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  • a common incidental finding on the L/S spine Xray in the ED which is usually long standing but may be the result of acute trauma and may be the cause of the back pain and nerve compression.
  • spondylolisthesis refers to the forward slippage (anterolisthesis) of one vertebral body with respect to the one beneath it.
  • most commonly occurs with L5 slipping over S1, but it can occur at higher levels (particularly degenerative types).
  • it may cause any degree of symptoms, from minimal symptoms of occasional low back pain to incapacitating mechanical low back pain, radiculopathy from nerve root compression, and neurogenic claudication.


  • 5 types:
    • congenital or dysplastic (type 1)
      • due to a defect in the upper sacrum or arch of L5.
      • 94% are associated spina bifida occulta and high rates of S1 foraminal nerve root compression exists, even with grade 1 slips
    • isthmic (type 2) (5% of people)
      • These typically present in the teenage or early adulthood years and are most common at L5-S1.
      • results from a defect in pars interarticularis, which permits forward slippage of the superior vertebra
      • The pars interarticularis, or isthmus, is the bone between the lamina, pedicle, articular facets, and the transverse process
      • The pars may be congenitally defective (eg, in spondylolytic subtype of isthmic spondylolisthesis) or undergo repeated stress under hyperflexion and rotation, resulting in microfractures.
      • 3 sub-types:
        • Lytic (ie, spondylolysis) or stress fracture of the pars
        • Elongated yet intact pars
        • Acutely fractured pars
      • risk factors:
        • genetics
        • both lumbar lordosis and rotational forces are also believed to play a role in the development of lytic pars defects and the fatigue of the pars in the young
        • an association exists between high levels of activity during childhood and the development of pars defects
      • clinical features:
        • variable pain
        • restricted spinal range of movement
        • hamstring tightness - inability to flex hips with fully extended knees
        • hyperlordosis of the lumbar and thoracolumbar regions
        • hyperkyphosis at lumbosacral junction (as the center of gravity shifts to compensate for slip progression)
        • high grade slips may result in palpable step off, gait difficulty and trunk shortening (if spondyloptosis occurs)
    • degenerative (type 3)
      • ~5% of elderly men and 9% elderly women - mainly L4/L5, and lesser prevalence at L3/4
      • The L5 nerve root is usually compressed from lateral recess stenosis as a result of facet and/or ligamentous hypertrophy, and causes weakness of the extensor hallucis longus
      • results from chronic disc degeneration and facet incompetence
      • spondylosis is a general term reserved for acquired age-related degenerative changes of the spine (ie, discopathy or facet arthropathy) that can lead to this type of spondylolisthesis
    • traumatic
      • rare, results from fracture of any part of the neural arch or pars that leads to listhesis
    • pathologic (type 5)
      • results from a generalized bone disease, such as Paget disease or osteogenesis imperfecta
    • post-surgical / iatrogenic complications (type 6)


  • grade of slippage in the sagiital plane:
    • Grade 1 - Less than 25% of vertebral diameter
    • Grade 2 - 25-50%
    • Grade 3 - 50-75%
    • Grade 4 - 75-100%
    • Spondyloptosis - > 100% ⇒ trunk shortening

Mx of the young adult with isthmic spondylolisthesis

  • surgical fusion MAY be indicated if high grade slip >50%, neurologic involvement, traumatic aetiology, or likely to progress to high grade slip:
    • age < 15 years
    • females
    • ligamentous laxity
    • type 1 dysplastic slip
    • lumbosacral hypermobility
  • most will not have surgery and be advised to modify activities

possible indications for surgery in the older adult

  • high grade slip >50%
  • neurologic involvement with signs
  • traumatic or iatrogenic aetiology
  • Type 1 and type 2 slips, with evidence of instability, progression of listhesis, or lack of response to conservative measures
  • Type 3 (degenerative) listhesis with gross instability and incapacitating pain
  • Postural deformity and gait abnormality1)
spondylolisthesis.txt · Last modified: 2021/11/11 05:07 by gary1

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