History and Physical Examination
The clinical presentation differs, depending on the type of slip and the age of the patient.
During the early years of life, the presentation is one of mild low back pain that occasionally radiates into the buttocks and posterior thighs, especially during high levels of activity. The symptoms rarely correlate with the degree of slippage, though they are attributable to segmental instability.
Neurologic signs often correlate with the degree of slippage and involve motor, sensory, and reflex changes corresponding to nerve-root impingement (usually S1). Progression of listhesis in these young adults usually occurs in the setting of bilateral pars defects and can be associated with the following physical findings:
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Palpable stepoff in higher-grade slips
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Restricted spinal motion
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Hamstring tightness
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Inability to flex the hips with fully extended knees
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Hyperlordosis of the lumbar and thoracolumbar regions
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Hyperkyphosis at the lumbosacral junction (as the center of gravity shifts to compensate for slip progression)
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Trunk shortening when a complete slip is present (spondyloptosis)
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Gait difficulty (worse with high-grade slips)
The patient with degenerative spondylolisthesis is typically older and presents with back pain, radiculopathy, neurogenic claudication, or a combination of these symptoms. The slip is most common at L4-5 and less common at L3-4. The radicular symptoms often result from lateral recess stenosis from facet and ligamentous hypertrophy, disk herniation, or both. The L5 nerve root is affected most commonly and causes weakness of the extensor hallucis longus. Concomitant central stenosis and neurogenic claudication may or may not exist.
The cause of claudication symptoms during ambulation is multifactorial. The pain is relieved when the patient flexes the spine by sitting or by leaning on shopping carts. Flexion increases canal size by stretching the protruding ligamentum flavum, reducing the overriding laminae and facets, and enlarging the foramina. This relieves the pressure on the exiting nerve roots and thus decreases the pain.
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Spondylolisthesis, spondylolysis, and spondylosis. Isthmic spondylolisthesis (type IIa) with grade 2 slippage of L5 over S1 and spondylolysis (lytic pars defect) is depicted posteriorly.
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Spondylolisthesis, spondylolysis, and spondylosis. Although interbody devices afford immediate stability to anterior column, their use as standalone devices has been associated with pseudoarthrosis. Thus, concomitant posterior fixation is often used to augment their stability.
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Spondylolisthesis, spondylolysis, and spondylosis. Use of direct electrical current for stimulation of fusion has been advocated by some to enhance fusion rates in patients at risk for pseudoarthrosis (ie, persons who smoke).
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Spondylolisthesis, spondylolysis, and spondylosis. Spontaneous reduction of slip (either partial or complete) has been reported by surgeons using interbody grafts after complete disk excision. In this case, reduction was achieved immediately after placement of carbon fiber interbody device packed with autologous bone. Cage is outlined in image.
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Spondylolisthesis, spondylolysis, and spondylosis. Carbon fiber interbody cage used in reduction of slip.
