What is Sponylolisthesis - Scoliosis
Degenerative spondylolisthesis is a disease of the older adult that develops as a result facet arthritis and facet remodeling. As the facets remodel, they take on a more sagittal orientation, allowing a mild slip to occur. These slips are very common, a study of osteoporosis found a 30% incidence among Caucasian women older than 65 years and a 60% incidence among African-American women older than 65 years. Most slips are asymptomatic, but can worsen the symptoms of neurogenic claudication when associated with lumbar]]spinal stenosis[[. Degenerative spondylolisthesis with spinal stenosis is one of the most common indications for spine surgery among older adults and current evidence suggests that patients have much better success rates and more clinical benefit with decompression and fusion than decompression alone.
Spondylolisthesis occurs when one vertebra slips forward in ..
Additionally, the cause of pain in patients with isthmic spondylolisthesis remains unclear. The first theory of pain production was segmental instability with excessive forward translation during flexion. This notion was logical from the mechanical standpoint as the pars defect eliminated the vertebral body’s primary restraint to forward translation, the inferior facet joint. This theory has now been evaluated by multiple radiographic studies, none of which were able to demonstrate excessive forward translation as a common feature of isthmic spondylolisthesis. A more contemporary theory of pain generation is excessive tension on the annulus of the inferior disc and foraminal stenosis at the level of the slip. Excessive annular tension is also mechanically logical as without the restraint of the inferior facet joints; the disc has to both resist shear forces from the slip and compressive forces from the body’s mass. However, this theory does not explain why some patients have symptoms while so many others do not, since the inferior discs all patients with isthmic spondylolisthesis are subjected to similar forces. Foraminal stenosis is also thought to play a role, but long-term studies on surgical outcome have shown that many patients have poor results following decompression alone. Since the mid-1950s, surgeons have been advocating the combination of decompression and fusion. A recent biomechanical study of flexion-extension X-rays in patients with isthmic spondylolisthesis and normal controls found paradoxical motion at the level of the slip in 46% of patients and 0% of controls without back pain. Paradoxical motion has not been previously reported in cases of spondylolisthesis, but its role in the symptomatic and asymptomatic patient is unclear.
High-grade isthmic spondylolisthesis and dysplastic spondylolisthesis are regarded as separate clinical entities from low-grade isthmic slips. High-grade slips are defined as those with greater than 50% forward displacement. These slips are also accompanied by a significant amount of lumbosacral kyphosis, which is forward bending of the L5 vertebral body over the sacral promontory. Rounding of the sacral body and trapezoidal deformation of L5 are also common features. High-grade slips are much rarer than low-grade slips, representing less than 10% of all isthmic slips, and the vast majority present during adolescence, most during the early teenage years.
Low Back Pain - OrthoInfo - AAOS
Posterolateral fusion in adult lumbar isthmic spondylolisthesis results in a significant improvement in 2 year outcomes, but the difference between surgical and nonsurgical treatment narrows with time.1 There has been one randomized controlled trial for low-grade isthmic spondylolisthesis that compared non-operative therapy to surgery. 2,3,4 The study evaluated the severity of pain and limitations of daily function in patients with 'lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severely restricted functional ability in individuals 18 to 55 years of age'. At two years follow-up, patients who underwent surgery had significantly better scores for both pain and daily function. 2,3 The benefits were reduced after nine years. 4 While the patients undergoing non-operative care did show some improvement in pain, their daily activities and physical function did not change during the follow-up period. The follow-up was relatively short, but the study clearly favored surgery and was the first prospective randomized trial for spondylolisthesis . This was also the first prospective trial demonstrating that surgery could be effective for the treatment of some types of low-back pain. Several other retrospective studies have found significant and reliable benefit for patients with isthmic spondylolisthesis, but none compared the results of surgery to natural history of the disorder. Nevertheless, posterolateral fusion for isthmic spondylolisthesis has been one of the least controversial surgeries for spinal pathology and has consistently demonstrated good outcomes.
Just getting older also plays a role in many back conditions
Uncontrolled studies have focused on the role of fusion in patient with both back pain and radicular pain. The success of stand-alone posterolateral fusion for treating adolescent isthmic spondylolisthesis has led some authors to speculate about the effectiveness of posterolateral fusion without a decompression for patients with both back and leg pain. In 1989, Drs. Peek and Wiltse, et al reported on eight cases of adults with high-grade spondylolisthesis who presented with back pain and severe radicular pain. 5 These patients were all treated with an in situ uninstrumented posterolateral fusion and followed for an average of 5.5 years. At final follow-up, all eight patients reported complete relief of their back pain and leg pain, no patients were taking analgesics for back pain, and all patients were unrestricted with respect to work and recreational activities. The mean time to complete resolution of symptoms was 2.8 months and all patients achieved a solid fusion. No patients underwent subsequent surgery for either back pain or leg pain throughout the follow-up period. This was the first report of excellent relief of leg pain in cases of isthmic spondylolisthesis from posterolateral fusion without decompression. Another study by de Loubresse, et al6 reported on 48 adults with low grade isthmic spondylolisthesis and radiculopathy, half treated by posterolateral fusion or posterolateral fusion and a Gill laminectomy . With respect to radicular pain during activity, 92% of patients treated by posterolateral fusion reported complete relief, while only 65% of those treated with fusion and decompression reported relief. Several natural history studies have also reported that foraminal stenosis is common among asymptomatic isthmic patients and does not correlate well with radiculopathy.