Further Outpatient Care
See the list below:
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Because risk of progression exists in younger patients with isthmic or congenital spondylolisthesis, obtain serial radiographs on a semiannual basis to rule out the possibility of progression if symptoms are persistent.
Inpatient & Outpatient Medications
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Anti-inflammatories and other analgesics are the only medications used in the care of patients with spondylolysis or spondylolisthesis.
Deterrence
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Prevention of isthmic spondylolisthesis may be difficult in athletes who must perform repetitive activities requiring hyperextension. [12] The best prevention is to avoid repetitive hyperextension if at all possible, since this activity appears to place athletes at the greatest risk.
Complications
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The most common complication of spondylolisthesis of any type is nerve root impingement/radiculopathy at the level of spondylolisthesis. Spinal stenosis and cauda equina syndrome may occur when a significant slip has occurred.
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Disk degeneration occurs at the level of the spondylolisthesis faster than at other levels of the spine, increasing the risk of diskogenic low back pain.
Prognosis
In general, patients with grade 1 or grade 2 isthmic slips do quite well with conservative management. Patients may return to play once they are asymptomatic. A flexion-based home exercise protocol is vital. Overall long-term outcome is quite favorable, specifically with lower grades of listhesis not accompanied by neurologic impairment.
A literature review by Overley et al found that among adolescent athletes with symptomatic spondylolysis but without spondylolisthesis, rate of return to play after nonoperative treatment was 92.2%, compared with 90.3% after surgical management. [23]
A study by Tatsumura et al found that in patients of high school age or below with lumbar spondylolysis who underwent conservative treatment, the vertebral lesions had a 76.2% union rate. More specifically, in unilateral cases, in which only one side of the vertebra was affected, the union rate was higher than in bilateral cases, at 95.8% versus 75.5%, respectively. [24]
A study by Yamazaki et al indicated that in pediatric and adolescent athletes with spondylolysis, the likelihood of bone healing is negatively impacted by a high defect stage, a high contralateral pars interarticularis defect stage, and poor flexibility. For example, for very early stage contralateral pars interarticularis defect, the bony-union rate was 84.2%, compared with 37.1% for the progressive stage. [25]
Higher grades of isthmic spondylolisthesis have a variable prognosis with regard to persistent low back pain. Surgical intervention does provide nice improvement in claudication or radicular symptoms. Diskogenic pain may produce more persistent lower lumbar discomfort.
Patients with degenerative spondylolisthesis seem to have persistent waxing and waning pain originating from the facet joints. Surgical decompression for neurologic compromise has a high rate of success in relieving lower extremity symptoms. A literature review by Joaquim et al indicated that in degenerative lumbar spondylolisthesis, decompression alone, without instrumented fusion, may be a useful treatment in some patients. The data suggested, however, that long-term outcomes may be better with fusion. The investigators suggested that isolated fusion may not be suitable in patients with a facet angle of greater than 50°, a disk space of greater than 6.5 mm, low back pain (in contrast to lower extremity symptoms), hypermobility at the listhetic level (>1.25-2 mm) on dynamic radiographs, and resection of the posterior elements. [26]
A prospective, randomized, controlled trial by Inose et al reported that for low-grade (< 30%) degenerative lumbar spondylolisthesis, outcomes for decompression plus fusion or decompression plus stabilization were no better at 1- and 5-year follow-up than for decompression alone. [27]
However, a study by Haddas et al indicated that in patients with degenerative lumbar spondylolisthesis, decompression plus fusion surgery significantly improves stance stability. The investigators reported that following treatment, range of sway for the center of mass and head were reduced in the sagittal, coronal, and axial planes, with total sway for the center of mass and head also decreased. Nonetheless, total sway did not shrink to the levels of normal controls, and range of sway in the sagittal head was also greater than in controls. [28]
Patient Education
See the list below:
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Instruction regarding an appropriate home exercise program, including a flexion-based spine exercise protocol and hamstring stretching, should be a part of treatment.
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Radiograph of the lumbosacral junction showing a grade 1 spondylolytic spondylolisthesis at L5-S1.
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Lumbar oblique radiograph showing the "Scottie Dog." A pars defect is seen at L5.
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Bone scan with single-photon emission computed tomography (SPECT) imaging showing acute spondylolysis
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Axial computed tomography (CT) scan shows bilateral spondylolysis. Note elongation of the spinal canal at this level.
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Grade 4 traumatic spondylolisthesis.
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Diagram in the oblique projection shows the components of the vertebrae that result in the appearance of a Scottie dog with a collar.
