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Adult Isthmic Spondylolisthesis
Adult Isthmic Spondylolisthesis
19
Review Article
Abstract
Thomas R. Jones, MD, PhD Isthmic spondylolisthesis is present in a small subset of the adult
Raj D. Rao, MD population. Although the incidence of low back pain in these
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of Orthopaedic Surgery, Medical he pars interarticularis, some- trician Herbiniaux3 in 1782, when he
College of Wisconsin, Milwaukee,
WI. Dr. Rao is Professor, times referred to as the “isth- noted obstruction of the pelvic outlet
Department of Orthopaedic Surgery, mus,” is a thin bicortical region of during delivery caused by what he
Medical College of Wisconsin. the posterior arch of the lumbar ver- termed a lumbosacral dislocation.
Dr. Rao or a member of his tebra, where the lamina and the infe- Killian4 coined the term “spondy-
immediate family serves as a board rior articular process intersect with lolisthesis” (from the Greek spondyl
member, owner, officer, or [vertebra] and olisthesis [to slip]) in
committee member of the North the pedicle and superior articular
American Spine Society and the process. A fibrocartilaginous cleft in 1854. In 1855, it was observed that
Lumbar Spine Research Society. this region is referred to as a spondy- a defect in the pars was required for
Neither Dr. Jones nor a member of
lolysis or a pars defect; this finding is slip to occur.5 In 1888, Neugebauer6
his immediate family has received
expanded on these observations,
anything of value from or owns present in 6% of the North Ameri-
publishing his own data on 26 clini-
stock in a commercial company or can adult population.1 Dissociation
institution related directly or cal cases and 17 cadaver specimens.
indirectly to the subject of this
of the anterior and posterior verte-
He postulated that an intact neural
article. bral arch in these persons can result
arch prevented the slippage and that
in isthmic spondylolisthesis, or ante-
Reprint requests: Dr. Rao, pars elongation or failure permitted
Department of Orthopaedic Surgery, rior translation of the vertebra. This
listhesis.
Medical College of Wisconsin, 9200 occurs in 50% to 75% of persons
West Wisconsin Avenue, Milwaukee, with spondylolysis.1 Isthmic spondy-
WI 53226-0099.
lolisthesis can also result from elon- Incidence and
J Am Acad Orthop Surg 2009;17: gation or fractures of the pars inter-
609-617 Pathogenesis
articularis (Table 1).
Copyright 2009 by the American Spondylolisthesis of L5 on S1 was Spondylolysis may result from a ge-
Academy of Orthopaedic Surgeons.
first described by the Belgian obste- netic predisposition to a dysplastic
acerbating factors. Neurologic in- As opposed to degenerative spondy- ing of the degree of slip as well as
continence of the bladder or bowel is lolisthesis, with the isthmic form, the measurement of the slip angle, which
unusual, but occasionally patients re- vertebral body and posterior ele- is a measure of kyphosis at the lis-
port subtle changes in urinary fre- ments are dissociated; thus, forward thetic level (Figure 1). The lumbar
quency or emptying that correspond slip of the vertebral body itself does index, a measure of deformity of the
temporally with their back and/or not typically result in foraminal or listhetic vertebral body (frequently
radicular symptoms. Precipitating central stenosis. Similarly, complete referred to as a trapezoidal shape),
occupational and recreational risk occlusion of the cauda equina is un- and pelvic incidence, a measure of
factors must be explored. likely in patients who have bilateral lumbosacral-pelvic orientation that
On physical examination, the patient defects of the pars interarticularis is related to spinal sagittal alignment,
with spondylolisthesis may have a pal- can also be determined with this
and a loose posterior neural arch.
pable step-off at the spinous process view (Figures 2 and 3). If the lateral
However, it can occur occasionally in
above the slip level. The trunk is short- radiograph fails to show the pars de-
patients with an elongated pars inter-
ened, and lumbar hyperlordosis is fect and clinical suspicion remains, a
articularis and high-grade listhesis, 30° oblique lateral view of the lum-
present in persons with increased sa-
as the thecal sac gets stretched over bar spine should be obtained. AP
cral inclination. Affected patients fre-
the posterosuperior border of the and 30° caudal-tilt AP radiographs
quently have limited lumbar spine range
sacrum. Axial low back pain in isth- may show associated scoliosis or
of motion, with worsening pain on ex-
mic spondylolisthesis is most fre- spina bifida occulta. The physician
tension, and tight hamstrings.
quently caused by chronic lumbar should note dysplastic features such
In a series of 255 patients, Saraste10
muscle strain secondary to lumbar as a trapezoidal L5 vertebra, sacral
reported that neurologic findings
hyperlordosis and sagittal malalign- doming, and deficient inferior articu-
were rare at initial presentation in
ment. Other causes of axial low back lar process as well as degenerative
both adolescents and adults (2%)
pain include referred pain from the changes, such as loss of disk height
but increased to 18% at 29-year
degenerative disk, facet joints, and fi- and osteophyte formation. Flexion
follow-up. Pain radiating into the
brocartilaginous pars defect as well and extension lateral radiographs
buttocks and posterior thighs is com-
as from increased stress on the anu- may be useful in visualizing dynamic
mon in the adult with back pain. mobility at the listhetic segment and
lus fibrosus at the slip level.9,10
This may represent referred pain subtle spondylolisthesis in a patient
The presence of radicular symptoms
from stimulation of the strained anu- with a known pars defect.
or findings that anatomically corre-
lus fibrosus, degenerative disks, or Long-term studies have shown no
spond to the level of the pars defect are
degenerative facet joints. Radicular correlation between lumbar index,
useful in verifying that the pars defect
pain or paresthesia that travels in a spondylolysis level, or percentage of slip
is indeed the pain generator. In persons
dermatomal pattern below the knee and progression of slip during adult-
with axial back pain alone, careful as-
is more specific for nerve root im- hood. Loss of radiographic disk height
sessment of the history and clinical ex-
pingement and may be accompanied at L5-S1 has been shown to be statis-
amination is required to diagnose the
by corresponding neurologic deficits. tically correlated to greater percentage
source of pain. We have found the fol-
Neurologic symptoms and signs in of slip at this level.9 A low lumbar
lowing factors to be generally reliable
spondylolisthesis result from im- index, a measure of vertebral body
in determining that the pars defect may
pingement on the exiting nerve root wedging, correlates with high-grade
be a source of axial back pain: neuro-
by hypertrophic fibrocartilaginous or slips. Saraste10 reported that a lum-
logic pain correlating to the level of the
bony tissue at the site of the pars in- bar index below 75 was associated
pars defect, a history of adolescent back
terarticularis defect, vertebral end with a higher degree of slip at pre-
pain, the absence of other spinal pathol-
plate osteophytes, or nerve root trac- sentation but did not correlate with
ogy, pathologic motion as demonstrated
tion from static or dynamic listhe- progression of slip at a mean 29-year
on dynamic radiographs, and the ab-
sis.18,19 Disk bulges or herniations follow-up. Mean pelvic incidence in
sence of secondary gain.
can result in nerve root impinge- adults has been shown to be 57°;
ment. Rarely, impingement of the L5 normal range is 53.2° ± 7.0° in men
nerve root has been reported to oc- Imaging and 48.7° ± 7.0° in women. Pelvic
cur between the L5 transverse pro- incidence >68.5° correlates strongly
cess and the sacral ala in cases of A pars interarticularis defect may be with the degree of slip (P = 0.03).21
isthmic spondylolisthesis >20% and seen on a lateral lumbosacral spine CT provides the best detail of bony
large transverse process diameter.20 radiograph. This view allows grad- architecture, and it is highly sensitive
Figure 1
Illustration showing measurements used in radiographic diagnosis of spondylolisthesis. A, With the Meyerding method
of classifying the severity of slip, the superior end plate of the subjacent vertebra is divided into quarters, and the loca-
tion of the posterior margin of the listhetic vertebra within these divisions is determined. A grade 5 slip, spondyloptosis,
is complete (>100%) slippage of one vertebra on the other. The lytic defect is indicated with an arrow. Inset, Grade III
L5-S1 slip. B, The slip angle (A) is a measure of kyphosis at the listhetic level. It is calculated by determining the angle
between a line perpendicular to the posterior margin of the subjacent vertebral body and a line parallel to the superior
end plate of the olisthetic vertebra. (Panel B adapted with permission from Herman MJ, Pizzutillo PD, Cavalier R:
Spondylolysis and spondylolisthesis in the child and adolescent athlete. Orthop Clin North Am 2003;34:461-467.
http://www.sciencedirect.com/science/journal/00305898.)
Figure 2 for spondylolysis. CT is also useful articularis that are not visualized on
in monitoring healing of the pars in- plain radiographs or CT scans. Sub-
terarticularis in patients treated with stantial uptake at the pars may indi-
immobilization or repair of a defect. cate healing potential of an acute
CT following myelography is used stress fracture. It also may be helpful
for neuroimaging in patients with a in distinguishing an acute pars frac-
pacemaker and in those with exten- ture from a chronic defect. Single-
sive instrumentation or marked coro- photon emission CT has been shown
nal plane deformity, for whom MRI to be more sensitive than and supe-
is less effective. MRI is less useful for rior to MRI and standard technetium
evaluating pars defects, but it allows Tc-99m bone scanning in detecting
evaluation of associated degenerative spondylolysis and can be used as a
or herniated disks. Assessment of tool to monitor healing of spondy-
central or foraminal stenosis at the lolytic defects treated with brac-
level of the slip can be correlated to ing.22,23
nerve root impingement and is help-
The lumbar index is calculated by
ful in identifying specific pain gener-
dividing the height of the posterior Treatment
cortex (P) of the olisthetic vertebral ators in conjunction with the history
body by the height of the anterior and physical examination (Figure 4).
cortex (A) of the vertebral body. Particularly in adolescent patients, Nonsurgical
The value is expressed as a
percentage (P/A × 100%). bone scans can be helpful in diagnos- Most adults with axial or radicular pain
ing stress reactions at the pars inter- related to lumbar spondylolisthesis will
Posterior and Posterolateral Circumferential Fusion TLIF has shown a fusion rate of
Lumbar Arthrodesis Some surgeons combine posterior de- 94.8% and significant improvement
In 1943, Meyerding36 reported pos- compression of the neural elements in Oswestry Disability Index score (P
terior fusion of the laminae and and posterior instrumented fusion < 0.01).46 Complications with both
spinous processes using autograft in with an interbody fusion, using a PLIF and TLIF include postoperative
patients with back pain and spondy- separate anterior lumbar interbody radiculopathy from injury to the
lolisthesis. Good or improved clini- fusion (ALIF), posterior lumbar in- nerve root during exposure of the
cal outcomes were obtained in >88% terbody fusion (PLIF), or transfo- disk space, incidental durotomy, mi-
of patients regardless of initial grade raminal lumbar interbody fusion gration of the interbody implant, and
of slip. Unilateral posterolateral fu- (TLIF). The large vertebral end-plate epidural bleeding.
sion (PLF) between the transverse surfaces theoretically increase the A meta-analysis of outcomes from 35
processes was initially described by likelihood of a successful fusion, and studies of low-grade adult isthmic
Watkins37 in 1953 and was later re- the combined release and distraction spondylolisthesis revealed a statistically
of the disk space allows improved significant difference in fusion rate of
vised to include fusion of bilateral
deformity correction. 98% for circumferential stabilization
transverse processes, or the modern
ALIF involves complete disk re- versus 83% for PLF and 74% for an-
PLF.
moval under direct visualization terior fusion alone (P < 0.0001).39
A broad range of outcomes of PLF in
through an abdominal approach, fol- Clinical outcomes were best in pa-
isthmic spondylolisthesis has been re-
lowed by insertion of a structural tients who underwent anterior fusion
ported. In a systematic review of the lit-
bone graft or synthetic cage. The alone (90%), followed by circumfer-
erature, Jacobs et al38 reported an ential fusion (86%) and PLF (75%).
published clinical success and fusion
81% to 100% fusion rate and 60% rates for isolated use of ALIF for More recent comparative studies, in-
to 98% clinical success with PLF isthmic spondylolisthesis have been cluding short- and long-term follow-
alone. A meta-analysis of published comparable to those with PLF.38,42 up, have shown statistically signifi-
studies through the year 2003 dem- PLIF is performed following decom- cant improvement in clinical scores
onstrated an overall 83% fusion rate pressive laminectomy at the level of for circumferential fusion using PLF
and a 75% clinical success rate in the spondylolisthesis. Access to the combined with either ALIF or PLIF
patients undergoing posterior fusion disk space is obtained through the over PLF alone, with nonsignificant
for isthmic spondylolisthesis.39 No interlaminar window by retraction trends toward improved fusion
statistically significant difference in of the thecal sac and traversing nerve rates.42,47
clinical outcomes or incidence of fu- root. Short-term clinical outcomes
sion was found in patients who un- are largely equivalent to those of PLF Reduction
derwent PLF either with or without alone, but correction of sagittal Reduction of high-grade slips and cor-
decompression. alignment and maintenance of reduc- rection of slip angle theoretically pro-
The role of instrumentation in the tion is better with PLIF.43-45 In one vide an improved mechanical environ-
treatment of isthmic spondylolisthe- study, a higher proportion of unsatis- ment for fusion, allow for fewer
sis is unclear. Some studies, including factory outcomes was found in the segments to be fused, and provide im-
the only randomized, controlled trial PLIF group compared with the PLF proved sagittal alignment and correc-
comparing instrumented with nonin- group, despite superior radiographic tion of cosmetic deformity. A degree of
strumented fusion,40 have failed to results with PLIF.44 passive slip reduction is obtained intra-
show either improved fusion rates or The TLIF technique includes lami- operatively by muscle relaxation dur-
clinical outcomes with the use of in- nectomy and unilateral facetectomy, ing anesthesia, patient positioning, and
strumentation.41 However, a meta- after which the disk space is ap- intraoperative release during decom-
analysis of published studies demon- proached through the unroofed fo- pression and diskectomy. The benefits
strated clear benefit in fusion rates raminal zone. The lateralized portal of further active attempts at improve-
(90% versus 77%) and clinical suc- allows for reduced manipulation of ment in sagittal alignment need to be
cess (85% versus 64%) with the in- the thecal sac and nerve roots com- weighed against the potential risks of
clusion of instrumentation.39 Neu- pared with PLIF while enabling the neurologic injury.
rologic complications are more surgeon to simultaneously decom- Active reduction of slip is at-
common with pedicle screw instru- press both exiting and traversing tempted via pedicle screw instrumen-
mentation. This outcome is largely nerve roots. In patients with grade I tation under neurologic monitoring
attributable to screw misplacement. and II isthmic spondylolisthesis, (ie, somatosensory-evoked poten-
High-grade Spondylolisthesis
High-grade slips (ie, >50%) present
unique challenges. Posterior fusion
alone in affected patients results in a
greater likelihood of pseudarthrosis,
slip progression, neurologic deficit,
and implant failure.31,49,53 The evi-
dence suggests that circumferential
fusion techniques in these patients al-
low for improved correction of slip
angle and degree of slip, provide sta-
ble fixation, maintain deformity cor-
rection, and carry a low risk of ma-
jor complications (Figure 5).
Transsacral fixation is an alterna-
Transsacral fibular strut graft following L4-S2 laminectomy in an adolescent
tive technique specific to high-grade girl with high-grade spondylolisthesis and neurologic deficit. AP (A) and
slips.54 Following lumbosacral lami- lateral (B) radiographs show passage of a fibular strut from posterior to
nectomy, a fibular strut is passed anterior, followed by bilateral alo-transverse fusion and L4-S1 pedicle screw
fixation.
from posterior to anterior through
the body of S1 into the body of L5
(Figure 6). Bilateral posterolateral In patients with a fixed spondylopto- L5 through separate anterior and pos-
fusion from L4 to the sacrum is per- sis of L5 on S1, complete resection of terior approaches has been de-
formed in routine fashion. the anterior and posterior elements of scribed.55 This is followed by fusion
and pedicle screw instrumentation of 13, 15, 17, 24, 29, 30, 38, 39, and (Phila Pa 1976) 1994;19:222-227.
L4 to S1. Gaines55 reported long- 42-46 are level III studies. Most of 12. Floman Y: Progression of lumbosacral
term outcomes of 30 patients, aged the remaining references are level IV isthmic spondylolisthesis in adults. Spine
(Phila Pa 1976) 2000;25:342-347.
12 to 50 years, who underwent the studies.
13. Soler T, Calderón C: The prevalence of
procedure. Only two cases of pseud- Citation numbers printed in bold spondylolysis in the Spanish elite athlete.
arthrosis were noted, and all 30 pa- type represent references published Am J Sports Med 2000;28:57-62.
tients reported satisfaction with the within the past 5 years. 14. Engstrom CM, Walker DG: Pars
procedure, even though 23 experi- interarticularis stress lesions in the
1. Fredrickson BE, Baker D, McHolick WJ, lumbar spine of cricket fast bowlers.
enced transient postoperative L5 Yuan HA, Lubicky JP: The natural Med Sci Sports Exerc 2007;39:28-33.
neurapraxia, with 2 patients having history of spondylolysis and
spondylolisthesis. J Bone Joint Surg Am 15. Rosenberg NJ, Bargar WL, Friedman B:
permanent deficits requiring ankle- The incidence of spondylolysis and
1984;66:699-707.
foot arthroses. Long-term correction spondylolisthesis in nonambulatory
2. Wiltse LL: The etiology of patients. Spine (Phila Pa 1976) 1981;6:
of sagittal alignment was achieved, spondylolisthesis. J Bone Joint Surg Am 35-38.
and no bowel, bladder, or sexual 1962;44:539-560.
16. McCarroll JR, Miller JM, Ritter MA:
dysfunction occurred. 3. Herbiniaux G: Traité sur divers Lumbar spondylolysis and
accouchements laborieux, et sur les spondylolisthesis in college football
polypes de la matrice. Brussels, Belgium, players: A prospective study. Am J Sports
JL Boubers, 1782. Med 1986;14:404-406.
Summary
4. Killian HF: Schilderungen neuer becken 17. Saraste H: Symptoms in relation to the
formen und ihres verhaltens im leben. level of spondylolysis. Int Orthop 1986;
Isthmic spondylolisthesis is present in Mannheim, Germany, Verlag von 10:183-185.
6% of adults, most of whom are Bosserman, 1854.
18. Edelson JG, Nathan H: Nerve root
asymptomatic. In persons who present 5. Robert zu Coblenz: Eine eigenthümliche compression in spondylolysis and
angeborene Lordose, wahrscheinlich spondylolisthesis. J Bone Joint Surg Br
with axial back pain or radicular find- bedingt durch eine Verschiebung des 1986;68:596-599.
ings and show evidence on imaging of Körpers des Lendenwirbels auf die
vordere Fläche des ersten 19. Jinkins JR, Rauch A: Magnetic
a pars defect, careful assessment is re- Kreuzbeinwirbel (Spondylolisthesis resonance imaging of entrapment of
quired to ensure that the pars defect is Kilian), nebst Bermerkungen über die lumbar nerve roots in spondylolytic
Mechanik dieser Beckenformation. spondylolisthesis. J Bone Joint Surg Am
in fact the source of pain. Nonsurgical Monatsschr Geuburts Frauenkr (Berlin) 1994;76:1643-1648.
management, including nonsteroidal 1855;5:81-94.
20. Wiltse LL, Guyer RD, Spencer CW,
anti-inflammatory drugs, specific phys- 6. Neugebauer FI: The classic: A new Glenn WV, Porter IS: Alar transverse
ical therapy regimens, and bracing, are contribution to the history and etiology process impingement of the L5 spinal
of spondyl-olisthesis by F. L. nerve: The far-out syndrome. Spine
generally successful in controlling symp- Neugebauer. Clin Orthop Relat Res (Phila Pa 1976) 1984;9:31-41.
toms. Several surgical options are avail- 1976;117:4-22.
21. Hanson DS, Bridwell KH, Rhee JM,
able for patients with intractable symp- 7. Wynne-Davies R, Scott JH: Inheritance Lenke LG: Correlation of pelvic
and spondylolisthesis: A radiographic incidence with low- and high-grade
toms despite nonsurgical management family survey. J Bone Joint Surg Br 1979; isthmic spondylolisthesis. Spine (Phila Pa
and include decompression, PLF, ALIF, 61:301-305. 1976) 2002;27:2026-2029.
and circumferential fusion. The specific 8. Stewart TD: The age incidence of neural- 22. Masci L, Pike J, Malara F, Phillips B,
surgical technique selected for any given arch defects in Alaskan natives, Bennell K, Brukner P: Use of the one-
considered from the standpoint of legged hyperextension test and magnetic
patient depends on the patient’s clini- etiology. J Bone Joint Surg Am 1953;35: resonance imaging in the diagnosis of
cal and imaging findings as well as in- 937-950. active spondylolysis. Br J Sports Med
2006;40:940-946.
dividualized consideration of patient- 9. Beutler WJ, Fredrickson BE, Murtland
A, Sweeney CA, Grant WD, Baker D: 23. Saifuddin A, Burnett SJ: The value of
specific risks and benefits. The natural history of spondylolysis and lumbar spine MRI in the assessment of
spondylolisthesis: 45-year follow-up the pars interarticularis. Clin Radiol
evaluation. Spine (Phila Pa 1976) 2003; 1997;52:666-671.
28:1027-1035.
References 24. Sinaki M, Lutness MP, Ilstrup DM, Chu
10. Saraste H: Long-term clinical and CP, Gramse RR: Lumbar
radiological follow-up of spondylolysis spondylolisthesis: Retrospective
Evidence-based Medicine: Levels of and spondylolisthesis. J Pediatr Orthop comparison and three-year follow-up of
evidence are described in the table of 1987;7:631-638. two conservative treatment programs.
Arch Phys Med Rehabil 1989;70:594-
contents. In this article, references 26 11. Grobler LJ, Novotny JE, Wilder DG, 598.
and 40 are level I studies. References Frymoyer JW, Pope MH: L4-5 isthmic
spondylolisthesis: A biomechanical 25. O’Sullivan PB, Phyty GD, Twomey LT,
1, 9, 11, 14, 16, 19, 21-23, 25, and analysis comparing stability in L4-5 and Allison GT: Evaluation of specific
47-49 are level II studies. References L5-S1 isthmic spondylolisthesis. Spine stabilizing exercise in the treatment of
chronic low back pain with radiologic 36. Meyerding HW: Spondylolisthesis: in degenerative and isthmic
diagnosis of spondylolysis or Surgical treatment and results. J Bone spondylolisthesis grades 1 and 2. Spine
spondylolisthesis. Spine (Phila Pa 1976) Joint Surg Am 1943;25:65. (Phila Pa 1976) 2006;31:1693-1698.
1997;22:2959-2967.
37. Watkins MB: Posterolateral fusion of the 47. Swan J, Hurwitz E, Malek F, et al:
26. Möller H, Hedlund R: Surgery versus lumbar and lumbosacral spine. J Bone Surgical treatment for unstable low-
conservative management in adult Joint Surg Am 1953;35:1014-1018. grade isthmic spondylolisthesis in adults:
isthmic spondylolisthesis: A prospective A prospective controlled study of
randomized study. Part 1. Spine (Phila 38. Jacobs WC, Vreeling A, De Kleuver M: posterior instrumented fusion compared
Pa 1976) 2000;25:1711-1715. Fusion for low-grade adult isthmic with combined anterior-posterior fusion.
spondylolisthesis: A systematic review of Spine J 2006;6:606-614.
27. Steiner ME, Micheli LJ: Treatment of the literature. Eur Spine J 2006;15:391-
symptomatic spondylolysis and 402. 48. Muschik M, Zippel H, Perka C: Surgical
spondylolisthesis with the modified management of severe spondylolisthesis
Boston brace. Spine (Phila Pa 1976) 39. Kwon BK, Hilibrand AS, Malloy K, et al: in children and adolescents: Anterior
1985;10:937-943. A critical analysis of the literature fusion in situ versus anterior
regarding surgical approach and spondylodesis with posterior
28. d’Hemecourt PA, Zurakowski D, outcome for adult low-grade isthmic transpedicular instrumentation and
Kriemler S, Micheli LJ: Spondylolysis: spondylolisthesis. J Spinal Disord Tech reduction. Spine (Phila Pa 1976) 1997;
Returning the athlete to sports 2005;18(suppl):S30-S40. 22:2036-2042.
participation with brace treatment.
Orthopedics 2002;25:653-657. 40. Möller H, Hedlund R: Instrumented and 49. Molinari RW, Bridwell KH, Lenke LG,
noninstrumented posterolateral fusion in Ungacta FF, Riew KD: Complications in
29. Sys J, Michielsen J, Bracke P, Martens adult spondylolisthesis: A prospective the surgical treatment of pediatric high-
M, Verstreken J: Nonoperative treatment randomized study. Part 2. Spine (Phila grade, isthmic dysplastic
of active spondylolysis in elite athletes Pa 1976) 2000;25:1716-1721. spondylolisthesis: A comparison of three
with normal X-ray findings: Literature surgical approaches. Spine (Phila Pa
review and results of conservative 41. McGuire RA, Amundson GM: The use 1976) 1999;24:1701-1711.
treatment. Eur Spine J 2001;10:498-504. of primary internal fixation in
spondylolisthesis. Spine (Phila Pa 1976) 50. Petraco DM, Spivak JM, Cappadona JG,
30. Harris IE, Weinstein SL: Long-term 1993;18:1662-1672. Kummer FJ, Neuwirth MG: An
follow-up of patients with grade-III and anatomic evaluation of L5 nerve stretch
IV spondylolisthesis: Treatment with and 42. Remes V, Lamberg T, Tervahartiala P, in spondylolisthesis reduction. Spine
without posterior fusion. J Bone Joint et al: Long-term outcome after (Phila 1976) 1996;21:1133-1138.
Surg Am 1987;69:960-969. posterolateral, anterior, and
circumferential fusion for high-grade 51. Spruit M, van Jonbergen JP, de Kleuver
31. Boxall D, Bradford DS, Winter RB, Moe isthmic spondylolisthesis in children and M: A concise follow-up of a previous
JH: Management of severe adolescents: Magnetic resonance imaging report: Posterior reduction and anterior
spondylolisthesis in children and findings after average of 17-year follow- lumbar interbody fusion in symptomatic
adolescents. J Bone Joint Surg Am 1979; up. Spine (Phila Pa 1976) 2006;31:2491- low-grade adult isthmic
61:479-495. 2499. spondylolisthesis. Eur Spine J 2005;14:
828-832.
32. Pizzutillo PD, Hummer CD III: 43. Ekman P, Moller H, Tullberg T,
Nonoperative treatment for painful Neumann P, Hedlund R: Posterior 52. Shufflebarger HL, Geck MJ: High-grade
adolescent spondylolysis or lumbar interbody fusion versus isthmic dysplastic spondylolisthesis:
spondylolisthesis. J Pediatr Orthop posterolateral fusion in adult isthmic Monosegmental surgical treatment.
1989;9:538-540. spondylolisthesis. Spine (Phila Pa 1976) Spine (Phila Pa 1976) 2005;30(6 suppl):
2007;32:2178-2183. S42-S48.
33. Gill GG, Manning JG, White HL:
Surgical treatment of spondylolisthesis 44. Madan S, Boeree NR: Outcome of 53. Schoenecker PL, Cole HO, Herring JA,
without spine fusion: Excision of the posterior lumbar interbody fusion versus Capelli AM, Bradford DS: Cauda equina
loose lamina with decompression of the posterolateral fusion for spondylolytic syndrome after in situ arthrodesis for
nerve roots. J Bone Joint Surg Am 1955; spondylolisthesis. Spine (Phila Pa 1976) severe spondylolisthesis at the
37:493-520. 2002;27:1536-1542. lumbosacral junction. J Bone Joint Surg
Am 1990;72:369-377.
34. Gill GG: Long-term follow-up evaluation 45. Suk SI, Lee CK, Kim WJ, Lee JH, Cho
of a few patients with spondylolisthesis KJ, Kim HG: Adding posterior lumbar 54. Bohlman HH, Cook SS: One-stage
treated by excision of the loose lamina interbody fusion to pedicle screw decompression and posterolateral and
with decompression of the nerve roots fixation and posterolateral fusion after interbody fusion for lumbosacral
without spinal fusion. Clin Orthop Relat decompression in spondylolytic spondyloptosis through a posterior
Res 1984;182:215-219. spondylolisthesis. Spine (Phila Pa 1976) approach: Report of two cases. J Bone
1997;22:210-219. Joint Surg Am 1982;64:415-418.
35. Amuso SJ, Neff RS, Coulson DB, Laing
PG: The surgical treatment of 46. Lauber S, Schulte TL, Liljenqvist U, 55. Gaines RW: L5 vertebrectomy for the
spondylolisthesis by posterior element Halm H, Hackenberg L: Clinical and surgical treatment of spondyloptosis:
resection. J Bone Joint Surg Am 1970; radiologic 2-4-year results of Thirty cases in 25 years. Spine (Phila
52:529-536. transforaminal lumbar interbody fusion 1976) 2005;30(6 suppl):S66-S70.