Adult Is TH Mics Pondy Lolis Thesis

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

Spine Care
Diagnosis and Treatment of

Adult Isthmic
Spondylolisthesis
NASS Evidence-Based Clinical Guidelines Committee

D. Scott Kreiner, MD Jamie Baisden, MD Daniel Mazanec, MD Rakesh Patel, MD Robert Shay Bess, MD
Committee Co- Diagnosis/Imaging Medical/Interventional Surgical Treatment Value Section Chair
Chair and Natural Section Chair Treatment Section Section Chair
History Section Chair
Chair
Douglas Burton, MD Amgad S. Hanna, MD Anil K. Sharma, MD

Norman B. Chutkan, MD Steven W. Hwang, MD Christopher K. Taleghani, MD
Bernard A. Cohen, PhD Cumhur Kilincer, MD, PhD Terry R. Trammel, MD
Charles H. Crawford III, MD Mark E. Myers, MD Andrew N. Vo, MD
Gary Ghiselli, MD Paul Park, MD Keith D. Williams, MD
North American Spine Society
Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of Adult Isthmic Spondylolisthesis
Copyright © 2014 North American Spine Society
7075 Veterans Boulevard
Burr Ridge, IL 60527 USA
630.230.3600
www.spine.org
This clinical
ISBN guideline should
1-929988-37-0 not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-
ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physi-
cian and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.
Introduction/Guideline Methodology 2 Diagnosis and Treatment of Adult Isthmic Spondylolisthesis | NASS Clinical Guidelines
Financial Statement
This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating
authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy. Disclosures are listed below:
Scott Kreiner Nothing to disclose. (2/4/13)

Jamie Baisden Nothing to disclose. (1/29/13)
Range Key:
Robert Shay Bess Royalties: Pioneer (Level B); Consulting: Allosource, DePuy Spine (Level Level A. $100 to $1,000
B), Alphatec (Level B), Medtronic (Level B); Speaking and/or teaching Level B. $1,001 to $10,000
arrangements: DePuy Spine (Level B), Medtronic (Level B); Trips/Travel:
DePuy Spine (Level B), Medtronic (Level B), Alphatec (Level B); ScientificLevel C. $10,001 to $25,000
Advisory Board: Allosource (Level B); Research Support (Investigator Level D. $25,001 to $50,000
Salary): DePuy Spine (Level B), Medtronic (Level B); Grants: Orthopedic Level E. $50,001 to $100,000
Research and Education Foundation (Level C). (1/28/13) Level F. $100,001 to $500,000
Norman B. Chutkan Royalties: Globus Medical (Level E); Speaking and/or teaching arrange- Level G. $500,001 to $1M
ments: AO North America (Nonfinancial, Travel expenses and per diem); Level H. $1,000,001 to $2.5M
Board of Directors: Walton Rehabilitation Hospital (Nonfinancial); Scien- Level I. Greater than $2.5M
tific Advisory Board: Orthopedics Journal (Nonfinancial). (1/29/13)
Bernard A. Cohen Stock Ownership: NuVasive (7000, 0, Shares equal less than 1/10th of 1%
of outstanding shares), Medtronic (5000, 0, Shares equal less than 1/10th of 1% of outstanding shares), General
Electric (10000, 0, Shares equal less than 1/10th of 1% of outstanding shares), Synthes (1000, 0, Shares equal less
than 1/10th of 1% of outstanding shares), Zimmer (520, 0, Shares equal less than 1/10th of 1% of outstanding
shares), Johnson & Johnson (1500, 0, Shares equal less than 1/10th of 1% of outstanding shares), Hanson Medical
(1000, 0, Shares equal less than 1/10th of 1% of outstanding shares); Consulting: NuVasive (Less than Level B last
calendar year), Johnson & Johnson (Less than Level B last calendar year); Speaking and/or teaching arrangements:
Milwaukee School of Engineering (Nonfinancial, Bioengineering & Nursing Faculty Lectures), Numerous National
and International Hospitals (Nonfinancial, Lecture and Teach Intraoperative Neurophysiology); Board of Directors:
American Society for Neurophysiological Monitoring (Nonfinancial); Research Support (Staff/Materials): Neurovi-
sion Medical Products (Level B, Supplied ET tubes). (1/29/13)
Charles H. Crawford Consulting: Medtronic (D), Alphatec (D); Speaking and/or Teaching Arrangements: Depuy-Synthes (B); Trips/Travel:
NASS (A), SRS (A); Other Office: Scoliosis Research Society (Nonfinancial, Committee Member), NASS (Nonfinan-
cial, Committee Member) (11/01/13)
Daniel P. Elskens Nothing to disclose. (2/7/13)
Gary Ghiselli Private Investments: DiFusion (100000, 9); Consulting: Biomet (Level B for product development and teaching).
(2/1/13)
Amgad S. Hanna Nothing to disclose. (2/15/13)
Steven W. Hwang Nothing to disclose. (1/29/13)
Cumhur Kilincer Nothing to disclose. (1/29/13)
Daniel J. Mazanec Consulting: First consult (Level A). (1/29/13)
Mark E. Myers Stock Ownership: Spineology (2500, 1); Consulting: Spinewave (Level A/hour consulting). (2/7/13)
Paul Park Consulting: Globus Medical (Level B), Medtronic (Level B); Speaking and/or teaching arrangements: Globus Medi-
cal (Level C); Scientific Advisory Board: Neuralstem (Level B); Grants: NIH (Level B, Paid directly to institution/
employer), SMISS (Level B, Paid directly to institution/employer); Relationships Outside the One Year Requirement:
DePuy (NASS Annual Meeting, 08/2011, Speaking and/or Teaching Arrangement, Level B). (1/27/13)
Rakesh D. Patel Speaking and/or Teaching Arrangements: Stryker (Level B) and Globus (Level B) (11/7/13)
Anil K. Sharma Nothing to disclose. (2/7/13)
Christopher K. Taleghani Royalties: Seaspine (Level D), Globus (Less than Level A); Consulting: Seaspine (Level B), Theken (Level C); Speaking
and/or teaching arrangements: Globus (Level B for teaching a course). (2/14/13)
Terry R. Trammel Consulting: Medtronic (Level D in 2011, Level C in 2012), Biomet (Level C in 2011, Level C in 2012); Speaking and/
or teaching arrangements: Biomet (Financial, Amount is included in Consulting Income (1099) statement previously
listed); Other: K2m (Financial, Participation in clinical data collection-paid for entering patient data per IRB autho-
rization of enrolled patients. Also during 2011 compensated for my time and attendance at investigators meetings
and presentations - estimated amount paid in 2011 Level B, 2012 Level C). (2/5/13)
Andrew N.Vo Nothing to disclose. (2/8/13)
Keith D. Williams Nothing to disclose. (2/3/13)
Comments
Comments regarding the guideline may be submitted to the North American Spine Society and will be considered in develop-
ment of future revisions of the work.
This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-
Table of Contents
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
II. Guideline Development Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
III. Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
IV. Definition and Indicence of Adult Isthmic Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
V. Recommendations for Diagnosis and Treatment of Adult Isthmic Spondylolisthesis . . . . . . . . . 15

A. Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
B. Diagnosis/Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
C. Outcome Measures for Medical/Interventional and Surgical Treatment . . . . . . . . . . . . . . . . . . . . 34
D. Medical/Interventional Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
E. Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
F. Value of Spine Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

VI. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
A. Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
B. Levels of Evidence for Primary Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
C. Grades of Recommendations for Summaries or Reviews of Studies . . . . . . . . . . . . . . . . . . . . . . 71
D. Linking Levels of Evidence to Grades of Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
E. NASS Literature Search Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

VII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
A technical report, including the literature search parameters and evidentiary tables developed by
the authors, can be accessed at https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/
AdultIsthmicSpondyGuidelineTechReport.pdf.
I. Introduction
Objective THIS GUIDELINE DOES NOT REPRESENT A “STAN-
The objective of the North American Spine Society (NASS) Clin- DARD OF CARE,” nor is it intended as a fixed treatment pro-
ical Guideline for the Diagnosis and Treatment of Adult Isthmic tocol. It is anticipated that there will be patients who will require
Spondylolisthesis is to provide evidence-based recommendations less or more treatment than the average. It is also acknowledged
to address key clinical questions surrounding the diagnosis and that in atypical cases, treatment falling outside this guideline
treatment of adult patients with isthmic spondylolisthesis. This will sometimes be necessary. This guideline should not be seen
guideline is based upon a systematic review of the evidence and as prescribing the type, frequency or duration of intervention.
reflects contemporary treatment concepts for symptomatic isth- Treatment should be based on the individual patient’s need and
mic spondylolisthesis as reflected in the highest quality clinical doctor’s professional judgment and experience. This document
literature available on this subject as of June 2013. The goals of is designed to function as a guideline and should not be used as
the guideline recommendations are to assist in delivering opti- the sole reason for denial of treatment and services. This guide-
mum, efficacious treatment and functional recovery from this line is not intended to expand or restrict a health care provider’s
spinal disorder. scope of practice or to supersede applicable ethical standards or
provisions of law.
Scope, Purpose and Intended User
This document was developed by the North American Spine So- Patient Population
ciety Evidence-based Guideline Development Committee as an The patient population for this guideline encompasses adults (18
educational tool to assist practitioners who treat adult patients years or older) with variable back, lower extremity pain and/or
with isthmic spondylolisthesis. The goal is to provide a tool that neurologic deficit related to isthmic spondylolisthesis.
assists practitioners in improving the quality and efficiency of
care delivered to these patients. The NASS Clinical Guideline
for the Diagnosis and Treatment of Adult Isthmic Spondylolisthe-
sis provides a definition of this disorder, outlines a reasonable
evaluation of patients suspected to have isthmic spondylolisthe-
sis and outlines treatment options for adult patients with this
diagnosis.
II. Guideline Development Methodology

Through objective evaluation of the evidence and transparency Levels of Evidence and Grades of
in the process of making recommendations, it is NASS’ goal Recommendation
to develop evidence-based clinical practice guidelines for the NASS has adopted standardized levels of evidence (Appendix B)
diagnosis and treatment of adult patients with various spinal and grades of recommendation (Appendix C) to assist practi-
conditions. These guidelines are developed for educational tioners in easily understanding the strength of the evidence and
purposes to assist practitioners in their clinical decision- recommendations within the guidelines. The levels of evidence
making processes. It is anticipated that where evidence is very range from Level I (high quality randomized controlled trial) to
strong in support of recommendations, these recommendations Level V (expert consensus). Grades of recommendation indi-
will be operationalized into performance measures. cate the strength of the recommendations made in the guideline
based on the quality of the literature.
Multidisciplinary Collaboration Grades of Recommendation:
With the goal of ensuring the best possible care for adult patients A: Good evidence (Level I studies with consistent findings) for
suffering with spinal disorders, NASS is committed to multidis- or against recommending intervention.
ciplinary involvement in the process of guideline and perfor- B: Fair evidence (Level II or III studies with consistent find-
mance measure development. To this end, NASS has ensured ings) for or against recommending intervention.
that representatives from both operative and non-operative, C: Poor quality evidence (Level IV or V studies) for or against
medical, interventional and surgical spine specialties have par- recommending intervention.
ticipated in the development and review of NASS guidelines. To I: Insufficient or conflicting evidence not allowing a recom-
ensure broad-based representation, NASS welcomes input from mendation for or against intervention.
other societies and specialties.
Levels of evidence have very specific criteria and are assigned
to studies prior to developing recommendations. Recommenda-
Evidence Analysis Training of All NASS
tions are then graded based upon the level of evidence. To better
Guideline Developers understand how levels of evidence inform the grades of recom-
All Evidence-Based Guideline Development Committee mendation and the standard nomenclature used within the rec-
Members have completed NASS’ Fundamentals of Evidence- ommendations see Appendix D.
Based Medicine Training. Members have the option to attend
a one-day course or complete training via an online program. Guideline recommendations are written utilizing a standard
In conjunction with Qwogo Inc., a University of Alberta affili- language that indicates the strength of the recommendation.
ated enterprise, NASS offers an online training program geared “A” recommendations indicate a test or intervention is “recom-
toward educating guideline developers about evidence analysis mended”; “B” recommendations “suggest” a test or intervention
and guideline development. All participants in guideline de- and “C” recommendations indicate a test or intervention “may
velopment for NASS have completed the live or online training be considered” or “is an option.” “I” or “Insufficient Evidence”
prior to participating in the guideline development program at statements clearly indicate that “there is insufficient evidence to
NASS. Both trainings include a series of readings and exercises, make a recommendation for or against” a test or intervention.
or interactivities, to prepare guideline developers for system- Work group consensus statements clearly state that “in the ab-
atically evaluating literature and developing evidence-based sence of reliable evidence, it is the work group’s opinion that” a
guidelines. The live course takes approximately 8-9 hours to test or intervention may be appropriate.
complete and the online course takes approximately 15-30
hours to complete. Participants are awarded CME credit upon The levels of evidence and grades of recommendation imple-
completion of the course. mented in this guideline have also been adopted by the Journal
of Bone and Joint Surgery, the American Academy of Orthopae-
Disclosure of Potential Conflicts of Interest dic Surgeons, Clinical Orthopaedics and Related Research, the
All participants involved in guideline development have journal Spine and the Pediatric Orthopaedic Society of North
disclosed potential conflicts of interest to their colleagues America.
in accordance with NASS’ Disclosure Policy for committee
members (https://www.spine.org/Documents/WhoWeAre/ In evaluating studies as to levels of evidence for this guideline,
DisclosurePolicy.pdf) and their potential conflicts have the study design was interpreted as establishing only a potential
been documented in this guideline. NASS does not restrict level of evidence. As an example, a therapeutic study designed
involvement in guidelines based on conflicts as long as as a randomized controlled trial would be considered a poten-
members provide full disclosure. Individuals with a conflict tial Level I study. The study would then be further analyzed as
relevant to the subject matter were asked to recuse themselves to how well the study design was implemented and significant
from deliberation. Participants have been asked to update their shortcomings in the execution of the study would be used to
disclosures regularly throughout the guideline development downgrade the levels of evidence for the study’s conclusions. In
process. the example cited previously, reasons to downgrade the results of
a potential Level I randomized controlled trial to a Level II study
would include, among other possibilities: an underpowered ian at InfoNOW at the University of Minnesota, consistent with
study (patient sample too small, variance too high), inadequate the Literature Search Protocol. Following these protocols en-
randomization or masking of the group assignments and lack of sures that NASS recommendations (1) are based on a thorough
validated outcome measures. review of relevant literature; (2) are truly based on a uniform,
comprehensive search strategy; and (3) represent the current
In addition, a number of studies were reviewed several times in best research evidence available. NASS maintains a search his-
answering different questions within this guideline. How a given tory in Endnote, for future use or reference.
question was asked might influence how a study was evaluat-
ed and interpreted as to its level of evidence in answering that Step 5: Review of Search Results/Identification of
particular question. For example, a randomized controlled trial Literature to Review
reviewed to evaluate the differences between the outcomes of Work group members reviewed all abstracts yielded from the
surgically treated versus untreated patients with lumbar disc literature search and identified the literature they will review
herniation with radiculopathy might be a well designed and im- in order to address the clinical questions, in accordance with
plemented Level I therapeutic study. This same study, however, the Literature Search Protocol. Members have identified the
might be classified as providing Level II prognostic evidence if best research evidence available to answer the targeted clinical
the data for the untreated controls were extracted and evaluated questions. That is, if Level I, II and or III literature is available to
prognostically. answer specific questions, the work group was not required to
review Level IV or V studies.
Guideline Development Process
Step 1: Identification of Clinical Questions Step 6: Evidence Analysis
Trained guideline participants were asked to submit a list of clin- Members have independently developed evidentiary tables sum-
ical questions that the guideline should address. The proposed marizing study conclusions, identifying strengths and weakness-
questions were compiled into a master list, which was then cir- es and assigning levels of evidence. In order to systematically
culated to each member for review and comment. A conference control for potential biases, at least two work group members
call was held to review comments and condense and refine the have reviewed each article selected and independently assigned
draft clinical question list. The draft clinical question list was levels of evidence to the literature using the NASS levels of evi-
then submitted to the NASS Health Policy and Research Coun- dence. Any discrepancies in scoring have been addressed by two
cils for review. The councils submitted additional questions that or more reviewers. Final ratings are completed at a final meeting
may be useful for health policy or research purposes and ap- or webconference of all section workgroup members including
proved the master list. the section chair and the guideline chair. The consensus level
was then assigned to the article. Multi-diagnosis studies that did
Step 2: Identification of Work Groups not include sub-group anlaysis of isthmic spondylolisthesis pa-
Multidisciplinary teams were assigned to work groups and as- tients failed to meet inclusion criteria and were excluded from
signed specific clinical questions to address. Because NASS is the guideline.
comprised of surgical, medical and interventional specialists, it
is imperative to the guideline development process that a cross- As a final step in the evidence analysis process, members have
section of NASS membership is represented on the work group. identified and documented gaps in the evidence to educate
This also helps to ensure that the potential for inadvertent biases guideline readers about where evidence is lacking and help guide
in evaluating the literature and formulating recommendations is further needed research by NASS and other societies.
minimized.
Step 7: Formulation of Evidence-Based
Step 3: Identification of Search Terms and Parameters Recommendations and Incorporation of Expert
One of the most crucial elements of evidence analysis is the Consensus
comprehensive literature search. Thorough assessment of the Work groups held web-conferences and face-to-face meetings
literature is the basis for the review of existing evidence and the to discuss the evidence-based answers to the clinical questions,
formulation of evidence-based recommendations. In order to the grades of recommendations and the incorporation of expert
ensure a thorough literature search, NASS has instituted a Lit- consensus. Expert consensus was incorporated only where Lev-
erature Search Protocol (Appendix E) which has been followed el I-IV evidence is insufficient and the work group has deemed
to identify literature for evaluation in guideline development. In that a recommendation is warranted. Transparency in the incor-
keeping with the Literature Search Protocol, work group mem- poration of consensus is crucial, and all consensus-based rec-
bers have identified appropriate search terms and parameters ommendations made in this guideline very clearly indicate that
to direct the literature search. Specific search strategies, includ- Level I-IV evidence is insufficient to support a recommendation
ing search terms, parameters and databases searched, are docu- and that the recommendation is based only on expert consensus.
mented in the technical report that accompanies this guideline.
Consensus Development Process
Step 4: Completion of the Literature Search Voting on guideline recommendations was conducted using
Once each work group identified search terms/parameters, the a modification of the nominal group technique in which each
literature search was implemented by a medical/research librar- work group member independently and anonymously ranked
a recommendation on a scale ranging from 1 (“extremely inap- Step 10: Submission for Publication and National
propriate”) to 9 (“extremely appropriate”). Consensus was ob- Guideline Clearinghouse (NGC) Inclusion
tained when at least 80% of work group members ranked the Following NASS Board approval, the guidelines have been slat-
recommendation as 7, 8 or 9. When the 80% threshold was not ed for publication and submitted for inclusion in the National
attained, up to three rounds of discussion and voting were held Guidelines Clearinghouse (NGC). No revisions were made after
to resolve disagreements. If disagreements were not resolved af- submission to NGC, but comments have been and will be saved
ter these rounds, no recommendation was adopted. for the next iteration.
After the recommendations were established, work group mem- Step 11: Review and Revision Process
bers developed the guideline content, addressing the literature The guideline recommendations will be reviewed every three to
supporting the recommendations. five years by an EBM-trained multidisciplinary team and revised
as appropriate based on a thorough review and assessment of
Step 8: Submission of the Draft Guidelines for Review/ relevant literature published since the development of this ver-
Comment sion of the guideline.
Guidelines were submitted to the full Evidence-Based Guideline
Development Committee and the Research Council for review Use of Acronyms
and comment. Revisions to recommendations were considered Throughout the guideline, readers will see many acronyms with
for incorporation only when substantiated by a preponderance which they may not be familiar. A glossary of acronyms is avail-
of appropriate level evidence. able in Appendix A.
Step 9: Submission for Board Approval Nomenclature for Medical/Interventional Treatment

Once any evidence-based revisions were incorporated, the drafts Throughout the guideline, readers will see that what has tra-
were prepared for NASS Board review and approval. Edits and ditionally been referred to as “nonoperative,” “nonsurgical” or
revisions to recommendations and any other content were con- “conservative” care is now referred to as “medical/interventional
sidered for incorporation only when substantiated by a prepon- care.” The term medical/interventional is meant to encompass
derance of appropriate level evidence. pharmacological treatment, physical therapy, exercise therapy,
manipulative therapy, modalities, various types of external stim-
ulators and injections.
8 Diagnosis and Treatment of Adult Isthmic Spondylolisthesis | NASS Clinical Guidelines
III. Summary of Recommendations

Clinical Question Guideline Reccomendation
*See recommendation sections for supporting text
A= Recommended; B=Suggested; C=May be considered; I=Insufficient or Conflicting Evidence

Definition and Natural History
What is the best working Isthmic spondylolisthesis is the anterior translation of one lumbar vertebra relative to the next caudal
definition of isthmic segment as a result of an abnormality in the pars interarticularis. When symptomatic, this causes a
spondylolisthesis 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
What is the likelihood that Spondylolisthesis occurs in 40% to 66% of patients with bilateral spondylolysis. Spondylolisthesis
spondylolysis (unilateral is unlikely to occur in patients with unilateral spondylolysis.
and/or bilateral, identified Grade of Recommendation: B
in adolescence or
Recommendation Summary
adulthood) will progress

to become a symptomatic
spondylolisthesis?
Diagnosis and Imaging
What are the most There is insufficient evidence to make a recommendation for or against the use of palpation in the
appropriate physical physical exam diagnosis of adult patients with isthmic spondylolisthesis.
examination findings Grade of Recommendation: I (Insufficient Evidence)
consistent with the
diagnosis of isthmic Approximately half of adult patients with symptomatic isthmic spondylolisthesis will have a positive
spondylolisthesis in adult straight leg test on examination.
patients? Grade of Recommendation: B
In adult patients, what In adult patients with symptomatic isthmic spondylolisthesis, most patients present with low back
symptoms or clinical pain and at least half present radicular lower extremity pain.
presentation are associated Grade of Recommendation: B
with the diagnosis of
isthmic spondylolisthesis?
What are the most There is a relative paucity of high quality studies on imaging in adult patients with isthmic
appropriate diagnostic spondylolisthesis. It is the opinion of the work group that in adult patients with history and physical
tests for adult isthmic examination findings consistent with isthmic spondylolisthesis, standing plain radiographs, with or
spondylolisthesis? without oblique views or dynamic radiographs, be considered as the most appropriate, noninvasive
test to confirm the presence of isthmic spondylolisthesis. In the absence of a reliable diagnosis on
plain radiographs, CT scan is considered the most reliable diagnostic test to diagnose a defect of
the pars interarticularis. In adult patients with radiculopathy, MRI should be considered.
MRI is suggested to identify neuroforaminal stenosis in adult patients with isthmic

spondylolisthesis.
Grade of Recommendation: B
There is insufficient evidence to make a recommendation for or against the use of MRI to
differentiate isthmic versus degenerative spondylolisthesis in adult patients.
Grade of Recommendation: I (Insufficient Evidence)
There is insufficient evidence to make a recommendation for or against the use of discography to
evaluate adult patients with isthmic spondylolisthesis.
CT may be considered as an option to diagnose isthmic spondylolisthesis in adult patients.

Grade of Recommendation: C
There is insufficient evidence to make a recommendation for or against the use of SPECT in
evaluating isthmic spondylolisthesis in adult patients.
ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-
sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution


In adult patients, what is A systematic review of the literature yielded no studies to adequately address this question.
the relationship between
the radiological grade of
isthmic spondylolisthesis
and expected clinical
presentation?
How frequently do adult Adult patients with a diagnosis of isthmic spondylolisthesis have a higher pelvic incidence, sacral
patients with isthmic slope, pelvic tilt and lumbar lordosis compared to patients without isthmic spondylolisthesis.
spondylolisthesis have Grade of Recommendation: B
abnormal findings of
their sagittal spinopelvic
alignment, sacral
alignment and spinopelvic
parameters?
Outcome Measures for Medical/Interventional and Surgical Treatment
What are the appropriate For information on outcome measures for spinal disorders, the North American Spine Society
outcome measures for the has a publication entitled Compendium of Outcome Instruments for Assessment and Research
treatment of adult isthmic of Spinal Disorders. To purchase a copy of the Compendium, visit https://webportal.spine.org/
spondylolisthesis? Purchase/ProductDetail.aspx?Product_code=68cdd1f4-c4ac-db11-95b2-001143edb1c1.
For additional information about the Compendium, please contact the NASS Research Department
at nassresearch@spine.org.
Medical and Interventional Treatment
What is the role of There was no evidence to address this clinical question. Due to the paucity of literature addressing
pharmacological treatment this question, the work group was unable to generate a recommendation.
in the management of
manipulation in the this question, the work group was unable to generate a recommendation.
treatment of isthmic
spondylolisthesis?
steroid injections for this question, the work group was unable to generate a recommendation.
the treatment of isthmic
spondylolisthesis?
ancillary treatments such this question, the work group was unable to generate a recommendation.
as bracing, traction,
electrical stimulation and
transcutaneous electrical
stimulation (TENS) in
spondylolisthesis?
What is the role of physical There is insufficient evidence to make a recommendation for or against the use of physical therapy/
therapy/exercise in the exercise for the treatment of isthmic spondylolisthesis.
treatment of isthmic Grade of Recommendation: I (Insufficient Evidence)
spondylolisthesis?


Does the degree of There was no evidence to address this clinical question. Due to the paucity of literature addressing
radiological grade, sagittal this question, the work group was unable to generate a recommendation.
spinopelvic alignment,
sacral and spinopelvic
parameters, or the
presence of dynamic
instability in patients with
affect the outcomes of
patients treated with
medical or interventional
treatment?
What is the long-term result There is insufficient evidence to make a recommendation for or against the use of medical/
of medical/interventional interventional treatment for the long-term management of patients with isthmic spondylolisthesis.
management of isthmic Grade of Recommendation: I (Insufficient Evidence)

spondylolisthesis?
Surgical Treatment
In adult patients, is surgical There is insufficient evidence to make a recommendation for or against the efficacy of surgical
treatment more effective treatment as compared to medical/interventional alone for the management of adult patients with
than medical/interventional isthmic spondylolisthesis.
treatment alone for the Grade of Recommendation: I (Insufficient Evidence)
treatment of isthmic
spondylolisthesis?
Does the addition of There was no evidence to address this clinical question. Due to the paucity of literature addressing
lumbar fusion, with or this question, the work group was unable to generate a recommendation.
without instrumentation,
to surgical decompression
improve surgical outcomes
in the treatment of adult
patients with isthmic
spondylolisthesis
compared to treatment by
decompression alone?
Does the addition of In patients with low-grade isthmic spondylolisthesis, the addition of instrumentation may not
instrumentation to improve outcomes in the setting of posterolateral fusion, with or without decompression.
decompression and fusion Grade of Recommendation: B
for adult patients with
improve surgical
outcomes compared with
decompression and fusion
alone?
How do outcomes of Posterolateral fusion and 360° fusion surgeries are recommended to improve the clinical outcomes
decompression with in adult patients with low grade isthmic spondylolisthesis.
posterolateral fusion Grade of Recommendation: A
compare with those for
360° fusion in the treatment 360° fusion is recommended to provide higher radiographic fusion rates compared to
of adult patients with posterolateral fusion in adult patients with low grade isthmic spondylolisthesis.
isthmic spondylolisthesis? Grade of Recommendation: A
There is conflicting evidence whether 360° fusion provides better clinical outcomes than
posterolateral fusion alone.
Grade of Recommendation: I (Insufficient/Conflicting Evidence)


Does reduction with fusion There was no evidence to address this clinical question. Due to the paucity of literature addressing
result in better outcomes this question, the work group was unable to generate a recommendation.
than fusion in situ in adult
spondylolisthesis?
What is the role of Anterior lumbar interbody fusion (ALIF) may be considered as an option to indirectly decompress
stand-alone interbody foraminal stenosis in adult patients with low grade isthmic spondylolisthesis.
fusion, for the purpose of Grade of Recommendation: C
indirect decompression,
in the treatment of adult
spondylolisthesis?
How do outcomes from In adult patients undergoing ALIF, supplemental posterior percutaneous pedicle screws lead to
minimally invasive spinal shorter hospital stays, less operation room time and less blood loss compared to open posterior
surgery (for decompression instrumentation.
and/or fusion) for the Grade of Recommendation: B
management of adult
patients with isthmic There is conflicting evidence whether in adult patients undergoing ALIF, supplemental posterior
spondylolisthesis compare percutaneous pedicle screws lead to comparable clinical outcomes to those undergoing open
with traditional/open posterior instrumentation.
techniques? Grade of Recommendation: I (Insufficient/Conflicting Evidence)
How do outcomes of There was no evidence to address this clinical question. Due to the paucity of literature addressing
dynamic stabilization this question, the work group was unable to generate a recommendation.
compare with fusion for
spondylolisthesis in adult
patients?
Does the degree of There is insufficient evidence to make a recommendation regarding the degree of radiological
radiological grade, grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, or the presence of
sagittal spinopelvic dynamic instability on the outcomes of adult patients undergoing surgical treatment for isthmic
alignment, sacral and spondylolisthesis.
spinopelvic parameters, Grade of Recommendation: I (Insufficient Evidence)
or the presence of
dynamic instability in
adult patients with isthmic
spondylolisthesis affect
the outcomes of patients
treated with surgery?
Does the addition of There was no evidence to address this clinical question. Due to the paucity of literature addressing
fusion levels (cephalad, this question, the work group was unable to generate a recommendation.
caudal or iliac) in the
setting of a high grade
in adult patients improve
outcomes?


What is the long-term In adult patients undergoing surgical treatment for isthmic spondylolisthesis, fusion is suggested to
result (four+ years) of provide long term clinical improvements.
surgical management of Grade of Recommendation: B
adult patients with isthmic
spondylolisthesis? There is insufficient evidence to indicate that fusion leads to improved long term outcomes as
compared with a directed exercise program.
There is insufficient evidence to recommend one surgical fusion technique over another to improve
long term outcomes in adult patients undergoing surgical treatment for isthmic spondylolisthesis.
There is insufficient evidence to determine the clinical significance of adjacent segment

degeneration on the long term outcomes of fusion.

Are the results of surgical There was no evidence to address this clinical question. Due to the paucity of literature addressing
management for adult this question, the work group was unable to generate a recommendation.
spondylolisthesis affected
by the presence of scoliosis
or concurrent deformity?
Which prognostic factors There is insufficient evidence to make a recommendation regarding which prognostic factors have
have been associated with been associated with good or poor outcomes.
good or poor outcomes in Grade of Recommendation: I (Insufficient Evidence)
the surgical management
of adult patients with
Value of Spine Care
Which medical or There was no evidence to address this clinical question. Due to the paucity of literature addressing
interventional treatment this question, the work group was unable to generate a recommendation.
method of isthmic
spondylolisthesis is the
most cost-effective?
Is the surgical treatment of There was no evidence to address this clinical question. Due to the paucity of literature addressing
isthmic spondylolisthesis this question, the work group was unable to generate a recommendation.
cost-effective compared
to the medical and
interventional therapies?
Which surgical treatment There was no evidence to address this clinical question. Due to the paucity of literature addressing
method of isthmic this question, the work group was unable to generate a recommendation.
spondylolisthesis is the
IV. Definition and Incidence of Adult Isthmic

Spondylolisthesis
What is the best working definition of

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 symptomatic, 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.
What is incidence of radiographic isthmic

spondylolisthesis in adults?
In the general adult population, the incidence of isthmic spondylolisthesis
ranges between 3.7% and 8%.
Definition for Adult Isthmic

In 1954, Fredrickson1 et al enrolled 500 first grade children to and the prevalance of isthmic spondylolisthesis was found to be
Spondylolisthesis
evaluate the progression of the natural history of spondyloysis 8.2% in this study population. The highest prevalence of isthmic
and spondylolisthesis to adulthood. At enrollment, supine an- spondylolisthesis was found at the L5-S1 level.
teroposterior, lateral and oblique roentgenograms of the lumbar Sakai et al4 investigated the true incidene of lumbar spon-
spine were taken for each child. Twenty-two patients, or 4.4%, dylolysis in the Japanese general population. Investigators re-
were determined to have a lytic defect of the pars interarticularis. viewed the CT scans of 2,000 subjects who had undergone ab-
Repeat roentgenograms were taken at ages 10-12, 15-16 and 18 dominal and pelvic CT on a single multidetector CT scanner
years or older. At age 18 years or older, films were available for for reasons unrelated to low back pain. Scans were reviewed for
170 subjects (34%). By age 18 years or older, the rate of lytic de- spondylolysis, isthmic spondylolisthesis and spina bifida occul-
fects to the pars interarticularis had risen to 6%. In 1999, at 45- ta. Of the 124 vertebrae with spondylolysis, 75 (60.5%) showed
year follow-up, Beutler et al2 evaluated MRI and radiograph data grade I or II spondylolisthesis, whereas none showed high grade.
for 30 patients with unilateral or bilateral pars defects. Of the Spondylolisthesis was found in 74.5% of the vertebrae with bi-
8 patients with unilateral defects, none showed progression to lateral spondylolysis and in 7.7% of the vertebrae with unilateral
spondylolisthesis. Of the 22 patients with bilateral pars defects, spondylolysis. Isthmic spondylolisthesis was found in 3.7% of
18 (82%) developed spondylolisthesis. study patients.
Kalichman et al3 conducted a cross-sectional study to de-
termine prevalance rates of spondylolysis, isthmic spondylolis- References
thesis and degenerative spondylolithesis in patients who were 1. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP.
originally enrolled in the Framingham Heart Study to assess The natural history of spondylolysis and spondylolisthesis. J
aortic calcification. As part of their ancillary project to assess the Bone Joint Surg Am. Jun 1984;66(5):699-707.
aforementioned spinal conditions, 188 pariticipants were con- 2. Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA,
secutively enrolled to assess the association between CT scan Grant WD, Baker D. The natural history of spondylolysis and
spondylolisthesis: 45-year follow-up evaluation. Spine. May 15
observed characterstics of the lumbosacral spine and low back
2003;28(10):1027-1035; discussion 1035.
pain. Spondylolisthesis was identified in 39 subjects (20.7%) 3. Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ.
Spondylolysis and spondylolisthesis: Prevalence and association 6. Kotani T, Nagaya S, Sonoda M, et al. Virtual endoscopic imag-
with low back pain in the adult community-based population. ing of the spine. Spine. 2012;37(12):E752-E756.
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4. Sakai T, Sairyo K, Takao S, Nishitani H, Yasui N. Incidence of SP. The use of interventional open MRI to assess the kinematics
lumbar spondylolysis in the general population in Japan based of the lumbar spine in patients with spondylolisthesis. Spine.
on multidetector computed tomography scans from two thou- 2002;27(14):1582-1586.
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Grosskurth D. Spondylolisthesis and posterior instability. Acta
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Definition for Adult Isthmic
Spondylolisthesis
V. Recommendations for the Diagnosis

and Treatment of Adult Isthmic
Spondylolisthesis
A. Natural History
What is the likelihood that spondylolysis

(unilateral 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.
In 1954, Fredrickson1 et al enrolled 500 first grade children to found to be greatest early in life regardless of whether the patient
evaluate the progression of the natural history of spondyloysis had early or late defects or segmental laxity. The average slip pro-
and spondylolisthesis to adulthood. At enrollment, supine an- gression was 7% in the first decade for those who did progress,
teroposterior, lateral and oblique roentgenograms of the lum- 4% in the second and third decades and 2% in the fourth decade
bar spine were taken for each child. Spondylolysis and isthmic of follow-up. The Beautler study offers Level I prognostic evi-
spondylolisthesis were diagnosed according to the American dence that the slippage progression is more rapid at a younger
Academy of Orthopeadic Surgeons’ A Glossary on Spinal Ter- age and the progression of spondylolisthesis tends to slow with
minology. Twenty-two patients, or 4.4%, were determined to each decade.
have a unilateral or bilateral lytic defect of the pars interarticu- Fuji et al3 retrospectively reviewed clinical and radiographic
laris. Repeat roentgenograms were taken at ages 10-12, 15-16 data for 134 adolescent patients who had been treated conser-
and 18 years or older. At age 18 years or older, films were avail- vatively for lumbar spondylolysis to investigate prognostic vari-
able for 170 subjects (34%). Between the ages of 12 to 25, eight ables for successful bony union. Patients with ages ranging from
additional patients developed unilateral or bilateral pars inter- 7 to 17 years were evaluated by CT scan and followed for one
articular defects of the lumbar spine, increasing the rate to 6%. to 9 years (average 3.4 years). Pars defects at L4 were present
Of the 30 total patients with the defect, 22 had bilateral L5 pars in 20 patients and at L5 in 114 patients. Bilateral defects were
defects and 8 had unilateral defects. observed in 105 patients and unilateral defects were observed
In 1999, at 45-year follow-up of the above patients, Beutler et in 29 patients. For the purposes of reviewing CT images, pars
al2 evaluated MRI and radiograph data for the 30 patients with defects were classified into early, progressive or terminal stages
unilateral or bilateral pars defects. Of the 8 patients with unilat- and the maturity of the lumbar spine was classified into carti-
eral defects, none showed progression to spondylolisthesis. Of laginous, apophyseal and epiphyseal stages. A total of 52 of 134
the 22 patients with bilateral pars defects, 18 (82%) developed (39%) patients were initially diagnosed with or developed spon-
spondylolisthesis. Slip at the lumbosacral level was seen in 10 dylolisthesis during the study period. Results indicated that pars
Recommendations: Natural History
of 16 bilateral L5 defects at the initial screening. The average defects at L4 achieving union were significantly higher than that
slip for patients with initial spondylolisthesis was 11% in 1954 for defects at L5 (p<0.0001). Defects without contralateral de-
and progressed to an average of 18% in 1999. There were 10 pa- fects or with contralateral early stage defects achieved union at
tients with early segmental laxity. These patients presented with significantly higher rates than those with contralateral progres-
bilateral pars defects and initial spondylolisthesis at 6 years old. sive or terminal stage defects (p < 0.001). Six of 13 defects with-
Initial slip in this group ranged from 7-17%. Over the next 45 out contralateral defects and 8 of 15 defects with contralateral
years, 5 of these patients had no slip progression and the other early or progressive stage defects showed union, but the 3 early
5 patients had progression of slip from 7-20% of the initial slip. stage defects with contralateral terminal stage defects at L5 did
Three patients, who initially presented with bilateral pars de- not. Union occurred less often in the presence of spondylolis-
fects, but no documented spondylolisthesis at 6 years old, had thesis greater than 5% at initial presentation compared to those
late segmental laxity at 45 years follow-up. Slip progression was without spondylolisthesis (p<0.01). The percentage of vertebra
without spondylolisthesis at the time of follow-up increased in tions after 4 (2-7) years. Acta Orthop Scand. Jun 1994;65(3):309-
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listhésis par lyse isthmique. 2005;2(2):125-150.
Recommendations: Diagnosis/Imaging 22 Diagnosis and Treatment of Adult Isthmic Spondylolisthesis | NASS Clinical Guidelines
B. Diagnosis and Imaging
What are the most appropriate physical

examination findings consistent with the
diagnosis of isthmic spondylolisthesis in adult
patients?
There is insufficient evidence to make a recommendation for or against the
use of palpation in the physical exam diagnosis of adult patients with isthmic
spondylolisthesis.
Collaer et al1 assessed the diagnostic utility of lumbar spinous spondylolisthesis. A total of 72 patients were included in the
palpation in detecting isthmic spondylolisthesis. Consecutive study, including 34 females and 38 males with an average age
patients were enrolled in the study if they had low back pain and/ of 40 years old. Conventional x-rays of the lumbar spine and
or radiculopathy, were aged 16 years or older, had no history of oblique views were taken on all patients in order to characterize
thoracic, lumbar or sacral surgery, and had a same-day standing the spondylolytic gap in the isthmus. Isthmic spondylolisthesis
lateral lumbar radiograph, which was evaluated according to the was located at the L4/L5 in 14% of patients and L5/S1 in 86% of
Meyerding method for grading. Three physical therapists carried patients. According to Meyerding classification, isthmic spondy-
out the lumbar spinous process palpation to determine the inter- lolisthesis was Grade I in 65% of patients, Grade II in 33%, and
rater reliability of this test. The palpation procedure consisted Grade III in 2% of patients. For the analysis, the patients were
of applying and maintaining firm contact on the lumbosacral separated into two groups; group 1 consisted of 35 patients in
spinous process while sliding the examining fingertips from the whom back pain and pain in the lower limb(s) was present for a
upper lumbar region to the sacrum. A total of 44 patients, in- mean of 10 years, and group 2 consisted of 37 patients in whom
cluding 21 men and 23 women with an average age of 40 years isthmic spondylolisthesis became symptomatic within a short-
old, were included in the analysis. Isthmic spondylolisthesis was er period of time (mean 3 years). During assessment, patients
found in 11.3% of patients based on radiograph findings. Valid- usually complained of low back pain, which was restricted or
ity of the palpation test was confirmed by comparing palpation was diffuse, often associated with burning sensations. For both
findings to the radiograph findings. Results suggested that the groups, radiating pain in the lower limb(s) was radicular, pseu-
sensitivity of identifying an isthmic spondylolisthesis by way of doradicular or combined in 53%, 21%, and 14%, respectively.
step palpation was 60% (95% CI: 72.6-95.7) and the specificity Neurological examination showed that 40% of patients in Group
was 87.2% (95% CI: 72.6-95.7). The post-test probability for a 1 and 70% in Group 2 had radicular syptoms. Radicular symp-
spondylolisthesis with a positive palpation test result was 32% toms were predominant (64%) in patients with Grade I isthmic
and 5% with a negative test result based on the established preva- spondylolisthesis. The L4/L5 level was more frequently associ-
lence of isthmic spondylolisthesis in the patient group. In cri- ated with radicular signs compared to the L5/S1 level (70% vs
tique of this study, the sample size was small, but the work group 50%). Intra-operative findings revealed that root compression
did not find this sufficient reason to downgrade the study. This due to spondylolysis tissue, bony spurs or Gill nodes was found
study provides Level II diagnostic evidence that palpation is not in half of all patients, including in 22 patients in Group 1 and 16
an effective test to rule out isthmic spondylolisthesis. However, patients in Group 2. Root compression was mostly present in
the high specificity suggests that there is a high likelihood for comparable amounts on both sides, although radicular symp-
presence of the condition in the event that a step off is detected. toms were unilateral (55%), absent (13%) combined with pseu-
doradicular symptoms (14%) or present with pseudoradicular
signs alone (19%). Positive straight leg raising tests were found
Approximately half of adult patients with in 49% of patients, including positive results in 23% of patients
symptomatic isthmic spondylolisthesis in group 1 and 73% of patients in Group 2. This study provides
level II diagnostic evidence that a positive straight leg test may
will have a positive straight leg test on be consistent with radiculitis resulting from isthmic spondylo-
examination. listhesis, though it is not specific in relation to the cause of ra-
Grade of Recommendation: B diculitis.
Rijk et al3 evaluated the results of patients treated with che-
Markwalder et al2 conducted a prospective study to analyze the monucleolysis by comparing MRI findings before and after
clinical and radiological presentation in relation to the intra- treatment. Fifteen patients, including 6 women and 9 men with a
operative findings and surgical results of patients with isthmic mean age of 35, were included in the analysis. According to Mey-
Recommendations: Diagnosis/Imaging
erding classification, 13 patients had a Grade I slip and 2 patients pedics. 2004;27(6):610-613.
had a Grade II slip. The mean slip was 20% (range 10%-38%). All 8. Colomina MJ, Puig L, Godet C, Villanueva C, Bago J. Prevalence
but one patient had low back pain for an average of 51 months of asymptomatic cardiac valve anomalies in idiopathic scoliosis.
and all had unilateral sciatica for an average of 33 months. On Pediatric cardiology. 2002;23(4):426-429.
9. Danielson BI, Frennered AK, Irstam LKH. Radiologic progres-
physical examination, 11 patients had restricted mobility of the
sion of isthmic lumbar spondylolisthesis in young patients.
lumbar spine, 8 patients had positive results for the straight leg Spine. 1991;16(4):422-425.
raising test, 3 patients had positive results for the crossed straight 10. Don AS, Robertson PA. Facet joint orientation in spondylolysis
leg raising test, and one patient had a weakness of the extensor and isthmic spondylolisthesis. Journal of Spinal Disorders &
halluces longus muscle. In critique, the sample size for this study Techniques. 2008;21(2):112-115.
is small and investigators did not utilize statistical methods to 11. Ekman P, Moller H, Hedlund R. Predictive factors for the
analyze results. Due to these reasons, the work group decided outcome of fusion in adult isthmic spondylolisthesis. Spine.
to downgrade the level of evidence. This potential level II study 2009;34(11):1204-1210.
provides level III diagnostic evidence that a positive straight leg 12. Ergun T, Sahin MS, Lakadamyali H. Evaluation of the relation-
ship between L5-S1 spondylolysis and isthmic spondylolisthesis
test was present in about half of the patients and can be consis-
and lumbosacral-pelvic morphology by imaging via 2- and
tent with a diagnosis of radiculopathy associated with isthmic 3-dimensional reformatted computed tomography. Journal of
spondylolisthesis. computer assisted tomography. 2011;35(1):9-15.
13. Fu TS, Wong CB, Tsai TT, Liang YC, Chen LH, Chen WJ. Pedi-
Future Directions For Research cle screw insertion: computed tomography versus fluoroscopic
The work group recommends the undertaking of prospective image guidance. International orthopaedics. 2008;32(4):517-
studies evaluating specific clinical physical examination findings 521.
14. Goyal N, Wimberley DW, Hyatt A, et al. Radiographic and
that may be consistent with the diagnosis of isthmic spondylo-
clinical outcomes after instrumented reduction and transfo-
listhesis. raminal lumbar interbody fusion of mid and high-grade isthmic
spondylolisthesis. Journal of Spinal Disorders and Techniques.
References 2009;22(5):321-327.
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spondylolisthesis detection with palpation: Interrater reliability Somatosensory evoked potential monitoring of lumbar pedicle
and concurrent criterion-related validity. Journal of Manual and screw placement for in situ posterior spinal fusion. Spine Jour-
Manipulative Therapy. 2006;14(1):22-29. nal. 2003;3(5):370-376.
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thesis--an analysis of the clinical and radiological presentation mentation with posterolateral fusion in isthmic spondylolisthe-
in relation to intraoperative findings and surgical results in 72 sis: 53 cases followed for 18-89 months. Spine. 1985;10(4):383-
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In adult patients, what symptoms or clinical

presentation are associated with the
diagnosis of isthmic spondylolisthesis?
In adult patients with symptomatic isthmic spondylolisthesis, most
patients present with low back pain and at least half present radicular
lower extremity pain.
Markwalder et al1 conducted a prospective study to analyze the usually complained of low back pain, which was restricted or
clinical and radiological presentation in relation to the intra- was diffuse, often associated with burning sensations. For both
operative findings and surgical results of patients with isthmic groups, radiating pain in the lower limb(s) was of the radicu-
spondylolisthesis. A total of 72 patients were included in the lar, pseudoradicular and combined type in 53%, 21% and 14%,
study, including 34 females and 38 males with an average age respectively. Neurological examination showed that 40% of pa-
of 40 years old. Isthmic spondylolisthesis was located at the L4/ tients in Group 1 and 70% in Group 2 had radicular syptoms.
L5 in 14% of patients and L5/S1 in 86% of patients. According Radicular symptoms were predominant (64%) in patients with
to Meyerding classification, isthmic spondylolisthesis was Grade Grade I isthmic spondylolisthesis. The L4/L5 level was more fre-
I in 65%, Grade II in 33%, and Grade III in 2% of patients. For quently associated with radicular signs compared to the L5/S1
the analysis, the patients were separated in two groups; Group 1 level (70% vs 50%). Intra-operative findings revealed that root
consisted of 35 patients in whom back pain and pain in the lower compression due to spondylotic tissue, bony spurs or Gill nodes
limb(s) was present for a mean of 10 years and Group 2 consisted was found in 36 patients. Root compression was mostly present
of 37 patients in whom isthmic spondylolisthesis became symp- in comparable amounts on both sides although radicular symp-
tomatic within a mean of 3 years. During assessment, patients toms were unilateral (55%), absent (13%) combined with pseu-
doradicular symptoms (14%) or present with pseudoradicular myelography. Acta radiologica. 1990;31(5):449-453.
signs alone (19%). This study provides Level II prognostic evi- 6. Axelsson P, Johnsson R, Stromqvist B. Is there increased inter-
dence that patients with isthmic spondylolisthesis present most vertebral mobility in isthmic adult spondylolisthesis? A matched
often with back and leg pain. comparative study using roentgen stereophotogrammetry.
Spine. 2000;25(13):1701-1703.
Moller et al2 conducted a retrospective case-control study to
7. Cohen MW, Maurer PM, Balderston RA. Preoperative evalua-
determine whether there are any specific symptoms, signs and tion of adult isthmic spondylolisthesis with diskography. Ortho-
functional disability associated with a diagnosis of adult isthmic pedics. 2004;27(6):610-613.
spondylolisthesis. A total of 111 isthmic spondylolisthesis pa- 8. Collaer JW, McKeough DM, Boissonnault WG. Lumbar isthmic
tients were included in this analysis, including 54 women and spondylolisthesis detection with palpation: Interrater reliability
57 men with a mean age of 39. Standardized physical and neuro- and concurrent criterion-related validity. Journal of Manual and
logic exams were conducted on all patients. Functional disabil- Manipulative Therapy. 2006;14(1):22-29.
ity was measured by the Disability Rating Index (DRI), which is 9. Colomina MJ, Puig L, Godet C, Villanueva C, Bago J. Prevalence
composed of 12 functional visual analog scales (VAS). Pain was of asymptomatic cardiac valve anomalies in idiopathic scoliosis.
Pediatric cardiology. 2002;23(4):426-429.
quantified on a scale of 0 to 100 for intolerable pain and by pain
10. Danielson BI, Frennered AK, Irstam LKH. Radiologic progres-
drawings. Isthmic spondylolisthesis patient findings were com- sion of isthmic lumbar spondylolisthesis in young patients.
pared to the records of 39 patients with nonspecific back pain. Spine. 1991;16(4):422-425.
The majority of isthmic spondylolisthesis patients had a level of 11. DeWald CJ, Vartabedian JE, Rodts MF, Hammerberg KW.
slippage at L5 (n=94). Spondylolisthesis was radiographically Evaluation and management of high-grade spondylolisthesis in
verified and patients with sciatica were examined with MRI or adults. Spine. Mar 15 2005;30(6 Suppl):S49-59.
myelography. Sixty-two percent of patients had low back pain 12. Don AS, Robertson PA. Facet joint orientation in spondylolysis
and sciatica, 31% had low back pain only and 7% had sciatica and isthmic spondylolisthesis. Journal of Spinal Disorders &
only. No symptom free periods were reported by 92% patients Techniques. 2008;21(2):112-115.
13. Ekman P, Moller H, Hedlund R. Predictive factors for the
and sleeping disturbances, back stiffness, and worsening of pain
outcome of fusion in adult isthmic spondylolisthesis. Spine.
when walking and sitting were reported by 80% of patients. This 2009;34(11):1204-1210.
study provides Level III prognostic evidence that patients with 14. Ergun T, Sahin MS, Lakadamyali H. Evaluation of the relation-
isthmic spondylolisthesis present with low back pain with or ship between L5-S1 spondylolysis and isthmic spondylolisthesis
without sciatica. and lumbosacral-pelvic morphology by imaging via 2- and
3-dimensional reformatted computed tomography. Journal of
Future Directions For Research computer assisted tomography. 2011;35(1):9-15.
15. Fu TS, Wong CB, Tsai TT, Liang YC, Chen LH, Chen WJ. Pedi-
The work group recommends the undertaking of population-
cle screw insertion: computed tomography versus fluoroscopic
based observational studies, such as multi-center registry data image guidance. International orthopaedics. 2008;32(4):517-
studies, examining the clinical characteristics associated with 521.
isthmic spondylolisthesis. 16. Goyal N, Wimberley DW, Hyatt A, et al. Radiographic and
clinical outcomes after instrumented reduction and transfo-
References raminal lumbar interbody fusion of mid and high-grade isthmic
1. Markwalder TM, Saager C, Reulen HJ. “Isthmic” spondylolis- spondylolisthesis. Journal of Spinal Disorders and Techniques.
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in relation to intraoperative findings and surgical results in 72 17. Gundanna M, Eskenazi M, Bendo J, Spivak J, Moskovich R.
consecutive cases. Acta Neurochirurgica. 1991;110(3-4):154- Somatosensory evoked potential monitoring of lumbar pedicle
159. screw placement for in situ posterior spinal fusion. Spine Jour-
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34. Rajnics P, Templier A, Skalli W, Lavaste F, Illés T. The association degenerative and isthmic spondylolisthesis on sagittal MR im-
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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 physical examination
findings consistent with isthmic spondylolisthesis, standing plain
radiographs, with or without oblique views or dynamic radiographs,
be considered as the most appropriate, noninvasive test to confirm
the presence of isthmic spondylolisthesis. In the absence of a reliable
diagnosis on plain radiographs, CT scan is considered the most reliable
diagnostic test to diagnose a defect of the pars interarticularis. In adult
patients with radiculopathy, MRI should be considered.
MRI is suggested to identify neuroforaminal stenosis in adult patients

with isthmic spondylolisthesis.
There is insufficient evidence to make a recommendation for or

against the use of MRI to differentiate isthmic versus degenerative
spondylolisthesis in adult patients.
Annertz et al1 conducted a radiographic study to evaluate the ing 5 mm. All foramina had an altered shape with the long axis
usefulness of MRI and myelogram in adult patients with isthmic horizontal instead of vertical at the affected level bilaterally. In
spondylolisthesis and sciatica. Seventeen patients, including 9 addition, the following was found in the 33 foramina evaluated:
men and 8 women with a mean age of 41, underwent conven- normal nerve (n=8); compressed nerve (n=16); disappearance of
tional radiography and MRI of the lumbar spine. Thirteen pa- fat and nerve not possible to identify (n=9). The authors suggest
tients also received myelogram. Vertebral displacement, reactive that since the site of nerve compression was often peripheral to
changes within the vertebrae, intervertebral disc, and thecal sac the root sleeves, myelography was of limited value. In critique,
were studied. On conventional radiography, reduction of the in- the study’s sample size was small and it is unclear whether the
tervertebral disc space was a constant finding at the level of olis- patients were enrolled consecutively. This study offers Level III
thesis. In 9 of the 17 patients, it was estimated to exceed 50%. The diagnostic evidence that MR imaging provides superior imaging
vertebral slipping varied from 5 to 25 mm. In 9 patients, there of the nerve root compared to myelography. It should be noted
was no evident bone reaction. There was a correlation between that post myleogram CT was not performed in any study pa-
the degree of vertebral displacement and occurrence of reactive tients.
bone changes. In 5 of the 13 patients in whom myelography was Jinkins et al2 conducted a prospective radiographic analysis
performed, waist-like deformation of the dural sac and bilateral using MRI to examine the relationship between evidence of im-
shortening of the root sleeves at the level of the spondylolisthe- pingement of a nerve root and clinical evidence of radiculopathy
sis was seen. In 4 patients, the myelogram was normal except in 15 consecutive patients with isthmic spondylolisthesis. The
for the spondylolisthesis, and in several of the pathological cas- analysis was conducted by a neuroradiologist blinded to the pa-
es, the influence on the nerve roots seen on myelography was tient’s clinical history. Parasagittal T1-weighted images were re-
minimal despite severe olisthesis. On MRI examination, reactive viewed to identify whether the nerve root was impinged within
changes within one or both vertebrae adjacent to the olisthesis the neural foramen at the level of spondylolisthesis. Impinge-
were seen in eight cases. The degree of disc space reduction cor- ment was considered to be present if MRI demonstrated circum-
related well with radiograph readings. At the level of the pars ferential or pincer-like entrapment of the nerve root and oblit-
defect, 2 patients had a complete disc space reduction without eration of the perineural fat. A diagnosis of radiculopathy was
any protrusion. In 14 patients, a posterolateral bulge extending based on electromyographic data or the presence of pain that
towards the foramina was found. At the level above the pars de- radiated into the lower extremity in a dermatomal pattern. The
fect, four patients had a symmetric disc protrusion not exceed- neuroradiologists found that 17 out of 30 nerve roots appeared
to be impinged on at the level of the spondylolisthesis. Thirteen thesis. Fourteen consecutive patients with Grade I or II spon-
out of these 17 nerve roots were associated with clinical evidence dylolisthesis underwent 4-level provocative discography using
or radiculopathy on the side of root impingements. Nine patients fluoroscopy. The L2-L3, L3-L4, L4-L5, and L5-S1 were studied.
had symptoms of a unilateral radiculopathy of the fifth lumbar All patients were subsequently treated with AP spinal fusion. A
nerve root, 2 had pain that radiated into both lower extremities, level was considered positive only if provocation of high-inten-
which suggested bilateral radiculopathy of the fifth lumbar nerve sity low back pain occurred with disc pressurization. Half of the
root, and 4 patients had diffuse low-back pain, but no signs of ra- patients (7/14) had a concordant pain response at a level adja-
diculopathy. Results suggested that the association between the cent to the spondylolisthesis and 2 patients had no pain at the
clinical findings of radiculopathy and the evidence of impinge- slip level. The level of the spondylolisthesis was positive in 12 out
ment on MRI was highly significant (p<0.001). In critique, this of 14 patients. No patients had provocation of symptoms at the
study had a small sample size and a narrow subgroup of patients L2-L3 and L3-L4 levels. Of the 11 patients with L5-S1 slips, 4
with either Grade I or II isthmic spondylolisthesis. Due to these had a single positive level at L5-S1, one had a positive level lim-
reasons, this potential Level II study has been downgraded and ited to L4-L5, and 6 had positive levels at L4-L5 and L5-S1. The
provides Level III diagnostic evidence that MRI is useful to cor- investigators suggested that the disc adjacent to an isthmic slip is
relate clinical radiculopathy to neuroforaminal stenosis in pa- predisposed to symptomatic degeneration in patients with low-
tients with isthmic spondylolisthesis. grade isthmic spondylolisthesis and discography may be helpful
Ulmer et al3 evaluated MR images to determine whether a in selecting fusion levels in these patients. In critique, this study
visually apparent increase in the anteroposterior diameter of the contains a very small sample size and does not contain statistical
spinal canal (wide canal sign) is a reliable indicator in differen- methods to analyze findings. Due to these reasons, this potential
tiating degenerative from isthmic spondylolisthesis on midline Level III study has been downgraded to Level IV. This study pro-
sagittal images. The investigators hypothesized that the wide vides Level IV diagnostic evidence that spondylolisthesis may or
canal sign would be present only in patients with isthmic spon- may not be the sole cause of back pain as diagnosed by discogra-
dylolisthesis. To establish the normal range of sagittal canal di- phy in workers compensation patients planned for surgery.
ameters at the various lumbar levels, the investigators reviewed
the midline sagittal MR images of 100 control patients without CT may be considered as an option to
spondylolysis or spondylolisthesis. These images were compared diagnose isthmic spondylolisthesis in adult
to 53 patients with a diagnosis of either isthmic (n=35) or de-
generative (n=18) spondylolisthesis, which were confirmed by patients.
conventional radiography and/or CT. The sagittal canal ratio Grade of Recommendation: C
(SCR) for each level was calculated and defined as the maxi-
mum anteroposterior diameter of the canal at that level divided Kalichman et al5 conducted a community-based, cross-sectional
by the diameter of the canal at L1. Per analysis of the control study to determine the prevalence of spondylolysis, isthmic and
MR images, an SCR of 1.25 or more was considered to repre- degenerative spondylolisthesis and the relationship of these con-
sent abnormal widening of the spinal canal, and the wide canal ditions with low back pain. The analysis was an ancillary proj-
sign was considered to be present whenever the SCR was 1.25 ect to the Framingham Heart study, which included 3,529 total
or greater at any level. Results of the evaluation by two blinded patients aged 40 to 80 years old. All of the patients underwent
neuroradiologists indicated that the SCR did not exceed 1.25 in multi-detector CT imaging to assess aortic calcification, and 188
the 100 patients without spondylolisthesis and 18 patients with patients were enrolled in this study to assess radiographic fea-
degenerative spondylolisthesis. An SCR of 1.25 or higher was tures associated with low back pain. In addition, these patients
found in 97% (34/35) of the isthmic spondylolisthesis patients. were asked to complete the modified Nordic Low Back Ques-
The investigators conclude that the presence of the wide canal tionnaire. CT scans were reviewed by blinded musculoskeletal
sign is a useful indicator in the diagnosis of isthmic spondylo- radiologists and multiple logistic regression analysis was used to
listhesis. This study provides Level II diagnostic evidence that examine the association between low back pain and spondyloly-
on MR imaging, the wide canal sign is a reliable predictor of the sis and spondylolisthesis. The results suggested that there was
presence of defects of the pars interarticularis at the level of the no significant association found between the occurrence of low
spondylolisthesis. back pain and spondylolysis, isthmic and degenerative spondy-
lolisthesis. In this sample, 15 (8.2%) patients had isthmic spon-
There is insufficient evidence to make a dylolisthesis. The highest prevalence of isthmic spondylolisthe-
sis was found at the L5-S1 level. In critique, this study was not
recommendation for or against the use of constructed with the intention to validate diagnostic criteria.
discography to evaluate adult patients with This study provides Level IV diagnostic evidence that CT scans
isthmic spondylolisthesis. can be used to diagnose isthmic spondylolisthesis.
Grade of Recommendation: I Sakai et al6 conducted a community-based, cross-sectional
(Insufficient Evidence) analysis to investigate the true incidence of spondylolysis in the
general population in Japan. The CT scans of 2,000 Japanese sub-
Cohen et al4 conducted a preoperative evaluation of patients jects, who had undergone abdominal and pelvic CT for reasons
with isthmic spondylolisthesis to determine the usefulness of unrelated to low back pain, were reviewed for signs of spondy-
discography in evaluating the disc adjacent to the spondylolis- lolysis, isthmic spondylolisthesis, and spine bifida occulta. All
images were reviewed by a certified spine surgeon and certified
radiologist and the diagnosis was achieved by consensus. Of Recommendation #2:

the 2,000 subjects, 117 patients (5.9%), including 124 vertebrae, An additional prospective study evaulating the canal diameter to
were found to have lumbar spondylolysis. Of the 124 vertebrae differentiate the diagnosis of isthmic versus degenerative spon-
with spondylolysis, 75 (60.5%) showed Grade I or II spondylolis- dylolisthesis.
thesis, whereas none showed high grade. Spondylolisthesis was
found in 74.5% of the vertebrae with bilateral spondylolysis and Recommendation #3:
in 7.7% of the vertebrae with unilateral spondylolysis. In cri- Prospective study comparing CT myleography to MRI in diag-
tique, this study does not include a gold standard and was not nosing isthmic spondylolisthesis.
constructed with the intention to validate diagnostic criteria.
This study provides Level IV diagnostic evidence that isthmic References
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in relation to intraoperative findings and surgical results in 72
consecutive cases. Acta Neurochirurgica. 1991;110(3-4):154-
159.
23. McAfee PC, Yuan HA. Computed tomography in spondylolis-
thesis. Clinical Orthopaedics & Related Research. 1982(166):62-
In adult patients, what is the relationship

between the radiological grade of isthmic
spondylolisthesis and expected clinical
presentation?
A systematic review of the literature yielded no studies to adequately

address this question.
Future Directions For Research Spine. 2004;29(18):2049-2054.

The work group identified the following potential studies that 7. Lamberg T, Remes V, Helenius I, Schlenzka D, Seitsalo S, Poussa
would generate meaningful evidence to assist in the understand-
ing of the relationship between radiological grade of isthmic come. Journal of Bone & Joint Surgery - American Volume.
spondylolisthesis and clinical presentation: 2007;89(3):512-518.
8. Lenke LG, Bridwell KH. Evaluation and surgical treatment of
Recommendation #1: high-grade isthmic dysplastic spondylolisthesis. Instructional
Observational study examining the relationship between the course lectures. 2003;52:525-532.
presence and radiological grade of isthmic spondylolisthesis and 9. Markwalder TM, Saager C, Reulen HJ. “Isthmic” spondylolis-
expected clinical presentation. thesis--an analysis of the clinical and radiological presentation
in relation to intraoperative findings and surgical results in 72
consecutive cases. Acta Neurochirurgica. 1991;110(3-4):154-
Recommendation #2:
159.
Population-based observational studies, such as multi-center 10. McGregor AH, Anderton L, Gedroyc WM, Johnson J, Hughes
registry data studies, examining the relationship between the SP. The use of interventional open MRI to assess the kinematics
presence and radiological grade of isthmic spondylolisthesis and of the lumbar spine in patients with spondylolisthesis. Spine.
expected clinical presentation. 2002;27(14):1582-1586.
11. McGregor AH, Cattermole HR, Hughes SP. Global spinal mo-
Bibliography tion in subjects with lumbar spondylolysis and spondylolisthe-
1. Amoretti N, Huwart L, Hauger O, et al. Computed tomogra- sis: does the grade or type of slip affect global spinal motion?
phy- and fluoroscopy-guided percutaneous screw fixation of Spine. 2001;26(3):282-286.
low-grade isthmic spondylolisthesis in adults: a new technique. 12. O’Brien MF. Low-grade isthmic/lytic spondylolisthesis in adults.
European radiology. 2012;22(12):2841-2847. Instructional course lectures. 2003;52:511-524.
2. Axelsson P, Johnsson R, Stromqvist B. Is there increased inter- 13. Pape D, Adam F, Fritsch E, Muller K, Kohn D. Primary lum-
vertebral mobility in isthmic adult spondylolisthesis? A matched bosacral stability after open posterior and endoscopic anterior
comparative study using roentgen stereophotogrammetry. fusion with interbody implants: a roentgen stereophotogram-
Spine. 2000;25(13):1701-1703. metric analysis. Spine. 2000;25(19):2514-2518.
3. Helenius I, Lamberg T, Österman K, et al. Scoliosis research 14. Remes V, Lamberg T, Tervahartiala P, et al. Long-term outcome
society outcome instrument in evaluation of long-term surgical after posterolateral, anterior, and circumferential fusion for
results in spondylolysis and low-grade isthmic spondylolisthesis high-grade isthmic spondylolisthesis in children and adoles-
in young patients. Spine. 2005;30(3):336-341. cents: magnetic resonance imaging findings after average of
4. Helenius I, Lamberg T, Österman K, et al. Posterolateral, ante- 17-year follow-up. Spine. 2006;31(21):2491-2499.
rior, or circumferential fusion in situ for high-grade spondy- 15. Sakai T, Sairyo K, Takao S, Nishitani H, Yasui N. Incidence of
lolisthesis in young patients: A long-term evaluation using the lumbar spondylolysis in the general population in Japan based
Scoliosis Research Society questionnaire. Spine. 2006;31(2):190- on multidetector computed tomography scans from two thou-
196. sand subjects. Spine. 2009;34(21):2346-2350.
5. Jalanko T, Helenius I, Remes V, et al. Operative treatment of 16. Schlenzka D, Remes V, Helenius I, et al. Direct repair for treat-
isthmic spondylolisthesis in children: A long-term, retrospec- ment of symptomatic spondylolysis and low-grade isthmic
tive comparative study with matched cohorts. European Spine spondylolisthesis in young patients: No benefit in comparison to
Journal. 2011;20(5):766-775. segmental fusion after a mean follow-up of 14.8 years. European
6. Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis, Spine Journal. 2006;15(10):1437-1447.
pelvic incidence, and spinopelvic balance: a correlation study.
How frequently do adult patients with isthmic

spondylolisthesis have abnormal findings of
their sagittal spinopelvic alignment, sacral
alignment and spinopelvic parameters?
Adult patients with a diagnosis of isthmic spondylolisthesis have a
higher pelvic incidence, sacral slope, pelvic tilt and lumbar lordosis
compared to patients without isthmic spondylolisthesis.
Inoue et al1 conducted a radiographic study to investigate low- and to define significant spinopelvic compensations for sagittal
grade spondylolisthesis in patients with pre-existing isthmic balance. Lateral radiograph findings of 50 control patients were
spondylolisthesis of L5. Investigators sought to radioghically compared to 50 patients with symptomatic degenerative disc
distinguish between vertebral slips before and after skeletal ma- disease, 30 patients with low grade (L5-S1) isthmic spondylolis-
turity as determined by deformities of the sacral endplate. The thesis and 30 patients with idiopathic or degenerative scoliosis.
study included 367 patients, aged 20 to 59 years, presenting Measurements for standing spinopelvic balance, angulations,
with bilateral pars defects of L5, including 213 without slippage and associated compensations around the pelvic hip axis were
and 154 with Grade I or II spondylolisthesis. Standing lumbar compared among the groups. Patients with spondylolisthesis
radiographs were taken of these patients to confirm the pres- and scoliosis showed less thoracic kyphosis while standing com-
ence of pars defects and included anteroposterior, lateral, and pared to controls; however, this was only signicant in patients
bilateral oblique views. On the lateral radiographs, the following with degenerative disorders. When compared to controls, stand-
variables were examined: vertebral slippage, sacral table index, ing patients who had spondylolisthesis showed more total lordo-
the sacral table angle, the relative thickness of the L5 transverse sis, more lower lumbar segmental lordosis at L4-L5 and a signifi-
process and the iliac crest height. These findings were compared cant increase in sacropelvic angle. The S1-C7 balance correlated
to a random sample of 310 control patients, aged 20 to 59 years, with lower lumbar segmental lordosis at L5-S1 in patients with
with low back pain who received the same radiographs, but spondylolisthesis (r=0.36, p<0.05). In all patient groups, there
had normal results. For analysis purposes, the patients were di- were significant angular correlations between the lumbar spinal
vided into three groups and included control patients (n=310), alignment and the sacropelvis. By the S1 endplate technique, to-
patients with pars defects without significant slippage (n=213) tal lordosis correlated with sacral incliniation in patients with
and patients with pars defects with significant slippage (n=154). spondylolisthesis (r=0.48, p<0.01). To ensure reliability of mea-
Results indicated that there was a significant difference in the surements, 20 percent of each group was randomly selected and
sacral table index between the control, nonslip and slip groups remeasured. No statistically significant differences were found
(94.4% vs 96.6% vs 102.5%, p<0.0001). The sacral table angle was between initial and remeasurements. This study provides Level
signficantly smaller in the slip group (mean 91.6o) compared to II prognostic evidence that patients who have spondylolisthesis
the other groups (p<0.0001). Statiscally significant differences have increased lumbar lordosis, increased L4-L5 segmental lor-
were found in the lumbar indexes when comparing groups, 89% dosis and increased sacral pelvic angle.
in the control group, 82.6% in the nonslip group and 80.3% in Labelle et al3 conducted a retrospective radiographic analy-
the slip group (p<0.0001). The relative thickness of the trans- sis to investigate the role of pelvic anatomy and its effect on the
verse process was signifcantly greater in the nonslip group com- global balance of the trunk in developmental spondylolisthesis.
pared to controls (p<0.0001). No signficant differences were The lateral standing radiographs of 214 patients with develop-
found between groups for the iliac crest measurements. When mental L5-S1 spondylolisthesis were analyzed and compared to
analyzing the association between age and slippage, investigators films of 160 asymptomatic patients with no history of spine, hip
found that the prevelance of patients without slippage decreased or pelvic disorders. The following measurements were analyzed:
gradually with age and elderly patients had relatively broader pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar
transverse processes and a higher iliac crest line. In critique of lordosis (LL), thoracic kypothosis (TK), and grade of spondy-
this study, the control patients were not consecutive and the pro- lolisthesis. Statistically significant differences were found when
cess for random sampling was not discussed. This study provides comparing the spondylolisthesis patients to control patients
Level II prognostic evidence that the lumbar index and sacral for the measurements of PI (71.6 vs 51.8, p<0.01), SS (49.4 vs
table angle are different in spondylolisthesis patients compared 39.7, p<0.01), PT (22.2 vs 12.1, p<0.01), LL (66 vs 42.7, p<0.01)
to low back pain patients without spondylolisthesis. and TK (38.9 vs 47.5, p<0.01). The differences in the spinal and
Jackson et al2 conducted a radiographic study to determine pelvic parameters in the spondylolisthesis group increased pro-
the most reliable methods for measuring lumbopelvic lordosis gressively between Newman Grades I and IV for PI, SS, PT and
LL and decreased progressively between Grades I and IV for correlated with the degree of slippage. SS, PT, LL measurements
TK. This study provides Level II prognostic evidence that pel- were also found to be significantly higher (46.57 vs 41.86; 26.53
vic anatomy may have a direct influence on the development of vs 13.21; -70.22 vs -43.13; p<0.0001, respectively). SS was found
spondylolisthesis. to gradually increase with Grade I, II and III slip and decrease
Lee et al4 conducted a retrospective radiographic analysis of in Grade IV and V slip. This study provides Level II prognostic
211 patients with various spinal disorders to define the relation- evidence that patients with a diagnosis of isthmic spondylolis-
ship between pelvic parameters and lumbar spinal disorders. thesis have a higher pelvic incidence, sacral slope, pelvic tilt and
Lateral radiographs were taken on patients with spinal steonisis lumbar lordosis compared to controls.
(n=57), degenerative spondylolisthesis (n=78), isthmic spondy-
lolisthesis (n=34), Takemitsu Type 1 lumbar degenerative ky- References
phosis (LDK) (n=20) and Takemitsue Type 2 LDK (n=22) and 1. Inoue H, Ohmori K, Miyasaka K. Radiographic classification of
spinal analysis software was used to calculate pelvic incidence L5 isthmic spondylolisthesis as adolescent or adult vertebral slip.
(PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), tho- Spine. Apr 15 2002;27(8):831-838.
racic kyphosis (TK) and sagittal vertical axis. Results indicated 2. Jackson RP, Peterson MD, McManus AC, Hales C. Compen-
that the mean pelvic incidence was much higher in patients with satory spinopelvic balance over the hip axis and better reli-
ability in measuring lordosis to the pelvic radius on standing
degenerative spondylolisthesis (58.8°), isthmic spondylolisthesis
lateral radiographs of adult volunteers and patients. Spine.
(56.7°) and Takemitsu Type 1 LDK (65.8°) compared to spinal 1998;23(16):1750-1767.
stenosis (48.7°) and Takemitsue Type 2 (50.9°) patients. In cri- 3. Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis,
tique of this study, it is unclear whether the patients studied were pelvic incidence, and spinopelvic balance: a correlation study.
consecutive and the sample sizes were small. This study provides Spine. Sep 15 2004;29(18):2049-2054.
Level II prognostic evidence that patients with isthmic spondy- 4. Lee JH, Kim KT, Suk KS, et al. Analysis of spinopelvic param-
lolisthesis have increased pelvic incidence compared to those eters in lumbar degenerative kyphosis: correlation with spinal
with spinal stenosis; however, pelvic incidence in isthmic spon- stenosis and spondylolisthesis. Spine. 2010;35(24):E1386-1391.
dylolisthesis patients was not found to be higher than in patients 5. Rajnics P, Templier A, Skalli W, Lavaste F, Illes T. The association
of sagittal spinal and pelvic parameters in asymptomatic persons
with degenerative spondylolisthesis.
and patients with isthmic spondylolisthesis. Journal of spinal
Using digitzed lateral radiographs and orthopedics softo- disorders & techniques. Feb 2002;15(1):24-30.
ware, Rajnics et al5 investigated the sagittal spinal shape and pos- 6. Vialle R, Ilharreborde B, Dauzac C, Lenoir T, Rillardon L,
tion of the pelvis in patients with isthmic spondylolisthesis com- Guigui P. Is there a sagittal imbalance of the spine in isthmic
pared to controls. Investigators examined the radiographs of 48 spondylolisthesis? A correlation study. European Spine Journal.
patients with isthmic spondylolisthesis and 30 control patients 2007;16(10):1641-1649.
to assess the sacrofemoral anatomic constant (SFAC), thickness
of the pelvis, sacral slope, sacrofemoral tilting and overhang. Ac- Bibliography
cording to Meyerding classification, in the isthmic sponodylolis- 1. Bourghli A, Aunoble S, Reebye O, Le Huec JC. Correlation of
thesis patient group, 5% had no slippage, 31% had Grade I, 58% clinical outcome and spinopelvic sagittal alignment after surgi-
had Grade II and 6% had Grade III. Analysis indicated that the cal treatment of low-grade isthmic spondylolisthesis. European
SFAC, sacral slope and degree of L1-L5 lorsosis were greater in Spine Journal. 2011;20(Suppl 5):663-668.
isthmic spondylolisthesis patients compared to controls. How- 2. Ergun T, Sahin MS, Lakadamyali H. Evaluation of the relation-
ship between L5-S1 spondylolysis and isthmic spondylolisthesis
ever, the analysis revealed no signiificant difference between
and lumbosacral-pelvic morphology by imaging via 2- and
groups in pelvis thickness, lumbar angle, degree of T4-T12 ky- 3-dimensional reformatted computed tomography. Journal of
phosis, sagittal tilting angle, amplitude of curvatures or inclini- computer assisted tomography. Jan-Feb 2011;35(1):9-15.
ation of the spine. This study provides Level II prognostic evi- 3. Park SJ, Lee CS, Chung SS, Kang KC, Shin SK. Postoperative
dence that the degree of lordosis in the lumbar spine and sacral changes in pelvic parameters and sagittal balance in adult isth-
slope are increased in patients with isthmic spondylolisthesis. mic spondylolisthesis. Neurosurgery. 2011;68(2 Suppl Opera-
Vialle et al6 compared the angular parameters of the sagittal tive):355-363.
balance of the spine in patients with developmental L5-S1 spon- 4. Schuller S, Charles YP, Steib JP. Sagittal spinopelvic alignment
dylolisthesis to control patients. Standing lateral radiographs of and body mass index in patients with degenerative spondylolis-
thesis. European Spine Journal. 2011;20(5):713-719.
244 isthmic spondylolisthesis and 300 healthy/control patients
were analyzed and measurements for sacral slope (SS), pelvic tilt
(PT), pelvic incidence, lumbar lordosis, thoracic kyphosis (TK),
T9 sagittal offset (T9SO) and degree of L5 anterior slip (L5S)
were computed through digital spine software. Among the spon-
dylolisthesis patients, 27 were classified as Meyerding’s Grade I,
43 as Grade II, 98 as Grade III, 59 as Grade IV and 17 as Grade V.
Investigators found significant correlation between lumbar lor-
dosis, pelvic tilt and the severity of L5 anterior slipping and be-
tween lumbosacral angle and severity of L5 anterior slipping. PI
was significantly higher in spondylolisthesis patients when com-
pared to controls (73.05 vs 54.67, p<0.001); however, PI was not
C. Outcome Measures for Medical/Interventional and

Surgical Treatment
What are the appropriate outcome

measures for the treatment of adult isthmic
spondylolisthesis?
For information on outcome measures for spinal disorders, the North American Spine Society has
a publication entitled Compendium of Outcome Instruments for Assessment and Research of Spinal
Medical/Interventional & Surgical Treatment
Disorders. To purchase a copy of the Compendium, visit https://webportal.spine.org/Purchase/

Recommendations: Outcome Measures for
ProductDetail.aspx?Product_code=68cdd1f4-c4ac-db11-95b2-001143edb1c1.
For additional information about the Compendium, please contact the NASS Research Department
at nassresearch@spine.org.
D. Medical and Interventional Treatment
A systematic review of the literature yielded no studies to adequately

address any of the following medical/interventional treatment questions:
What is the role of pharmacological treatment in the

management of isthmic spondylolisthesis?
What is the role of manipulation in the treatment of

What is the role of steroid injections for the treatment

of isthmic spondylolisthesis?
What is the role of ancillary treatments such as bracing,

traction, electrical stimulation and transcutaneous
electrical stimulation (TENS) in the treatment of isthmic
spondylolisthesis?
Recommendations: Medical/
Interventional Treatment
Relevant literature was found to address the clinical questions that
follow; however, due to the paucity of evidence, no recommendations
could be made.
What is the role of physical therapy/exercise

in the treatment of isthmic spondylolisthesis?
There is insufficient evidence to make a recommendation for or against
the use of physical therapy/exercise for the treatment of isthmic
spondylolisthesis.
Moller et al1 conducted a prospective randomized trial to de- consented to participation. Of the patients who underwent pos-
termine whether posterolateral fusion results in improved out- terolateral fusion, 37 received rigid pedicle screw fixation and 40
comes compared to an exercise program in adult patients un- underwent fusion without instrumentation. Patients, enrolled in
dergoing treatment for isthmic spondylolisthesis. A total of 111 the exercise group, participated in the program under supervi-
patients were included in the study, including 34 in the exercise sion of a physiotherapist, and the program included 12 different
group and 77 in the posterolateral fusion group. The patients exercises. Four exercises included a pully and leg press machine
were randomly allocated to their treatment group by blindly and the other 8 exercises did not require specific equipment so
choosing one of three note cards upon enrollment in the pro- that patients could easily perform at home. Patients exercised 3
gram. Treatment allocation was kept blinded until the patient times a week for 45 minutes a session during the first 6 months
and twice a week between 6 and 12 months. After one year, the up was 9 years with a range of 5 to 13 years. Results suggested
patients were instructed to continue with the home exercises. that there were no significant differences in terms of functional-
After one year, patients were no longer under the supervision ity and pain in the exercise group at 2 and 9 years follow-up.
of the physiotherapist. Patients in both groups completed pre- When comparing the surgical and exercise groups, there were no
treatment questionnaires and were followed-up with at one and significant differences in outcome measurements at long-term
2 years. Functional disability was assessed using the Disability follow-up in any of the outcomes assessed except for the global
Rating Index (DRI) and pain was quantified by using the visual assessment, which was found to be significantly better for surgi-
analogue scale (VAS). At 2 year follow-up, the surgical group re- cal patients (p=0.015). In the exercise group, all scores except the
ported a significantly lower DRI (p=0.004) and pain index score ODI improved nonsignificantly between short-term and long-
(p=0.002) compared to the exercise group. At 2 years, the mean term follow-up. The ODI worsened from 28 to 31; however, this
DRI remained unchanged in the exercise group, which had a was not statistically significant. In the surgical group, 11 patients
mean DRI of 44 before and after treatment. The mean pain index experienced complications, including 2 nerve root injuries, one
significantly improved in both groups with 63 to 37 (p<0.001) in pseudoarthrosis, one discectomy and 7 implant removals. There
the surgical group and 65 to 56 in the exercise group (p=0.024). were no early or late deep infections reported. In critique of this
Prior to the start of the program, 61% of exercise patients were study, compliance with the exercise program was not assessed
not working compared to 45% at the 2 year follow-up. after one year. Two-thirds of the exercise patients complied with
In a follow-up study, Ekman et al2 evaluated the long term the program at one year; however, it is unknown how many and
outcome of exercise versus surgical treatment in the same group to what extent the patients continued the recommended ex-
of patients. The 106 patients who completed the 2-year follow- ercises beyond one year. Although this study is a randomized
up were invited by mail to take part in the long-term follow-up controlled trial, only the results from the exercise group can be
study. A total of 101 patients responded to the invitation result- directly applied to this clinical question. Therefore, this potential
ing in a 91% long-term follow-up rate. In addition to the VAS Level I study provides Level IV therapeutic evidence that adult
and DRI, the Oswestry Disability Index (ODI), SF-36 and global isthmic spondylolisthesis patients treated with an exercise pro-
outcome measurement were added to the patients’ outcome as- gram experience short term improvements in pain, but not in
sessments for long-term follow-up. The average long term follow functionality.
Does the degree of radiological grade,

sagittal spinopelvic alignment, sacral and
spinopelvic parameters, or the presence of
dynamic instability in patients with isthmic

spondylolisthesis affect the outcomes of

patients 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.
What is the long-term result of medical/

interventional management of isthmic
spondylolisthesis?
against the use of medical/interventional treatment for the long-term
management of patients with isthmic spondylolisthesis.
As discussed earlier in this section, Ekman et al2 evaluated the sis patients treated with an exercise program experience short
long term outcome of exercise versus surgical treatment in adult term improvements in pain, but not in functionality. For long
patients receiving treatment for isthmic spondylolisthesis. A to- term improvement, treatment of isthmic spondylolisthesis with
tal of 111 patients were initially included in the study1, includ- exercise may provide little improvement compared to the natu-
ing 34 in the exercise group and 77 in the posterolateral fusion ral history of the disease.
group. Of the patients who underwent posterolateral fusion,
37 received rigid pedicle screw fixation and 40 underwent fu- Future Directions For Research
sion without instrumentation. Patients enrolled in the exercise The work group recommends the undertaking of prospective
group participated in the program under supervision of a phys- and retrospective studies, including large multi-center regis-
iotherapist, and the program included 12 different exercises. try database studies with long term follow-up, evaluating the
Four exercises included a pully and leg press machine and the outcomes of various medical/interventional treatments for the
other 8 exercises did not require specific equipment so that pa- management of adult patients with isthmic spondylolisthesis.
tients could easily perform at home. Patients exercised 3 times
a week for 45 minutes a session during the first 6 months and References
twice a week between 6 and 12 months. After one year, the pa- 1. Moller H, Hedlund R. Surgery versus conservative management
tients were instructed to continue with the home exercises. After in adult isthmic spondylolisthesis--a prospective randomized
one year, patients were no longer under the supervision of the study: part 1. Spine. Jul 1 2000;25(13):1711-1715.
physiotherapist. 2. Ekman P, Moller H, Hedlund R. The long-term effect of postero-
The 106 patients who completed the 2-year follow-up were lateral fusion in adult isthmic spondylolisthesis: a randomized
invited by mail to take part in the long-term follow-up study. controlled study. Spine J. Jan-Feb 2005;5(1):36-44.
A total of 101 patients responded to the invitation resulting in
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9 years with a range of 5 to 13 years. At 2 years, the mean DRI lumbar fusion: a randomized controlled trial. Spine. Apr 15
2010;35(8):848-857.
remained unchanged in the exercise group, which had a mean
2. Agabegi SS, Fischgrund JS. Contemporary management of
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improved nonsignificantly between short-term and long-term tional and radiographic follow-up of surgically treated isthmic
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not statistically significant. In critique of this study, compliance
of isthmic spondylolisthesis in adults. (Review of 44 cases with
with the exercise program was not assessed after one year. Two- long-term control). Italian Journal of Orthopaedics and Trau-
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Although this study is a randomized controlled trial, only the fusion cage in treatment of spondylolisthesis. Spine J. May-Jun
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wiley.com/doi/10.1002/14651858.CD010264/abstract
E. Surgical Treatment
In adult patients, is surgical treatment

more effective than medical/interventional
treatment alone for the treatment of isthmic
spondylolisthesis?
against the efficacy of surgical treatment as compared to medical/
interventional alone for the management of adult patients with isthmic
spondylolisthesis.
In a 2 part study, Moller et al1,2 evaluated the outcomes of 111 for 91% of the patients was available at 5 years follow-up. At
isthmic spondylolisthesis patients randomly treated with pos- long-term follow-up, the authors also collected Oswestry Dis-
terolateral fusion in situ, with or without instrumentation, ver- ability Index (ODI) and SF-36 data. When comparing results
sus an exercise program. For purposes of answering this clinical for the surgical patients, no significant differences were found in
question, the work group included only Part 22 of the analysis, pain index, DRI, ODI, global assessment, SF-36 or work ability
which specifically compared the outcomes of 40 patients allo- scores between the instrumented and noninstrumented groups.
cated to posterolateral fusion (PLF) without instrumentation to The Moller and Ekman analyses offer Level I therapeutic evi-
37 patients who received PLF with pedicle screw instrumenta- dence that there were no significant differences in clinical out-
tion. The majority of patients had a diagnosis of either Grade I comes or fusion rates between instrumented or noninstrument-
or II isthmic spondylolisthesis (98%). Functional disability was ed posterolateral patients.
assessed by the Disability Rating Index (DRI) and Global Assess- In a randomized controlled trial, Thomsen et al4 evaluated
ment and pain was quantified using the Visual Analogue Scale the effect of instrumentation on reoperation rates and func-
(VAS). Patients were followed for 2 years and the follow-up rate tional outcome. A total of 129 patients with severe chronic low
was 94%. At one and 2 years follow-up, DRI and pain scores im- back pain were included in the study, including 35 patients with
proved significantly in both the instrumented and noninstru- Grade I or II isthmic spondylolisthesis, 41 patients with primary
mented groups from preoperative measurements, although there degenerative instability and 53 patients with secondary degen-
were no statistically significant differences between the groups. erative instability. Upon enrollment, patients were consecutively
There was no significant difference in percentage of sick leave and allocated using a 20-number-per-block concealed randomiza-
disability pension at 2 years between groups with 66% of nonin- tion process into either fusion with or without supplementary
strumented patients on leave prior to surgery vs 42% at follow-up transpedicular screw fixation. Functional outcomes were as-
(p=0.016) compared to 84% of instrumented patients on leave sessed by the Dallas Pain Questionnaire (DPQ) and the Low
prior to surgery vs 50% at follow-up (p=0.002). Noninstrumented Back Pain Rating Scale (LBPR) and scored by an independent
patients had a 78% solid fusion success rate while 65% of instru- observer. At 2 years follow-up, there were no significant differ-
mented patients were categorized as fused. Mean operation time ences found in fusion rates between instrumented (73%) and
and intraoperative blood loss were significantly greater in the in- non-instrumented groups (84%) or DPQ scores in the isthmic
strumented group compared to noninstrumented patients (298 spondylolisthesis sub-group.
minutes vs 201 minutes, p<0.001; 1517 mL vs 861mL, p<0.0001, Using the above patient population, Bjarke Christensen et
respectively). Three patients experienced major postoperative al5 evaluated the long term effect of instrumentation on reop-
complications, including 2 instrumented patients sustaining an eration and functional outcome. At 5 years follow-up, 8 isthmic
Recommendations: Surgical
L5 root injury with permanent sequelae and one noninstrument- spondylolisthesis patients in the instrumented group underwent
ed patient became permanently blind in one eye. or were planning reoperation and 2 isthmic spondylolisthe-
Using the above surgical population, Ekman et al3 evaluated sis patients in the noninstrumented group underwent or were
the long-term outcomes of patients undergoing posterolateral planning reoperation. Isthmic spondylolisthesis patients in the
Treatment
fusion versus an exercise program. In addition to the 40 ran- noninstrumented group had highly significant improvement in
domly allocated to posterolateral fusion without pedicle screw 3 out of 4 DPQ categories (daily activity, anxiety/depression, and
instrumentation and 37 allocated to posterolateral fusion with social concerns) and in all 3 LPBQ questions compared to in-
pedicle screw instrumentation, this analysis also included data strumented patients. Overall, among all diagnosis groups, there
for 34 patients randomly allocated to an exercise program. Data was no significant difference in functional outcome as measured
by the DPQ and LBPR between the instrumented and nonin- 6. Boachie-Adjei O, Do T, Rawlins BA. Partial lumbosacral
strumented groups. When analyzing diagnosis subgroups, the kyphosis reduction, decompression, and posterior lumbo-
authors found that patients with isthmic spondylolisthesis in the sacral transfixation in high-grade isthmic spondylolisthesis:
noninstrumented group had significantly better outcomes than clinical and radiographic results in six patients. Spine. Mar 15
2002;27(6):E161-168.
patients who received instrumented fusion (p<0.03). In critique,
7. Bridwell KH. Utilization of iliac screws and structural interbody
due to the small sample size of the subgroup of isthmic spondy- grafting for revision spondylolisthesis surgery. Spine. Mar 15
lolisthesis patients, the work group decided to downgrade the 2005;30(6 Suppl):S88-96.
study from Level I to Level II. The Thomsen and Bjarke Chris- 8. Butt MF, Dhar SA, Hakeem I, et al. In situ instrumented
tensen studies offer Level II therapeutic evidence that there was posterolateral fusion without decompression in symptomatic
no benefit found with adding instrumentation for Grade I and II low-grade isthmic spondylolisthesis in adults. International
isthmic spondylolisthesis patients undergoing fusion. Orthopaedics. Oct 2008;32(5):663-669.
9. Carragee EJ. Single-level posterolateral arthrodesis, with or
without posterior decompression, for the treatment of isthmic
Future Directions For Research spondylolisthesis in adults. A prospective, randomized study.
The work group recommends the undertaking of a large pro- Journal of Bone & Joint Surgery - American Volume. Aug
spective study of isthmic spondylolisthesis patients only eval- 1997;79(8):1175-1180.
uating the addition of instrumentation to fusion, including 10. Choi BK, Han IH, Cho WH, Cha SH. Lumbar osteochondroma
subgroup analysis, for factors potentially impacting surgical out- arising from spondylolytic L3 lamina. Journal of Korean Neuro-
comes such as segmental instability, smoking and the addition surgical Society. // 2010;47(4):313-315.
of decompression. 11. Dantas FL, Prandini MN, Ferreira MA. Comparison between
posterior lumbar fusion with pedicle screws and posterior lum-
bar interbody fusion with pedicle screws in adult spondylolis-
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Treatment
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Does the addition of lumbar fusion, with

or without instrumentation, to surgical
decompression improve surgical outcomes in
the treatment of adult patients with isthmic
spondylolisthesis compared to treatment by
decompression alone?

Although there was no literature evaluating the addition of fu- without posterior decompression, for the treatment of isthmic
sion to decompression versus decompression alone in adult spondylolisthesis in adults. A prospective, randomized study.
isthmic spondylolisthesis patients, the work group observed the Journal of Bone & Joint Surgery - American Volume. Aug
presence of literature evaluating the addition of decompression 1997;79(8):1175-1180.
10. Cheng CL, Fang D, Lee PC, Leong JC. Anterior spinal fusion for
to fusion versus fusion alone. Because the literature search was
spondylolysis and isthmic spondylolisthesis. Long term results
not specifically designed to address this topic, the work group in adults. Journal of Bone & Joint Surgery - British Volume. Mar
opted not to comment on findings. A clinical question compar- 1989;71(2):264-267.
ing the addition of decompression to fusion versus fusion alone 11. Dantas FL, Prandini MN, Ferreira MA. Comparison between
may be considered for a future guideline on this topic. posterior lumbar fusion with pedicle screws and posterior lum-
bar interbody fusion with pedicle screws in adult spondylolis-
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interbody fusion cages in the treatment of spondylolisthesis: posterior lumbar interbody fusion to pedicle screw fixation
analysis of 120 cases. Spine. Mar 15 2005;30(6 Suppl):S60-65. and posterolateral fusion after decompression in spondylolytic
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Disorders and Techniques. // 2003;16(2):144-149. mented posterolateral fusion in spondylolisthetic and failed back
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1340. 47. Vaccaro AR, Ring D, Scuderi G, Cohen DS, Garfin SR. Predic-
32. Moller H, Hedlund R. Instrumented and noninstrumented tors of outcome in patients with chronic back pain and low-grade
posterolateral fusion in adult spondylolisthesis--a prospective spondylolisthesis. Spine. Sep 1 1997;22(17):2030-2034; discussion
randomized study: part 2. Spine. Jul 1 2000;25(13):1716-1721. 2035.
33. Musluman AM, Yilmaz A, Cansever T, et al. Posterior lumbar 48. Virta L, Osterman K. Radiographic correlations in adult symp-
interbody fusion versus posterolateral fusion with instrumenta- tomatic spondylolisthesis: a long-term follow-up study. Journal of
tion in the treatment of low-grade isthmic spondylolisthesis: Spinal Disorders. Feb 1994;7(1):41-48.
midterm clinical outcomes. Journal of Neurosurgery Spine. Apr 49. Wenger M, Sapio N, Markwalder TM. Long-term outcome in 132
2011;14(4):488-496. consecutive patients after posterior internal fixation and fusion
34. Nooraie H, Ensafdaran A, Arasteh MM. Surgical management for Grade I and II isthmic spondylolisthesis. Journal of Neurosur-
of low-grade lytic spondylolisthesis with C-D instrumentation gery Spine. Mar 2005;2(3):289-297.
in adult patients. Archives of Orthopaedic & Trauma Surgery. 50. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Long-term
1999;119(5-6):337-339. results of pediculo-body fixation and posterolateral fusion for
35. Peek RD, Wiltse LL, Reynolds JB, Thomas JC, Guyer DW, Widell lumbar spondylolisthesis. European Spine Journal. Jun 2009;18
EH. In situ arthrodesis without decompression for Grade-III or Suppl 1:151-155.
IV isthmic spondylolisthesis in adults who have severe sciatica. 51. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus
Journal of Bone & Joint Surgery - American Volume. Jan non-surgical treatment for lumbar spinal stenosis. Cochrane Da-
1989;71(1):62-68. tabase of Systematic Reviews. 2012(12). http://onlinelibrary.wiley.
com/doi/10.1002/14651858.CD010264/abstract.
Treatment
Does the addition of instrumentation to

decompression 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 decompression.
Grade of Recommendation: B (Suggested)
In a 2 part study, Moller et al1,2 evaluated the outcomes of 111 ability Index (ODI) and SF-36 data. When comparing results
isthmic spondylolisthesis patients randomly treated with pos- for the surgical patients, no significant differences were found in
terolateral fusion in situ, with or without instrumentation, ver- pain index, DRI, ODI, global assessment, SF-36 or work ability
sus an exercise program. For purposes of answering this clinical scores between the instrumented and noninstrumented groups.
question, the work group included only Part 22 of the analysis, The Moller and Ekman analyses offer level I therapeutic evidence
which specifically compared the outcomes of 40 patients allo- that there were no significant differences in clinical outcomes or
cated to posterolateral fusion (PLF) without instrumentation to fusion rates between instrumented or noninstrumented postero-
37 patients who received PLF with pedicle screw instrumenta- lateral patients.
tion. The majority of patients had a diagnosis of either Grade I In a randomized controlled trial, Thomsen et al4 evaluated
or II isthmic spondylolisthesis (98%). Functional disability was the effect of instrumentation on reoperation rates and func-
assessed by the Disability Rating Index (DRI) and Global As- tional outcome. A total of 129 patients with severe chronic low
sessment and pain was quantified using the Visual Analogue back pain were included in the study, including 35 patients with
Scale (VAS). Patients were followed for 2 years and the follow-up Grade I or II isthmic spondylolisthesis, 41 patients with primary
rate was 94%. At one and 2 years follow-up, DRI and pain scores degenerative instability and 53 patients with secondary degen-
improved significantly in both the instrumented and nonin- erative instability. Upon enrollment, patients were consecutively
strumented groups from preoperative measurements, although allocated using a 20-number-per-block concealed randomiza-
there were no statistically significant differences between the tion process into either fusion with or without supplementary
groups. There was no significant difference in percentage of sick transpedicular screw fixation. Functional outcomes were as-
leave and disability pension at 2 years between groups with 66% sessed by the Dallas Pain Questionnaire (DPQ) and the Low
of noninstrumented patients on leave prior to surgery vs 42% at Back Pain Rating Scale (LBPR) and scored by an independent
follow-up (p=0.016) compared to 84% of instrumented patients observer. At 2 years follow-up, there were no significant differ-
on leave prior to surgery vs 50% at follow-up (p=0.002). Nonin- ences found in fusion rates between instrumented (73%) and
strumented patients had a 78% solid fusion success rate while non-instrumented groups (84%) or DPQ scores in the isthmic
65% of instrumented patients were categorized as fused. Mean spondylolisthesis sub-group.
operation time and intraoperative blood loss were significantly Using the above patient population, Bjarke Christensen et
greater in the instrumented group compared to noninstrument- al5 evaluated the long term effect of instrumentation on reop-
ed patients (298 minutes vs 201 minutes, p<0.001; 1517 mL vs eration and functional outcome. At 5 years follow-up, 8 isthmic
861mL, p<0.0001, respectively). Three patients experienced ma- spondylolisthesis patients in the instrumented group underwent
jor postoperative complications, including 2 instrumented pa- or were planning reoperation and 2 isthmic spondylolisthe-
tients sustaining an L5 root injury with permanent sequelae and sis patients in the noninstrumented group underwent or were
one noninstrumented patient became permanently blind in one planning reoperation. Isthmic spondylolisthesis patients in the
eye. noninstrumented group had highly significant improvement in
Using the above surgical population, Ekman et al3 evaluated 3 out of 4 DPQ categories (daily activity, anxiety/depression, and
the long-term outcomes of patients undergoing posterolateral social concerns) and in all 3 LPBQ questions compared to in-
fusion versus an exercise program. In addition to the 40 ran- strumented patients. Overall, among all diagnosis groups, there
Treatment
domly allocated to posterolateral fusion without pedicle screw was no significant difference in functional outcome as measured
instrumentation and 37 allocated to posterolateral fusion with by the DPQ and LBPR between the instrumented and nonin-
pedicle screw instrumentation, this analysis also included data strumented groups. When analyzing diagnosis subgroups, the
for 34 patients randomly allocated to an exercise program. Data authors found that patients with isthmic spondylolisthesis in the
for 91% of the patients was available at 5 years follow-up. At noninstrumented group had significantly better outcomes than
long-term follow-up, the authors also collected Oswestry Dis- patients who received instrumented fusion (p<0.03). In critique,
due to the small sample size of the subgroup of isthmic spondy- 7. Bridwell KH. Utilization of iliac screws and structural inter-
lolisthesis patients, the work group decided to downgrade the body grafting for revision spondylolisthesis surgery. Spine. Mar
study from level I to level II. The Thomsen and Bjarke Chris- 15 2005;30(6 Suppl):S88-96.
tensen studies offer level II therapeutic evidence that there was 8. Butt MF, Dhar SA, Hakeem I, et al. In situ instrumented
posterolateral fusion without decompression in symptomatic
no benefit found with adding instrumentation for Grade I and II
low-grade isthmic spondylolisthesis in adults. International
isthmic spondylolisthesis patients undergoing fusion. Orthopaedics. Oct 2008;32(5):663-669.
9. Carragee EJ. Single-level posterolateral arthrodesis, with or
Future Directions for Research without posterior decompression, for the treatment of isthmic
The work group recommends the undertaking of a large pro- spondylolisthesis in adults. A prospective, randomized study.
spective study of isthmic spondylolisthesis patients only eval- Journal of Bone & Joint Surgery - American Volume. Aug
uating the addition of instrumentation to fusion, including 1997;79(8):1175-1180.
10. Choi BK, Han IH, Cho WH, Cha SH. Lumbar osteochondroma
subgroup analysis, for factors potentially impacting surgical
arising from spondylolytic L3 lamina. Journal of Korean Neuro-
outcomes such as segmental instability, smoking and the addi- surgical Society. // 2010;47(4):313-315.
tion of decompression. 11. Dantas FL, Prandini MN, Ferreira MA. Comparison between
posterior lumbar fusion with pedicle screws and posterior
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Treatment
spondylolisthesis. Cochrane Database of Systematic Reviews.

2012(10). http://onlinelibrary.wiley.com/doi/10.1002/14651858.
CD010150/abstract.
How do outcomes of decompression with

posterolateral fusion compare with those for
360° fusion in the treatment of adult patients
with isthmic spondylolisthesis?
Posterolateral fusion and 360° fusion surgeries are recommended to

improve the clinical outcomes in adult patients with low grade isthmic
spondylolisthesis.
Grade of Recommendation: A
360° fusion is recommended to provide higher radiographic fusion

rates compared to posterolateral fusion in adult patients with low
grade isthmic spondylolisthesis.
Grade of Recommendation: A
There is conflicting evidence whether 360° fusion provides better

clinical outcomes than posterolateral fusion alone.
Farokhi et al1 compared the clinical outcomes of posterolateral 5% of PLIF patients. Intraoperative blood loss was significantly
fusion (PLF) to posterior lumbar interbody fusion (PLIF) with greater in the PLIF Group (0.04) and surgical duration was lon-
posterior instrumentation for the treatment of isthmic spon- ger for PLIF patients, although the difference was not statistically
dylolisthesis. Patients were randomized to receive either PLF significant. At 6 months after surgery, 66.7% of PLF patients and
(n=40) or PLIF (n=40) using computerized random number 89.1% of PLIF patients reported good fusion results; this differ-
generator software. Almost half of patients (45%) had isthmic ence was not statistically significant. At 3 days after surgery, re-
spondylolisthesis at the L5-S1 level. Isthmic spondylolisthesis ports of low back pain were statistically lower in PLF patients. In
was present at the L4-L5 in 35% and at the L3-L4 in 12.5% of pa- PLF patients, there was no significant correlation between slip,
tients. Patients were followed for one year, although most results Meyerding grade and disc height, radicular pain and low back
were only reported for 6 months after surgery. Outcomes were pain. This study offers Level I therapeutic evidence that at one
assessed using the Oswestry Low Back Pain Disability (OLBP) year, PLF is clinically superior to PLIF as measured by ODI low
sale and Visual Analogue Scale (VAS) and by comparing radio- back pain measures; however, PLIF was found to have more suc-
logic results. Radiological evaluation included static and func- cessful postoperative fusion rates when compared to PLF.
tional lumbar spine plain x-rays and CT, and MRI scans assessed Musluman et al2 randomly allocated patients into receiving
foraminal stenosis and the presence of lumbar spinal stenosis. either posterolateral fusion (PLF) or posterior lumbar inter-
At baseline, neurogenic claudication was observed in 38 (95%) body fusion (PLIF) for the treatment of Grades I and II isthmic
patients in the PLF group and in 36 (90%) patients in the PLIF spondylolisthesis. Patients were only considered for surgery af-
group. At one year after surgery, complaints of neurogenic clau- ter undergoing at least 6 months of unsuccessful conservative
dication were significantly higher in the PLIF patients compared treatment measures. Using a computerized random number
to PLF patients (33.3% vs 7.3%, p=0.004). Improvement in low generator, 25 patients were enrolled per group. Posterior de-
back pain as measured by the OLBP was significantly higher in compression, laminectomy, medial facetectomy and foraminot-
PLF patients compared to PLIF patients (25.34+9.36 vs 17.1, omy were performed in all patients. In addition, bone fragments
p=0.001). It is important to highlight that the standard deviations collected from the iliac wing during decompression were used
for these two measurements overlap; thus, the work group ques- as autografts in the PLF Group and lamina obtained during de-
tions the significance of this finding. There were no significant compression, and spinous process bone autograft was used in
Treatment
differences in postoperative complications at one year between the PLIF Group. The spondylolisthesis levels in the PLF Group
the groups. In the PLF Group 4.3% experienced cerebrospinal were located at L4-L5 (13, 52%), L5-S1 (8, 32%) and L3-L4 (4,
fluid leak compared to 5% of PLIF patients. The infection rate 16%). In the PLIF Group, spondylolisthesis levels were located
was 2.1% for the PLF Group and 2.5% for the PLIF Group. Per- at the L4-L5 (13, 52%), L5-S1 (6, 24%) and L3-L4 (5, 20%). Pa-
manent motor impairment occurred in 4.3% of PLF patients and tients were followed for a minimum of 18 months and an aver-
age of 3.3 years. Radiologic examinations were performed via cant differences in clinical outcomes as measured by DPQ and
plain and dynamic radiographs, MR imaging and CT scanning. LBPR in PLF compared to 360° fusion in patients with low grade
Clinical and functional evaluations were conducted via Visual isthmic spondylolisthesis at one year and 2 years follow-up.
Analogue Scale (VAS), Oswestry Disability Index (ODI) and SF- In a prospective comparative study, Swan et al4 compared the
36. The mean operating time was 146 minutes in the PLF Group early and medium treatment outcomes of patients undergoing
and 168 minutes in the PLIF Group. The mean amount of blood either single-Level Instrumented posteriorlateral fusion (PLF)
lost during operation and the first postoperative day was signifi- or PLF plus anterior interbody fusion (ALIF) for the treatment
cantly greater in the PLF Group compared to the PLIF Group of unstable Grade I or II isthmic spondylolisthesis at L5-S1 or
(1100 + 280ml vs 830 + 215ml, p<0.05). There were no signifi- L4-L5. For the purposes of this study, the authors defined “un-
cant differences in complications between groups. Postoperative stable” spondylolisthesis as documented slip progression (3mm
complications in the PLF Group included one case of transient or one Meyerding Grade) under observation in the 2 years prior
nerve palsy, 2 deep infections, 3 patients with pain in the bone to surgery or > 3mm translation and/or > 22o of angulation seen
graft donor site and 4 nonunions. In the PLIF Group, there was on standing flexion-extension or prone lateral radiographs. Pa-
1 case of transient nerve palsy, one deep infection and one cage tient selection was conducted through sequential enrollment,
dislocation. Significant decreases in both low back and leg pain with the first 50 enrolled in the PLF Group and the second group
were observed in both groups after surgery. When compar- of 50 patients enrolled in the PLF ALIF Group. Follow-up as-
ing pain levels between the groups, PLIF patients experienced sessments occurred at 6 months, 12 months and 24 months. The
more improvement in low back pain (p<0.05); however, there primary outcome measurement of success was an Oswestry Dis-
were no significant differences in leg pain improvements be- ability Index (ODI) <20 and secondary outcome measures in-
tween groups. There was a statistically significant improvement cluded pain intensity as measured by the Visual Analogue Scale
in mean ODI scores from pre to postop in both groups, favor- (VAS), medication intake and work status. Radiographic mea-
ing the PLIF Group at early follow-up. At baseline, PLF patients sures were evaluated via flexion-extension x-rays. Operative re-
scored 29.20 + 6.42 and improved to 18.2 + 3.65 at 3 months and sults indicated that operation duration for the PLF ALIF Group
14.12 + 2.42 at 1.5 to 6 years (p<0.0001). PLIF patients had a was one hour longer than that for the PLF Group; however,
mean preoperative ODI of 30.2 + 5.70, which improved to 13.60 blood loss and length of hospital stay were similar between the
+ 1.95 at 3 months and 13.40 + 1.95 at 1.5 to 6 years (p<0.0001). groups. At 6 and 12 months VAS, ODI, medication and occupa-
In critique, the work group would like to highlight the inconsis- tional outcomes were significantly better in the PLF ALIF Group
tent follow-up period for patients (ie, range 1.5 to 6 years); how- compared to the PLF Group only, although differences were not
ever, they didn’t feel that this critique alone justified downgrad- statistically significant at 24 months. When comparing the per-
ing the study as all patients were followed for at least 1.5 years. centage of patients who met the primary outcome (ODI < 20),
This study offers Level I therapeutic evidence that statistically more patients in the PLF ALIF Group achieved this outcome at
significant improvement in outcome measures occurred in both 6, 12 and 24 months compared to PLF only patients (30 vs 11 pa-
groups; however, the PLIF Group had statistical superiority in tients, RR=2.67, p=0.0001; 34 vs 20 patients, RR=1.66, p<0.005;
some outcome measures compared to PLF. 36 vs 29 patients, RR=1.21, p=0.47, respectively). It is important
In a randomized controlled trial, Christensen et al3 assessed to note that although that the combined group met the primary
the surgical outcomes of 148 patients undergoing either pos- outcome at a significantly higher rate at 6 and 12 months com-
terolateral fusion (PLF) with titanium instrumentation or cir- pared to the PLF Group, this difference was no longer significant
cumferential fusion for the treatment of Grade I or II isthmic at 24 months. Improvements in preoperative anterolisthesis, disc
spondylolisthesis, primary degeneration, secondary degenera- height and slip angle measurements were maintained at a sig-
tion, or accelerating degeneration. Circumferential fusion was nificantly greater rate at 24 months postop in combined patients
performed via anterior lumbar interbody fusion with the use of compared to PLF patients (20.9 + 12.1 to 9.9 + 6.7 vs 21.2 + 9.9
a radiolucent cage, using a retroperitoneal approach to the lum- to 19.5 + 7.2, p=0.001; 17.3 + 6.7 to 24.0 + 5.9 vs. 16.9 + 7.5 to
bar discus plus posterolateral fusion. Within the isthmic spon- 18.1 + 8.0, p=0.01; -18.1 + 11 to 125.2 + 9 vs. -19.2 + 9 to -20.2 +
dylolisthesis subgroup, 19 patients were randomized to the PLF 12, p=0.03, respectively). The majority of complications report-
Group and 24 were randomized to the circumferential group. ed were minor, but occurred more frequently after combined
Patients were followed for two years and outcomes were assessed surgery. Regarding major infections, 2 patients in each group
using the Dallas Pain Questionnaire (DPQ), Low Back Pain Rat- had to undergo reoperation and one combined and 3 PLF pa-
ing Scale (LBPR) and radiographic measurements. For isthmic tients experienced nonunion. In critique, it is important to note
spondylolisthesis patients, no statistical differences were found that the authors only included patients with unstable, low-grade
between the groups for DPQ or LBPR scores at either the one slips and that no direct decompression was performed in either
or 2 year follow-up assessments, although there were significant group. This study provides Level II therapeutic data that at 6 and
improvements in scores for each group before and after surgery. 12 months, there were statistically significant improvements in
In critique, there was no subgroup analysis of isthmic spondy- ODI and VAS scores in patients receiving posterolateral fusion
Treatment
lolisthesis patients for radiographic measures and the subgroup plus anterior interbody fusion versus posterolateral fusion alone;
sample size was small and, thus, potentially underpowered to however, at 2 year follow-up, these differences were no longer
detect any statistical differences. Due to these reasons, the work statistically significant. Radiographic measurements, including
group downgraded the level of evidence from I to II. This data improvements in preoperative anterolisthesis, disc height and
provides Level II therapeutic evidence that there were no signifi- slip angle, were maintained at a significantly greater rate at 2
years after surgery in the posterolateral fusion plus anterior in- PLF without instrumentation patients (p=0.0004). However,
terbody fusion group. there were no statistically significant differences in outcomes
In a retrospective comparative study, Suk et al5 evaluated the based on preoperative slip level between the groups. In both
advantages of adding PLIF to posterior segmental pedicle screw PLIF and PLF groups, VAS and DRI scores improved significant-
instrumentation and PLF for the surgical treatment of instabil- ly from the preoperative period to the 2 year follow-up; however,
ity created by decompressive surgery in spinal stenosis caused there were no statistically significant differences in improve-
by isthmic spondylolisthesis. The records of patients who had ments between the groups. ODI scores for both groups at 2 year
undergone PLF (n=40) or PLF plus PLIF (n=36) were com- follow-up was 25. At baseline, there were no significant differ-
pared. Patients were followed for a minimum of two years; PLF ences in the proportion of patients with sciatica between groups,
patients were followed for a mean of 5.4 years and PLIF patients but at 2 years, sciatica was present in more PLIF patients (48%
were followed for a mean of 3.3 years. Clinical outcomes were vs. 37%, p=0.18). The percentage of patients at work increased
assessed using Kirkaldy-Willis criteria and radiographic mea- from 36% to 52% (p=0.0008) at follow-up in the PLIF Group and
surements were evaluated using standing and flexion-extension 25% to 54% (p<0.0001) in the PLF Group. Return to work status
radiographs and CT scan or MRI. At preoperative radiographic was not significantly different between the groups. According to
evaluation, spinal stenosis was one Level In 22 patients (61%), the Global Outcome Assessment, 74% of patients in both groups
two levels in 11 patients (30.5%) and three levels in 3 patients evaluated their surgical results as “much better” or “better.” In
(8.5%). In the PLF Group, isthmic defects were at L4 in 25 pa- the PLIF Group, there were 12 major complications, including
tients (62.5%), L5 in 14 (35%) and double Level In L4-L5 in 1 pa- 3 deep wound infections, 2 patients were permanent leg pain, 2
tient (2.5%). According to Meyerding’s Grade, 14 (35%) patients patients with transient leg pain, one patient with DVT, one pa-
were Grade I, 24 (60%) Grade II and 2 (5%) Grade III. In the PLF tient with pulmonary embolism, 2 foot drops, and one patient
plus PLIF Group, the isthmic defect was at L3 in 1 (3%) patient, with postoperative paraparesis. There were 4 major complica-
L4 in 20 (55.5%) patients, L5 in 15 (41.6%) patients and double- tions in the PLF group, including 2 permanent L5 injuries, one
level L4-L5 in 1 (2.5%) patient. Meyerding Grade I slippage was permanent blindness, and one transient dermatomal pain, which
present in 12 (33.3%) patients, Grade II in 21 (58.3%) patients resolved after one month. In critique, there were statistically sig-
and Grade III in 3 (8.3%) patients. At follow-up, solid union nificant differences in Grade slip level between the groups. Due
was obtained in all PLF plus PLIF patients and 35 of 40 (87.5%) to this heterogeneity, the work group downgraded the level of
of PLF patients. As measured by the Taillard method, the mean evidence from III to IV. This potential Level III study offers Level
preoperative slip in the PLF Group improved from 28.3 + 13.2% IV therapeutic evidence that in patients with low grade isthmic
to 15.1 + 7.7% immediately after surgery and to 20.3 + 8.5% at spondylolisthesis, there are no statistically significant differences
final follow-up. In the PLF plus PLIF Group, the mean preop- as measured by VAS, DRI and ODI between PLIF and PLF.
erative slip of 27.9 + 9.7% improved to 13.5 + 7.3% immediately
after surgery and to 16.3 + 8.8% at final follow-up. The difference Future Directions For Research
in measurements was statistically significant (p<0.05) favoring The work group recommends the undertaking of a prospective
the PLF plus PLIF Group. There were no significant differences study evaluating the outcomes of 360° fusion (posterolateral plus
in total lumbar, segmental lordosis, sacral inclination or sagit- interbody fusion) versus posterolateral fusion alone in adult pa-
tal rotation between groups. As measured by Kirkaldy-Willis tients undergoing surgical treatment for isthmic spondylolisthe-
criteria, excellent or good results were obtained in 95% of PLF sis.
patients and 97% of PLIF plus PLIF patients. When narrowing
these findings, 75% of PLIF patients reported excellent results References
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1 and 0 patients, respectively, in the PLF Group versus 0, 0, 1, and 2. Müslüman AM, A Yl, Cansever T, et al. Posterior lumbar
1 patient, respectively, in the PLF plus PLIF Group. This study interbody fusion versus posterolateral fusion with instrumenta-
provides Level III therapeutic data that the addition of PLIF to tion in the treatment of low-grade isthmic spondylolisthesis:
PLF is radiographically and clinically superior when compared midterm clinical outcomes. Journal of neurosurgery. Spine.
2011;14(4):488-496. http://onlinelibrary.wiley.com/o/cochrane/
to PLF and pedicle screw instrumentation only.
clcentral/articles/634/CN-00787634/frame.html.
In a retrospective comparative study, Ekman et al6 compared 3. Christensen FB, Hansen ES, Eiskjaer SP, et al. Circumferential
the outcomes of posterior lumbar interbody fusion (PLIF) to lumbar spinal fusion with Brantigan cage versus posterolateral
posterolateral fusion (PLF) in adult isthmic spondylolisthesis
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Treatment
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posterior instrumented fusion compared with combined ante-
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and posterolateral fusion after decompression in spondylolytic isthmic spondylolisthesis in adults. J Spinal Disord Tech. Oct
spondylolisthesis. Spine. Jan 15 1997;22(2):210-219; discussion 2008;21(7):477-483.
219-220. 4. Jacobs WC, Vreeling A, De Kleuver M. Fusion for low-grade
6. Ekman P, Möller H, Tullberg T, Neumann P, Hedlund R. Pos- adult isthmic spondylolisthesis: a systematic review of the litera-
terior lumbar interbody fusion versus posterolateral fusion in ture. European Spine Journal. Apr 2006;15(4):391-402.
adult isthmic spondylolisthesis. Spine. 2007;32(20):2178-2183. 5. Kwon BK, Hilibrand AS, Malloy K, et al. A critical analysis of
the literature regarding surgical approach and outcome for adult
low-grade isthmic spondylolisthesis (Structured abstract). Jour-
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1. Chaloupka R, Krbec M, Cienciala JVA, Repko MF, Valis P. Two
1):S30-s40.
year clinical results of 360 degree fusion of lumbar spondylolis-
6. Madan S, Boeree NR. Outcome of posterior lumbar interbody
thesis managed by transpedicular fixation and plif or alif tech-
fusion versus posterolateral fusion for spondylolytic spondylo-
nique. EuroSpine 2006. 8th Annual Meeting of the European
listhesis. Spine. Jul 15 2002;27(14):1536-1542.
Spine Society, 25-28 October 2006, Istanbul, Turkey-Abstracts
7. Samuel S, David Kenny S, Gray Randolph J, Tharyan P. Fusion
P11. Eur Spine J. 2006;15(Suppl 4):S506-s507.
versus conservative management for low-grade isthmic spondy-
2. Dehoux E, Fourati E, Madi K, Reddy B, Segal P. Posterolateral
lolisthesis. Cochrane Database of Systematic Reviews. 2012(10).
versus interbody fusion in isthmic spondylolisthesis: functional
8. Videbaek TS, Christensen FB, Soegaard R, et al. Circumferential
results in 52 cases with a minimum follow-up of 6 years. Acta
fusion improves outcome in comparison with instrumented
Orthopaedica Belgica. Dec 2004;70(6):578-582.
posterolateral fusion: long-term results of a randomized clinical
3. Floman Y, Millgram MA, Ashkenazi E, Smorgick Y, Rand N.
trial. Spine. Dec 1 2006;31(25):2875-2880.
Instrumented slip reduction and fusion for painful unstable
Does reduction with fusion result in better

outcomes than fusion in situ in adult patients
with isthmic spondylolisthesis?
unable to generate a recommendation
Future Directions for Research screw placement for in situ posterior spinal fusion. Spine J.
The work group recommends the undertaking of a prospective 2003;3(5):370-376.
4. Molinari RW, Bridwell KH, Lenke LG, Baldus C. Anterior
or retrospective study to determine if there is a clinical benefit of
column support in surgery for high-grade, isthmic spondy-
actively attempting a reduction prior to fusion. lolisthesis. Clinical Orthopaedics & Related Research. Jan
2002(394):109-120.
Bibliography 5. Osterman K, Schlenzka D, Poussa M, Seitsalo S, Virta L. Isthmic
1. Floman Y, Millgram MA, Ashkenazi E, Smorgick Y, Rand N. spondylolisthesis in symptomatic and asymptomatic subjects,
Instrumented slip reduction and fusion for painful unstable epidemiology, and natural history with special reference to disk
isthmic spondylolisthesis in adults. Journal of Spinal Disorders abnormality and mode of treatment. Clinical Orthopaedics &
& Techniques. Oct 2008;21(7):477-483. Related Research. Dec 1993(297):65-70.
2. Gong K, Wang Z, Lou Z. Reduction and transforaminal lumbar 6. Riouallon G, Lachaniette CHF, Poignard A, Allain J. Outcomes
interbody fusion with posterior fixation versus transsacral cage of anterior lumbar interbody fusion in low-grade isthmic spon-
fusion in situ with posterior fixation in the treatment of Grade 2 dylolisthesis in adults: A continuous series of 65 cases with an
adult isthmic spondylolisthesis in the lumbosacral spine. Jour- average follow-up of 6.6years. Orthopaedics and Traumatology:
nal of Neurosurgery: Spine. // 2010;13(3):394-400. Surgery and Research. // 2013;99(2):155-161.
3. Gundanna M, Eskenazi M, Bendo J, Spivak J, Moskovich R. 7. Sasso RC, Shively KD, Reilly TM. Transvertebral Transsacral
Somatosensory evoked potential monitoring of lumbar pedicle strut grafting for high-grade isthmic spondylolisthesis L5-S1 wi
Treatment
What is the role of stand-alone interbody

fusion, for the purpose of indirect
decompression, in the treatment of adult
patients with isthmic spondylolisthesis?
Anterior lumbar interbody fusion (ALIF) may be considered as an
option to indirectly decompress foraminal stenosis in adult patients
with low grade isthmic spondylolisthesis.
Grade of Recommendation: C
Kim et al1 retrospectively compared the clinical and radiograph- fusions, length of hospital stay, complications and radiologic re-
ic results of isthmic spondylolisthesis patients who had under- sults. Independent observers evaluated the radiologic outcomes
gone ALIF (n=20) to those who received posterolateral fusion on anteroposterior, lateral and flexion-extension radiographs.
(PLF) with transpedicular fixation (n=20). Patient follow-up was Patients in the ALIF group were followed for a mean of 41.1
a minimum of one year after surgery. ALIF patients were fol- months and circumferential fusion patients were followed for
lowed for a mean of 3.6 years, and PLF patients were followed a mean of 32.9 months. In both groups, disc height, segmen-
for a mean of 2.3 years. At follow-up, patients underwent radio- tal lordosis, and degree of listhesis significantly improved from
graphic assessments, measurement of the correction rate of an- pre to post-op. In ALIF patients, disc height, segmental lordosis,
terior displacement using the Taillard method and evaluation of whole lumbar lordosis and degree of listhesis changed from 8.0,
clinical results using criteria outlined in a 1991 study by one of 13.9, 50.6o and 21.9, respectively to 15.9, 20.8, 56.3o and 11.3,
the authors. No validated instruments or criteria were utilized respectively (all p<0.001), at postoperative follow-up. Radiologic
in evaluating postoperative outcomes. According to Meyerding’s evidence of successful arthrodesis was noted in 97.7% of ALIF
classification, Grade I spondylolisthesis was present in 70% of patients versus 100% of circumferential fusion patients. There
ALIF patients and 75% of PLF patients. Grade II was present in were no statistically significant differences in pre to postop VAS
30% of ALIF patients and 25% of PLF patients. Results indicated and ODI scores between the groups. The mean VAS scores for
that there were no statistically significant differences in correc- back and leg pain and ODI scores significantly improved in the
tion rate, fusion rate and clinical results between the groups. In ALIF group from 7.6, 7.5 and 49.3%, respectively to 2.1, 2.0 and
the ALIF Group, the preoperative anterior slippage was 16.1% 13.7%, respectively (all p<0.0001). For ALIF patients, the mean
compared to 10.4% after surgery. The degree of anterior slippage operation time, hospital stay, blood loss and return to work was
in PLF patients was 15.2% before surgery compared to 9.8% 190 minutes, 7.4 days, 300mL and 3.7 months, respectively.
after surgery. The correction rate was 35% in the ALIF Group There were no cases of life-threatening complications or wound
compared to 36% in the PLF Group. Complete or partial fusion infection in either group. In the ALIF group, there was one case
was obtained in 90% of ALIF patients and 95% of PLF patients of postoperative pneumonia, one case of urinary tract infection,
by one year after surgery. Satisfactory results were obtained in one venous injury and one patient with a break in the pedicle
85% of ALIF patients and 90% of PLF patients. When review- screw. For the purposes of answering this clinical question,
ing postoperative complications in the ALIF Group, 2 patients findings from the ALIF group only are applied. This study offers
experienced warm sensations in lower extremities, 2 developed Level IV therapeutic data that ALIF provides significant indirect
transient paralytic ileus, 2 experienced delayed union and one reduction leading to improved clinical scores.
experienced urinary retention. All symptoms in these patients In a case-series study, Riouallon et al3 evaluated the efficacy
improved over time. In the PLF Group, loosening of a pedicle of ALIF without using a reduction maneuver in 65 patients with
screw was reported in one patient. In critique, outcomes were isthmic spondylolisthesis. The olisthetic level was at L5-S1 in 52
not measured using validated criteria; thus, the work group patients and at L4-L5 in 13 patients. According to Meyerding
downgraded the level of evidence from III to IV. This study offers classification, 32 patients presented with Grade I and 33 pre-
Level IV therapeutic evidence that in adult patients with isthmic sented with Grade II. Patient follow-up was approximately 6.6
spondylolisthesis, ALIF provides adequate indirect decompres- years (range 2.5-22 years) and outcomes were evaluated via VAS
sion with similar results as direct decompression. for lumbar and radicular pain and ODI and Beaujon score for
In a retrospective review of low-grade isthmic spondylolis- functional status. Standard AP, lateral and three-quarter oblique
thesis patients, Kim et al2 compared surgical outcomes of instru- radiographs were used to evaluate pre- and postoperative radio-
Treatment
mented ALIF (n=43) to instrumented circumferential fusion logic parameters. According to their findings, the overall fusion
(n=32). All patients had single-level, low-grade spondylolisthe- rate was 91%, 97.5% when the segment was instrumented and
sis. Clinical outcomes were evaluated using the Visual Analog 80% when it was noninstrumented. The fusion rate was 77% for
Scale (VAS) and functional outcomes were measured using the patients at the L4-L5 level and 96% at L5-S1. At postop, slippage
Oswestry Disability Index (ODI) and return to work status. The decreased by 30% and disc height increased by 177%. On the
authors also compared operation time, blood loss, blood trans- sagittal plane, lordosis improved by 5o, without any changes in
pelvic parameters. Patients improved an average of 4.6 points on References

the VAS for lumbar pain and an average of 5 points for radicu- 1. Kim NH, Lee JW. Anterior interbody fusion versus posterolat-
lar pain. On average, there was a 38 point improvement in ODI eral fusion with transpedicular fixation for isthmic spondylolis-
scores from preoperative to postoperative measurement and a thesis in adults. A comparison of clinical results. Spine. Apr 15
7.3 point increase for Beaujon scores. The preoperative maxi- 1999;24(8):812-816; discussion 817.
mum walking time was 20 minutes, which improved to one hour 2. Kim JS, Kim DH, Lee SH, et al. Comparison study of the in-
strumented circumferential fusion with instrumented anterior
or more in the majority of patients (84%) after surgery. The in-
lumbar interbody fusion as a surgical procedure for adult
tensity of painful claudication at follow-up was reduced in 71% low-grade isthmic spondylolisthesis. World Neurosurg. May
of patients. There were no cases of surgical site infection, vascu- 2010;73(5):565-571.
lar injury or thromboembolic complications, but one patient ex- 3. Riouallon G, Lachaniette CHF, Poignard A, Allain J. Outcomes
perienced transient retrograde ejaculation and 9 required intra- of anterior lumbar interbody fusion in low-grade isthmic
operative transfusion. This study provides Level IV therapeutic spondylolisthesis in adults: A continuous series of 65 cases with
evidence that ALIF alone can provide good results clinically and an average follow-up of 6.6 years. Orthop Traumatol Surg Res.
radiographically. 2013;99(2):155-161.
Future Directions for Research Bibliography

1. Samuel S, David Kenny S, Gray Randolph J, Tharyan P. Fusion
The work group recommends the undertaking of a randomized
versus conservative management for low-grade isthmic spondy-
controlled trial comparing indirect decompression via ALIF to lolisthesis. Cochrane Database Syst Rev. 2012(10).
direct posterior decompression for the surgical treatment of 2. Shim JH, Kim WS, Kim JH, Kim DH, Hwang JH, Park CK.
isthmic spondylolisthesis. Comparison of instrumented posterolateral fusion versus percu-
taneous pedicle screw fixation combined with anterior lumbar
interbody fusion in elderly patients with L5-S1 isthmic spondy-
lolisthesis and foraminal stenosis: Clinical article. J Neurosurg
Spine. 2011;15(3):311-319.
How do outcomes from minimally invasive

spinal surgery (for decompression and/or
fusion) for the management of adult patients
with isthmic spondylolisthesis compare with
traditional/open techniques?
For the purposes of the literature analysis, the work group defined
minimally invasive surgery as a posterior muscle sparing procedure.
In adult patients undergoing ALIF, supplemental posterior percutaneous

pedicle screws lead to shorter hospital stays, less operation room time
and less blood loss compared to open posterior instrumentation.
There is conflicting evidence whether in adult patients undergoing

ALIF, supplemental posterior percutaneous pedicle screws lead to
comparable clinical outcomes to those undergoing open posterior
instrumentation.
Treatment
Kim et al1 retrospectively compared the surgical outcomes of patients had single-level low-grade spondylolisthesis. Clinical
low-grade isthmic spondylolisthesis patients who had under- outcomes were evaluated using the Visual Analog Scale (VAS)
gone ALIF with percutaneous pedicle screw fixation (n=43) to and functional outcomes were measured using the Oswestry
instrumented circumferential fusion (n=32), which comprised Disability Index (ODI) and return to work status. The authors
of mini-ALIF and instrumented PLF with iliac bone graft. All also compared operation time, blood loss, blood transfusions,
length of hospital stay, complications and radiologic results. In- postoperatively, this difference was no longer significant. Com-
dependent observers evaluated the radiologic outcomes on an- plications rates were low, occurring in one patient per group.
teroposterior, lateral and flexion-extension radiographs. Patients This study offers Level III therapeutic data that both ALIF and
in the ALIF group were followed for a mean of 41.1 months and instrumented posterolateral fusion and ALIF with percutaneous
circumferential fusion patients were followed for a mean of 32.9 pedicle screw fixation result in significant improvement in VAS
months. In both groups, disc height, segmental lordosis, and de- scores. In patients over 65 years of age, ALIF followed by open
gree of listhesis significantly improved from pre to post-op. Ra- posterior instrumented fusion had superior VAS back pain mea-
diologic evidence of successful arthrodesis was noted in 97.7% sures compared to ALIF followed by percutaneous pedicle screw
of ALIF patients and 100% of circumferential fusion patients. instrumentation at 6 months and 2 years follow-up. At 6 months,
There were no statistically significant differences in pre- to post- fusion rates were statistically better in the fusion group; however,
operative VAS and ODI scores between the groups. The mean at 2 years, there was no difference between groups. Patients in
VAS scores for back and leg pain and ODI scores significantly the ALIF with percutaneous pedicle screw fixation group had
improved in the ALIF group from 7.6, 7.5 and 49.3%, respective- shorter hospital stays, less OR time, less blood loss and less need
ly to 2.1, 2.0 and 13.7%, respectively (all p<0.0001). In the cir- for transfusion.
cumferential group, VAS back and leg pain and ODI scores im-
proved from 7.4, 6.0 and 60.8% to 1.6, 0.8 and 6.8%, respectively Future Directions for Research
(all p<0.001). The mean hospital stay was significantly shorter The work group recommends the undertaking of a randomized
in the ALIF Group compared to circumferential fusion patients controlled trial or prospective comparative study comparing tra-
(7.4 days vs 15.2 days, p<0.05). There were also statistically sig- ditional open techniques to minimally invasive spine surgery for
nificant differences in mean operation time and mean blood loss the treatment of adult patients with isthmic spondylolisthesis.
between the ALIF and circumferential patients (190 minutes vs.
260.8 minutes, p<0.05; 300mL vs. 379mL, p<0.05, respectively). References
There were no cases of life-threatening complications or wound 1. Kim JS, Kim DH, Lee SH, et al. Comparison study of the in-
infection in either group. In the ALIF group, there was one case strumented circumferential fusion with instrumented anterior
of postoperative pneumonia, one case of urinary tract infection, lumbar interbody fusion as a surgical procedure for adult
one venous injury and one patient with a break in the pedicle low-grade isthmic spondylolisthesis. World Neurosurg. May
screw. There were 2 cases of venous injury in the circumferential 2010;73(5):565-571.
fusion group. This study offers Level III therapeutic data that 2. Shim JH, Kim WS, Kim JH, Kim DH, Hwang JH, Park CK.
ALIF followed by percutaneous screw fixation leads to compa- Comparison of instrumented posterolateral fusion versus
percutaneous pedicle screw fixation combined with anterior
rable clinical results as ALIF followed by open posterior instru-
lumbar interbody fusion in elderly patients with L5-S1 isthmic
mented fusion. Patients who had undergone instrumented ALIF spondylolisthesis and foraminal stenosis.[Erratum appears in J
Group had shorter length of hospital stays, shorter operation Neurosurg Spine. 2011 Sep;15(3):343]. Journal of Neurosurgery
time and less blood loss when compared to instrumented cir- Spine. Sep 2011;15(3):311-319.
cumferential fusion patients.
Shim et al2 retrospectively compared the clinical and radio- Bibliography
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grade isthmic spondylolisthesis following circumferential 155.
release via bilateral minimally invasive transforaminal lumbar
Treatment
How do outcomes of dynamic stabilization

compare with fusion for the treatment of
isthmic spondylolisthesis in adult patients?
Future Directions For Research Bibliography

The work group recommends the undertaking of comparative 1. Kim JS, Choi WG, Lee SH. Minimally invasive anterior lumbar
studies and multi-center registry database studies comparing interbody fusion followed by percutaneous pedicle screw fixa-
dynamic stabilization to fusion for the treatment of isthmic tion for isthmic spondylolisthesis: minimum 5-year follow-up.
Spine Journal. 2010;10(5):404-409.
spondylolisthesis in adult patients.
Does the degree of radiological grade,

sagittal spinopelvic alignment, sacral and
spinopelvic parameters, or the presence
of dynamic instability in adult patients with
isthmic spondylolisthesis affect the outcomes
of patients treated with surgery?
There is insufficient evidence to make a recommendation regarding
the degree of radiological grade, sagittal spinopelvic alignment, sacral
and spinopelvic parameters, or the presence of dynamic instability
on the outcomes of adult patients undergoing surgical treatment for
isthmic spondylolisthesis.
Ming Li et al1 conducted a prospective study to analyze the fac- relation between pre and postoperative variables. Results from
tors affecting surgical outcomes of low-grade isthmic spondy- the analysis indicated that length of disease, preoperative JOA
lolisthesis patients undergoing posterolateral fusion (PLF). All score and postoperative percentage of slipping were significantly
125 consecutive patients received a 6-month trial of conservative related to postoperative JOA score and postoperative improved
therapy with no improvement before undergoing surgical treat- JOA score. Length of disease and postoperative percentage of
ment. Preoperative and postoperative x-rays were taken of all slipping were significantly related to postoperative recovery rate.
patients and follow-up data and measurements were collected at Age, gender, spondylolisthetic position and postoperative disc
a minimum of two years after surgery. Five cases were ultimately height were not significant factors. In critique, the preoperative
excluded from the analysis due to breakage of pedicle screws and and postoperative measurements, including percentage slip, for
pseudarthrosis and one death due to myocardial infarction. A most variables are unclear and the authors did not utilize a vali-
total of 119 patients were evaluated for potential factors affecting dated outcome assessment tool. Due to these reasons, the work
the surgical outcome including the following preoperative vari- group has downgraded the level of evidence. For the purposes
Treatment
ables: gender, age at operation, spondylolisthetic position, length of addressing this clinical question, this potential Level I study
of disease history and Japanese Orthopaedic Association (JOA) offers Level II prognostic data that postoperative percentage slip
score; and the following postoperative variables: percentage disc is significantly correlated to postoperative JOA score.
height, percentage slip, JOA score and recovery rate. Multifac- Park et al2 investigated the relationship between adjacent-
tor stepwise correlation analysis was used to evaluate the cor- segment degeneration (ASD) and pelvic parameters in isth-
mic spondylolisthesis patients. The records of 132 consecutive 5. Gehrchen MP, Dahl B, Katonis P, Blyme P, Tøndevold E, Kiær T.
Grade I isthmic spondylolisthesis patients, who had undergone No difference in clinical outcome after posterolateral lumbar fu-
one stage, single-level (L4-L5 or L5-S1) 360o fixation and had sion between patients with isthmic spondylolisthesis and those
follow-up data available for 1, 3, 6 and 12 months, were con- with degenerative disc disease using pedicle screw instrumenta-
tion: A comparative study of 112 patients with 4 years of follow-
sidered for this retrospective case-series review. The records of
up. European Spine Journal. 2002;11(5):423-427.
34 patients, who had both pre and postoperative lateral radio- 6. Giudici F, Minoia L, Archetti M, Corriero AS, Zagra A. Long-
graph images depicting the femur head, met inclusion criteria term results of the direct repair of spondylolisthesis. European
and were included in the prognostic analysis. Of the 34 patients, Spine Journal. 2011;20(SUPPL. 1):S115-S120.
7 had ASD and 27 did not. The 7 patients with ASD developed 7. Hanley Jr EN. Indications for fusion in the lumbar spine. Bul-
this condition after undergoing fusion. Radiographic measure- letin: Hospital for Joint Diseases. 1996;55(3):154-157.
ments for degree of spondylolisthesis, lordotic angle, segmen- 8. Huang RP, Bohlman HH, Thompson GH, Poe-Kochert C.
tal lordosis, sacral slope angle, pelvic tilt and pelvic incidence Predictive value of pelvic incidence in progression of spondylo-
were compared between the groups. The authors found that all listhesis. Spine. 2003;28(20):2381-2385.
9. Jacobs WCH, Vreeling A, De Kleuver M. Fusion for low-grade
cases of ASD occurred at the adjacent rostral segment and that
adult isthmic spondylolisthesis: A systematic review of the
the pre and postoperative measurements for degree of spondy- literature. European Spine Journal. 2006;15(4):391-402.
lolisthesis, segmental lordosis, lordotic angle, sacral slope angle 10. Jalanko T, Helenius I, Remes V, et al. Operative treatment of
and preoperative pelvic tilt and pelvic incidence did not differ isthmic spondylolisthesis in children: a long-term, retrospec-
significantly between groups. The only measures that were sig- tive comparative study with matched cohorts. European Spine
nificantly different were postoperative pelvic tilt and pelvic inci- Journal. 2011;20(5):766-775.
dence. The authors suggest that these parameters may be related 11. Luk KD, Chow DH, Holmes A. Vertical instability in spondylo-
to the development of ASD. This study offers Level IV prognos- listhesis: a traction radiographic assessment technique and the
tic data that postoperative pelvic tilt and pelvic incidence may principle of management. Spine. 2003;28(8):819-827.
be related to ASD.
listhesis. Spine. 2002;27(14):1536-1542.
Future Directions for Research 13. Mehta VA, Amin A, Omeis I, Gokaslan ZL, Gottfried ON.
The work group recommends the undertaking of prospective or Implications of spinopelvic alignment for the spine surgeon. Vol
retrospective observational studies assessing influence of preop- 702012:707-721.
erative radiographic parameters on postoperative outcomes for 14. Rampersaud YR, Gray R, Lewis SJ, Massicotte EM, Fehlings
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compared with conventional open fusion for lumbar spondylo-
dylolisthesis.
listhesis. SAS Journal. 2011;5(2):29-35.
15. Schnee CL, Freese A, Ansell LV. Outcome analysis for adults
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2007;7(2):139-144. 18. Soegaard R, Bünger CE, Christiansen T, Christensen FB. De-
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fusion cage in treatment of spondylolisthesis. Spine Journal. tors of outcome in patients with chronic back pain and low-
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2009;18(8):1175-1186. spondylolisthesis: A systematic review. Spine. 2011;36(21
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Treatment
terior lumbar interbody fusion versus posterolateral fusion in 22. Zhao J, Hou T, Wang X, Ma S. Posterior lumbar interbody fu-
adult isthmic spondylolisthesis. Spine. 2007;32(20):2178-2183. sion using one diagonal fusion cage with transpedicular screw/
rod fixation. European Spine Journal. 2003;12(2):173-177.
Does the addition of fusion levels (cephalad,

caudal or iliac) in the setting of a high grade
isthmic spondylolisthesis in adult patients
improve outcomes?
Future Directions for Research 3. Ilharreborde B, Fitoussi F, Morel E, Bensahel H, Penneçot

The work group recommends the undertaking of prospective or GF, Mazda K. Jackson’s intrasacral fixation in the manage-
ment of high-grade isthmic spondylolisthesis. J Ped Orthop B.
retrospective observational studies assessing the influence of the
2007;16(1):16-18.
addition of fusion levels on radiographic levels and clinical out- 4. Kuklo TR, Bridwell KH, Lewis SJ, et al. Minimum 2-year analy-
comes in adult patients undergoing surgical treatment for high sis of sacropelvic fixation and L5-S1 fusion using S1 and iliac
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5. Molinari RW, Bridwell KH, Lenke LG, Baldus C. Anterior column
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results in 52 cases with a minimum follow-up of 6 years. Acta 7. Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic
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Treatment
What is the long-term result (four+ years) of

surgical management of adult patients with
In adult patients undergoing surgical treatment for isthmic
spondylolisthesis, fusion is suggested to provide long term clinical
improvements.
There is insufficient evidence to indicate that fusion leads to improved

long term outcomes as compared with a directed exercise program.
There is insufficient evidence to recommend one surgical fusion

technique over another to improve long term outcomes in adult
patients undergoing surgical treatment for isthmic spondylolisthesis.
There is insufficient evidence to determine the clinical significance of

adjacent segment degeneration on the long term outcomes of fusion.
Ekman et al1 evaluated the long-term effects of patients who and pain index (63 to 40, p<0.0001), but no significant improve-
were randomly allocated to either posterolateral fusion or exer- ments in the conservative group for these measures. There were
cise for the treatment of isthmic spondylolisthesis. A total of 111 no statistically significant differences in VAS, DRI, ODI, SF-36
patients initially participated in the study, including 34 random- or work ability between the surgical and conservative groups.
ly allocated to an exercise program and 77 randomly allocated Although not a validated measurement, the global assessment
to posterolateral fusion, with or without transpedicular fixation. was significantly better for the surgical group with 76% classify-
Patients in the exercise program completed 12 different exer- ing their overall outcome as “much better” compared to 50% of
cises and required approximately 45 minutes per session. Four conservative care patients (p=0.015). This study provides Level
exercises included a pully and leg press machine, while 8 did I therapeutic evidence that the surgical group had significantly
not include specific training equipment so they could be per- better outcomes at 9 years as measured by the global outcome
formed at home. The patients exercised 3 times a week during compared to the conservative treatment group; however, there
the first 6 months and twice a week between 6 and 12 months. were no statistically significant differences in VAS, DRI, ODI
Functional disability was assessed by the Disability Rating In- and SF36 scores between the groups.
dex (DRI) and pain was quantified using the Visual Analogue Using the same patient population as above, Ekman et al2
Scale (VAS). In addition, the observer and patients classified evaluated the long-term correlation of lumbar fusion to the de-
their overall outcome into “much better,” “better,” “unchanged,” velopment of adjacent segment disorder (ASD) in isthmic spon-
or “worse.” Long-term follow-up with an average of 9 years was dylolisthesis patients. A total of 80 (72%) patients, including 63
obtained in 101 of 111 (91%) patients. Long-term follow-up of fusion patients and 17 exercise patients, whose standing A-P
the surgical group revealed that 11 patients (14%) underwent and lateral radiographs were available at 10-year follow-up, were
reoperation due to 2 nerve root injuries, one case of pseudar- included in this analysis. Using measurements taken on the ra-
throsis, one discectomy and 7 removal of implants. There were diographs, the authors used three different methods to quantify
no early or late deep infections. In addition to evaluation for disc degeneration, including: digital radiographic measurement
pain and functional disability using the VAS and DRI instru- method, quantitative analysis software and the UCLA grading
ments, researchers also assessed patient reported quality of life scale of disc degeneration. The prevalence of ASD at long-term
Treatment
using the SF-36, work status, disability using the Oswestry Dis- follow-up was determined using four different diagnostic crite-
ability Index (ODI) and global assessment classifying results ria: (1) disc height reduction > 2SD over the mean reduction as
into “much better,” “better,” “unchanged,” or “worse.” There were observed in the exercise group, (2) remaining mean disc height
statistically significant improvements in the surgical group at less than 20% of anterior vertebral height, (3) worsening of the
long term follow-up measurements for DRI (48 to 33, p<0.001) UCLA score from pretreatment and (4) totally reduced poste-
rior disc height at long-term follow-up. Using the first, second, mented groups. When analyzing diagnosis subgroups, the au-
third and fourth criteria to determine the prevalence of ASD, thors found that patients with isthmic spondylolisthesis in the
it was found that 6%, 6%, 0% and 0% of exercise patients, re- no instrumentation group had significantly better outcomes
spectively, versus 14%, 11%, 38% and 6% of fusion patients, re- than patients who received instrumented fusion (p<0.03). In
spectively, were found to have ASD. In fusion patients, the use of critique, due to the small sample size of the subgroup of isth-
instrumentation did not affect the prevalence of ASD using any mic spondylolisthesis patients and use of non-validated outcome
definition. In a subgroup analysis of laminectomy versus non- instruments, the work group has downgraded this study from
laminectomy patients, 22 of 47 patients who received combined Level I to Level II. At the 5-year follow-up, isthmic spondylo-
PLF and laminectomy were diagnosed with ASD using the third listhesis patients who received posterolateral fusion without
(UCLA) criteria compared to only 2 of 16 PLF without lami- supplemental instrumentation had a significantly better DBQ
nectomy patients (p=0.015). When comparing prevalence rates outcomes compared to patients who received instrumented fu-
between these subgroups using the other criteria, however, there sion (p=0.03).
were not any statistically significant differences in prevalence Vidabeck et al4 described the long-term outcomes of patients
rates. When evaluating the impact of ASD on outcomes using undergoing either posterolateral fusion (PLF) with titanium
the first criteria, it was found that only 11% of PLF patients with instrumentation or circumferential fusion for the treatment of
ASD rated themselves as “much better” according to global out- Grade I or II isthmic spondylolisthesis, primary degeneration,
come assessment compared to 49% of PLF patients without ASD secondary degeneration, or accelerating degeneration. Circum-
(p<0.036). No statistically significant differences in outcomes ferential fusion was performed via anterior lumbar interbody fu-
comparing ASD versus non-ASD patients were found using the sion with the use of a radiolucent cage, using a retroperitoneal
other diagnostic criteria. In general, the outcome measurements approach to the lumbar discus plus posterolateral fusion. Within
for Pain Index, DRI, ODI and global outcome were insignifi- the isthmic spondylolisthesis subgroup, 19 patients were initially
cantly worse for the patients defined as having ASD regardless randomized to the PLF Group and 24 were initially random-
of the criteria used. In critique, less than 80% of patient records ized to the circumferential group. A total of 125 patients com-
were available at 10 years follow-up; thus, necessitating the work pleted the final follow-up at 5 to 9 years after surgery, resulting
group to downgrade the level of evidence from I to II. Although in an overall response rate of 86%. The long-term response rate
this patient population was used in the previous study, the study for isthmic spondylolisthesis subgroup was not documented.
objectives for this analysis are different and therefore provide Outcomes were assessed using the Dallas Pain Questionnaire
different study conclusions. Thus, this potential Level I study of- (DPQ), Low Back Pain Rating Scale (LBPR), Oswestry Disability
fers Level II therapeutic data that at a mean 12 years follow-up, Index (ODI) and Short Form-36 (SF-36) and radiographic mea-
fusion is more likely to lead to an ASD compared to an exercise surements; however, only DPQ scores were available for isthmic
program. In addition, subgroup analysis reveals that patients spondylolisthesis patients. As measured by the DPQ, there were
with laminectomy in addition to their fusions are more likely no significant differences in functional outcomes between sur-
to develop ASD when compared to patients undergoing fusion gical groups at long term follow-up. In critique, there was no
alone. There is insufficient data to make a conclusion about the subgroup analysis of isthmic spondylolisthesis patients for most
long term clinical correlation of ASD on outcomes. outcome measures and the subgroup sample size was small and
In a randomized controlled trial, Bjarke Christensen et al3 thus potentially underpowered to detect any statistical differenc-
evaluated the long term effect of instrumentation on reopera- es. Due to these reasons, the work group downgraded the level
tion and functional outcome. A total of 129 patients with severe of evidence of this study from I to II. This study provides Level
chronic low back pain were included in the study, including 35 II therapeutic evidence that at a minimum of 5 years follow-up,
patients with Grade I or II isthmic spondylolisthesis, 41 patients there were no significant functional differences between instru-
with primary degenerative instability and 53 patients with sec- mented posterolateral fusion versus circumferential fusion in
ondary degenerative instability. Upon enrollment, patients were the subgroup of patients with isthmic spondylolisthesis.
consecutively allocated using a 20-number-per-block concealed
randomization process into either fusion with or without sup- Future Directions for Research
plementary transpedicular screw fixation. Functional outcomes The work group recommends the undertaking of prospective
were assessed by the Dallas Pain Questionnaire (DPQ) and the or retrospective studies comparing the long term effectiveness
Low Back Pain Rating Scale (LBPR) and scored by an indepen- of various surgical treatments and nonoperative treatments on
dent observer. At 5 years follow-up, 8 isthmic spondylolisthesis clinical outcomes, radiographic outcomes and adjacent segment
patients in the instrumented group underwent or were planning degeneration in adult patients with isthmic spondylolisthesis.
reoperation and 2 isthmic spondylolisthesis patients in the non-
instrumented group underwent or were planning reoperation. References

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Are the results of surgical management for

adult patients with isthmic spondylolisthesis
affected by the presence of scoliosis or
concurrent deformity?
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40. Sasso RC, Shively KD, Reilly TM. Transvertebral Transsacral 2003;15(2):160-166.
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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 recommendation regarding
which prognostic factors have been associated with good or poor
outcomes.
Ekman et al1 evaluated the long term correlation of lumbar fu- Using the first, second, third and fourth criteria to determine
sion to the development of adjacent segment disorder (ASD) in the prevalence of ASD, it was found that 6%, 6%, 0% and 0% of
isthmic spondylolisthesis patients. A total of 111 patients initial- exercise patients, respectively, versus 14%, 11%, 38% and 6% of
ly participated in the study, including 34 randomly allocated to fusion patients, respectively, were found to have ASD. In fusion
an exercise program and 77 randomly allocated to posterolateral patients, the use of instrumentation did not affect the prevalence
fusion, with or without transpedicular fixation. Patients in the of ASD using any definition. In a subgroup analysis of laminec-
exercise program completed 12 different exercises and required tomy versus non-laminectomy patients, 22 of 47 patients who
approximately 45 minutes per session. Four exercises included a received combined PLF and laminectomy were diagnosed with
pully and leg press machine, while eight did not include specific ASD using the third (UCLA) criteria compared to only 2 of 16
training equipment so they could be performed at home. The PLF without laminectomy patients (p=0.015). When comparing
patients exercised three times a week during the first 6 months prevalence rates between these subgroups using the other crite-
and twice a week between 6 and 12 months. Functional disability ria, however, there were not any statistically significant differ-
was assessed by the Disability Rating Index (DRI) and pain was ences in prevalence rates. When evaluating the impact of ASD
quantified using the Visual Analogue Scale (VAS). In addition, on outcomes using the first criteria, it was found that only 11%
the observer and patients classified their overall outcome into of PLF patients with ASD rated themselves as “much better” ac-
“much better,” “better,” “unchanged” or “worse.” For the purposes cording to global outcome assessment compared to 49% of PLF
of this analysis, a total of 80 (72%) patients, including 63 fusion patients without ASD (p<0.036). No statistically significant dif-
patients and 17 exercise patients, whose standing A-P and lateral ferences in outcomes comparing ASD versus non-ASD patients
radiographs were available at 10 year follow-up, were included. were found using the other diagnostic criteria. In general, the
Using measurements taken on the radiographs, the authors used outcome measurements for Pain Index, DRI, ODI and global
three different methods to quantify disc degeneration, including: outcome were insignificantly worse for the patients defined as
digital radiographic measurement method, quantitative analysis having ASD regardless of the criteria used. In critique, less than
software and the UCLA grading scale of disc degeneration. The 80% of patient records were available at 10 years follow-up; thus,
prevalence of ASD at long-term follow-up was determined using necessitating the work group to downgrade the level of evidence
Treatment
four different diagnostic criteria: (1) disc height reduction > 2SD from I to II. Although this patient population was used in the
over the mean reduction as observed in the exercise group, (2) previous study, the study objectives for this analysis are differ-
remaining mean disc height less than 20% of anterior vertebral ent and therefore provide different study conclusions. Thus, this
height, (3) worsening of the UCLA score from pretreatment and potential Level I study offers Level II prognostic evidence that
(4) totally reduced posterior disc height at long-term follow-up. that fusion is more likely to lead to an ASD compared to an ex-
ercise program, but ASD does not negatively affect outcomes at tive comparative study with matched cohorts. European Spine
two year follow-up. Subgroup analysis reveals that patients with Journal. 2011;20(5):766-775.
laminectomy in addition to their fusions are more likely to de- 10. Luk KDK, Chow DHK, Holmes A. Vertical instability in spon-
velop ASD when compared to patients undergoing fusion alone. dylolisthesis: A traction radiographic assessment technique and
the principle of management. Spine. 2003;28(8):819-827.
Future Directions For Research 11. Madan S, Boeree NR. Outcome of posterior lumbar interbody
The work group recommends the undertaking of multi-center fusion versus posterolateral fusion for spondylolytic spondylo-
registry database studies assessing the clinical characteristics as- listhesis. Spine. 2002;27(14):1536-1542.
sociated with the successful short and long-term outcomes in 12. Mehta VA, Amin A, Omeis I, Gokaslan ZL, Gottfried ON.
adult patients undergoing surgical treatment for isthmic spon- Implications of spinopelvic alignment for the spine surgeon. Vol
dylolisthesis. 702012:707-721.
13. Park JY, Cho YE, Kuh SU, et al. New prognostic factors for
adjacent-segment degeneration after one-stage 360° fixation for
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VI. Appendices
A. Acronyms
CI confidence interval
CT computed tomography
DH disc height
DRI Disability Rating Index
EBM evidence-based medicine
EMG electromyelography
JOA Japanese Orthopaedic Association
LBPR Low Back Pain Rating Scale
LL lumbar lordosis
MR magnetic resonance
MRI magnetic resonance imaging
NASS North American Spine Society
NCOS Neurogenic Claudication Outcome Score
Appendices
NSAIDs nonsteroidal anti-inflammatory drugs
ODI Oswestry Disability Index
PI pelvic incidence
PLIF Posterior lumbar interbody fusion
PLF Posterolateral fusion
PT pelvic tilt
RDQ Roland-Morris Disability Questionnaire
RCT randomized controlled trial
SR sagittal rotation
SS sacral slope
ST sagittal translation
SEP somatosensory evoked potentials
SNRB selective nerve root block
TK thoracic kyphosis
TENS transcutaneous electrical nerve stimulation
VAS Visual analog scale
B. Levels of Evidence for Primary Research Question1

Types of Studies
Therapeutic Studies – Prognostic Studies – Diagnostic Studies – Economic and Decision
Investigating the results of Investigating the effect of Investigating a diagnostic Analyses –
treatment a patient characteristic on test Developing an economic or
the outcome of disease decision model
Level I • High quality • High quality • Testing of previously • Sensible costs and
randomized trial with prospective study4 (all developed diagnostic alternatives; values
statistically significant patients were enrolled criteria on consecutive obtained from many
difference or no at the same point in patients (with studies; with multiway
statistically significant their disease with universally applied sensitivity analyses
difference but narrow ≥ 80% follow-up of reference “gold” • Systematic review2 of
confidence intervals enrolled patients) standard) Level I studies
• Systematic review2 • Systematic review2 of • Systematic review2 of
of Level I RCTs (and Level I studies Level I studies
study results were
Appendices
homogenous3)
Level II • Lesser quality RCT • Retrospective6 study • Development of • Sensible costs and
(eg, < 80% follow- • Untreated controls diagnostic criteria on alternatives; values
up, no blinding, from an RCT consecutive patients obtained from limited
or improper • Lesser quality (with universally studies; with multiway
randomization) prospective study applied reference sensitivity analyses
• Prospective4 (eg, patients enrolled “gold” standard) • Systematic review2 of
comparative study5 at different points in • Systematic review2 of Level II studies
• Systematic review2 their disease or <80% Level II studies
of Level II studies or follow-up)
Level 1 studies with • Systematic review2 of
inconsistent results Level II studies
Level III • Case control study7 Case control study7 • Study of non- • Analyses based on
• Retrospective6 consecutive patients; limited alternatives
comparative study5 without consistently and costs; and poor
• Systematic review2 of applied reference estimates
Level III studies “gold” standard • Systematic review2 of
• Systematic review2 of Level III studies
Level III studies
Level IV Case series8 Case series • Case-control study Analyses with no sensitivity
• Poor reference analyses
standard
Level V Expert Opinion Expert Opinion Expert Opinion Expert Opinion
1. A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
2. A combination of results from two or more prior studies.
3. Studies provided consistent results.
4. Study was started before the first patient enrolled.
5. Patients treated one way (eg, cemented hip arthroplasty) compared with a group of patients treated in another way (eg, unce-
mented hip arthroplasty) at the same institution.
6. The study was started after the first patient enrolled.
7. Patients identified for the study based on their outcome, called “cases” (eg, failed total arthroplasty) are compared to those
who did not have outcome, called “controls” (eg, successful total hip arthroplasty).
8. Patients treated one way with no comparison group of patients treated in another way.
C. Grades of Recommendations for Summaries or Reviews

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

Recommendation
Grade of Standard Language Levels of Evidence

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

PubMed, EMBASE, and Cochrane Library. Additional databas-
es may be searched depending upon the topic.
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Adult Is TH Mics Pondy Lolis Thesis

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Introduction/Guideline Methodology

Diagnosis and Treatment of Adult Isthmic Spondylolisthesis | NASS Clinical Guidelines 1

Evidence-Based Clinical Guidelines for Multidisciplinary

Diagnosis and Treatment of

NASS Evidence-Based Clinical Guidelines Committee

Douglas Burton, MD Amgad S. Hanna, MD Anil K. Sharma, MD

Scott Kreiner Nothing to disclose. (2/4/13)

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

III. Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

IV. Definition and Indicence of Adult Isthmic Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

V. Recommendations for Diagnosis and Treatment of Adult Isthmic Spondylolisthesis . . . . . . . . . 15

II. Guideline Development Methodology

Step 9: Submission for Board Approval Nomenclature for Medical/Interventional Treatment

III. Summary of Recommendations

A= Recommended; B=Suggested; C=May be considered; I=Insufficient or Conflicting Evidence

adulthood) will progress

MRI is suggested to identify neuroforaminal stenosis in adult patients with isthmic

CT may be considered as an option to diagnose isthmic spondylolisthesis in adult patients.

Clinical Question Guideline Reccomendation

A= Recommended; B=Suggested; C=May be considered; I=Insufficient or Conflicting Evidence

Clinical Question Guideline Reccomendation

A= Recommended; B=Suggested; C=May be considered; I=Insufficient or Conflicting Evidence

management of isthmic Grade of Recommendation: I (Insufficient Evidence)

Clinical Question Guideline Reccomendation

A= Recommended; B=Suggested; C=May be considered; I=Insufficient or Conflicting Evidence

Clinical Question Guideline Reccomendation

A= Recommended; B=Suggested; C=May be considered; I=Insufficient or Conflicting Evidence

There is insufficient evidence to determine the clinical significance of adjacent segment

Grade of Recommendation: I (Insufficient Evidence)

IV. Definition and Incidence of Adult Isthmic

What is the best working definition of

What is incidence of radiographic isthmic

Definition for Adult Isthmic

V. Recommendations for the Diagnosis

What is the likelihood that spondylolysis

8. Arnold P, Winter M, Scheller G, Konermann W, Rumetsch D,

2005;43(8):486-490. miadianos MN, Crow W. Percutaneous transpedicular discec-

painful adolescent spondylolysis or spondylolisthesis. J Pediatr 1987;7(6):631-638.

Recommendations: Natural History

B. Diagnosis and Imaging

What are the most appropriate physical

In adult patients, what symptoms or clinical

What are the most appropriate diagnostic

MRI is suggested to identify neuroforaminal stenosis in adult patients

There is insufficient evidence to make a recommendation for or

radiologist and the diagnosis was achieved by consensus. Of Recommendation #2:

In adult patients, what is the relationship

A systematic review of the literature yielded no studies to adequately

Future Directions For Research Spine. 2004;29(18):2049-2054.

How frequently do adult patients with isthmic

C. Outcome Measures for Medical/Interventional and

What are the appropriate outcome

Disorders. To purchase a copy of the Compendium, visit https://webportal.spine.org/Purchase/

D. Medical and Interventional Treatment

A systematic review of the literature yielded no studies to adequately

What is the role of pharmacological treatment in the

What is the role of manipulation in the treatment of

What is the role of steroid injections for the treatment

What is the role of ancillary treatments such as bracing,

What is the role of physical therapy/exercise

Does the degree of radiological grade,

dynamic instability in patients with isthmic

spondylolisthesis affect the outcomes of