Treatment Options for Spondylolisthesis

Surgery for Spondylolisthesis

Surgery for spondylolisthesis is recommended only when conservative therapy has not been effective, symptoms progress, and pain is unremitting leading to significant disruption of quality of life.

The goals of surgery include:

• Relieve pressure or compression of the affected nerves
• Stabilize the vertebrae by fusion to prevent further slippage, thus preventing further nerve pressure
• Restore spinal alignment

The indications for surgery in adults with spondylolisthesis include:

• Failure of conservative therapy and continuation of severe symptoms

• Presence of symptoms and radiographic signs of instability including:

  • documented slip progression greater than Grade II
  • documented Grade III or Grade IV slip in a symptomatic patient who has failed nonoperative treatment
  • documented symptomatic spondyloptosis (L5 vertebra slides completely over the sacrum)
  • radiculopathy

  • neurogenic claudication (a combination of low back pain, leg pain, numbness, and motor weakness caused by compression of spinal nerve roots)

  • Progressive neurological deficit, especially the presence of bowel or bladder dysfunction

  • Postural or gait abnormalities

Indications for surgery in children with spondylolisthesis include:

• A slip greater than 50% which has shown progression
• Progression of a slip between 25-50% whether or not the child is symptomatic (this is the most common reason for surgery)
• Progressive or persistent neurological symptoms such as pain in the lower back and into the legs that is unresponsive to physical therapy
• Gait or postural abnormalities unresponsive to physical therapy

Surgical management of spondylolisthesis varies and there is still debate among surgeons about the best approach to surgery (e.g., posterior, anterior, or posterolateral; with instrumentation or without; combination of surgical procedures or separate procedures).

There are risks and benefits that are associated with each surgical procedure. Some factors that the surgeon and the patient may consider before deciding which procedure to choose include:

• Subsequent risks of progression if more conservative or less aggressive treatment is followed
• The exact type and grade of spondylolisthesis and the positioning of the vertebrae involved in the slip
• The amount of risk that patients and their families can tolerate that is associated with each surgical procedure being considered
• The patient's ability to handle the recuperation period as well as the social and psychological factors involved with undergoing surgery
• How much experience the surgeon has in performing each of the procedures being considered

Contraindications for surgery for spondylolisthesis include:

• A patient in poor medical health
• A person who cannot stop anticoagulation medication temporarily
• Smokers who cannot commit to stop smoking before surgery. Smokers have considerably reduced chances for favorable outcome from surgery.

Risks of any spinal surgery include:

• Bleeding (1-3% risk)
• Infection (1-3% risk)
• Pain does not subside following the surgical procedure

Instrumentation in Surgery for Spondylolisthesis

Instrumentation in surgery for spondylolisthesis is used to achieve better fusion rate and improve stabilization of the spine. It is associated with better outcomes, especially when used in fusion surgery combined with decompression (see below). It involves the implantation of special devices, including rods, hooks, wires, plates, screws, and more recently threaded interbody titanium cages that hold the disks apart and results in better fusion. Instruments may be made of titanium, titanium-alloy, stainless steel, or non-metallic components.

Some of the complications association with use of instrumentation includes:

• Greater blood loss
• Longer operating time

For this reason, there continues to be debate regarding the use of instrumentation in various surgical procedures and techniques are constantly being improved to minimize these risks.