Review ArticleContemporary management of isthmic spondylolisthesis: pediatric and adult
Introduction
Isthmic spondylolisthesis is the forward slippage of a vertebra on the caudad vertebra resulting from a defect in the pars interarticularis. It is most common at the L5–S1 segment. Classifying an isthmic spondylolisthesis into low- versus high-grade has important implications regarding treatment decisions. Low-grade spondylolisthesis refers to slippage less than 50% according to the Meyerding [1] classification and high grade refers to slippage of greater than 50%.
Typically considered a pediatric condition, isthmic spondylolisthesis is more commonly symptomatic in adults. Although the pars defect develops before skeletal maturity, skeletally immature individuals with pars defects with or without low-grade spondylolisthesis are typically asymptomatic. It is usually in adulthood when patients who become symptomatic seek medical attention and treatment.
The purpose of this article is to review the contemporary management of isthmic spondylolisthesis, both low-grade and high-grade, in pediatric and adult patients. This article will address several controversies in the management of these conditions, such as the need for decompression, instrumentation, reduction, and anterior column fusion. Treatment decisions and surgical strategies are significantly different in pediatric and adult patients, although the underlying principles remain similar.
Fredrickson et al. [2], in a landmark study on the natural history of spondylolysis and spondylolisthesis, reported the incidence of spondylolysis at L5 to be 4.4% in 6-year-old children and increased to 5.8% in adulthood. Spondylolysis is very rare in children younger than 5 years [2]. Patients who developed pars defects during the period of observation did not develop symptoms during the time that the defects developed. Furthermore, slip progression was rarely observed and when it did occur, patients did not develop symptoms.
In a 45-year follow-up study of the same group of patients, those with bilateral pars defects followed a clinical course similar to that of the general population [3]. Other studies on the natural history of isthmic spondylolisthesis have also confirmed a very low rate of slip progression [3], [4], [5].
Saraste [5], in a large longitudinal study, demonstrated that the onset of symptoms tends to occur after childhood, with a mean age at presentation of 20 years. Many patients may not present to the spine surgeon until adulthood.
- 1.
Slip progression. Progression is more common in skeletally immature patients who have not reached the adolescent growth spurt. The higher the grade of slip, the more likely it is to progress. Slip progression rarely occurs in adults. Regardless of patient age, radiographic evidence of a progressive slip is usually an indication for surgery. Patients with progressive slips almost always have significant pain that does not respond to conservative treatment.
- 2.
High-grade slip with significant lumbosacral kyphotic deformity causing sagittal imbalance.
- 3.
Neurologic deficit. In most cases, the L5 nerve root is involved. Objective weakness is not very common in this condition, but if present, surgery should be strongly considered to relieve nerve root compression.
- 4.
Low back pain unresponsive to a prolonged course of conservative treatment.
- 5.
Radicular pain with associated nerve root compression on imaging studies that is not responsive to conservative treatment.
Several points of controversy in the surgical treatment of isthmic spondylolisthesis will be discussed in this article, that is, the need for decompression, instrumentation, reduction, and anterior column fusion. Decompression and instrumentation are primarily indicated for low-grade slips, whereas reduction and anterior column fusion are usually indicated for high-grade slips. The principles of managing pediatric/adolescent patients versus adult patients with isthmic spondylolisthesis have similarities but with some significant differences:
- 1.
With degenerative changes contributing to nerve root compression, adults are more likely to require direct neural decompression. Even in the presence of radicular symptoms, pediatric and adolescent patients often experience symptom relief with fusion alone when a hypermobile segment is stabilized.
- 2.
Adults tend to have more risk factors for pseudarthrosis (eg, smoking, poor general health, and steroid use). Therefore, instances in which a posterior-only approach may be suitable for adolescents may not be appropriate in the adult, in whom a circumferential fusion may be advisable to increase the likelihood of fusion success.
- 3.
Reduction of high-grade slips is generally more difficult in adults because of the increased rigidity of the deformity and stiffness across the lumbosacral junction. Because of the presence of secondary degenerative changes in adults, the deformity is less mobile. Therefore, the issue of reduction, and the controversy surrounding it, has traditionally been a pediatric topic.
- 4.
Risk of progression is higher in children and adolescents. The younger the patient is at the time of diagnosis, the greater the risk of progression because the deformity is likely to progress during periods of active spinal growth. For this reason, slip progression is a more common indication for surgery in children and adolescents with high-grade slips. Progression is very rare in adults, and surgery is rarely indicated for this reason in the adult patient. Most adults with high-grade slips who need surgery have pain or radicular symptoms that has not responded to conservative treatment.
Section snippets
Conservative treatment of low-grade slips
Low-grade isthmic spondylolisthesis has a benign clinical course in most patients, regardless of age. Slip progression is rare, even during the adolescent growth spurt and has been estimated to occur in less than 4% of cases [4], [5], [6], [7], [8]. Pediatric and adolescent patients with a low-grade slip that is asymptomatic only need observation. It may be advisable to avoid contact sports and sports that require lumbar hyperextension, such as gymnastics, in patients with a Grade II slip. If
Conservative treatment
Symptomatic high-grade isthmic spondylolisthesis in children and adolescents has an unfavorable natural history with high risk of progression and low likelihood of symptomatic relief. Conservative treatment is generally not recommended in symptomatic patients, which constitute the majority of patients with high-grade slips in this age group [9], [45]. Pizzutillo et al. [35] found that only one of 11 symptomatic patients treated conservatively had significant pain relief at long-term follow-up.
Posterolateral in situ fusion for high-grade spondylolisthesis
Many authors have advocated in situ fusion without reduction for high-grade spondylolisthesis in pediatric and adult patients [36], [70], [72], [87], [112], [113]. Although long-term follow-up after in situ fusion for high-grade slips generally yields good function and pain relief [36], [114], [115], fusion rates have been shown to be lower in pediatric and adolescent patients [109], [116]. Circumferential fusion has been recommended in these patients [96] as will be discussed below. Most of
Role of anterior column support (circumferential fusion)
Despite the reported success rates of in situ posterolateral fusion for high-grade slips, many authors advocate circumferential fusion. Regardless of patient age, high-grade spondylolisthesis creates increased shear stress at the lumbosacral junction. Several authors have advised against posterior in situ fusion because of the high rate of pseudarthrosis and progression of the postoperative slip [36], [88], [99], [118]. The addition of anterior column structural support not only provides
Spondyloptosis
The surgical treatment of spondyloptosis is very challenging. These patients generally have severe symptoms of low back pain, deformity, and neurologic symptoms or deficits. Surgical options include the in situ circumferential fusion technique described by Smith and Bohlman (see above) and the Gaines procedure. The former has a much lower rate of neurologic injury but does not address the severe lumbosacral deformity. The latter involves resection of L5 and reduction of L4 onto the sacrum as
Summary points
- 1.
Low-grade isthmic spondylolisthesis has a favorable outcome, and surgery is rarely required. Patients with pars defects typically become symptomatic in adulthood.
- 2.
Regardless of the degree of slip, age of the patient, and the surgical approach used, achieving a solid fusion leads to improved functional outcomes and reduction in pain. A circumferential fusion is associated with a higher fusion rate and has become more common, especially with high-grade slips.
- 3.
Because of the risk of neurologic
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This Contemporary Concepts in Spine Care review is part of a series of referenced reviews of contemporary issues in spine care produced by the North American Spine Society (NASS). Each review represents the current state of knowledge on a particular topic. Prior to entering the review process for The Spine Journal, the authors were assisted by members of the NASS Committee on Contemporary Concepts: Darrel Brodke, MD, Chair; Christopher Bono, MD; Robert Dawe, MD; and Mitchell B. Harris, MD.
FDA device/drug status: not applicable.
Author disclosures: JSF (royalties, DePuy; consulting, Stryker, releavant, Apatech, Smith and Nephew; research support, Smith and Nephew).