Lumbar Spondylolysis and Spondylolisthesis Treatment & Management
- Author: Beth B Froese, MD; Chief Editor: Stephen Kishner, MD, MHA more...
Most patients with low-grade isthmic spondylolisthesis and degenerative spondylolisthesis can be treated conservatively. If an isthmic lesion is acute, the patient should be restricted from provocative activities or sports until they are asymptomatic. Physical therapy is an integral part of the patient's rehabilitation process. The most accepted protocol includes activity and exercise that reduces extension stress.
The goals of exercise are to improve abdominal strength and increase flexibility. Since tight hamstrings are almost always part of the clinical picture, appropriate hamstring stretching is important. Instruction in pelvic tilt exercises may help reduce any postural component causing increased lumbar lordosis. Myofascial release may play a role as well in reducing pain from the surrounding soft tissues.
If conservative treatment is indicated for congenital spondylolisthesis, the above principles apply. Adequate work up must be completed for pathologic causes of spondylolisthesis prior to treating with conservative means. Traumatic spondylolisthesis most often requires surgical stabilization.
Younger patients have a higher risk for progression of isthmic or congenital spondylolisthesis. Serial radiographic studies (standing lateral films only) should be performed every 6 months to follow these patients. Progression rarely occurs after adolescence. Patients with a unilateral pars defect may be prone to developing a contralateral pars defect with extension stress. Patients with degenerative spondylolisthesis are often older and have coexisting medical issues that must be taken into consideration when deciding appropriate treatment.
Surgical treatment is indicated when any type of spondylolisthesis is accompanied by a neurologic deficit. Persistent disabling back pain after conservative management may be considered an indication. High-grade slips (greater than 50%) more commonly require surgical intervention. Traumatic spondylolisthesis is rare but almost always requires surgical stabilization.
A literature review by Longo et al suggested that in patients with high-grade spondylolisthesis, surgical treatment with reduction followed by arthrodesis may be more beneficial than arthrodesis in situ. The report was based on eight studies, involving a total of 165 operations in which reduction was performed prior to arthrodesis and 101 surgeries in which patients underwent arthrodesis in situ, with no reduction performed. The investigators found that in the patients treated first with reduction, the percentage of slippage and slip angle and the frequency of pseudarthrosis were significantly lower than in the arthrodesis in situ patients. Moreover, there was no significant difference between the two groups with regard to the prevalence of neurologic deficits.
See the list below:
Bracing for acute isthmic spondylolysis/spondylolisthesis is controversial, but it has been shown in some studies to reduce symptoms and to facilitate healing. Most sources discuss use of a thoracolumbosacral spinal orthosis or modified Boston Brace for low-grade slips or for isolated spondylolytic lesions (without spondylolisthesis). Some sources advocate more extensive bracing with inclusion of most of the thorax (to the nipple line) and the thighs. Recommend use of the device for 3-6 months. 
Steroid injections for pars pain have been advocated by some physicians. Epidural steroid injections may help radicular pain or neurogenic claudication.
Matsudaira et al tested the effectiveness of limaprost, an oral prostaglandin E1 derivative, against that of etodolac, a nonsteroidal anti-inflammatory drug (NSAID), in improving the health-related quality of life in patients with symptomatic lumbar spinal stenosis.  In a randomized, controlled trial, 66 patients suffering from central stenosis with acquired, degenerative lumbar spinal stenosis, along with neurogenic intermittent claudication and bilateral leg numbness related to the cauda equina, were administered a daily dose of limaprost (15 μg) or etodolac (400 mg) for 8 weeks. The results indicated that limaprost was more effective than etodolac in improving patients' physical functioning, vitality, and mental health, and in reducing pain and leg numbness.
Treatment for degenerative spondylolisthesis may include bracing, facet or epidural steroid injections, along with the above mentioned physical therapy approach.
Niggemann P, Kuchta J, Beyer HK, Grosskurth D, Schulze T, Delank KS. Spondylolysis and spondylolisthesis: prevalence of different forms of instability and clinical implications. Spine (Phila Pa 1976). 2011 Oct 15. 36(22):E1463-8. [Medline].
Wiltse LL. Spondylolisthesis: classification and etiology. Symposium of the Spine. Am Acad Orthop Surg. 1969. 143.
Grobler LJ, Wiltse LL. Classification, and nonoperative and operative treatment of spondylolisthesis. Frymoyer's The Adult Spine: Principles and Practice. 2nd ed. Philadelphia, Pa: Lippincott; 1997. 1865-921.
Huang KY, Lin RM, Lee YL, et al. Factors affecting disability and physical function in degenerative lumbar spondylolisthesis of L4-5: evaluation with axially loaded MRI. Eur Spine J. 2009 Jun 14. [Medline].
Beutler WJ, Fredrickson BE, Murtland A, et al. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine. 2003 May 15. 28(10):1027-35; discussion 1035. [Medline].
d'Hemecourt PA, Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med. 2000 Oct. 19(4):663-79. [Medline].
Comstock CP, Carragee EJ, O'Sullivan GS. Spondylolisthesis in the young athlete. The Physician and Sportsmedicine. 1994. 22(12):39-46.
Rossi F. Spondylolysis, spondylolisthesis and sports. J Sports Med Phys Fitness. 1978 Dec. 18(4):317-40. [Medline].
Sairyo K, Katoh S, Sasa T, et al. Athletes with unilateral spondylolysis are at risk of stress fracture at the contralateral pedicle and pars interarticularis: a clinical and biomechanical study. Am J Sports Med. 2005 Apr. 33(4):583-90. [Medline].
Kruse D, Lemmen B. Spine injuries in the sport of gymnastics. Curr Sports Med Rep. 2009 Jan-Feb. 8(1):20-8. [Medline].
Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. 2004 Feb. 86-A(2):382-96. [Medline].
Oh JY, Liang S, Louange D, Rahmat R, Hee HT, Kumar VP. Paradoxical motion in L5-S1 adult spondylolytic spondylolisthesis. Eur Spine J. 2011 Jun 15. [Medline].
Peterson JB, Wenger DR. Asymmetric spondylolisthesis as the cause of childhood lumbar scoliosis--can new imaging modalities help clarify the relationship?. Iowa Orthop J. 2008. 28:65-72. [Medline]. [Full Text].
Sakai T, Goda Y, Tezuka F, et al. Clinical features of patients with pars defects identified in adulthood. Eur J Orthop Surg Traumatol. 2015 Dec 13. [Medline].
Sairyo K, Sakai T, Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing. J Bone Joint Surg Br. 2009 Feb. 91(2):206-9. [Medline].
Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am. 1999 Jul. 30(3):487-99, ix. [Medline].
Longo UG, Loppini M, Romeo G, et al. Evidence-based surgical management of spondylolisthesis: reduction or arthrodesis in situ. J Bone Joint Surg Am. 2014 Jan 1. 96(1):53-8. [Medline].
Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine. 1985 Dec. 10(10):937-43. [Medline].
Matsudaira K, Seichi A, Kunogi J, et al. The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis. Spine. 2009 Jan 15. 34(2):115-20. [Medline].
Joaquim AF, Milano JB, Ghizoni E, Patel AA. Is There a Role for Decompression Alone for Treating Symptomatic Degenerative Lumbar Spondylolisthesis?: A Systematic Review. J Spinal Disord Tech. 2015 Dec 24. [Medline].
Whitesides TE Jr, Horton WC, Hutton WC, et al. Spondylolytic spondylolisthesis: a study of pelvic and lumbosacral parameters of possible etiologic effect in two genetically and geographically distinct groups with high occurrence. Spine. 2005 Mar 15. 30(6 Suppl):S12-21. [Medline].