Spondylolisthesis


Article Author:
Steven Tenny


Article Editor:
Christopher Gillis


Editors In Chief:
Donald Kushner
Annabelle Dookie


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/27/2019 12:50:58 AM

Introduction

Spondylolisthesis is the slippage of one vertebral body in respect to the adjacent vertebral body causing mechanical or radicular symptoms or pain. It can be due to congenital, acquired or idiopathic causes. Spondylolisthesis is graded based on the degree of slippage of one vertebral body on the adjacent vertebral body.[1]

Etiology

Spondylolisthesis is commonly classified as one of five major etiologies: degenerative, isthmic, traumatic, dysplastic or pathologic. Degenerative spondylolisthesis occurs from degenerative changes in the spine without any defect in the pars interarticularis and is usually related to combined facet joint and disc degeneration leading to instability and forward movement of one vertebral body in relation to the adjacent vertebral body. Isthmic spondylolisthesis results from defects in the pars interarticularis. The cause of isthmic spondylolisthesis is undetermined, but a possible etiology includes microtrauma in adolescence related to sports such as wrestling, football, and gymnastics where repeated lumbar extension occurs. Traumatic spondylolisthesis occurs after fractures of the pars interarticularis or the facet joint structure and is most commonly seen after trauma. Dysplastic spondylolisthesis is congenital and secondary to variation in the orientation of the facet joints to an abnormal alignment.  In dysplastic spondylolisthesis, the facet joints are more sagittally oriented than the typical coronal orientation. Pathologic spondylolisthesis can be from systemic causes such as bone or connective tissue disorders or a focal process including infection, neoplasm or iatrogenic origin.  Additional risk factors for spondylolisthesis include a first-degree relative with spondylolisthesis, scoliosis or occult spinal bifida at the S1 level.[1]

Epidemiology

Spondylolisthesis most commonly occurs in the lower lumbar spine but can also occur in the cervical spine and rarely, except for trauma, in the thoracic spine. Degenerative spondylolisthesis predominately occurs in adults and is more common in females than males with increased risk in the obese.  Isthmic spondylolisthesis is more common in the adolescent and young adult population but may go unrecognized until symptoms develop in adulthood. There is a higher prevalence of isthmic spondylolisthesis in males. Dysplastic spondylolisthesis is more common in the pediatric population with females more commonly affected than males. Current estimates for prevalence are 6-7% for isthmic spondylolisthesis by the age of 18 years and up to 18% of adult patients undergoing MRI of the lumbar spine. Grade I spondylolisthesis accounts for 75% of all cases.  Spondylolisthesis most commonly occurs at the L5-S1 level with anterior translation of the L5 vertebral body on the S1 vertebral body.  The L4-5 level is the second mose common location for spondylolisthesis. 

Pathophysiology

Any process that can weaken the supports keeping vertebral bodies aligned can allow spondylolisthesis to occur. As one vertebra moves in relation to the adjacent vertebrae, local pain can occur from mechanical motion or radicular or myelopathic pain can occur due to compression of the exiting nerve roots or spinal cord respectively. Pediatric patients are more likely to increase spondylolisthesis grade when going through puberty. Older patients with lower grade I or II spondylolisthesis are less likely to progress to higher grades over time.

History and Physical

Patients typically have intermittent and localized low back pain for lumbar spondylolisthesis and localized neck pain for cervical spondylolisthesis. The pain is exacerbated by flexing and extending at the affected segment as this can cause mechanic pain from motion. Pain may be exacerbated by direct palpation of the affected segment. Pain can also be radicular in nature as the exiting nerve roots are compressed due to the narrowing of nerve foramina as one vertebra slips on the adjacent vertebrae, the traversing nerve root (root to the level below) can also be impinged through associated lateral recess narrowing, disc protrusion, or central stenosis.  Pain can sometimes be improved in a positional manner such as laying supine. This improvement is due to the instability of the spondylolisthesis that reduces with supine posture thus relieving the pressure on the bony elements as well as opening the spinal canal or neural foramen.  Other symptoms associated with lumbar spondylolisthesis include buttock pain, numbness or weakness in the leg(s), difficulty walking and rarely loss of bowel or bladder control.

Evaluation

Anteroposterior and lateral plain films, as well as lateral flexion-extension plain films, are the standard for the initial diagnosis of spondylolisthesis. One is looking for the abnormal alignment of one vertebral body to the next as well as possible motion with flexion and extension which would indicate instability.  In isthmic spondylolisthesis, there may be a pars defect which is termed the "Scotty dog collar." The "Scott dog collar" shows a hyperdensity where the collar would be on the cartoon dog which represents the fracture of the pars interarticulars. Computed tomography (CT) of the spine provides the highest sensitivity and specificity for diagnosing spondylolisthesis.  Spondylolisthesis can be better appreciated on sagittal reconstructions as compared to axial CT imaging. MRI of the spine can show associated soft tissue and disc abnormalities, but it is relatively more difficult to appreciate bony detail and a possible pars defect on MRI.[2][3]

Treatment / Management

For grade I and II spondylolisthesis treatment typically begins with conservative therapy including nonsteroidal anti-inflammatory drugs (NSAIDs), heat, light exercise, traction, bracing and/or bed rest. Approximately 10% to 15% of younger patients with low-grade spondylolisthesis will fail conservative treatment and need surgical treatment. No definitive standards exist for surgical treatment. Surgical treatment includes a varying combination of decompression, fusion with or without instrumentation or interbody fusion. Patients with instability are more likely to require operative intervention.  Some surgeons recommend a reduction of the spondylolisthesis if able as this not only decreases foraminal narrowing but also can improve spinopelvic sagittal alignment and decrease the risk for further degenerative spinal changes in the future. The reduction can be more difficult and riskier in higher grade and impacted spondylolisthesis.[4][5][6][7][8][2][9][10]

Pearls and Other Issues

Meyerding’s classification of spondylolisthesis is the most commonly used classification. It is based on the percentage of anterior translation relative to the adjacent level. Grade I spondylolisthesis is 1-25% slippage, grade II is up to 50% slippage, grade III is up to 75% slippage, and grade IV is 76-100% slippage. If there is more than 100% slippage, it is known as spondyloptosis or grade V spondylolisthesis.  

Subclasses of isthmic spondylolisthesis are subtype A (stress fractures of the pars), subtype B (elongation of the pars without overt fracture), subtype C (acute fracture of the pars).

Subclasses of pathologic spondylolisthesis are subtype A (systemic causes) and subtype B (focal processes).

Enhancing Healthcare Team Outcomes

An interprofessional team consisting of a specialty trained nurse, physical therapist, and an orthopedic surgeon or neurosurgeon will provide the best outcome and long-term care of patients with degenerative spondylolisthesis. The team should encourage weight loss as weight reduction may reduce symptoms and increase the quality of life. [Level V]


  • Image 469 Not availableImage 469 Not available
    Contributed by Christopher Gillis, MD and Steven Tenny, MD
Attributed To: Contributed by Christopher Gillis, MD and Steven Tenny, MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Spondylolisthesis - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is defined as the anterior slippage of one vertebra on another?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most common cause of low back pain in a 22-year-old athlete?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the correct explanation of spondylolisthesis.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of traumatic spondylolisthesis is characterized by acute fracture of the pars?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of traumatic spondylolisthesis is characterized by elongation of the pars?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of traumatic spondylolisthesis is characterized by fatigue fracture of the pars?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most appropriate treatment for a new diagnosis of spondylolisthesis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 42-year-old female presents with low intermittent back pain for 6 months which worsens as she bends to pull weeds in her garden. The pain improves when she reclines in her recliner. A plain film x-ray of the lumbar spine is reported as showing "mild grade I spondylolisthesis without significant change between flexion or extension and without other significant abnormalities." What is the probability that she will fail conservative therapy and require surgical treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the Meyerding classification for the pictured spondylolisthesis?

(Move Mouse on Image to Enlarge)
  • Image 473 Not availableImage 473 Not available
    Contributed by Christopher Gillis, MD and Steven Tenny, MD.
Attributed To: Contributed by Christopher Gillis, MD and Steven Tenny, MD.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common reason that adults develop spondylolisthesis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Spondylolisthesis - References

References

Degenerative Spondylolisthesis., Koreckij TD,Fischgrund JS,, Journal of spinal disorders & techniques, 2015 Aug     [PubMed]
Randall RM,Silverstein M,Goodwin R, Review of Pediatric Spondylolysis and Spondylolisthesis. Sports medicine and arthroscopy review. 2016 Dec;     [PubMed]
Bouras T,Korovessis P, Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review. European journal of orthopaedic surgery     [PubMed]
Baker JF,Errico TJ,Kim Y,Razi A, Degenerative spondylolisthesis: contemporary review of the role of interbody fusion. European journal of orthopaedic surgery     [PubMed]
Matz PG,Meagher RJ,Lamer T,Tontz WL Jr,Annaswamy TM,Cassidy RC,Cho CH,Dougherty P,Easa JE,Enix DE,Gunnoe BA,Jallo J,Julien TD,Maserati MB,Nucci RC,O'Toole JE,Rosolowski K,Sembrano JN,Villavicencio AT,Witt JP, Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. The spine journal : official journal of the North American Spine Society. 2016 Mar;     [PubMed]
Schöller K,Alimi M,Cong GT,Christos P,Härtl R, 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 Mar 1;     [PubMed]
Kreiner DS,Baisden J,Mazanec DJ,Patel RD,Bess RS,Burton D,Chutkan NB,Cohen BA,Crawford CH 3rd,Ghiselli G,Hanna AS,Hwang SW,Kilincer C,Myers ME,Park P,Rosolowski KA,Sharma AK,Taleghani CK,Trammell TR,Vo AN,Williams KD, Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis. The spine journal : official journal of the North American Spine Society. 2016 Dec;     [PubMed]
Alqarni AM,Schneiders AG,Cook CE,Hendrick PA, Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2015 Aug;     [PubMed]
Schulte TL,Ringel F,Quante M,Eicker SO,Muche-Borowski C,Kothe R, Surgery for adult spondylolisthesis: a systematic review of the evidence. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2016 Aug;     [PubMed]
Alfieri A,Gazzeri R,Prell J,Röllinghoff M, The current management of lumbar spondylolisthesis. Journal of neurosurgical sciences. 2013 Jun;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Podiatry APMLE Part 3. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Podiatry APMLE Part 3, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Podiatry APMLE Part 3, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Podiatry APMLE Part 3. When it is time for the Surgery-Podiatry APMLE Part 3 board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Podiatry APMLE Part 3.