eMedicine Specialties > Orthopedic Surgery > Spine

Spondylolisthesis, Spondylolysis, and Spondylosis: Follow-up

Author: Amir Vokshoor, MD, Staff Neurosurgeon, Department of Neurosurgery, Spine Surgeon, Diagnostic and Interventional Spinal Care, St John's Health Center
Contributor Information and Disclosures

Updated: Jan 12, 2009

Outcome and Prognosis

Lumbar fusion is being performed with more frequency across the United States, with considerable regional variation. These variations have been attributed to a multitude of factors, from advancements in instrumentation to the understanding of bone healing. Lack of clearly defined indications for fusion has been another contributing factor. The evidence in support of fusion for spondylolistheses types I, II, IV, and V and iatrogenic spondylolisthesis is strong. Some controversy exists regarding persons with degenerative-type slips (type III), degenerative scoliosis, and mechanical back pain.

Very few prospective randomized trials are assessing the long-term outcome of lumbar fusion in these patients. Variables used to evaluate the effectiveness of this procedure have included patient level of function, pain, satisfaction, return to work, and quality of life. Radiographic confirmation of fusion, complications, and cost are other important criteria in the evaluation of the overall outcome.

Zdeblick et al performed a prospective randomized study, which confirmed that the addition of rigid posterior instrumentation increases the rate of fusion and correlates with less pain and a greater rate of returning to work.10,11

In contrast, Franklin retrospectively evaluated the outcome of lumbar fusion in patients receiving Workers' Compensation in Washington state. They found 68% of patients experienced worsening of back and leg pain, and 56% reported their quality of life had not improved or was worse. They concluded that the use of instrumentation doubled the risk of a second surgical procedure. Ironically, 62% reported they would undergo the surgery again. The influence of psychosocial factors must be considered in any outcome study, and this retrospective study demonstrates that indeed it is difficult to ascertain whether a poor result is due to inappropriate patient selection process, surgical procedure, or failure of outcome measurement. Prospective studies with clearly defined diagnostic categories would probably produce the greatest improvement to the outcome of lumbar fusions.12

In a prospective study of degenerative slips, Herkowitz showed that an attempted fusion gave better clinical outcomes than decompression alone.13

The results on isthmic-type spondylolisthesis have been the most promising. Most investigators report a 75-95% rate of good-to-excellent outcome. Most patients undergoing surgery report an improvement in the quality of life and level of pain. Surprisingly, the outcome in most studies does not correlate with the degree of spondylolisthesis or the slip angle. Some long-term follow-up studies support conservative treatment of asymptomatic children and teenagers with spondylolisthesis (type I, type II), regardless of the grade; however, most investigators advocate fusion when the slip is symptomatic, unresponsive to conservative measures, or when it is high grade.

Future and Controversies

As the understanding of spinal instability and biology of bone healing increases, we will be able to better define the population of patients with spondylolisthesis that would benefit most from lumbar fusion or particular methods of fusion and fixation.

The production of bone morphogenic protein is only one of the promising ventures that undoubtedly will affect the outcome of lumbar fusion. Advances in technology allowing for better instrumentation are here, and more are anticipated. Artificial discs and lordotic tapered cage devices are 2 of these advances undergoing investigations; they clearly will affect the technical aspects of the operation. The use of bone growth stimulators is a potentially useful tool for higher fusion rates, although long-term studies are not yet available. Osteoinductive pastes and other semisolid mixtures have been introduced to the market; they also promise to enhance the success of this operation.

Although the technology continues to improve how surgery is performed, the most challenging task is simply optimal patient selection. As the authors stated earlier, clear indications for fusion must be present in order to optimize outcome, and controversies still exist especially in the treatment of degenerative spondylolisthesis, which must be resolved in a methodic and scientific manner. Prospective randomized studies with independent evaluators probably will produce the greatest improvement to the outcome of lumbar fusions.

 
Acknowledgments

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References
Further Reading
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Keywords

spondylolisthesis, spondylolysis, spondylosis, subluxation, spondyloptosis, spine, vertebra, vertebrae, spinal instability, radiculopathy, neurogenic claudication, postural abnormality, gait abnormality, slip progression, back pain

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Contributor Information and Disclosures

Author

Amir Vokshoor, MD, Staff Neurosurgeon, Department of Neurosurgery, Spine Surgeon, Diagnostic and Interventional Spinal Care, St John's Health Center
Amir Vokshoor, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Medical Association, and North American Spine Society
Disclosure: Nothing to disclose.

Medical Editor

Lee H Riley III, MD, Chief, Division of Orthopedic Spine Surgery, Assistant Professor, Departments of Orthopedic Surgery and Neurosurgery, Johns Hopkins University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

William O Shaffer, MD, Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington
William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; No present Industry grants or funds. None None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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