What is the treatment for spondylolisthesis?

Treatment of Spondylolisthesis

For patients with symptomatic spondylolisthesis and stenosis who have failed at least 3-6 months of comprehensive conservative management, surgical decompression with fusion provides superior outcomes compared to decompression alone or continued nonoperative treatment, with 93-96% reporting excellent/good results versus 44% with decompression alone. 1

Initial Conservative Management (Required 3-6 Months Before Surgery)

Conservative treatment must be comprehensive and include all of the following components before surgical intervention is considered:

• Formal supervised physical therapy for at least 6 weeks, focusing on flexion-based exercises (abdominal strengthening, posterior pelvic tilts) rather than extension exercises, as flexion programs result in only 19% having moderate/severe pain at 3 years versus 67% with extension programs 1, 2
• Neuropathic pain medications (gabapentin or pregabalin) for radicular symptoms 1
• Anti-inflammatory medications (NSAIDs) and activity modification 1, 3
• Epidural steroid injections for short-term relief of radiculopathy, though duration of relief is typically less than 2 weeks 1
• Facet joint injections can be both diagnostic and therapeutic, as facet-mediated pain causes 9-42% of chronic low back pain 1

Surgical Indications (All Must Be Present)

Fusion with decompression is indicated when all of the following criteria are met:

1. Failed comprehensive conservative management for at least 3-6 months as outlined above 1, 4
2. Documented spondylolisthesis of any grade on imaging (forward displacement of one vertebra on another) 1, 5
3. Moderate-to-severe stenosis with neural compression at the level corresponding to clinical symptoms 1, 5
4. Persistent disabling symptoms including neurogenic claudication, radiculopathy, or chronic axial back pain that significantly limits function 1

Critical Distinction: When Fusion Is NOT Indicated

• Decompression alone is recommended for stenosis without documented instability or spondylolisthesis, as fusion does not improve outcomes in isolated stenosis (Grade B recommendation) 5
• In the absence of deformity or instability, lumbar fusion has not been shown to improve outcomes and increases operative time, blood loss, and surgical risk without proven benefit 5
• Only 9% of patients without preoperative instability develop delayed slippage after decompression alone 5

Surgical Technique Selection

Instrumentation with Pedicle Screws

Pedicle screw fixation is recommended when spondylolisthesis or instability is present, as it improves fusion success rates from 45% to 83% (p=0.0015) compared to non-instrumented fusion 5

• Instrumentation is NOT recommended for stenosis without deformity or instability, as it increases complications without improving outcomes 5
• The addition of pedicle screw instrumentation is specifically contraindicated in posterolateral fusion following decompression for lumbar stenosis in patients without spinal deformity or instability 5

Interbody Fusion Techniques

Multiple interbody approaches provide equivalent outcomes when appropriately selected:

• TLIF (Transforaminal Lumbar Interbody Fusion) offers high fusion rates (92-95%) through a unilateral approach, minimizing dural retraction 1, 6
• PLIF (Posterior Lumbar Interbody Fusion) provides similar fusion rates but requires bilateral dural retraction 7
• ALIF (Anterior Lumbar Interbody Fusion) with posterior instrumentation is preferred for L5-S1 pathology, providing superior outcomes and improved lumbar lordosis 1
• XLIF/OLIF (Lateral approaches) are alternatives depending on anatomy and surgeon preference 1

No significant differences in clinical outcomes (ODI, SF-36, VAS scores) have been detected between different fusion techniques (noninstrumented PLF, instrumented PLF, or 360° approach) when maintained over 4 years 7

Bone Graft Options

• Local autograft harvested during laminectomy combined with allograft provides equivalent fusion outcomes for single-level procedures 1
• Iliac crest bone graft remains the gold standard but causes donor-site pain in 58-64% of patients at 6 months 1
• rhBMP-2 (Grade B evidence) can be used as a bone graft extender in instrumented posterolateral fusions, though it carries a 14% risk of postoperative radiculitis 1
• β-tricalcium phosphate with local autograft (Grade C evidence) provides comparable fusion rates to iliac crest bone in single-level instrumented fusion 1

Expected Outcomes and Evidence Quality

Superior Outcomes with Fusion for Spondylolisthesis

Level II evidence from the SPORT trial demonstrates that patients with stenosis and spondylolisthesis who choose surgery experience superior outcomes in every clinical measure at every time point for at least 4 years following treatment 7

Specific outcome data:

• 93-96% report excellent/good results with decompression plus fusion versus 44% with decompression alone 1, 5
• Statistically significant reductions in back pain (p=0.01) and leg pain (p=0.002) compared to decompression alone 1
• 93% patient satisfaction rates at long-term follow-up 5
• Fusion rates of 89-95% are achievable with appropriate instrumentation and graft materials 1

Complications and Risks

• Instrumented fusion procedures carry higher complication rates (31-40%) compared to non-instrumented procedures (6-12%) 1
• Common TLIF-specific complications include cage subsidence, new nerve root pain, and hardware issues that typically don't require immediate intervention 1
• Extensive decompression without fusion can lead to iatrogenic instability in approximately 38% of cases 5
• Adjacent segment disease may develop and requires long-term monitoring 6

Common Pitfalls to Avoid

1. Performing fusion for isolated stenosis without documented instability increases surgical risk without improving outcomes and is specifically not recommended (Grade B) 5
2. Inadequate conservative management (less than 3-6 months or lacking formal supervised physical therapy) does not meet criteria for surgical intervention 1
3. Decompression alone in the setting of spondylolisthesis leads to higher rates of poor outcomes due to progression of spinal deformity, with up to 73% risk of progressive slippage 5
4. Prophylactic fusion without documented instability is not indicated, as only 9% develop delayed slippage after decompression alone 5
5. Extension-based physical therapy programs result in worse outcomes (67% with moderate/severe pain) compared to flexion-based programs (19% with moderate/severe pain) 2

Special Populations

High-Grade Spondylolisthesis (Grade III-IV)

High-grade spondylolisthesis requires specialized care unique to this condition and typically necessitates reduction techniques with fusion 8

Degenerative Spondylolisthesis

• Most commonly occurs at L4-5 in women over age 40 2
• Decompression with fusion provides superior outcomes compared to decompression alone specifically in this population 1, 5
• Preoperative spondylolisthesis is a documented risk factor for 5-year clinical and radiographic failure after decompression alone 5

Pediatric Patients

More than 80% of children with spondylolisthesis treated conservatively have resolution of symptoms, making nonoperative management the first-line approach 8

Postoperative Monitoring

• Standard length of stay for single-level fusion is 2-3 days, with potential extension based on medical comorbidities 1
• Multilevel procedures require inpatient monitoring for neurological complications, pain management, and early mobilization 1
• CT with fine-cut axial and multiplanar reconstruction is superior to plain radiographs for assessing fusion status, with 70-90% sensitivity for interbody fusion 1
• Long-term follow-up is necessary to monitor for adjacent segment disease, pseudarthrosis, or need for reoperation 6