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Classification in Brief The Spinal Deformity Study Group
Classification in Brief The Spinal Deformity Study Group
Classification in Brief The Spinal Deformity Study Group
DOI 10.1097/CORR.0000000000001005
In Brief
Received: 21 July 2019 / Accepted: 3 October 2019 / Published online: 18 October 2019
Copyright © 2019 by the Association of Bone and Joint Surgeons
History (congenital); II-isthmic (described as a pars lysis (type
IIA), a pars elongation (type IIB) or an acute pars fracture
Spondylolisthesis is characterized by vertebral slippage (type IIC); III-degenerative; IV-traumatic and V-neoplastic
from a variety of causes, including degenerative changes, conditions. This system was useful in terms of etiology.
trauma, tumors or congenital dysplasia. Isthmic spondy- Marchetti and Bartolozzi [13] distinguished between de-
lolisthesis is an acquired condition that results from a pars velopmental and acquired forms of spondylolisthesis and
interarticularis disruption usually at the L5 vertebra that divided developmental spondylolisthesis into two major
exhibits a similar male:female distribution. The most types, high- and low-dysplastic, depending on the severity of
common symptoms are low back pain and unilateral or bony dysplastic changes of the lumbosacral region and the
bilateral leg pain caused by L5 radiculopathy, depending risk of further slippage. The high-dysplastic type is mainly
on severity. associated with substantial lumbosacral kyphosis, a trape-
The first classification of spondylolisthesis was de- zoidal L5 vertebra, dysplastic posterior elements of L5 and
veloped by Meyerding [14] in 1932, who described four S1, and an anomaly of the upper endplate of S1. By contrast,
types depending on the degree of slippage between two the low-dysplastic type corresponds to minimal lumbosacral
vertebral bodies. In that classification, Grade I involved a kyphosis, almost rectangular L5 vertebra, minimal sacral
slip of 0% to 25%, Grade II was defined as 25% to 50%, doming and relatively normal transverse processes. Al-
Grade III as 50% to 75%, and Grade IV as 75% to 100%. though they introduced the concept of low and high dys-
Later, a Grade V was added with a slip greater than 100% plasia in the classification, they did not provide strict criteria
slippage (a condition called spondyloptosis). In 1976, on how to differentiate between these two subtypes.
Wiltse et al. [17] described a classification based on etio- Many studies demonstrated the importance of global
logical and anatomical factors with 5 types: I-dysplastic and spinopelvic balance, mainly assessed through radio-
graphic measurements such as pelvic incidence, sacral
slope, pelvic tilt, sagittal vertical axis, and lumbar lordosis
Each author certifies that neither he, nor any member of his im- in the evaluation and progression of spondylolisthesis [2, 4,
mediate family, has funding or commercial associations (consul- 7]. The relationship between pelvic and global balance and
tancies, stock ownership, equity interest, patent/licensing spondylolisthesis progression has garnered more interest
arrangements, etc.) that might pose a conflict of interest in con- recently. Glassman et al. [3] and Mac-Thiong et al. [12]
nection with the submitted article.
demonstrated a direct relationship between sagittal balance
All ICMJE Conflict of Interest Forms for authors and Clinical Or-
thopaedics and Related Research® editors and board members are and health-related quality of life in patients with spinal
on file with the publication and can be viewed on request. deformity. In addition, the relationship between pelvic and
Each author certifies that his institution waived approval for the global balance with spondylolisthesis progression has
reporting of this investigation and that all investigations were garnered more interest recently [5]. For this reason, the
conducted in conformity with ethical principles of research.
Spinal Deformity Study Group developed a classification
system that consists of six types of progressive lumbosacral
G. Camino Willhuber, G. Kido, Institute of Orthopedics “Carlos E. spondylolisthesis based on radiographic parameters such
Ottolenghi” Hospital Italiano de Buenos Aires, Buenos Aires, as pelvic incidence, slip grade, and sacropelvic and spinal
Argentina
balance, and proposed a therapeutic guide for the man-
G. Camino Willhuber (✉), Potosı́ 4215 (C1199ACK), Buenos Aires, agement of these different types depending on spondylo-
Argentina, E-mail: gaston.camino@hospitalitaliano.org.ar listhesis severity.
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
2 Camino Willhuber & Kido Clinical Orthopaedics and Related Research®
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 00, Number 00 nnn 3
Fig. 1 This figure shows (A) Type 1, (B) Type 2, (C) Type 3, (D) Type 4, (E) Type 5, and (F) Type 6 spondylolisthesis as classified by the
Spinal Deformity Study Group classification. Used with permission from Franco De Cicco MD.
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
4 Camino Willhuber & Kido Clinical Orthopaedics and Related Research®
816 subjects. However, a key limitation in all of these studies 5. Hresko MT, Labelle H, Roussouly P, Berthonnaud E. Classifi-
is the absence of long-term follow-up, and because of that, cation of high-grade spondylolistheses based on pelvic version
and spine balance: possible rationale for reduction. Spine (Phila
we recommend taking considerable caution when using this
Pa 1976). 2007;32:2208-2213.
classification schema to guide treatment. 6. Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal
balance of spondylolisthesis: a review and classification. Eur
Spine J. 2011;20(Suppl 5):641-646.
Conclusions 7. Legaye J, Duval-Beaupere G, Hecquet J, Marty C. Pelvic in-
cidence: a fundamental pelvic parameter for three-dimensional
regulation of spinal sagittal curves. Eur Spine J. 1998;7:99-103.
Although the Spinal Deformity Study Group Classification 8. Li Y, Hresko MT. Radiographic analysis of spondylolisthesis
seems promising, we still lack robust clinical outcome and sagittal spinopelvic deformity. J Am Acad Orthop Surg.
studies to support the recommendations that have been made 2012;20:194-205.
by the authors. Until those studies appear, we suggest caution 9. Mac-Thiong JM, Duong L, Parent S, Hresko MT, Dimar JR,
about adopting the classification or these recommendations. Weidenbaum M, Labelle H. Reliability of the Spinal Deformity
Study Group classification of lumbosacral spondylolisthesis.
Although two studies showed substantial reliability [1, 8],
Spine (Phila Pa 1976). 2012;37:E95–102.
there was some disagreement, especially when classifying 10. Mac-Thiong J-M, Labelle H. A proposal for a surgical classifi-
low-grade spondylolisthesis. In particular, we note that even cation of pediatric lumbosacral spondylolisthesis based on cur-
in the better of those studies, there was disagreement between rent literature. Eur Spine J. 2006;15:1425-1435.
observers in the classification of about 1 in 8 patients with 11. Mac-Thiong JM, Labelle H. Reliability and development of a
spondylolisthesis [1]. In the other study, it was more than 1 in new classification of lumbosacral spondylolisthesis. Scoliosis.
2008;3:19.
4 [8]. This can have important implications for treatment, 12. Mac-Thiong JM, Transfeldt EE, Mehbod AA, Perra JH, Denis
prognosis, research, and communication among providers. F, Garvey TA, Lonstein JE, Wu C, Dorman CW, Winter RB.
Can c7 plumbline and gravity line predict health related quality
of life in adult scoliosis? Spine (Phila Pa 1976). 2009;34:
Acknowledgments We thank Franco De Cicco MD, for his valuable E519-27.
contribution on the figure. 13. Marchetti PC, Bartolozzi P. Classification of spondylolisthesis
as a guideline for treatment. In: Bridwell KH, DeWald RL, eds.
The Textbook of Spinal Surgery. 2nd ed. Philadelphia, PA: Lip-
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Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.