The Spine Book

Degenerative Spondylolisthesis of the Lumbar Spine

Definition

  • Anterior displacement of one vertebra over the caudal vertebra with degenerative changes and no disruption or defect in the vertebral ring

Symptoms

  • Asymptomatic, or occasional back pain
  • Chronic low back pain
  • Neurogenic claudication secondary to stenosis and/or dynamic stenosis
  • Radiculopathy and low back pain
    • radiculopathy can be pain alone, sensory symptoms, or motor changes.
  • Radiculopathy only

Imaging

  • Xray L-spine 4+ views (AP, lateral, flexion, extension)
    • AP view, used to match intraop AP rotation
    • Lateral, measure alignment for target sagittal balance
    • Flexion/Extension view, identify instability
      • Some compare the standing lateral xray to a supine MRI sagittal image to look for motion
    • EOS, consider global spine alignment
  • If neurologic symptoms, MRI without contrast, L-Spine
    • Review disc height and anterolisthesis grade
    • Review facets, presence of effusion >1.5mm may suggest degenerative spondylolisthesis
      • Presence of facet cysts and effusions are suggestive of degenerative spondylolisthesis
      • 1mm facet effusion = 29.6% probably of degen spondy (Chaput 2007)
      • 2mm facet effusion = 60.3%
      • 3mm facet effusion = 84.6%
    • Review pars to look for pars defect
    • Review for central or lateral recess stenosis
    • Review foraminal stenosis
  • If unable to obtain MRI, consider CT myelography
    • CT without myelography can still help evaluate for canal stenosis, but CT myelography is standard in patients who can not have an MRI

Classification

  • Meyerding Classification: Determined by measuring the % of slip using standing, neutral lateral radiographs of the lumbar spine
    • Severity grade
      • Grade 1: 0-25%
      • Grade 2: 25-50%
      • Grade 3: 50-75%
      • Grade 4: 75-100%
      • Grade 5: >100% (spondyloptosis)

(Wikipedia)

Natural History

  • Majority of patients with symptomatic degenerative lumbar spondylolisthesis and absence of neuro deficits do well with conservative care
  • Patients with sensory changes, muscle weakness, or cauda equina are more likely to develop progressive functional decline without surgery.
  • Progression of slip correlates with jobs that require repetitive anterior flexion of the spine.
    • Progression less likely if disc has lost >80% of native height and intervertebral osteophytes have formed
  • Progression of clinical symptoms does not correlate with progression of the slip

Treatment

  • Nonoperative
    • Activity restriction
    • Meds
      • NSAIDS
        • Ibuprofen, naproxen, meloxicam
      • Muscle relaxers
        • Robaxin, flexeril, tizanidine
      • Nerve pain meds
        • Gabapentin (Neurontin), Pregabalin (Lyrica)
    • Physical therapy
      • Core strengthening
    • Epidural steroid injections
      • Second line if non-invasive treatment fails
      • Transforaminal epidural steroid injections (TFESI)
        • Targeting the traversing and/or exiting nerve root at the level of degenerative spondylolisthesis
        • Lateral recess stenosis is common, so targeting bilateral traversing nerve roots are a common target or unilateral if symptoms are one-sided.
          • Example: L4-5 degenerative spondy = bilateral L5 nerve root TFESI
  • Operative Treatment
    • Posterior lumbar decompression alone
      • Indications
        • Usually not indicated due to instability (NASS Guidelines)
        • Stable grade 1 spondy in elderly, unhealthy patient with poor bone quality
      • Contraindications
        • Unstable spondylolisthesis
      • Outcomes
  • Decompression with preservation of midline structures
    • Indications
      • Symptomatic single-level degenerative spondylolisthesis that is low grade (<20%) and without lateral foraminal stenosis
      • Stable <~2-4mm of motion of spondy on flexion/extension xrays, or flexion xrays and supine MRI
    • Outcomes
      • Equivalent outcomes to decompression with fusion
  • Instrumented fusion with decompression +/- anterior cage
    • Indications
      • Symptomatic spinal stenosis with degenerative spondylolisthesis
        • Consider middle column height restoration with cage for up/down foraminal stenosis
    • Contraindications
    • Outcomes
      • Improved functional outcomes of single-level degenerative spondy compared to medical/interventional treatment alone (Allen, 2009)
      • Increased fusion rates with instrumented fusion + decompression, but no difference in clinical outcomes when compared to non-instrumented fusion + decompression (Fischgrund, 1997)
  • Indirect decompression (LLIF, OLIF)
    • Indications
      • Symptomatic grade 1-2 degenerative spondy with stenosis that improves with sitting or lying down and/or up-down foraminal stenosis
    • Contraindications
      • Severe stenosis with symptoms present in any position
      • Grade 3 and higher slip
      • Autofused level
    • Outcomes
  • Multi-level spondylolisthesis
    • Fusion with decompression (Insufficient evidence)

References

  1. NASS Clinical Guidelines Degenerative Spondylolisthesis
  2. Chaput, 2007
  3. Fischgrund, 1997
  4. Allen, 2009