Abstract
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Degenerative low-grade lumbar spondylolisthesis is the most common form of spondylolisthesis.
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The majority of patients are asymptomatic and do not require surgical intervention.
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Symptomatic patients present with a combination of lower back pain, radiculopathy and/or neurogenic claudication and may warrant surgery if non-operative measures fail.
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There is widespread controversy regarding the indications for surgery and appropriate treatment strategies for patients with this type of spondylolisthesis.
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This article provides a comprehensive evidence-based review of the available literature to support the management of degenerative low-grade spondylolisthesis.
Cite this article: EFORT Open Rev 2018;3:620-631. DOI: 10.1302/2058-5241.3.180020.
Introduction
Spondylolisthesis is the anterior displacement of one vertebra relative to the subjacent vertebra. The earliest cases of spondylolisthesis were allegedly reported by the Belgian obstetrician Herbinaux, 1 in 1782. It was not until Junghanns, 2 in 1931, and Macnab, 3 in 1950, in the German and English literature respectively, that a degenerative type of lumbar spondylolisthesis was recognized, although the term ‘degenerative spondylolisthesis’ was introduced later by Newman and Stone in 1963. 4 Spondylolisthesis has since been classified by Wiltse et al, 5 according to the underlying aetiology, and the severity of the listhesis can be graded using Meyerding’s classification for isthmic spondylolisthesis. 6 This review considers the management of degenerative (Wiltse type III), low-grade (Meyerding grade 1 or 2) lumbar spondylolisthesis only.
Degenerative lumbar spondylolisthesis is an acquired condition associated with age-related degenerative changes but no defect or disruption in the vertebral ring. It classically involves the L4/5 level (Fig. 1), due to the strong iliolumbar ligaments restraining movement of the fifth lumbar vertebra, although less frequently the L5/S1 level may be affected. It is thought to be triggered by a degenerate disc that becomes incompetent. The anteroposterior translational shear forces that arise from longstanding soft-tissue instability accelerate the degenerative changes observed in the facet joints until, over time, the facet joint complex fails and the vertebrae sublux relative to each other. 1 There is limited literature on the natural history of degenerative spondylolisthesis but various local and systemic factors have been proposed as potential contributors to slip progression, including a lower intercristal line (Fig. 2), 7 tilting of the intervertebral disc, 4 tropism and sagittal orientation of the facet joints (Figs 3 and 4), 8 increased pelvic incidence, 9 increased mechanical loading across the disc space and generalized joint laxity. 10 Degenerative spondylolisthesis is an inherently stable condition, with slip progression occurring in only 30% of patients, and no correlation seen with the severity of the slip, patient gender or clinical symptoms. 10 Furthermore, slip progression does not tend to occur in patients with greater than 80% loss of original disc height or with radiological evidence of spur formation, subcartilaginous sclerosis or ossification of ligaments, suggesting that the degenerative process itself acts as a self-limiting inhibitory control on further slip progression by naturally restabilizing the spine. 10 Degenerative lumbar spondylolisthesis is usually detected as an incidental finding on plain radiographs and the majority of patients with the condition are asymptomatic and do not require surgery. 11 In symptomatic patients, the clinical presentation can vary and includes a combination of lower back pain, lower limb radiculopathy and neurogenic claudication. Symptoms arise through a combination of the degenerative changes themselves, segmental ‘instability’ and the stenotic effects and foraminal narrowing caused by facet joint hypertrophy/subluxation, thickening of the ligamentum flavum, stretching of the facet capsule and the listhesis itself. Symptoms may not be constant and can be affected by position and movement.
Weight-bearing lateral radiograph demonstrating a low-grade degenerative spondylolisthesis at the L4/5 level.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Weight-bearing lateral radiograph demonstrating a low-grade degenerative spondylolisthesis at the L4/5 level.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Weight-bearing lateral radiograph demonstrating a low-grade degenerative spondylolisthesis at the L4/5 level.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
AP radiograph demonstrating lower intercristal line in relation to the L4/5 disc space.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
AP radiograph demonstrating lower intercristal line in relation to the L4/5 disc space.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
AP radiograph demonstrating lower intercristal line in relation to the L4/5 disc space.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Axial T2-weighted magnetic resonance image demonstrating facet tropism and a left-sided facet gap sign.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Axial T2-weighted magnetic resonance image demonstrating facet tropism and a left-sided facet gap sign.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Axial T2-weighted magnetic resonance image demonstrating facet tropism and a left-sided facet gap sign.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Axial T2-weighted magnetic resonance image demonstrating sagittally orientated facets joints.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Axial T2-weighted magnetic resonance image demonstrating sagittally orientated facets joints.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Axial T2-weighted magnetic resonance image demonstrating sagittally orientated facets joints.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
The challenge for surgeons managing patients with degenerative spondylolisthesis is firstly in deciding which patients would benefit from surgical intervention and secondly in deciding which surgical technique is likely to give the optimum clinical outcome. Currently, there is widespread variation in the treatment strategies used to manage this heterogeneous condition, with factors such as patient age, clinical symptoms, ‘dynamic instability’ and surgeon/institutional preference all influencing the management strategy. 12 This review considers the evidence to support the management of symptomatic degenerative low-grade lumbar spondylolisthesis and discusses a treatment algorithm used by the authors in their institution.
Assessment of stability
In the broadest terms, we define ‘instability’ as radiologically demonstrated motion of the spondylolisthesis beyond expected normal values in the normal spine. White and Panjabi considered sagittal plane displacement > 4.5 mm (or 15% of the anteroposterior diameter of the vertebral body) or sagittal plane angulation > 22°, to be potentially unstable (although this related to the acute traumatic setting), 13 while Nachemson considered instability to be > 3 mm translational motion and > 10° angular motion (between L1 and L5) and > 4 mm translational motion and > 20° angular motion (at L5/S1). 14 Degenerative spondylolisthesis is not always ‘unstable’ (i.e. it is static), as evidenced by intraoperative biomechanical findings, but identifying those patients with ‘dynamic instability’ may help in the management of this condition. 15 Currently, however, there is no clear definition of ‘motion segment instability’ in relation to degenerative spondylolisthesis, and there is poor correlation between radiological findings and clinical presentation. Furthermore, the term ‘instability’ has negative connotations and is misleading, and so this article will use the term ‘mobility/movement’ to describe a dynamic spondylolisthesis where possible.
Patient factors
Factors such as patient age, sex, occupation, body mass index and clinical symptoms have been found to correlate poorly with mobility of the listhesis, 7,10,16 although Jacobsen et al found that an increase in body mass index in females was an independent risk factor for the development of degenerative spondylolisthesis, 17 supporting the evidence that increased spinal loading predisposes to the condition. 10
Dynamic imaging
The comparison of flexion/extension films with direct standing lateral films has traditionally proved a useful means of identifying segmental mobility. 18 Parameters such as vertebral translation, disc angle, range of angular motion, disc height and the loss of lumbar lordosis on flexion have all been used to assess mobility, but there is currently no consensus on what the agreed values should be to define abnormal movement, 18–22 and the value of these radiological parameters in dictating the surgical strategy has been questioned. 23 Furthermore, Hammouri et al concluded that flexion/extension views rarely altered clinical management in the degenerative lumbar spine, compared to a standing lateral radiograph alone, and cautioned against their routine clinical use. 21 Magnetic resonance imaging (MRI), or computed tomography (CT) when MRI is contraindicated, has become a routine method of investigation for assessing the degree of stenosis in spondylolisthesis but it may also prove useful in the assessment of mobility. The supine positioning of patients during MRI can be utilized when considering the above parameters. Comparison with a standing lateral radiograph is often sufficient to identify mobility at the listhetic level, thereby negating the need for flexion/extension radiographs and the consequential additional radiation exposure (Fig. 5). 24 Studies have also shown that MRI scans performed with axial loading can identify lumbar spinal pathology not seen on recumbent scans, 25–29 although a study by McGregor et al disputes this. 30 In the future, there may be a role for dynamic MRI in the assessment of mobility in degenerative spondylolisthesis, but currently the cost and limited availability, in conjunction with the insufficient evidence, 31 prohibit its wider use.
Comparison of a load-bearing lateral radiograph with a supine sagittal magnetic resonance image demonstrating a dynamic spondylolisthesis at L4/5.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Comparison of a load-bearing lateral radiograph with a supine sagittal magnetic resonance image demonstrating a dynamic spondylolisthesis at L4/5.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Comparison of a load-bearing lateral radiograph with a supine sagittal magnetic resonance image demonstrating a dynamic spondylolisthesis at L4/5.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Facet joint morphology and effusion
The importance of facet joint morphology in degenerative spondylolisthesis remains widely debated. Sato et al found an association with ‘N-type’ laminae (where the interarticular distance is narrower than the lamina waist) and degenerative spondylolisthesis (Fig. 6). 32 While other studies have also shown a similar association with sagittally orientated facet joints and degenerative spondylolisthesis, 33–38 this has not always been borne out in the literature. 18 The importance of facet joint morphology as a direct cause of mobility is less clear, although a study by Blumenthal et al found that patients with a facet angle > 50° in the axial plane were more likely to demonstrate movement following decompression surgery for degenerative grade 1 lumbar spondylolisthesis. 20 A fluid signal in the facet joints on T2-weighted axial images has also been shown to correlate with mobility (Fig. 3). 39 Chaput et al demonstrated that a facet joint effusion > 1.5 mm is predictive of degenerative spondylolisthesis, with the size of the effusion directly correlating with the probability of having the condition. 40 This is further supported by studies by Lattig et al and Oishi et al who found that facet joint effusions of 1.77 mm and 1.3 mm respectively were associated with mobility. 41,42 Furthermore, a difference in the size of the effusion between left and right facet joints has been shown to correspond to rotational translation of the spondylolisthesis, 41 while a reduction in the size of the effusion was strongly suggestive of motion segment restabilization. 42
AP radiograph demonstrating N-type lamina at the L3/4 level.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
AP radiograph demonstrating N-type lamina at the L3/4 level.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
AP radiograph demonstrating N-type lamina at the L3/4 level.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Degenerative changes
It has been proposed that the spinal motion segment at the level of the listhesis stabilizes with advancing degenerative changes: a process termed restabilization. 43 Matsunaga et al found that patients with evidence of osteophytic spur formation, subcartilaginous sclerosis and ossification of the spinal ligaments had no slip progression, supporting this theory. 10 Lattig et al also highlighted the importance of hook-shaped osteophytes in providing stability, 41 although research by Anderson et al suggested that osteophytes conferred no additional stability. 19 Loss of disc height has also been implicated in the restabilization process, with 80% loss of original disc height correlating to a reduction in slip progression. 10 Sengupta and Herkowitz recommended an instrumented fusion if the disc height was > 2 mm to prevent slip progression. 44 Conversely, a number of studies have found no association with loss of disc height and stability. 18,37,41 While the objective evidence is divided into the importance of degenerative changes in preventing slip progression, it would seem logical that the presence of advanced degenerative changes would confer some degree of stability to the motion segment and should be considered in the decision-making process regarding management of the spondylolisthesis and the stenotic and/or back pain symptoms.
Classification systems
Although the Wiltse and Myerding classifications are probably the most recognized in relation to spondylolisthesis, they offer little in the way of guidance on how to manage the condition. Kepler et al have developed the clinical and radiographic degenerative spondylolisthesis (CARDS) classification to help subdivide this heterogeneous cohort of patients. 45 This classification system considers disc height, degree of translation, kyphotic alignment and the presence of leg symptoms, and has been validated for its reliability and clinical utility. 46 Although no attempt is made to guide management with this classification, it may prove a useful tool and could facilitate the decision-making process. The French Society of Spine Surgery (SFCR) have developed a classification that specifically considers the parameters that affect spino-pelvic sagittal balance in degenerative spondylolisthesis, and are the first to consider the therapeutic implications this may have. 47 Meanwhile, Simmonds et al have developed the degenerative spondylolisthesis instability classification (DSIC) which considers lower back pain, restabilization signs, disc angle/height and joint effusion on MRI as parameters of ‘instability’, and propose a treatment strategy stratified according to the grade of stability. 16
Non-operative management
For the majority of patients with low-grade degenerative spondylolisthesis who present with lower back pain without stenotic symptoms, the spondylolisthesis is static and symptoms do not deteriorate. 10 This group of patients may benefit from a combination of non-operative therapeutic measures. Vibert et al and Kalichman and Hunter reviewed the evidence for therapeutic modalities including physiotherapy, analgesia, ultrasound, electrical stimulation, bracing, flexion/extension strengthening exercises, core stability exercises and spinal manipulation. 48,49 While some patients undoubtedly derive benefit from these treatments, the evidence supporting these studies is often not specific to degenerative spondylolisthesis, is of low quality and is insufficient to develop a non-operative treatment protocol. For patients presenting with features of stenosis or radiculopathy in the presence of degenerative spondylolisthesis, the natural history of the condition is less clear. In a study by Matsunaga et al, 83% of patients were found to clinically deteriorate over 10 years and to have a poor outcome without treatment. 10 Conversely, in a recent study by Wessberg and Frennered, patients rarely showed symptomatic deterioration and those that were able to manage their symptoms continued to do so at a median of 3.3 years. 50 The non-operative arm of the randomized controlled Spine Patient Outcomes Research Trial (SPORT) found that epidural steroid injections, when used in conjunction with other non-operative modalities, gave demonstrable improvement in both lower back and leg pain for two years on patient-reported outcome measures. 51 The role of facet denervation for the management of lower back pain in patients with degenerative spondylolisthesis is less clear. Klessinger et al found that 65% of patients had symptomatic improvement of at least 50% for a minimum of three months, but the quality of the evidence is poor. 52 In their systematic review, Schulte et al found clinical outcomes were inferior with conservative management compared to surgical management, but highlighted the fact that this was based on only three studies. 53 For patients with dynamic spondylolisthesis, identifying the source of pain generation can be challenging. In conjunction with the clinical history and examination, single-photon emission computerized tomography (SPECT) scanning and diagnostic injection therapy may assist in ascertaining this.
Operative management
Symptomatic patients with low-grade degenerative spondylolisthesis who are refractory to non-operative management may benefit from surgical intervention, but currently there is considerable controversy regarding the appropriate surgical indications and optimum surgical technique in the management of the condition.
Direct surgical decompression
The evidence for direct surgical decompression in the management of low-grade degenerative spondylolisthesis is summarized in Table 1. There are few studies comparing direct surgical decompression with non-operative management, but in the published studies, clinical outcomes are significantly better following surgery. 54,55 However, subgroup analysis of data from the SPORT trial in those patients treated surgically has identified a reoperation rate of 22% at eight years, primarily due to slip progression and recurrence of stenosis, with predominant back pain symptoms in the absence of stenotic symptoms identified as the strongest baseline positive predictor for reoperation. 56 Several studies, comparing decompression alone with decompression and fusion (uninstrumented and instrumented), have found comparability in the patient-reported clinical outcomes, complications and reoperation rates, with no good evidence to support the routine use of instrumented fusion. 56–58
Summary of evidence for direct surgical decompression
| Author | No. of patients | Study type | Comparison groups | Mean follow-up | Main study findings |
|---|---|---|---|---|---|
| Matsudaira et al 54 | 53 | Retrospective case series | • Decompression alone • Decompression + instrumented PLF • Non-operative |
2 yrs | • Symptomatic improvement in operative groups only • No difference in clinical improvement between operative groups |
| Weinstein et al 55 | 607 | Multicentre prospective randomized and observational cohort study | • Decompression +/- fusion • Non-operative |
4 yrs | • Clinical outcome significantly better in operative groups (ODI score, SF-36 score, leg and back pain scores) |
| Gerling et al 56 | 406 | Retrospective subgroup analysis of SPORT trial | • Decompression alone • Decompression + fusion (instrumented and uninstrumented) |
8 yrs | • Overall reoperation rate of 22% in those treated surgically • No difference in reoperation rates between instrumented and uninstrumented groups |
| Dijkerman et al 57 | 3119 | Systematic review (11 studies − 2 RCTs) |
• Decompression alone • Decompression + instrumented PLF |
NA | • No difference in patient reported clinical outcomes (ODI score, leg and back pain scores) • No difference in complications or reoperation rates |
| Forsth et al 58 | 247 | RCT | • Decompression alone • Decompression + fusion |
5 yrs and 6.5 yrs | • No difference in clinical outcomes (ODI score, EQ-5D, VAS back and leg pain scores) • No difference in reoperation rates |
| Lombardi et al 60 | 47 | Single-centre case series | • Wide posterior decompression • Facet-sparing decompression |
2–7 yrs | • Patient-reported symptoms significantly improve following limited decompression (does not specify if leg and/or back symptoms) |
| Musluman et al 61 | 84 | Prospective cohort study | • Bilateral decompression via unilateral approach with preservation of midline structures (no comparison group) | 2 yrs | • Significant clinical improvement following surgery (ODI score and NCOS) • Significant improvement in VAS back pain score if single-level surgery but worse if multilevel surgery |
| Ahmad et al 62 | 83 | Prospective cohort study | • Decompression using spinous process osteotomy (no comparison group) | 3 yrs | • Significant clinical improvement following surgery (ODI, EQ-5D, VAS back and leg pain score) • 11% requiring conversion to fusion for slip progression |
| Inui et al 23 | 140 | Single-centre retrospective case series | • Decompression alone • Decompression and instrumented PLIF |
3 yrs and 6 yrs | • Clinical improvement comparable between groups (JOA score – considers both back and leg pain) • Radiological evidence of segmental mobility pre and postoperatively did not correlate with clinical outcome |
| Herkowitz and Kurz 64 | 50 | Prospective cohort study | • Decompression alone • Decompression + uninstrumented PLF |
3 yrs | • Significant improvement in back and leg pain and significant reduction in slip progression following fusion compared to decompression alone |
| Ghogawala et al 65 | 66 | RCT | • Decompression alone • Decompression + instrumented PLF |
4 yrs | • For stable slips, fusion results in significantly greater clinical improvement (ODI score, SF-36) and lower reoperation rates (36% versus 14%) compared to decompression alone |
| Sato et al 66 | 163 | Retrospective case series | • Decompression alone • Decompression and fusion |
6 yrs | • Fusion results in significantly lower reoperation rates |
| Mardjetko et al 67 | 889 | Meta-analysis (25 studies − 3 RCTs) |
• Decompression alone • Decompression + fusion (instrumented and uninstrumented) |
NA | • Fusion results in greater patient satisfaction (90% versus 69%) and reduced slip progression (17% versus 31%) compared to decompression alone |
| Martin et al 68 | 578 | Systematic review (13 studies − 4 RCTs) |
• Decompression alone • Decompression + fusion (instrumented & uninstrumented) |
NA | • Fusion results in improved clinical outcomes compared to decompression alone (although clinical benefit not as pronounced if patients’ predominant complaint was of stenotic symptoms • Instrumented fusion confers no additional benefit to uninstrumented fusion • Non-significant trend towards lower reoperation rates with uninstrumented fusion compared to other groups |
| Chen et al 69 | 77994 | Meta-analysis (18 studies − 4 RCTs) |
• Decompression alone • Decompression and fusion |
NA | • Fusion results in significant improvement in VAS back and leg pain scores (although this was not deemed to be a clinically important difference) • ODI score, SF-36 score, EQ-5D, patient satisfaction, reoperation rate and complication rate are comparable between groups |
| Liang et al 70 | 3858 | Systematic review and meta-analysis (17 studies − 4 RCTs) |
• Decompression alone • Decompression and fusion |
NA | • Fusion results in significantly higher rates of patient satisfaction and lower leg pain scores compared to decompression alone • ODI score, back pain score, complication rate and reoperation rate are comparable between groups |
Note. PLF, posterolateral fusion; PLIF, posterior lumbar interbody fusion; SPORT, Spine Patient Outcomes Research Trial; RCT, randomized controlled trial; ODI, Oswestry Disability Index; EQ-5D, EuroQol Five Dimension; VAS, Visual Analogue Scale; NCOS, Neurogenic Claudication Outcome Score; JOA, Japanese Orthopaedic Association; SF-36, Short Form 36; NA, not applicable.
One concern of performing decompression alone in patients with degenerative spondylolisthesis is the potential for iatrogenic postoperative segmental mobility, due to excessive resection of the facet joints. 59 By adopting techniques that preserve the stabilizing anatomical structures, studies using direct decompression alone have not only demonstrated symptomatic improvement in both back and leg pain, but have also found no significant progression of the listhesis. 23,60–62 There has also been much debate regarding the management of additional stenotic levels adjacent to a single-level spondylolisthesis. Subgroup analysis of data from the SPORT trial at four years compared multilevel decompression and single-level fusion (at the level of the spondylolisthesis) with multilevel decompression and multilevel fusion, and found no significant difference in clinical outcome between the two groups. 63 Although decompression alone appears to be effective in the management of degenerative spondylolisthesis in select patients, there is evidence to suggest that decompression in combination with a fusion procedure provides not only greater symptomatic relief, but also significantly lower reoperation rates and a reduced likelihood of slip progression. 64–68 Although patient satisfaction and leg symptoms appear to improve with the addition of a fusion procedure, the benefits of fusion in improving back symptoms are less certain. 69,70
Interpreting this evidence is difficult due to the heterogeneity of the patient groups being compared, limited subgroup analysis and poor quality of evidence. However, it seems intuitive that those patients with stenotic symptoms who do well with decompression alone are likely to be those who have a static slip, while those with a dynamic spondylolisthesis are the most likely to benefit from an additional fusion procedure to prevent symptom recurrence from slip progression. The role of fusion for the relief of back pain in patients with significant degenerative changes is less clear.
Decompression with dynamic stabilization
Dynamic stabilization devices have been used in the management of degenerative spondylolisthesis with mixed results. 71–75 In one of the earliest prospective studies, comparing decompression alone with decompression and Graf system stabilization, Konno and Kikuchi demonstrated improvement in lower back pain at three years using the Graf system but found no difference regarding the recurrence of leg symptoms between the two groups. 73 Schaeren et al and Hoppe et al, in separate case series with four and seven-year follow-up results respectively, found decompression combined with the Dynesys stabilization device gave improvement in both back and leg pain with little progression of the listhesis. 74,75 In a multicentre randomized controlled trial (RCT), Anderson et al compared indirect decompression, using the X Stop interspinous process device, with non-operative management in patients with neurogenic claudication, and found significant clinical improvement at two-year follow-up with the X Stop device. 71 However, the X Stop device was only found to be clinically successful in 67% of the patients it was used on, with 12% of patients requiring reoperation for symptomatic recurrence. 71 Furthermore, an association between degenerative spondylolisthesis and spinous process fracture following interspinous process spacer surgery has also been reported. 72 Reoperation rates following dynamic stabilization range from 0% to 21%, with adjacent segment degeneration being the most common reason for revision surgery. 73–75 While the evidence appears to suggest that dynamic stabilization devices are effective in preventing slip progression, no subgroup analysis has been performed in these studies, and it is likely that these slips were static in the first place. As for the motion-preserving effect of dynamic stabilization, in one study 47% of patients had radiographic evidence of adjacent segment degeneration at four-year follow-up, suggesting a degree of unpredictability in the ability of these devices to preserve motion. 74
Decompression with posterolateral lumbar fusion (PLF)
The supplementation of decompression with a PLF can be achieved with or without instrumentation. Herkowitz and Kurz found uninstrumented PLF was superior to decompression alone with regards to clinical outcome, and although they reported a non-union rate of 36%, this did not impact on the clinical outcome. 64 Surgeons have migrated towards instrumented PLF in an attempt to improve stability and subsequent outcome. In an RCT comparing decompressive laminectomy and PLF with and without instrumentation for degenerative spondylolisthesis, Fischgrund et al also found that clinical outcomes (in relation to back and leg pain) were comparable between the two fusion groups despite a significantly higher non-union rate with uninstrumented fusion (55% versus 18%) at two-year follow-up; 76 a finding that is supported by the results of a meta-analysis by Mardjetko et al and a systematic review by Martin et al. 67,68 However, some of the reported studies have been criticized for their relatively short follow-up period of between two and three years, and there is evidence to suggest that the clinical outcome with uninstrumented fusion deteriorates over time. 77 In their prospective study of patients treated with decompression and instrumented PLF only, Booth et al found that patient satisfaction remained high at a mean follow-up of 6.5 years. 78 Conversely, in their prospective cohort study of patients treated with decompression and uninstrumented PLF, Kornblum et al found a significant deterioration in clinical outcome in patients who had developed a non-union at mean 7.5 year follow-up. 77 The evidence appears to demonstrate superiority of instrumented over uninstrumented fusion with respect to sustained long-term improvement in clinical and functional outcomes, and this needs to be balanced against the non-significant trend towards higher reoperation rates with instrumented fusion (relative risk 1.86) when deciding which technique to use. 68
Interbody fusion
There has been much debate about the need for interbody fusion in the management of degenerative spondylolisthesis, fuelled in part by the paucity of clinical studies, but in recent years the evidence has started to mount. In a small retrospective study by Rousseau et al comparing PLF with posterolateral interbody fusion (PLIF), functional outcomes were significantly better in the PLIF group at mean two-year follow-up. 79 Ha et al also demonstrated significant clinical improvement (in Oswestry Disability Index [ODI] and Visual Analogue Scale [VAS] scores) with PLIF over PLF at a minimum two-year follow-up, but only in those patients with preoperative radiographic evidence of segmental mobility (> 4 mm translation or > 10° angulation). 80 In that study, disc height was significantly increased in both the dynamic and static groups following PLIF, suggesting that the additional stability conferred by the interbody device, and the resultant indirect decompression of the neural foramen, is not required if the spondylolisthesis is static. Although both these studies have demonstrated superiority of interbody fusion over PLF, the quality of these studies has been questioned. Liu et al conducted a systematic review and meta-analysis, identifying four RCTs and five comparative observational studies comparing PLF with PLIF, and found that PLIF resulted in better patient satisfaction and fusion rates with no increase in complication rates. 81 A systematic review and meta-analysis by Levin et al comparing PLF with transforaminal lumbar interbody fusion (TLIF) from five observational studies, also favoured TLIF for achieving improvement in ODI and back pain and better fusion rates. 82 However, these findings have been challenged by a recent RCT with two-year follow-up, which has found no additional benefit of TLIF over PLF with regard to clinical or radiographic alignment parameters despite a better fusion rate, 83 with similar findings reported in a retrospective cohort study by Fujimori et al. 84 Furthermore, a systematic review and meta-analysis by McAnany et al, comparing the effectiveness of PLF and interbody fusion from five observational studies, has found no difference in clinical outcome (ODI, Short Form-36 [SF-36], VAS score), fusion rates or complication rates. 85
While interbody devices are not required in all cases of low-grade degenerative spondylolisthesis, Derman and Albert believe there is now enough evidence to support their use if the spondylolisthesis is dynamic. 86 The choice of interbody technique comes down to surgeon preference, but a systematic review and meta-analysis by de Kunder et al, comparing TLIF with PLIF from one RCT and eight case series, has found TLIF has significantly lower complication rates (8.7% versus 17.0%) with statistically significant (but not clinically significant) improvement in clinical outcome. 87
Minimally invasive surgery
Minimally invasive surgical (MIS) decompression via a unilateral laminotomy and ‘over the top’ approach, in patients having an isolated decompression for the management of their degenerative spondylolisthesis, is thought to be less destabilizing than a traditional decompressive laminectomy. In a systematic review and meta-analysis of the two techniques, Scholler et al found that patient satisfaction was greater following MIS decompression with a reduced likelihood of slip progression, reoperation and secondary fusion. 88 Kelleher et al also found MIS decompression to be clinically effective at improving function in their observational cohort study, but in patients with a concomitant scoliosis, the significantly higher revision rate needed to be factored into the decision-making process when deciding what surgical strategy to adopt. 89 Minimally invasive surgical techniques have also been popularized to reduce soft-tissue trauma and subsequent postoperative pain, with reduced damage to the multifidus, a muscle which crosses multiple motion segments, potentially protecting against adjacent segment degeneration. Most studies comparing open with MIS-TLIF/PLIF have demonstrated reduced length of hospital stay, improved cost effectiveness and quicker return to work with the MIS technique, 90–92 but have found no difference in clinical or radiological outcomes or complication rates at mean two-year follow-up, 93,94 although a significant increase in neurological deficit following MIS-TLIF, attributed to the steep learning curve, was found in one study 95 and short-term clinical improvement following MIS-TLIF was noted in another. 94 These findings are further supported in a systematic review by Goldstein et al, but the authors acknowledge that the quality of the evidence in the literature is too poor to draw any firm conclusions. 96 Stand-alone lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF) have also been found to give good clinical outcomes while maintaining slip reduction and restoration of both disc height and segmental lordosis, 97–99 and the clinical outcomes following ALIF have been maintained at long-term follow-up. 100 Rodgers et al reported no complications or non-unions using LLIF at mean one-year follow-up, 97 as did Xu et al using LLIF and ALIF. 98 However, in their prospective observational study using LLIF, with minimum two-year follow-up, Marchi et al reported evidence of cage subsidence in 17% of patients, with 13% of patients requiring revision surgery. 99 In a prospective randomized trial comparing MIS-TLIF with LLIF, Sembrano et al demonstrated comparability between the procedures in relation to the improvement in back and leg pain at mean two-year follow-up and found both techniques to be acceptable in the management of degenerative spondylolisthesis. 101 While there appears to be some merit in adopting decompressive MIS techniques to prevent postoperative segmental mobility, due to the quality of the evidence the benefit of MIS techniques for interbody fusion is perhaps less clear. Furthermore, Satomi et al caution against the use of a stand-alone ALIF in the presence of advanced degenerative changes, advocating posterior decompressive surgery instead. 102
Biomechanical considerations
Recently, greater consideration has been directed towards improving spinal biomechanics, in particular, reduction of the listhesis and restoration of segmental lordosis and global sagittal balance. Bai et al conducted a systematic review and meta-analysis to establish whether reduction of the listhesis in patients with low-grade degenerative spondylolisthesis conferred any benefit over fusion in situ. 103 They identified four RCTs and three cohort studies and found no significant difference in clinical outcome, fusion rate, complication rate and lumbar lordosis. In a retrospective case series of patients treated with decompression and fusion for their degenerative spondylolisthesis, Radovanovic et al found that those with a positive sagittal balance (sagittal vertical axis > 50 mm) postoperatively had worse patient reported outcomes (ODI, SF-36 and back pain score) at mean three-year follow-up. 104 Furthermore, it appears that global sagittal balance can be effectively restored with single-level L4/5 interbody fusion using either the ALIF or PLIF technique, but whether this results in improved clinical outcome has yet to be fully established. 105,106
Summary
The management of patients with symptomatic degenerative low-grade lumbar spondylolisthesis who have failed non-operative management is controversial, not least because of the lack of robust clinical studies. The heterogeneity of the patient population, the absence of a precise definition of ‘segmental mobility’ and the difficulty in identifying the definitive source of pain generation are fundamental factors that contribute to the problem. Decompression to relieve stenotic symptoms has generally been considered the mainstay of surgical treatment, 44 but between 1999 and 2011, the United States witnessed a shift in surgical strategy, with a significant decrease in both stand-alone decompression and uninstrumented fusion and a corresponding increase in interbody fusion. 107 Yet the drivers for this change in national trend remain unclear. Following their systematic review, a guideline summary has been developed by the North American Spine Society in an attempt to facilitate decision-making, but this too recognizes the problem of insufficient or low-quality evidence to support a particular strategy. 31 Despite a number of review articles that consider the controversies of surgical management, 44,108–110 we are still unable to establish a definitive evidence-based answer to address the following questions:
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What parameters define abnormal mobility in patients with degenerative spondylolisthesis?
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Is an interbody device required when performing an instrumented fusion?
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Should MIS techniques be employed to improve clinical outcome?
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How important is slip reduction and restoration of sagittal balance in degenerative spondylolisthesis?
Based on the available evidence and our own experience, it is our belief that the clinical presentation, radiographic evidence of translational and angular motion and patient comorbidities are the key factors to consider in the decision-making process regarding surgery. Furthermore, a clear understanding of the surgical goal is required if the optimum clinical outcome is to be achieved. Here we present our treatment algorithm for symptomatic patients presenting with lower back pain and/or radicular pain and/or neurogenic claudication (Fig. 7).
Treatment algorithm for the management of symptomatic degenerative low-grade spondylolisthesis.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Treatment algorithm for the management of symptomatic degenerative low-grade spondylolisthesis.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Treatment algorithm for the management of symptomatic degenerative low-grade spondylolisthesis.
Citation: EFORT Open Reviews 3, 12; 10.1302/2058-5241.3.180020
Open access
This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.
None declared.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References
- 2.↑
Junghanns H . Spondylolisthesen ohne spalt im Zwishengelenkstuck. Arch Orthop Unfallchir 1931;29:118–127.
- 3.↑
Macnab I . Spondylolisthesis with an intact neural arch: the so-called pseudo-spondylolisthesis. J Bone Joint Surg Br 1950;32-B:325–333.
- 4.↑
Newman PH , Stone KH . The aetiology of spondylolisthesis. J Bone Joint Surg Br 1963;45-B:39–59.
- 5.↑
Wiltse LL , Newman PH , Macnab I . Classification of spondylolysis and spondylolisthesis. Clin Orthop Relat Res 1976;117:23–29.
- 7.↑
Fitzgerald JA , Newman PH . Degenerative spondylolisthesis. J Bone Joint Surg Br 1976;58-B:184–192.
- 8.↑
Liu Z , Duan Y , Rong X et al.. Variation of facet joint orientation and tropism in lumbar degenerative spondylolisthesis and disc herniation at L4-L5: a systematic review and meta-analysis. Clin Neurol Neurosurg 2017;161:41–47.
- 9.↑
Aono K , Kobayashi T , Jimbo S et al.. Radiographic analysis of newly developed degenerative spondylolisthesis in a mean twelve-year prospective study. Spine 2010;35:887–891.
- 10.↑
Matsunaga S , Sakou T , Morizono Y et al.. Natural history of degenerative spondylolisthesis: pathogenesis and natural course of the slippage. Spine 1990;15:1204–1210.
- 11.↑
Heary RF , Bono CM . Circumferential fusion for spondylolisthesis in the lumbar spine. Neurosurg Focus 2002;13:1–12.
- 12.↑
Schroeder GD , Kepler CK , Kurd MF et al.. Rationale for the surgical treatment of lumbar degenerative spondylolisthesis. Spine 2015;40:E1161–E1166.
- 13.↑
White AA III , Panjabi MM . Clinical biomechanics of the spine. Second ed. Baltimore, MD: Lippincott Williams & Wilkins, 1990.
- 15.↑
Hasegawa K , Kitahara K , Shimoda H et al.. Lumbar degenerative spondylolisthesis is not always unstable: clinicobiomechanical evidence. Spine 2014;39:2127–2135.
- 16.↑
Simmonds AM , Rampersaud YR , Dvorak MF et al.. Defining the inherent stability of degenerative spondylolisthesis: a systematic review. J Neurosurg Spine 2015;23:178–189.
- 17.↑
Jacobsen S , Sonne-Holm S , Rovsing H et al.. Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study. Spine 2007;32:120–125.
- 18.↑
Kanayama M , Hashimoto T , Shigenobu K et al.. Intraoperative biomechanical assessment of lumbar spinal instability: validation of radiographic parameters indicating anterior column support in lumbar spinal fusion. Spine 2003;28:2368–2372.
- 19.↑
Anderson DG , Limthongkul W , Sayadipour A et al.. A radiographic analysis of degenerative spondylolisthesis at the L4-5 level. J Neurosurg Spine 2012;16:130–134.
- 20.↑
Blumenthal C , Curran J , Benzel EC et al.. Radiographic predictors of delayed instability following decompression without fusion for degenerative Grade 1 lumbar spondylolisthesis. J Neurosurg Spine 2013;18:340–346.
- 21.↑
Hammouri QM , Haims AH , Simpson AK et al.. The utility of dynamic flexion-extension radiographs in the initial evaluation of the degenerative lumbar spine. Spine 2007;32:2361–2364.
- 22.↑
Boden SD , Wiesel SW . Lumbosacral segmental motion in normal individuals: have we been measuring instability properly? Spine 1990;15:571–576.
- 23.↑
Inui T , Murakami M , Nagao N et al.. Lumbar degenerative spondylolisthesis: changes in surgical indications and comparison of instrumented fusion with two surgical decompression procedures. Spine 2016;42:E15–E24.
- 24.↑
Liu N , Wood K , Schwab J et al.. Utility of flexion-extension radiographs in lumbar spondylolisthesis. Spine 2015;40:E929–E935.
- 25.↑
Jayakumar P , Nnadi C , Saifuddin A et al.. Dynamic degenerative lumbar spondylolisthesis: diagnosis with axial loaded magnetic resonance imaging. Spine 2006;31:E298–E301.
- 26.
Elsig JPL , Kaech DL . Dynamic imaging of the spine with an open upright MRI: present results and future perspectives of fMRI. Eur J Orthop Surg Traumatol 2007;17:119–124.
- 27.
Perez AF , Isidro MG , Ayerbe E et al.. Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical and lumbosacral spines. Eur J Radiol 2007;62:444–448.
- 28.
Ozawa H , Kanno H , Koizumi Y et al.. Dynamic changes in the dural sac cross-sectional area on axial loaded MR imaging: is there a difference between degenerative spondylolisthesis and spinal stenosis? AJNR Am J Neuroradiol 2012;33:1191–1197.
- 29.↑
Huang KY , Lin RM , Lee YL et al.. Factors affecting disability and physical fuction in degenerative lumbar spondylolisthesis of L4-5: evaluation with axially loaded MRI. Eur Spine J 2009;18:1851–1857.
- 30.↑
McGregor AH , Anderton L , Gedroyc WMW et al.. The use of interventional open MRI to assess the kinematics of the lumbar spine in patients with spondylolisthesis. Spine 2002;27:1582–1586.
- 31.↑
Matz PG , Meagher RJ , Lamer T et al.. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 2016;16(3):439–448.
- 32.↑
Sato K , Wakamatsu E , Yoshizumi A et al.. The configuration of the laminas and facet joints in degenerative spondylolisthesis: a clinicoradiographic study. Spine 1989;14:1265–1271.
- 33.↑
Smorgick Y , Mirovsky Y , Fischgrund JS et al.. Radiographic predisposing factors for degenerative spondylolisthesis. Orthopedics 2014;37:e260–e264.
- 34.
Toyone T , Ozawa T , Kamikawa K et al.. Facet joint orientation difference between cephalad and caudal portions: a possible cause of degenerative spondylolisthesis. Spine 2009;34:2259–2262.
- 35.
Grobler LJ , Robertson PA , Novotny JE et al.. Etiology of spondylolisthesis: assessment of the role played by lumbar facet joint morphology. Spine 1993;18:80–91.
- 36.
Berlemann U , Jeszenszky DJ , Buhler DW et al.. Facet joint remodelling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J 1998;7:376–380.
- 37.↑
Berlemann U , Jeszenszky DJ , Buhler DW et al.. The role of lumbar lordosis, vertebral end-plate inclination, disc height, and facet orientation in degenerative spondylolisthesis. J Spinal Disord 1999;12:68–73.
- 38.↑
Cinotti G , Postacchini F , Fassari F et al.. Predisposing factors in degenerative spondylolisthesis: a radiographic and CT study. Int Orthop 1997;21:337–342.
- 39.↑
Caterini R , Mancini F , Bisicchia S et al.. The correlation between exaggerated fluid in lumbar facet joints and degenerative spondylolisthesis: prospective study of 52 patients. J Orthop Traumatol 2011;12:87–91.
- 40.↑
Chaput C , Padon D , Rush J et al.. The significance of increased fluid signal on magnetic resonance imaging in lumbar facets in relationship to degenerative spondylolisthesis. Spine 2007;32:1883–1887.
- 41.↑
Lattig F , Fekete TF , Grob D et al.. Lumbar facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis? Eur Spine J 2012;21:276–281.
- 42.↑
Oishi Y , Murase M , Hayashi Y et al.. Smaller facet effusion in association with restabilization at the time of operation in Japanese patients with lumbar degenerative spondylolisthesis. J Neurosurg Spine 2010;12:88–95.
- 43.↑
Kirkadly-Willis WH , Farfan HF . Instability of the lumbar spine. Clin Orthop Relat Res 1982;165:110–123.
- 44.↑
Sengupta DK , Herkowitz HN . Degenerative spondylolisthesis: review of current trends and controversies. Spine 2005;30:S71–S81.
- 45.↑
Kepler CK , Hilibrand AS , Sayadipour A et al.. Clinical and radiographic degenerative spondylolisthesis (CARDS) classification. Spine J 2015;15:1804–1811.
- 46.↑
Sobol GL , Hilibrand A , Davis A et al.. Reliability and clinical utility of the CARDS classification for degenerative spondylolisthesis. Clin Spine Surg 2018;31:E69–E73.
- 47.↑
Gille O , Challier V , Parent H et al.. Degenerative lumbar spondylolisthesis: cohort of 670 patients, and proposal of a new classification. Orthop Traumatol Surg Res 2014;100(suppl):311–315.
- 48.↑
Kalichman L , Hunter DJ . Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J 2008;17:327–335.
- 49.↑
Vibert BT , Sliva CD , Herkowitz HN . Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006;443:222–227.
- 50.↑
Wessberg P , Frennered K . Central lumbar spinal stenosis: natural history of non-surgical patients. Eur Spine J 2017;26:2536–2542.
- 51.↑
Weinstein JN , Lurie JD , Tosteson TD et al.. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257–2270.
- 52.↑
Klessinger S . Radiofrequency neurotomy for treatment of low back pain in patients with minor degenerative spondylolisthesis. Pain Physician 2012;15:E71–E78.
- 53.↑
Schulte TL , Ringel F , Quante M et al.. Surgery for adult spondylolisthesis: a systematic review of the evidence. Eur Spine J 2016;25:2539–2567.
- 54.↑
Matsudaira K , Yamazaki T , Seichi A et al.. Spinal stenosis in grade 1 degenerative lumbar spondylolisthesis: a comparative study of outcomes following laminoplasty and laminectomy with instrumented spinal fusion. J Orthop Sci 2005;10:270–276.
- 55.↑
Weinstein JN , Lurie JD , Tosteson TD et al.. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis: four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomised and observational cohorts. J Bone Joint Surg Am 2009;91:1295–1304.
- 56.↑
Gerling MC , Leven D , Passias PG et al.. Risk factors for reoperation in patients treated surgically for degenerative spondylolisthesis: a subanalysis of the 8-year data from the SPORT trial. Spine 2017;42:1559–1569.
- 57.↑
Dijkerman ML , Overdevest GM , Moojen WA et al.. Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: a systematic review. Eur Spine J 2018;27:1629–1643.
- 58.↑
Forsth P , Olafsson G , Carlsson T et al.. A randomised controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J Med 2016;374:1413–1423.
- 59.↑
Johnsson KE , Willner S , Johnsson K . Postoperative instability after decompression for lumber spinal stenosis. Spine 1986;11:107–110.
- 60.↑
Lombardi JS , Wiltse LL , Reynolds J et al.. Treatment of degenerative spondylolisthesis. Spine 1985;10:821–827.
- 61.↑
Musluman AM , Cansever T , Yilmaz A et al.. Midterm outcome after a microsurgical unilateral approach for bilateral decompression of lumbar degenerative spondylolisthesis. J Neurosurg Spine 2012;16:68–76.
- 62.↑
Ahmad S , Hamad A , Bhalla A et al.. The outcome of decompression alone for lumber spinal stenosis with degenerative spondylolisthesis. Eur Spine J 2017;26:414–419.
- 63.↑
Smorgick Y , Park DK , Baker KC et al.. Single- versus multilevel fusion for single-level degenerative spondylolisthesis and multilevel lumbar stenosis. Spine 2013;38:797–805.
- 64.↑
Herkowitz HN , Kurz LT . Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802–808.
- 65.↑
Ghogawala Z , Dziura J , Butler WE et al.. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 2016;374:1424–1434.
- 66.↑
Sato S , Yagi M , Machida M et al.. Reoperation rate and risk factors of elective spinal surgery for degenerative spondylolisthesis: minimum 5-year follow-up. Spine J 2015;15:1536–1544.
- 67.↑
Mardjetko SM , Connolly PJ , Shott S . Degenerative lumbar spondylolisthesis: a meta-analysis of literature 1970–1993. Spine 1994;19:2256S–2265S.
- 68.↑
Martin CR , Gruszczynski AT , Braunsfurth HA et al.. The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine 2007;32:1791–1798.
- 69.↑
Chen Z , Xie P , Feng F et al.. Decompression alone versus decompression and fusion for lumbar degenerative spondylolisthesis: a meta-analysis. World Neurosurg 2018;111:e165–e177.
- 70.↑
Liang HF , Liu SH , Chen ZX et al.. Decompression plus fusion versus decompression alone for degenerative lumbar spondylolisthesis: a systematic review and meta-analysis. Eur Spine J 2017;26:3084–3095.
- 71.↑
Anderson PA , Tribus CB , Kitchel SH . Treatment of neurogenic claudication by interspinous decompression: application of the X STOP device in patients with lumbar degenerative spondylolisthesis. J Neurosurg Spine 2006;4:464–471.
- 72.↑
Kim DH , Shanti N , Tantorski ME et al.. Association between degenerative spondylolisthesis and spinous process fracture after interspinous process spacer surgery. Spine J 2012;12:466–472.
- 73.↑
Konno S , Kikuchi S . Prospective study of surgical treatment of degenerative spondylolisthesis: comparison between decompression alone and decompression with Graf system stabilisation. Spine 2000;25:1533–1537.
- 74.↑
Schaeren S , Broger I , Jeanneret B . Minimum four-year follow-up of spinal stenosis with degenerative spondylolisthesis treated with decompression and dynamic stabilisation. Spine 2008;33:E636–E642.
- 75.↑
Hoppe S , Schwarzenbach O , Aghayev E et al.. Longterm outcome after monosegmental L4/5 stabilisation for degenerative spondylolisthesis with the Dynesys device. Clin Spine Surg 2016;29:72–77.
- 76.↑
Fischgrund JS , Mackay M , Herkowitz HN et al.. 1997 Volvo Award Winner in Clinical Studies – degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomised study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807–2812.
- 77.↑
Kornblum MB , Fischgrund J , Herkowitz H et al.. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion with pseudarthrosis. Spine 2004;29:726–733.
- 78.↑
Booth KC , Bridwell KH , Eisenberg BA et al.. Minimum 5-year results of degenerative spondylolisthesis treated with decompression and instrumented posterior fusion. Spine 1999;24:1721–1727.
- 79.↑
Rousseau MA , Lazennec JY , Bass EC et al.. Predictors of outcomes after posterior decompression and fusion in degenerative spondylolisthesis. Eur Spine J 2005;14:55–60.
- 80.↑
Ha KY , Na KH , Shin JH et al.. Comparison of posterolateral fusion with and without additional posterior lumbar interbody fusion for degenerative lumbar spondylolisthesis. J Spinal Disord Tech 2008;21:229–234.
- 81.↑
Liu X , Wang Y , Qiu G et al.. A systematic review with meta-analysis of posterior interbody fusion versus posterolateral fusion in lumber spondylolisthesis. Eur Spine J 2014;23:43–56.
- 82.↑
Levin JM , Tanenbaum JE , Steinmetz MP et al.. Posterolateral fusion (PLF) vs transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis: a systematic review and meta-analysis. Spine J 2018;18:1088–1098.
- 83.↑
Challier V , Boissiere L , Obeid I et al.. One-level lumbar degenerative spondylolisthesis and posterior approach: is transforaminal lateral interbody fusion mandatory? Spine 2017;42:531–539.
- 84.↑
Fujimori T , Le H , Schairer WW et al.. Does transforaminal lumber interbody fusion have advantages over posterolateral lumbar fusion for degenerative spondylolisthesis? Global Spine J 2015;5:102–109.
- 85.↑
McAnany SJ , Baird EO , Qureshi SA et al.. Posterolateral fusion versus interbody fusion for degenerative spondylolisthesis: a systematic review and meta-analysis. Spine 2016;41:E1408–E1414.
- 86.↑
Derman PB , Albert TJ . Interbody fusion techniques in the surgical management of degenerative lumbar spondylolisthesis. Curr Rev Musculoskelet Med 2017;10:530–538.
- 87.↑
De Kunder SL , van Kuijk SMJ , Rijkers K et al.. Transforaminal lumber interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis. Spine J 2017;17:1712–1721.
- 88.↑
Scholler K , Alimi M , Cong GT et al.. Lumbar spinal stenosis associated with degenerative lumbar spondylolisthesis: a systematic review and meta-analysis of secondary fusion rates following open vs minimally invasive decompression. Neurosurgery 2017;80:355–367.
- 89.↑
Kelleher MO , Timlin M , Persaud O et al.. Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine 2010;35:E981–E987.
- 90.↑
Villavicencio AT , Burneikiene S , Bulsara KR et al.. Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech 2006;19:92–97.
- 91.
Parker SL , Adogwa O , Bydon A et al.. Cost effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis associated low back and leg pain over two years. World Neurosurg 2012;78:178–184.
- 92.↑
Parker SL , Mendenhall SK , Shau DN et al.. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg 2014;82:230–238.
- 93.↑
Wang J , Zhou Y , Zhang ZF et al.. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J 2010;19:1780–1784.
- 94.↑
Zhang D , Mao K , Qiang X . Comparing minimally invasive transforaminal lumbar interbody fusion and posterior lumbar interbody fusion for spondylolisthesis: a STROBE-compliant observational study. Medicine (Baltimore) 2017;96:e8011.
- 95.↑
Villavicencio AT , Burneikiene S , Roeca CM et al.. Minimally invasive versus open transforaminal lumber interbody fusion. Surg Neurol Int 2010;1:12.
- 96.↑
Goldstein CL , Macwan K , Sundararajan K et al.. Comparative outcomes of minimally invasive surgery for posterior lumbar fusion: a systematic review. Clin Orthop Relat Res 2014;472:1727–1737.
- 97.↑
Rodgers WB , Lehmen JA , Gerber EJ et al.. Clinical Study: grade 2 spondylolisthesis at L4–5 treated by XLIF: safety and midterm results in the ‘worst case scenario’. ScientificWorldJournal 2012;356712.
- 98.↑
Xu DS , Bach K , Uribe JS . Minimally invasive anterior and lateral transpsoas approaches for the closed reduction of grade 2 spondylolisthesis: initial clinical and radiographic experience. Neurosurg Focus 2018;44:E4.
- 99.↑
Marchi L , Abdala N , Oliveira L et al.. Stand-alone lateral interbody fusion for the treatment of low-grade degenerative spondylolisthesis. ScientificWorldJournal 2012;456346.
- 100.↑
Takahashi K , Kitahara H , Yamagata M et al.. Long-term results of anterior interbody fusion for treatment of degenerative spondylolisthesis. Spine 1990;15:1211–1215.
- 101.↑
Sembrano JN , Tohmeh A , Isaacs R . Two-year comparative outcomes of MIS lateral and MIS transforaminal interbody fusion in the treatment of degenerative spondylolisthesis: part 1 − clinical findings. Spine 2016;41(suppl 8):S123–S132.
- 102.↑
Satomi K , Hirabayashi K , Toyama Y et al.. A clinical study of degenerative spondylolisthesis: radiographic analysis and choice of treatment. Spine 1992;17:1329–1336.
- 103.↑
Bai X , Chen J , Liu L et al.. Is reduction better than arthrodesis in situ in surgical management of low-grade spondylolisthesis? A system review and meta-analysis. Eur Spine J 2017;26:606–618.
- 104.↑
Radovanovic I , Urquhart JC , Ganapathy V et al.. Influence of postoperative sagittal balance and spinopelvic parameters on the outcome of patients surgically treated for degenerative lumbar spondylolisthesis. J Neurosurg Spine 2017;26:448–453.
- 105.↑
Kim CH , Chung CK , Park SB et al.. A change in lumbar sagittal alignment after single-level anterior lumbar interbody fusion for lumbar degenerative spondylolisthesis with normal sagittal balance. Clin Spine Surg 2017;30:291–296.
- 106.↑
Cho JH , Joo YS , Lim C et al.. Effect of one- or two-level posterior lumbar interbody fusion on global sagittal balance. Spine J 2017;17:1794–1802.
- 107.↑
Kepler CK , Vaccaro AR , Hilibrand AS et al.. National trends in the use of fusion techniques to treat degenerative spondylolisthesis. Spine 2014;39:1584–1589.
- 108.↑
Samuel AM , Moore HG , Cunningham ME . Treatment for degenerative lumbar spondylolisthesis: current concepts and new evidence. Curr Rev Musculoskelet Med 2017;10:521–529.
- 109.
Baker JF , Errico TJ , Kim Y et al.. Degenerative spondylolisthesis: contemporary review of the role of interbody fusion. Eur J Orthop Traumatol 2017;27:169–180.
- 110.↑
Guigui P , Ferrero E . Surgical treatment of degenerative spondylolisthesis. Orthop Traumatol Surg Res 2017;103:S11–S20.
