Updated: 9/29/2020

Degenerative Spondylolisthesis

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Introduction
  • A condition characterized by lumbar spondylolisthesis without a defect in the pars
    • absent of pars defect differentiates from adult isthmic spondylolithesis
  • Epidemiology
    • prevalence
      • ~5% in men
      • ~9% in woman
    • demographics
      • more common in African Americans, diabetics, and woman over 40 years of age
      • ~8 times more common in woman than men
        • increase in prevalence in women postulated to be due to increased ligamentous laxity related to hormonal changes
    • location
      • degenerative spondylolisthesis is 5-fold more common at L4/5 than other levels
        • this is different that isthmic spondylolisthesis which is most commonly seen at L5/S1
    • risk factors
      • sacralization of L5 (transitional L5 vertebrae)
      • sagittally oriented facet joints
  • Pathoanatomy
    • forward subluxation (intersegmental instability) of vertebral body is allowed by
      • facet joint degeneration
      • facet joint sagittal orientation
      • intervertebral disc degeneration
      • ligamentous laxity (possibly from hormonal changes)
    • degenerative cascade involves
      • disc degeneration leads to facet capsule degeneration and instability
      • microinstability which leads to further degeneration and eventual macroinstability and anterolithesis
      • instability is worsening with sagittally oriented facets (congenital) that allow forward subluxation
    • neurologic symptoms caused by
      • central and lateral recess stenosis  
        • a degenerative slip at L4/5 will affect the descending L5 nerve root in the lateral recess
          • caused by slippage, hypertrophy of ligamentum flavum, and encroachment into the spinal canal of osteophytes from facet arthrosis
      • foraminal stenosis  
        • a degenerative slip at L4/5 will affect the L4 nerve root as it is compressed in the foramen
        • vertical foraminal stenosis (loss of height of foramen) caused by 
          • loss of disk height
          • osteophytes from posterolateral corner of vertebral body pushing the nerve root up against the inferior surface of the pedicle
        • anteroposterior foraminal stenosis (loss of anterior to posterior area) caused by 
          • degenerative changes of the superior articular facet and posterior vertebral body
Classification
 
Myerding Classification
Grade I < 25%
  
Grade II 25 to 50%
  
Grade III 50 to 75% (Grade III and greater are rare in degenerative spondylolithesis)   
Grade IV 75 to 100%   
Grade V Spondyloptosis (all the way off)   
 
Presentation
  • Symptoms
    • mechanical/ back pain
      • most common presenting symptom
      • usually relieved with rest and sitting
    • neurogenic claudication & leg pain
      • second most common symptoms
      • defined as buttock and leg pain/discomfort caused by upright walking
        • relieved by sitting
        • not relieved by standing in one place (as is vascular claudication)
        • may be unilateral or bilateral
      • same symptoms found with spinal stenosis
    • cauda equina syndrome (very rare)
  • Physical exam
    • L4 nerve root involvement (compressed in foramen with L4/5 DS)
      • weakness to quadriceps
        • best seen with sit to stand exam maneuver
      • weakness to ankle dorsiflexion (cross over with L5)
        • best seen with heel-walk exam maneuver
      • decreased patellar reflex
    • L5 nerve root involvement
      • weakness to ankle dorsiflexion (cross over with L4)
        • best seen with heel-walk exam maneuver
      • weakness to EHL (great toe extension)
      • weakness to gluteus medius (hip abduction)
    • provocative walking test
      • have patient walk prolonged distance until onset of buttock and leg pain
        • have patient stop but remain standing upright
          • if pain resolves this is consistent with vascular claudication
        • have patient sit
          • if pain resolves this is consistent with neurogenic claudication (DS)
    • hamstring tightness
      • commonly found in this patients, and must differentiate this from neurogenic leg pain
Imaging
  • Radiographs
    • recommended views
      • weight bearing lumbar AP, lateral neutral, lateral flexion, lateral extension
    • findings 
      • slip evident on lateral xray 
      • flexion-extension studies
        • instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment
  • MRI
    • indications
      • persistent leg pain that has failed nonoperative modalities
      • best study to evaluate impingement of neural elements
    • views
      • T2 weighted sagittal and axial images best to look for compression of neurologic elements  
  • CT
    • useful to identify bony pathology
  • CT myelogram
    • helpful in patients in which a MRI is contraindicated (pacemaker)
Treatment
  • Nonoperative
    • physical therapy and NSAIDS
      • indications
        • most patients can be treated nonoperatively
      • modalities include
        • activity restriction
        • NSAIDS
        • PT
    • epidural steroid injections
      • indications
        • second line of treatment if non-invasive methods fail
  • Operative
    • lumbar decompression with instrumented fusion, +/- interbody fusion       
      • indications
        • most common is persistent and incapacitating pain that has failed 6 mos. of nonoperative management and epidural steroid injections
        • progressive motor deficit
        • cauda equina syndrome
      • technique
        • often combined with a posterior lumbar interbody fusion or transforaminal interbody fusion
        • new data shows equivalent outcomes using cortical screw fixation verses pedicle screw fixation
        • decompression often performed with a PLC perserving unilateral (undercutting) approach
        • navigation and MIS techniques are widely used
      • outcomes 
        • ~79% have satisfactory outcomes
        • improved fusion rates shown with pedicle screws
        • improved outcomes with successful arthrodesis 
        • worse outcomes found in smokers 
          • smokers should undergo smoking cessation prior to surgery 
    • posterior lumbar decompression alone 
      • indications
        • usually not indicated due to instability associated with spondylolithesis
        • only indicated in medically frail patients who cannot tolerate the increased surgical time of performing a fusion
      • outcomes
        • ~69% treated with decompression alone are satisfied
        • ~ 31% have progressive instability
    • anterior lumbar interbody fusion (ALIF)
      • indications
        • reserved for revision cases with pseudoarthrosis
      • outcomes
        • injury to superior hypogastric plexus can cause retrograde ejaculation 
Surgical Techniques
  • Posterior decompression and posterolateral fusion (+/- instrumentation) 
    • approach
      • posterior midline approach
      • multiple parasagittal incisions for minimally invasive approaches
    • decompression  
      • usually done with laminectomy, wide decompression, and foraminotomy
    • fusion 
      • posterolateral fusion with instrumentation most common 
      • TLIF/PLIF growing in popularity and may increase fusion rates and decrease risk of postoperative slip progression
    • reduction of listhesis
      • limited role in adults
    • cost
      • in degenerative spondylolisthesis adding an interbody cage increases hospital costs without increasing fusion rates 
  • Cortical bone trajectory screw
    • designed to decrease the amount of lateral exposure for obtaining screw starting points
      • lower intraoperative blood loss, smaller skin incision, and decreased pain scores at 1-week post-op 
      • fusion rates and functional outcomes similar to conventional pedicle screw fixation
      • some studies suggest conventional pedicle screw fixation may be more stable
        • other studies have demonstrated greater screw pullout strength given cortical contact of screw
      • mostly described in combination with interbody fusion (PLIF or TLIF)
    • starting point is more medial and caudal than traditional pedicle screws 
      • trajectory is more cephalad and lateral than traditional screw
      • cortical trajectory screws are generally smaller than traditional pedicle screws 
Complications
  • Pseudoarthrosis (5-30%)  
    • CT scan is more reliable than MRI for identifying failed arthrodesis 
  • Adjacent segment disease (2-3%) 
    • risk of adjacent segment degeneration requiring surgery is about 20-29% at 10 years 
  • Surgical site infection (0.1-2%)
    • treat with irrigation and debridement (usually hardware can be retained) 
  • Dural tear
  • Positioning neuropathy
    • LFCN
      • seen with prone positioning due to iliac bolster 
    • ulnar nerve or brachial plexopathy
      • from prone positioning with inappropriate position 
  • Complication rates increase with  
    • older age
    • increased intraoperative blood loss
    • longer operative time
    • number of levels fused
 

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Questions (30)
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(OBQ13.7) A 70-year-old woman is seen back in follow-up in your clinic with persistent shooting pains down the back of her legs, which have been increasing over the last nine months. She can walk for about 3 minutes before the pain becomes unbearable. It is relieved only when she sits down or bends forward. Her neurological exam demonstrates difficulty with heel-walking and normal patellar tendon reflexes bilaterally. Pedal pulses are present. Figures A and B show a lateral x-ray and a sagittal MRI of her lumbar spine. She has failed all previous conservative management and would like to proceed with surgery. What is the most appropriate treatment? Tested Concept

QID: 4642
FIGURES:
1

Vascular surgery consult

1%

(39/4531)

2

Anterior lumbar interbody fusion

7%

(318/4531)

3

Laminectomy only

1%

(34/4531)

4

Laminectomy and instrumented fusion

90%

(4071/4531)

5

Laminectomy and uninstrumented fusion

1%

(38/4531)

L 1 A

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(OBQ13.111) A 44-year-old male presents with pain in the posterior aspect of his left thigh after walking more than 20 feet. Figures A demonstrates an upright lateral lumbar spine radiograph. There is 3mm of translation on flexion and extension radiography. Figure B is a sagittal MRI image and Figure C is an axial image through L4-5. He has failed non-operative treatment and elects to undergo surgery. Assuming he undergoes the appropriate surgery, which of the following places him at the highest risk for adjacent segment disease requiring future surgery? Tested Concept

QID: 4746
FIGURES:
1

Undergoing a laminectomy at the cranial adjacent level

44%

(1996/4493)

2

Undergoing a one level fusion

27%

(1210/4493)

3

Degenerative spondylolisthesis

13%

(578/4493)

4

Obesity

6%

(276/4493)

5

Circumfrential fusion

9%

(404/4493)

L 5 C

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(SBQ12SP.9) A 62-year-old male underwent posterior spinal instrumented fusion for degenerative lumbar spondylolithesis one year ago. He presents to office complaining of persistent lower back pain. The pain initially improved but over the last 6 months he has had recurring pain at the site of the surgery primarily with activity. He denies back pain at rest or night pain. Physical examination reveals a well healed wound and no physical abnormalities. He has no tenderness to palpation to the thoracic or lumbar spine. He has no neurological deficits. His laboratory results show an erythrocyte sedimentation rate (ESR) = 8 mm/h and C-reactive protein (CRP) = 3 mg/L at the last visit which are both within normal limits. Figure A shows a series of radiographs from his pre-operative, 3 month post-operative and 1 year post-operative clinic visits, respectively. Which of the following investigations would best confirm the suspected underlying diagnosis? Tested Concept

QID: 3707
FIGURES:
1

MRI of lumbar spine

10%

(250/2524)

2

Repeat ESR/CRP and whole body bone scan

2%

(52/2524)

3

CT of lumbar spine

60%

(1526/2524)

4

Dynamic flexion/extension plain film radiographs

26%

(662/2524)

5

Dynamic lateral bending plain film radiographs

0%

(8/2524)

L 4 B

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(SBQ12SP.4) A 65-year-old male presents for postoperative follow up after undergoing spinal surgery. His preoperative and postoperative radiographs are shown in Figure A and B respectively. His past medical history is significant for osteoarthritis, hypertension, and smoking 1.5 packs per day for greater than 35 years. Which variable in this patient’s history has been reported to be associated with lower functional outcomes after this surgery?
Tested Concept

QID: 3702
FIGURES:
1

Age > 60 years old

14%

(778/5607)

2

Gender

1%

(67/5607)

3

Hypertension

0%

(18/5607)

4

Osteoarthritis

2%

(91/5607)

5

Smoking

82%

(4613/5607)

L 2 C

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(OBQ12.5) A 57-year-old woman with a past medical history of diabetes mellitus and arrythmias, requiring prior insertion of a pacemaker, presents with severe bilateral leg pain for 12 months. She reports the symptoms are worse with prolonged walking and improved with sitting. The severity of her symptoms has led her to exercise primary on a stationary bicycle, which she reports does not cause her symptoms. On physical exam she is neurologically intact in her lower extremities. She has an ABI of 0.95. A flexion and extension radiograph is performed and shown in Figure A. An axial CT myelogram at the L4/5 level is shown in Figure B. Extensive nonoperative treatment with therapy and epidural steroid injections have failed to provide any relief of her symptoms. What would be the most appropriate next step in treatment? Tested Concept

QID: 4365
FIGURES:
1

Obtain magnetic resonance imaging

14%

(618/4501)

2

Refer the patient to a vascular surgeon for treatment of peripheral vascular disease

4%

(177/4501)

3

Proceed with a lumbar decompression

16%

(727/4501)

4

Proceed with a lumbar decompression and instrumented fusion

63%

(2826/4501)

5

Proceed with a lumbar decompression and uninstrumented fusion

2%

(96/4501)

L 3 A

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(OBQ11.37) A 71-year-old male presents with bilateral leg pain for the last two years. His pain is exacerbated when walking and is relieved when his sits or bends forward. He notes occasional periods where his legs feel weak, but motor examination reveals 5/5 motor strength throughout his bilateral lower extremities. He has diminished sensation on the medial aspect of his feet bilaterally. Management thus far has included NSAIDS with occasional narcotic usage, physical therapy, and two epidural steroid injections. Figure A shows a flexion radiograph, Figure B shows an extension radiograph, and Figures C and D show his current MRI scan. He feels his pain is substantially worse than it was one year ago. What is the most appropriate management at this time? Tested Concept

QID: 3460
FIGURES:
1

Posterior L4-5 laminectomy, wide decompression, and foraminotomy

14%

(381/2697)

2

Activity restriction

1%

(20/2697)

3

Bilateral microdiscectomy

0%

(12/2697)

4

Posterior L4-5 decompression with arthrodesis

83%

(2229/2697)

5

L5-S1 decompression and uninstrumented fusion

1%

(29/2697)

L 2 A

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(OBQ10.143) A 59-year-old male presents with worsening bilateral buttock and leg pain that is worse with prolonged standing and improves with sitting. His symptoms have worsened to the point that it is now difficult for him to walk small distances. Physical exam shows weakness to EHL on the right. A magnetic resonance image is shown in Figure A. Nonsurgical management, including epidural corticosteroid injections, has failed to relieve the patient’s symptoms. What is the most appropriate next step in management? Tested Concept

QID: 3231
FIGURES:
1

Continued nonsurgical management

0%

(12/2849)

2

Decompressive laminectomy alone

1%

(27/2849)

3

Right side microdiskectomy

0%

(12/2849)

4

Decompressive laminectomy with posterior instrumented fusion

92%

(2618/2849)

5

Anterior lumbar interbody fusion

6%

(164/2849)

L 1 B

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(OBQ09.66) A 62-year-old female presents with one year of severe back and bilateral buttock pain. Her symptoms are worse with walking and improve with sitting. She now finds it difficult to walk even small distances, such as to her mailbox. Six months of nonoperative management including physical therapy, oral medications, and epidural corticosteroid injections have failed to provide lasting relief of her symptoms. Flexion and extension lateral radiographs are shown in Figures A and B. Sagittal and axial MRI images are shown in Figure C and D. What is the next most appropriate step in mangement? Tested Concept

QID: 2879
FIGURES:
1

EMG to confirm a lumbar radiculopathy

3%

(69/2647)

2

A far-lateral microdiskectomy on the left

2%

(41/2647)

3

A lumbar total disc replacement

0%

(8/2647)

4

Lumbar laminectomy with partial facetectomy and foraminotomy

9%

(238/2647)

5

Lumbar laminectomy with partial facetectomy, foraminotomy, and instrumented posterior spinal fusion

86%

(2272/2647)

L 1 A

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(OBQ07.56) A 47-year-old male underwent L4-5 posterior lumbar decompression and fusion with instrumentation. At the six-week clinical visit he complains of pain in the region of his wound. On physical exam there is wound erythema but no exudate. Laboratory studies show an erythrocyte sedimentation rate of 78 mm/h (normal up to 20 mm/h) and WBC count of 11,200/mm3 (normal 3,500 to 10,500/mm3). An MRI is perfomed and shows a fluid collection dorsal to the thecal sac. What is the most appropriate next step in management? Tested Concept

QID: 717
1

CT guided aspiration of the fluid collection and cultures

25%

(730/2890)

2

Surgical debridement followed by delayed closure and retention of instrumentation

66%

(1905/2890)

3

Surgical debridement followed by delayed closure and removal of instrumentation

4%

(111/2890)

4

Parenteral Cephalexin for 10 days followed by repeart laboratory studies

2%

(52/2890)

5

Broad spectrum intravenous antibiotics for 6 weeks followed by repeart laboratory studies

2%

(72/2890)

L 2 C

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(OBQ05.24) A 60-year-old male presents with severe low back pain and pain and numbness in his buttocks with prolonged standing. His pain improves with forward bending. Lateral radiographs with flexion and extension reveal L4/5 spondylolisthesis with mobility. MRI shows significant spinal stenosis. Six months of nonoperative management, including epidural corticosteroid injections has failed. The next step in treatment should consist of? Tested Concept

QID: 61
1

Lumbar disc arthroplasty

0%

(5/1570)

2

Lumbar microdiskectomy

1%

(12/1570)

3

Lumbar decompression and fusion

95%

(1489/1570)

4

Lumbar decompression only

2%

(33/1570)

5

Lumbar fusion only

1%

(23/1570)

L 1 A

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(OBQ04.16) In patients with degenerative spondylolisthesis undergoing posterolateral fusion, use of pedicle screws has been shown to confer which of the following effects? Tested Concept

QID: 127
1

Have no effect on the rate of pseudoarthosis

6%

(152/2617)

2

Decrease the rate of pseudoarthrosis

85%

(2226/2617)

3

Increase the level of postoperative pain at one year

1%

(23/2617)

4

Increase patient satisfaction with the procedure

7%

(194/2617)

5

Decrease the rate of postoperative infection

0%

(8/2617)

L 2 B

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