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Surgery is usually only recommended when symptoms progress and pain is unremitting, leading to significant disruption in the lifestyle of the patient and all conservative treatment options have been exhausted.

The goals of surgery include:

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

The indications for surgery in adults with spondylolisthesis include:

• Failure of an adequate trial of conservative therapy

• Presence of symptoms and/or radiographic instability

  • 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)
  • radicular pain that is unresponsive to other treatments
• Progressive neurological deficit, especially the presence of bowel or bladder dysfunction

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 signs
• Back or leg symptoms unresponsive to physical therapy
• Gait or postural abnormalities unresponsive to physical therapy

The surgical management of spondylolisthesis varies and there is still debate among surgeons over the best approach to surgery (e.g., posterior, anterior, or posterolateral; with instrumentation or without; combination of surgical procedures or separate procedures). Some of the surgical options that may be considered alone or in combination, include:

• Direct repair of the defect
• Fusion surgery
• Decompression surgery
• Reduction of the isthmic deformity

There are risks and benefits that are associated with each of the following surgical procedures. Some factors that the surgeon may consider include:

• 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 are associated with each surgical procedure being considered
• Subsequent risks of progression if more conservative or less aggressive treatment is followed
• How much experience the surgeon has in performing each of the procedures being considered

Direct Repair of the Defect

This type of surgery is most successful in young adults with spondylolisthesis who have not had successful treatment with bracing and show no signs of degenerative disease. It involves debridement (surgical removal) of the lytic bone and the use of instrumentation (wires or screws) to repair the pars. Good to excellent results have been reported in up to 80% of patients who undergo this procedure.

Fusion Surgery

This type of surgery is also called arthrodesis or spinal fusion surgery. This is performed to stabilize two adjoining vertebrae at the slip level. It may be done alone or in combination with decompression surgery.

In fusion surgery, two or more vertebrae are fused together by placing a bone graft around the spine in the effected area. The body slowly heals the graft over several months and "welds" the vertebrae together. The bone graft used may be taken either from the patient (autograft) or from a bone bank (allograft). Fusion may involve the use of instrumentation (e.g. plates, screws, rods, cages) which is used as an internal splint to stabilize the spine and vertebrae while healing as well as to correct spinal deformity.