Last updated January 5, 2022

Diagnosis And Treatment Of Adult Isthmic Spondylolisthesis

Recommendations

DEFINITION AND NATURAL HISTORY

Isthmic spondylolisthesis is the anterior translation of one lumbar vertebra relative to the next caudal 17 segment as a result of an abnormality in the pars interarticularis. When symptomatic, this causes a 18 variable clinical syndrome of back and/or lower extremity pain, and may include varying degrees of 19 neurologic deficits at or below the level of the injury. (, )
(Work Group Consensus Statement)
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Spondylolisthesis occurs in 40% to 66% of patients with bilateral spondylolysis. Spondylolisthesis is unlikely to occur in patients with unilateral spondylolysis. (B: Suggested)
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DIAGNOSIS AND IMAGING

There is insufficient evidence to make a recommendation for or against the use of palpation in the physical exam diagnosis of adult patients with isthmic spondylolisthesis. (Insufficient)
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Approximately half of adult patients with symptomatic isthmic spondylolisthesis will have a positive straight leg test on examination. (B: Suggested)
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In adult patients with symptomatic isthmic spondylolisthesis, most patients present with low back pain and at least half present radicular lower extremity pain. (B: Suggested)
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There is a relative paucity of high quality studies on imaging in adult patients with isthmic 23 spondylolisthesis. It is the opinion of the work group that in adult patients with history and physical 24 examination findings consistent with isthmic spondylolisthesis, standing plain radiographs, with or without oblique views or dynamic radiographs, be considered as the most appropriate, noninvasive test 2 to confirm the presence of isthmic spondylolisthesis. In the absence of a reliable diagnosis on plain 3 radiographs, CT scan is considered the most reliable diagnostic test to diagnose a defect of the pars 4 interarticularis. In adult patients with radiculopathy, MRI should be considered. (, )
(Work Group Consensus Statement)
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MRI is suggested to identify neuroforaminal stenosis in adult patients with isthmic spondylolisthesis. (B: Suggested)
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There is insufficient evidence to make a recommendation for or against the use of MRI to differentiate isthmic versus degenerative spondylolisthesis in adult patients. (Insufficient)
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There is insufficient evidence to make a recommendation for or against the use of discography to evaluate adult patients with isthmic spondylolisthesis. (Insufficient)
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CT may be considered as an option to diagnose isthmic spondylolisthesis in adult patients. (C: Optional)
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There is insufficient evidence to make a recommendation for or against the use of SPECT in evaluating isthmic spondylolisthesis in adult patients. (Insufficient)
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Adult patients with a diagnosis of isthmic spondylolisthesis have a higher pelvic incidence, sacral slope, pelvic tilt and lumbar lordosis compared to patients without isthmic spondylolisthesis. (B: Suggested)
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MEDICAL/INTERVENTIONAL TREATMENT

There is insufficient evidence to make a recommendation for or against the use of physical therapy/ exercise for the treatment of isthmic spondylolisthesis. (Insufficient)
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There is insufficient evidence to make a recommendation for or against the use of 6 medical/interventional treatment for the long-term management of patients with isthmic spondylolisthesis. (Insufficient)
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SURGICAL TREATMENT

There is insufficient evidence to make a recommendation for or against the efficacy of surgical 14 treatment as compared to medical/interventional alone for the management of adult patients with isthmic spondylolisthesis. (Insufficient)
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In patients with low-grade isthmic spondylolisthesis, the addition of instrumentation may not improve outcomes in the setting of posterolateral fusion, with or without decompression. (B: Suggested)
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Posterolateral fusion and 360° fusion surgeries are recommended to improve the clinical outcomes in adult patients with low grade isthmic spondylolisthesis. (A: Recommended)
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360° fusion is recommended to provide higher radiographic fusion rates compared to posterolateral fusion in adult patients with low grade isthmic spondylolisthesis. (A: Recommended)
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There is conflicting evidence whether 360° fusion provides better clinical outcomes than posterolateral fusion alone. (Insufficient)
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Anterior lumbar interbody fusion (ALIF) may be considered as an option to indirectly decompress foraminal stenosis in adult patients with low grade isthmic spondylolisthesis. (C: Optional)
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In adult patients undergoing ALIF, supplemental posterior percutaneous pedicle screws lead to shorter 18 hospital stays, less operation room time and less blood loss compared to open posterior instrumentation. (B: Suggested)
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There is conflicting evidence whether in adult patients undergoing ALIF, supplemental posterior 22 percutaneous pedicle screws lead to comparable clinical outcomes to those undergoing open posterior instrumentation. (Insufficient)
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There is insufficient evidence to make a recommendation regarding the degree of radiological grade, 11 sagittal spinopelvic alignment, sacral and spinopelvic parameters, or the presence of dynamic instability on the outcomes of adult patients undergoing surgical treatment for isthmic spondylolisthesis. (Insufficient)
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In adult patients undergoing surgical treatment for isthmic spondylolisthesis, fusion is suggested to provide long term clinical improvements. (B: Suggested)
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There is insufficient evidence to indicate that fusion leads to improved long term outcomes as compared with a directed exercise program. (Insufficient)
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There is insufficient evidence to recommend one surgical fusion technique over another to improve long term outcomes in adult patients undergoing surgical treatment for isthmic spondylolisthesis. (Insufficient)
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There is insufficient evidence to determine the clinical significance of adjacent segment degeneration on the long term outcomes of fusion. (Insufficient)
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There is insufficient evidence to make a recommendation regarding which prognostic factors have been associated with good or poor outcomes. (Insufficient)
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Recommendation Grading

Overview

Title

Diagnosis And Treatment Of Adult Isthmic Spondylolisthesis

Authoring Organization

Publication Month/Year

December 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient

Scope

Assessment and screening, Diagnosis, Rehabilitation, Management, Treatment

Diseases/Conditions (MeSH)

D013168 - Spondylolisthesis

Keywords

Adult spondylolisthesis, Isthmic spondylolisthesis, Spondylolisthesis, Spondylolytic spondylolisthesis