause is idiopathic or so-called‘‘overuse’’29,30. The most common iden-tifiable cause of back pain in a child isspondylolysis. The child typically de-scribes a history of activity-related pain,and 40% recall a specific traumaticevent12.

The child may have lumbar hy-perlordosis, which may be the cause ofthe spondylolysis, or lumbar flatteningif he or she has severe pain or a high-grade spondylolisthesis. A high-gradespondylolysis in a child is characterizedby a palpable lumbosacral step-off aswell as lumbosacral kyphosis with aretroverted sacrum that results in aheart-shaped buttocks. Hyperextensionof the lumbar spine may cause pain,particularly during single-limb stance.Hamstring contracture is common,although the mechanism of this isunknown, but it resolves with spinalfusion. In severe cases, the child has a

Fig. 1

Lateral radiograph showing isthmic spondylolisthesis. The arrow points to the pars

interarticularis defect.

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gait disturbance characterized bycrouching, a short stride length, and anincomplete swing phase, as described byPhalen and Dickson31.

The child may have a radiculop-athy that manifests as changes in sen-sation, a motor deficit, or tension signsdistinct from the hamstring contracture.When a child has high-grade olisthesis(translation of >50%), a rectal exami-nation should be done. An abnormalfinding suggests compromise of thesacral roots. The importance of thisfinding is highlighted by reports ofcauda equina syndrome after surgerypresumably due to loss of reflex pro-tection under anesthesia, which makesthe patient more vulnerable to nerveroot injury32-34.

Scoliosis may be associated withspondylolysis35. When the scoliosis isdue to pain, it (the scoliosis) usuallyresolves spontaneously following suc-cessful treatment of the spondylolysis.

When an adult with low-gradeisthmic spondylolisthesis seeks medicalattention, pain, usually lower-limb pain,is invariably the chief symptom36. It isimportant to correlate the pain pattern

with the findings of the diagnostic work-up, since adults may have other spinaldisease that is causing the pain.

ImagingRadiographyCollimated lateral and angled (accord-ing to the inclination of the L5-S1intervertebral disc) anteroposterior ra-diographs of the lumbosacral spinereduce parallax and provide the bestdetail27,28,31. Oblique lumbar views high-light the ‘‘Scotty dog,’’ the ear of which isthe superior articular process, the eyeis the pedicle, the nose is the transverseprocess, the neck is the pars interarti-cularis, and the front limb is the inferiorarticular process. Spondylolysis is seenas a broken neck or a collar (Fig. 2).Full-length radiographs of the spine areessential to determine spinal balance,especially in the sagittal plane, and toevaluate for associated deformity. Flex-ion and extension lateral radiographshelp to determine how much posturalreduction of the lumbosacral angulationand translation can be obtained.

The degree of slip, slip angle,sacral inclination, chronicity of the slip,and pelvic incidence are all seen on thelateral radiograph13,14,37-39. The degree ofslip is the percentage of displacement,with a slip of >50% considered unstableand associated with progression and

Fig. 3

Computed tomography scan showing a right pars interarticularis defect.

Fig. 2

An oblique radiograph showing a ‘‘collar’’ (arrow), or ‘‘broken neck,’’ of the

‘‘Scotty dog.’’ The nose of the Scotty dog is the transverse process, the eye is

the pedicle, the neck is the pars interarticularis, the ear is the superior articular

facet, the front leg is the inferior articular facet, and the body is the lamina.

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lumbosacral kyphosis. The slip angle isthe angle between a line drawn per-pendicular to the posterior aspect of thesacrum and a line drawn along theinferior end plate of L5, and a positivevalue is defined as lumbosacral lordosis.The sacral inclination is the angle

between the posterior aspect of thesacrum and the vertical, and a value of>60� is associated with progression. Thechronicity of the slip is reflected byblunting of the osseous margins; atrapezoidal L5 and a domed shape orrounding of the superior end plate of S1

indicate long-standing alterations. Thepelvic incidence is the angle between aline drawn between the center of thefemoral head to the midpoint of thesacral end plate and a line perpendicularto the center of the sacral end plate; it isincreased in patients with spondylolis-thesis, and it correlates with the slipangle13,14. There is controversy about therelevance of this measurement40-42.

Single-Photon-EmissionComputed TomographyTomography of a scintigram enableslocalization of signal to the posteriorvertebral elements, specifically the parsinterarticularis43. In addition to facili-tating a diagnosis, the study may aidtreatment of spondylolysis. Increasedsignal intensity suggests osseous activityand healing potential, whereas absenceof an increased signal suggests a non-union and diminished healingpotential44.

Computed TomographyComputed tomography scans may playseveral roles45-47. When the pars inter-articularis appears normal on the com-puted tomography scan but there isincreased activity on the single-photon-emission computed tomography scan, astress response, or ‘‘pre-lysis’’ defect, isthe diagnosis. This is akin to the ‘‘pre-

Fig. 5-A Fig. 5-B

Anteroposterior (Fig. 5-A) and lateral (Fig. 5-B) radiographs made following internal fixation of a pars

interarticularis defect.

Fig. 4

Anteroposterior plain radiograph made after use of a bilateral lateral fusion

to treat a spondylolysis between L5 and S1.

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slip’’ condition in slipped capital femo-ral epiphysis. Pre-lysis may be evaluatedfurther with magnetic resonance imag-ing. On the other hand, when the parsinterarticularis is seen to have a defecton the computed tomography scan andthere is no increased activity on thesingle-photon-emission computed to-mography scan, the patient probablyhas a nonunion with little healingpotential. Computed tomography scansare also excellent for the follow-upevaluation of healing, to rule out an-other lesion (e.g., osteoid osteoma)when there is an atypical presentation,and for surgical planning in cases ofdysplastic vertebrae or associatedanomalies (Fig. 3).

Magnetic Resonance ImagingMagnetic resonance imaging is useful toevaluate an atypical presentation, in-cluding pre-lysis, when the computed

tomography scan shows normal find-ings48. Magnetic resonance imaging isindicated for patients with high-gradespondylolisthesis and for those with aradiculopathy49,50.

Medical TreatmentActivity modification, including cessa-tion of inciting sports activities, andnonsteroidal anti-inflammatory agentsare combined with an exercise regimenaimed principally at the reduction oflumbar lordosis as well as at the treat-ment of hip flexion and hamstringcontracture51. This is sufficient for achild in whom it alleviates symptoms orreduces them to an acceptable level. Thechild should be evaluated annuallythrough maturity because of the risk ofprogression during the adolescentgrowth acceleration52.

Physical therapy should be thefirst line of treatment for adults with

symptoms from spondylolisthesis.Hamstring stretching, trunk strength-ening, and avoidance of inciting activ-ities are beneficial for adults. Steroidinjections, at the nerve root and/or thepars interarticularis, can be both diag-nostic and therapeutic in adults.

The key role of spinal orthotics inthe treatment of spondylolysis is re-duction of the lumbar lordosis. Theorthotic device is typically molded at15� of flexion of the lumbar spine53,54.It is indicated for a child with unac-ceptable symptoms and for one withpositive findings on a single-photon-emission computed tomography scan,which suggest healing potential. Thetypical recommendation is threemonths of full-time wear (more thantwenty hours per day) with no sportsactivities followed by three months offull-time wear with sports activitiesallowed55. The patient is evaluated at the

Fig. 6-A Fig. 6-B

Figs. 6-A and 6-B An adult with severe lower-limb pain secondary to spondylolisthesis and a herniated disc at L5-

S1. Fig. 6-A Preoperative lateral radiograph. Fig. 6-B Postoperative lateral radiograph made after posterior spinal

fusion with transforaminal interbody fusion performed because removal of the herniated disc had increased the

instability of the spine.

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conclusion of each phase, principally toconfirm that the pain has been allevi-ated. If the pain persists, surgical inter-vention should be considered, asdiscussed below.

Outcome of Nonoperative ManagementMore than 80% of children treatednonoperatively have resolution ofsymptoms. There is no consensus in theliterature on the healing rate of spon-dylolysis, but it has been estimated that75% to 100% of acute lesions heal, allunilateral acute lesions heal, 50% ofbilateral acute lesions heal, but nochronic defects heal. There is an inter-mediate defect, with only magneticresonance imaging findings, that has avariable healing rate48. Cephalad lumbardefects heal more often than L5 lesionsdo. Even with these numbers, ‡90% ofchildren return to their previous levelsof activity56. This suggests that thestability of a fibrous union can beacceptable.

Surgical OptionsAn L5-S1 in situ fusion with autogenousposterior iliac crest bone graft is the

standard of care for patients with asymptomatic L5 spondylolysis57-60. In-strumentation is not necessary becausethe spine is inherently stable. The pro-cedure may be performed through amidline approach or through a para-spinous muscle-splitting approach61.The former approach has the advan-tages of familiarity to surgeons and agreater surface area for fusion, whereasthe latter approach is associated withless blood loss and preserves the soft-tissue stabilizers. Postoperative protocolsvary widely, from no immobilization tothe use of a lumbosacral orthotic withunilateral hip immobilization. We arenot aware of any data supporting theefficacy of one bracing protocol overanother, but we prefer to use at leasta lightweight rigid brace for mostpatients, with a greater degree of im-mobilization for younger patientswho have a greater slip and a lesserdegree of immobilization for olderadolescents or young adults with alesser degree of slip.

A repair of the pars interarticu-laris is recommended for adolescentsand young adults with L4 or more

cephalad spondylolysis and a normalintervertebral disc. The transverse pro-cess, which may serve as an anchor siteor a site for fusion, is sufficiently largecompared with a relatively small L5transverse process (Fig. 4). In addition,loss of motion from a fusion cephalad toL4 is more relevant clinically than a lossbetween L5 and S1. Instrumentationtechniques include placement of a screwacross the lytic defect in the parsinterarticularis, placement of a wirebetween the transverse process and thespinous process, or attachment of apedicle screw to the spinous processwith a rod and hook or a wire62-68

(Figs. 5-A and 5-B).Kakiuchi reported on sixteen pa-

tients treated with bilateral L5 trans-pedicular fixation with rod andsublaminar hook fixation66. Preopera-tively, the patients had persistent painand a positive response to lidocaineinfiltrated into the pars interarticularisdefect. Thirteen patients reported hav-ing no back pain after healing, and theother three had only occasional backpain without limitations in theiractivity.

Fig. 7-A Fig. 7-B

Figs. 7-A and 7-B A patient with spondylolisthesis and a degenerated disc between L5 and S1. Fig. 7-A

Preoperative lateral radiograph. Fig. 7-B Postoperative radiograph. Stability has been obtained with posterior

instrumentation, and the disc height has been restored with a bone graft placed from an anterior approach.

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In adults with a potentially repa-rable pars interarticularis defect, it isimportant to establish that that defect isthe source of the pain69. Pain relief aftera lidocaine injection at the pars inter-articularis supports the concept thatthe defect is the cause of the pain.When the L5-S1 intervertebral discappears normal on a magnetic reso-nance imaging scan and there isminimal dynamic instability, a parsinterarticularis repair can be considered.The most common technique is exci-sion of the nonunion site, placement ofa pedicle screw, bone-grafting, andplacement of a sublaminar hook withconnection of each hook by means ofa rod to the ipsilateral pedicle screw(Figs. 6-A and 6-B).

Surgical decompression is indi-cated when the patient has neuralcompromise, with a radiculopathy orbowel or bladder dysfunction34,70,71. De-compression must be wide and bilateralwith removal of the loose lamina (a Gillprocedure) and a foraminotomy, possi-bly including a facetectomy. Decom-pression increases the rate ofpseudarthrosis and increases instability,which can result in progression ofdeformity if instrumentation is notused72. In the literature, there is bothsupport for and advice against con-comitant decompression and fusion forpatients with spondylolisthesis70-76. Weusually recommend decompression atthe time of fusion with instrumentationif there is any lower-limb pain or neuralcompression.

Carragee enrolled forty-six adultswith symptomatic low-grade isthmicspondylolisthesis into a randomizedprospective study to evaluate the effectof decompression72. All smokers weretreated with transpedicular instrumen-tation, whereas the nonsmokers had noinstrumentation. Patients were ran-domized with regard to whether ornot they underwent a formal decom-pression. Only one of the twenty-fourpatients without decompression hadan unsatisfactory result. Obtainingfusion was more important than thedecompression, and use of instrumen-tation was found to improve thefusion rate.

InstrumentationThe use of instrumentation in thetreatment of low-grade isthmic spon-dylolisthesis in adults increased with thewidespread use of pedicle screws andthe belief that a fusion is necessary toobtain a good result. Transpedicularfixation does increase the rate of fusion,and there is a positive correlationbetween successful fusion and clinicaloutcome77-83. On the other hand, Mollerand Hedlund found that instrumenta-tion offered no advantage when theycompared patients treated with in situfusion with transpedicular fixation andthose treated with in situ fusion withouttranspedicular fixation84,85. Further-

more, the patients who were treatedwith instrumentation had greater bloodloss and a longer operative time84,85.Therefore, an in situ arthrodesis with-out instrumentation remains a reason-able option, particularly in patients withosteoporotic bone. Despite this, andbecause of better fusion rates and atleast a suggestion of better outcomeswith a solid fusion, we recommendinstrumentation with transpedicularfixation, especially when a decompres-sion is done.

Interbody FusionThere are several theoretical advantagesto adding anterior column support to

Fig. 8-A

Figs. 8-A through 8-E A patient with spondyloptosis who had severe lower-extremity and back

pain. Figs. 8-A and 8-B Preoperative anteroposterior (Fig. 8-A) and lateral (Fig. 8-B) radiographs.

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the standard posterolateral fusion.These include providing a larger surfacearea for bone graft incorporation, plac-ing the bone graft under compression,obtaining an indirect reduction of fo-raminal stenosis by using the graft torestore the height of the intervertebraldisc, improving lumbar lordosis, andablating the degenerated disc (a poten-tial source of pain) (Figs. 7-A and 7-B).The interbody device or bone graft maybe placed through a transforaminallumbar interbody fusion approach orthrough a posterolateral approach. Thedisadvantages of performing the inter-body fusion through a posterolateralapproach are the additional surgicaltime compared with that needed forposterior-only surgery and the risk ofinjury to the neural elements with

the retraction required for discexcision and placement of the inter-body device86-90.

The interbody fusion can be donethrough an anterior approach without aposterior fusion. This is called an ante-rior lumbar interbody fusion. Propo-nents of this approach prefer it becauseit provides the same treatment advan-tages of the interbody fusion whileavoiding disruption of the posteriorparaspinal muscles and the exposure ofthe neural elements91-93. An anterior-only interbody fusion in a patient withspondylolisthesis must achieve inherentstability or it will displace. One of us(C.B.T.) had encouraging results afterutilizing an anterior plate and an inter-body component to fuse the site of anisthmic spondylolisthesis with an

anterior-only approach in a small groupof patients. The anterior approach addsthe risk of retrograde ejaculation inmales and of vascular complications.Aunoble et al. reported successful out-comes of anterior lumbar interbodyfusion in a series of twenty patients92.

Combining both posterior andanterior approaches in the treatment oflow-grade isthmic spondylolisthesis inan adult has both advantages anddisadvantages compared with the singleapproaches. The anterior approach al-lows better reduction of the deformitythan is possible with the posteriorapproach, whereas the posterior ap-proach allows a direct decompression ofcompressed nerve roots and transpe-dicular fixation increases the rigidity ofthe construct. The combined approachaddresses the pars interarticularis de-fect, foraminal stenosis, degenerativedisc disease, a ‘‘loose lamina,’’ and thedynamic instability. The disadvantageis that this technique requires twoseparate procedures, with increasedoperative time and morbidity. In aprospective study, patients who hadundergone the combined approachhad better outcome measures in allcategories at six and twelve monthspostoperatively compared with patientstreated with posterior fusion only94.The differences were less pronouncedat two years.

The treatment approach for ahigh-grade spondylolisthesis shoulddiffer from that for a low-grade spon-dylolisthesis (Figs. 8-A through 8-E).The management of patients with >50%slippage (grade III or higher) or lum-bosacral kyphosis is more complex.High-grade spondylolisthesis can beassociated with dysplastic L5-S1 facetswithout a pars interarticularis defectand therefore is more likely to causesevere stenosis since, with the displace-ment of the vertebral body, the posteriorlamina is pulled forward rather thanremaining posteriorly (separated fromthe vertebral body), as occurs if thereis a pars interarticularis defect. Whilethe preferred surgical treatment is fu-sion in situ, that procedure is as-sociated with a higher rate of slipprogression, pseudarthrosis, neurologic

Fig. 8-B

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injury, and, if instrumentation is used,failure of the hardware even in youngpatients95-98.

Even without reduction, manage-ment of a high-grade spondylolisthesisis risky32,34. The management of an adultwith a high-grade spondylolisthesisshould start with nonoperative methodsthat include physical therapy and epi-dural steroids. A child with a high-gradespondylolisthesis or an adult who doesnot respond to nonoperative careshould have surgical stabilization. An insitu fusion can be successful in manyyoung patients. Because these patientsoften have a dysplastic L5 transverseprocess and because an L5-S1 fusionwould place the fusion bed under ten-sion, inclusion of L4 is generally re-

quired to achieve a successful fusion. Aparamedian Wiltse approach is pre-ferred, to maintain the integrity of themidline structures. An external brace isusually applied until the fusion siteheals. Patients followed over the longterm after an in situ fusion generally arefound to have good function and painrelief, although the surgery does notaffect their appearance99,100. Althoughthe hamstring tightness that many ofthese patients exhibit is suspected to berelated to neurologic compression, itusually resolves without decompressionwhen a successful fusion has beenachieved. This may take up to eighteenmonths, however, and some authorsbelieve that a subtle gait abnormalitypersists59.

Reduction of high-grade spondy-lolisthesis has become more common,probably because of the availability ofsmaller implants, which are needed inthese patients, as well as the higherprevalence of unsuccessful fusion inpatients with high-grade spondylolis-thesis100. A patient who is considered fora reduction of a spondylolisthesisshould have substantial angulation of L5over S1 (a slip angle of >45�, lumbosa-cral kyphosis, or an inability to standupright with the head balanced overthe pelvis), require a decompression,have demonstrated progression of theslip angle, have demonstrated progres-sion after an attempted fusion, or havean unacceptable clinical appearance. Itis important that the patient and his or

Fig. 8-C

Preoperative T2-weighted magnetic resonance imaging scans showing severe spinal canal stenosis. The

patient was treated with a resection of L5, reduction of the malalignment, interbody fusion, and posterior

instrumentation.

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her family understand and accept therisks associated with a reduction.

Reduction can be done with ex-ternal cast techniques, particularly invery young patients in whom pediclescrew fixation may not be possible101.The reduction is performed after thebone graft is placed and the wound isclosed. The patient is placed on a spicatable or Stryker frame and should beawake so that he or she can report anyneurologic changes. A padded supportis placed over the sacrum and the spine

is allowed to extend, to reduce thelumbosacral kyphosis. The trunk and atleast one thigh are then incorporatedinto a spica cast. A brace with a thighextension can be used when early heal-ing is apparent on radiographs, usuallyat six to twelve weeks.

Open reduction with instrumen-tation is used for patients who require adecompression or for whom a fusionattempt without instrumentation hasfailed, with progression of the slip. Awide surgical decompression is per-

formed, with care taken to adequatelydecompress the nerve roots (usuallyL5). A temporary distraction rod isapplied from L3 to the sacrum, usuallywith temporary hooks. Pedicle screwsare then placed in L4 and L5, and sacralscrews are directed to the sacral prom-ontory, where maximal purchase in thesacrum is achieved, or the sacral screwscan be drilled through the sacrum intoL5. Neurophysiologic monitoring isadvised. We have found that it helps tomonitor several muscle groups, both

Fig. 8-D Fig. 8-E

Postoperative anteroposterior (Fig. 8-D) and lateral (Fig. 8-E) radiographs.

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Page 13: Spondylolisthesis and Spondylolysis - Semantic Scholar · spondylolisthesis have a lower preva-lence of progression than those with high dysplastic spondylolisthesis. Pa-tients with

motor and sensory, as well as electro-myographic activity and sphincter ac-tivity. Removal of the L5-S1 disc and/orosteotomy of the sacral dome can bedone to improve the reduction. Thereduction maneuvers of distraction andtranslation should be performed slowly.The final millimeters of translation andthe final degrees of angular reductionare the most risky, and partial reductionis an option102. Care should be takenduring the reduction, not just becauseof the neurologic risk but also becauseof the risk of pedicle screw pullout. Thisis particularly true for the caudal fixa-tion. Transsacral screws, iliac screws,and Jackson intrasacral buttress rodshave all been used to improve thestrength of the caudal fixation withvarying degrees of success. Once cor-rection has been achieved, a decisionregarding whether to perform an inter-body fusion is made. A standard inter-body cage filled with bone or atranssacral fibular graft provides addi-tional stability during the posteriorapproach103-105. An alternative surgicaloption is combined anterior and pos-terior fusion, with the anterior fusiondone first to release the anterior struc-tures and thus make the reduction andplacement of the interbody spacereasier106,107.

The long-term results of the dif-ferent treatment options for high-gradespondylolisthesis are relatively good. Inone study of sixty-seven children andadolescents, the results of posterolateral,anterior, and circumferential fusionwere compared at an average of seven-teen years postoperatively, and the bestclinical outcome, as measured with theOswestry Disability Index, was foundafter the circumferential fusion108. Areview of the results of posterolateraldecompression and fusion with trans-sacral placement of a fibular graft infourteen patients demonstrated com-plete neurologic recovery in patients inwhom neurologic deficits had devel-oped after the surgery and incorpora-tion of the fibular graft and achievementof a solid fusion in all but one of thepatients105. In a similar series, onepatient was not satisfied with the cos-metic result and one patient had a

nonunion and continued back pain109.The results after reduction of high-grade spondylolisthesis are generallygood103,110-113.

When a patient has completespondyloptosis, particularly with L5below the level of the sacral end plate,resection of L5 and reduction of L4 ontothe sacrum, through a combined ante-rior and posterior approach (the Gainesprocedure), can be considered114. Al-though this is a spine-shortening pro-cedure and thus intended to beassociated with a decreased risk ofneurologic injury in this particularlyhigh-risk patient group, the rate ofneurologic injury was 76% in Gaines’soriginal series114; however, only two ofthe thirty patients in that series requiredlower-extremity bracing at the time oflong-term follow-up115.

Degenerative SpondylolisthesisUnlike isthmic spondylolisthesis, de-generative spondylolisthesis occurs

most often (in 85% of cases) at L4-L5.The L3-L4 level is the next most com-mon level (Figs. 9-A, 9-B, and 9-C),with L5-S1 rarely being involved. De-generative spondylolisthesis is mostcommon in the sixth decade of life andis more common in females than inmales (a ratio of 6:1).

The pathophysiology of this typeof spondylolisthesis has been postulatedto be a combination of disc and facetjoint degeneration. Patients with de-generative spondylolisthesis have moresagittally oriented facet joints than dopatients without degenerative spondy-lolisthesis; however, it is unclearwhether the facet orientation is a pri-mary cause or a secondary effect116,117.The slip rarely progresses beyondgrade I.

Patients usually present withneurogenic claudication or radicularsymptoms from the spinal stenosis, andsome patients recount a long history ofback pain prior to the development of

Fig. 9-A

Figs. 9-A, 9-B, and 9-C A patient with degenerative

spondylolisthesis at L3-L4 and severe lower-extremity

and low-back pain refractory to conservative treatment.

Fig. 9-A Preoperative lateral radiograph.

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Page 14: Spondylolisthesis and Spondylolysis - Semantic Scholar · spondylolisthesis have a lower preva-lence of progression than those with high dysplastic spondylolisthesis. Pa-tients with

lower-extremity symptoms. Evaluationof a patient with degenerative spondy-lolisthesis is similar to that of any patientwith a back condition, with a carefulneurologic examination and evaluationof the spine, including the patient’sstance and sagittal balance. Vascularinsufficiency and peripheral neuropathyneed to be considered as alternativecauses of the symptoms. Patients whosesymptoms do not correspond to the levelof the stenosis should have a completeneurologic work-up or electromyo-graphic studies. Patients who do not havepalpable peripheral pulses, do not haverelief of pain with sitting, or do not needto sit to relieve the claudication are more

likely to have vascular insufficiency.Spinal tumors, infection, and nonspinaletiologies also need to be considered. Asis the case with isthmic spondylolisthesis,upright radiographs are necessary todetermine the degree of degenerativespondylolisthesis118. Magnetic resonanceimaging scans are ideal for assessing theseverity of spinal canal and foraminalnarrowing.

Conservative management mayhelp many patients with symptoms ofdegenerative spondylolisthesis. Nonste-roidal anti-inflammatory medications,physical therapy, and cardiovascularconditioning as well as alternative treat-ments such as acupuncture may relieve

symptoms to the point where surgery isnot necessary. Patients with substantialradicular or claudication symptoms of-ten benefit from epidural steroid injec-tions or selective nerve root blocks.

Surgical management is offeredwhen nonoperative options have notadequately relieved symptoms. Whileboth nonoperative and operative treat-ment can substantially decrease symp-toms, surgery seems to provide fasterand greater improvement for patientswith severe symptoms and associatedsevere stenosis119. The most commonoperative treatment options are a lim-ited decompression (laminoforaminot-omy or interlaminar decompression),

Fig. 9-B

Fig. 9-B Preoperative sagittal T2-weighted magnetic resonance

imaging scan revealing moderately severe stenosis at L3-L4.

Fig. 9-C

Fig. 9-C Postoperative lateral radiograph.

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laminectomy, or laminotomy with fu-sion (with or without instrumentation).The severity of the stenosis and where itis located (foraminal, lateral recess,central, or [most commonly] a combi-nation of these sites) determine theextent of decompression required andtherefore the likelihood of slip progres-sion without fusion. A limited decom-pression may be considered for patientswho have unilateral disease withoutevidence of motion on flexion-extensionradiographs120. At least 50% of thefacet joints and the interspinous liga-ments need to be preserved during thedecompression to maintain inherentstability.

Most patients who undergo sur-gery should have a laminectomy andfusion. Herkowitz’s group and othershave shown that patients who have alaminectomy and fusion do better thanpatients who have a laminectomyalone121-125. Short-term follow-up didnot show an advantage to using instru-mentation with the fusion, which in-creased the prevalence of complications.However, longer follow-up revealed thatpatients did better if a fusion had beenachieved, and fusion was achieved morereliably with internal fixation. Patientswith substantial comorbidities or withosteoporosis and/or substantial discspace narrowing may be better treatedby fusion without internal fixation.The majority of symptomatic patientswith degenerative spondylolisthesiswho are in reasonable health and forwhom nonoperative treatment has

failed should have a laminectomy andfusion with instrumentation. Suchan approach has resulted in a highfusion rate and excellent clinicalsuccess124,126.

To improve the fusion rate andpatient outcomes, some surgeons areincluding interbody fusion in theirsurgical approach. Posterior-basedtransforaminal interbody fusion orposterolateral interbody fusion mayimprove restoration of disc and foram-inal height127,128. However, to ourknowledge there are no publishedstudies that demonstrate improvedoutcomes with the addition of poste-rior-based transforaminal interbodyfusion or posterolateral interbodyfusion to the surgical procedure inpatients with degenerativespondylolisthesis.

Currently, motion-preservationand nonfusion devices are receivingtremendous attention in the lay press.While early, preclinical InvestigationalDevice Exemption studies129,130 haveshown favorable results, the use of thesedevices in patients with degenerativespondylolisthesis has yet to bevalidated in independent randomizedprospective studies. Indeed, with theselection criteria used in the preclinicalstudies, only small numbers of cases ofdegenerative spondylolisthesis wereincluded.

OverviewSpondylolisthesis is a common condi-tion and the majority of people are

successfully treated without surgery.Patients for whom surgery is indicatedusually have good outcomes. Youngpatients may require only a fusion insitu; however, patients who have evi-dence of neural compression may needa decompression to relieve symptoms,and fusion is usually also indicated inthese cases. Additional adjuncts havebeen proposed to improve outcomes,but there are few randomized prospec-tive trials to demonstrate superiority ofone technique over another.

Serena S. Hu, MDMohammad Diab, MDDepartment of Orthopaedic Surgery,University of California, San Francisco,500 Parnassus Avenue, Room MU 320W,San Francisco, CA 94143

Clifford B. Tribus, MDDepartment of Orthopedic Surgery andRehabilitative Medicine, University ofWisconsin, K4/746 Clinical Science Center,600 Highland Avenue, Madison, WI 53792Alexander J. Ghanayem, MDDepartment of Orthopaedic Surgery andRehabilitation, Loyola University Chicago,2160 South 1st Avenue, Maywood,IL 60153Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. Thisarticle, as well as other lectures presentedat the Academy’s Annual Meeting, will beavailable in March 2008 in InstructionalCourse Lectures, Volume 57. The completevolume can be ordered online atwww.aaos.org, or by calling800-626-6726 (8 A.M.-5 P.M.,Central time).

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