Talk:Spondylolisthesis/Archive 1

Informative
Just wanted to say great article. I was diagnosed with grade 2 of the L5 back in September after years of back back. Let me tell you, it was nice to at least have a reason for my own piece of mind. Some parts are a bit frightening such as the section on escalation into paralysis of the lower limbs. How rare is this? --MWillMS 21:52, 13 February 2007 (UTC)

Concern about recent edits
While the anonymous edits on April 26, 2007 (comparison) added much substance to the treatment section, I am concerned that: Badgettrg 14:18, 3 May 2007 (UTC)
 * These edits deleted the only references to MEDLINE, including an attempted meta-analysis and two other references.
 * The new content, while noting authors names, is not linked with references
 * The content is pretty dense without topic sentences to help the reader through the long paragraphs.
 * The author cites an older version of . I added the long term follow-up of this study.
 * I am not clear on the intent of the paragraph that starts 'The success of stand-alone posterolateral fusion...' It appears to cite studies of fusion alone for patients with both back and radicular symptoms. As the randomized controlled trial in its preceding paragraph included such patients and the two studies the author cites are uncontrolled case series, I proposed this paragraph be deleted. A comment from the author would help in case I misunderstood the intent. For now I have prepended this paragraph so it starts with 'Uncontrolled studies have focused on the role of fusion in patient with both back pain and radicular pain.' I have isolated this edit so it can be reverted.

Addressing your concerns

 * The intent of the paragraph that starts 'The success of stand-alone posterolateral fusion...' was to give the readers some background as to why several different authors, including Eugene Carragee and de Loubresse, chose to study the difference between decompression with posterolateral fusion (PLF) to PLF alone. Given both existing practice patterns and the prevailing theories on the causes of radiculopathy in cases of isthmic spondy, it may seem counterintuitive that several authors chose to study laminectomy with PLF vs PLF alone expecting that PLF alone would result in better outcomes. This paragraph attempts to give some of the background that led to this interesting finding, but I agree that it may be confusing to some readers.
 * As I am new to wikipedia, I inadvertently deleted some citations while typing the article, I apologize for this. However, the attempted meta-analysis was centered on spinal stenosis with some reference to degenerative spondylolisthesis and does not effectively review the literature on isthmic spondylolisthesis.
 * Also, I will attempt to begin adding references besides the bibliography that follows the article. Is there a quicker way to add citations besides manually typing the code?
 * With respect to citing vs, I cited the earlier study in my article and not the longer-term study (originally) for a few reasons. I have not been able to obtain a full version of  and without in-depth evaluation of the article, it is difficult for me to accurately interpret their findings. Also, factors such as patient attrition, regression towards the mean, and possibly, the natural history of the disorder may have diminished the measured differences in outcome, even if a difference persists. Also, the short-term differences were highly significant and something of a landmark study for isthmic. I feel these results deserve mention. Finally, some of the descriptions within the abstract of , such as deterioration in DRI scores, but not ODI scores raises questions about the reliability of the findings. Nevertheless, 15653083 does have some validity and I feel that the results of both studies should be mentioned.
 * I agree that the article is very dense and is aimed towards those with a medical background. I believe that the topic is difficult to address accurately without this density, especially in the light of evolving controversies and the numerous unknowns concerning this interesting disorder. I will attempt to simplify portions of it, especially the section of High-grade isthmic.
 * Finally, I retained very little of the old arcicle because almost nothing withn the article was accurate. I also feel that it painted a rather sinister picture for isthmic spondylolisthesis and led many readers to believe that surgery is a must when very few patients with this disorder have surgery. The risk of paralysis from isthmic spondylolisthesis is such a rare event that instances would require a case report (except for Hangman's fracture) and very, very few case reports of this complication have been published.

nicholas.pirnia@gmail.com
 * Thank you for your feedback. Nicholas Pirnia MD - Orthopaedic surgery resident

Great article- if the reader happens to be a physician or chiropractor
This article makes no sense to the typical layman. It reads like something out of a medical journal. No, even THAT'S not true; even I have been able to read articles from a medical journal. This article is not the kind of article that one would ever find in an encyclopedia. An encyclopedia is supposed to be something that is readable by all people. This article is EXLUSIVE. Slater79 19:11, 30 May 2007 (UTC)

Although most of us want clear language in articles we read, I doubt that you really want articles written at the level of a 12 year old. Such simplistic articles can be easily found with a Google search and read like the pamphlets you find in MD's waiting rooms. A Wiki article on spondylolisthesis using simple language would have a title such as "lower back pain" and not spondylolisthesis. Anybody searching or clicking on "spondylolisthesis" will be seeking more advanced concepts and will already have some knowledge of spinal anatomy, physiology, pathology, and the jargon that goes with it such as "anterior" instead of "front". To replace technical words with simple words in the present article would destroy it and will be reverted. However, it might be useful to have a "See also" article that uses simple concepts and language. You could reference it with the words: "For an explanation in simple words, see ". Greensburger 22:37, 30 May 2007 (UTC)

The article is informative and appropriate for Wikipedia I believe. I agree with the previous post.I've been reading around the subject of back conditions in general as a sufferer of back pain for some time. This week I was diagnosed rather hastily by a spinal surgeon as having Spondylolisthesis. The subject was most clearly defined within the six top google searches I read. The x-ray nicely mirrors mine, maybe a MRI scan image would be beneficial. My background: former psychology degree student, so some basic anatomy and some number of hours spent as aforementioned reading about back conditions. But I feel that this article is suitable for individuals who require something more than a basic level of understanding of Spondylolisthesis. —Preceding unsigned comment added by Chesh1975 (talk • contribs) 11:35, 6 February 2010 (UTC)

Obstructed vagina? Sounded fishy to me, but...
The line in the first paragraph about spondylolisthesis obstructing patients' vaginas sounded anatomically improbable to me. I was sure it was vandalism, but I checked it out first. What do you know: it is true. Obviously, I am not an anatomist! I provided a reference, and am writing this note for future editors who might likewise suspect vandalism. --Ginkgo100talk 16:12, 24 June 2009 (UTC)

Treatment, Post-Treatment, and Follow up
Editors of this article and any expert are invited to add details regarding:

Treatment Outcome, does the patient fully recover (under section "Conservative Management")?

Any Post-treatment, especially for Cartilage "re-invigoration"?

The possibility, then, for the MRI, to show, not the Cartilage structural anomaly, but "texture" and composition anomaly.

Cheers.--Connection (talk) 13:31, 29 June 2013 (UTC)

Rewrite
This is a fantastic article, however I have edited it accordingly:
 * Reordered to introduce the classification initially and orient the viewer.
 * Removed uncited material, particularly material that has remained uncited for 4+ years.
 * Summarised extensive discussions of studies into short segments. With proper citation, the reader can view the study results themselves. These studies, whilst valuable, by virtue of notability (Wikipedia: Notability Guidelines) do not merit such extensive discussion.
 * Attempted to reduce somewhat the discursive form of the article. LT90001 (talk) 02:37, 9 June 2013 (UTC)

I think http://orthoinfo.aaos.org/topic.cfm?topic=A00588 might be a good place to start rewriting with a focus on some basic foundations for this article. LT90001 (talk) 02:59, 9 June 2013 (UTC)

I will next begin removing uncited text. Sandy Georgia (Talk) 13:47, 28 January 2014 (UTC)
 * 1) New talk page posts go at the bottom of the page; I have moved LT's post.
 * 2) There is nothing remotely "fantastic" about an article which is uncited, has been for five years, was written from primary sources, and is a potential copyvio.
 * 3) The article had been tagged since December 2008 as being completely uncited; review of the talk page entries indicates that a good deal of the content was likely taken from one primary sources where the author mentions s/he forgot to add the citations when entering the text-- raising the possibility of copied content.
 * 4) This series of edits by LT incorrectly removed the tag indicating the article as uncited since 2008, and after citing a few statements, replaced it with a tag dated June 2013-- obscuring the fact that the article has been uncited for five years.  The December 2008 tag should not have been removed; I have restored the correct date and tag.

Grading
The most common grading system for spondylolisthesis is the Meyerding grading system for severity of slip; it categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This distance is reported as a percentage of the total superior vertebral body length:
 * Grade 1 is 0–25 percent
 * Grade 2 is 25–50 percent
 * Grade 3 is 50–75 percent
 * Grade 4 is 75–100 percent
 * Over 100 percent is spondyloptosis.

Low-grade isthmic
Isthmic spondylolisthesis refers to a degeneration of the pars interarticularis; when symptomatic, patients typically present with activity-related back pain and often with radicular symptoms as well.

Patients with low grade spondylolisthesis are usually young adults (90 percent adults and 10 percent adolescents) who present with low back pain and often with radiculopathy. High grade spondylolisthesis may also present with back pain, but may also present with cosmetic deformity, hamstring tightness, radiculopathy, abnormal gait, or it may be asymptomatic.

High-grade isthmic
High-grade isthmic spondylolisthesis and dysplastic spondylolisthesis are regarded as separate clinical entities from low-grade isthmic slips. High-grade slips are defined as those with greater than 50 percent forward displacement. These slips are also accompanied by a significant amount of lumbosacral kyphosis, which is forward bending of the L5 vertebral body over the sacral promontory. Rounding of the sacral body and trapezoidal deformation of L5 are also common features. High-grade slips are much rarer than low-grade slips, representing less than 10 percent of all isthmic slips, and the vast majority present during adolescence, most during the early teenage years.

Unlike low-grade slips, many patients present without pain. Instead symptoms like bodily deformity, neurologic abnormalities, tight hamstrings, and abnormal gait are often the reason for consultation.

Degenerative
Patients with isthmic spondylolisthesis almost universally have a neural arch defect, meaning widening of the central spinal canal at the level of the slip. In contrast, in degenerative spondylolisthesis the forward translation of the vertebral body also causes narrowing of the central spinal canal at the level of the slip, termed the "napkin ring effect" depecting the spinal canal as a series of napkin rings with one of the rings slid forward in comparison to the others. The classic symptomology of patients with symptomatic degenerative spondylolisthesis are similar to those with symptomatic lumbar spinal stenosis; either neurogenic claudication or radiculopathy (either unilateral or bilateral radiculopathy) with or without low back pain.

Neurogenic claudication is thought to result from central canal narrowing that is exacerbated by the listhesis (forward slip). The classic symptoms of neurogenic claudication are bilateral (both legs) posterior leg pain that worsens with activity, but is relieved by sitting or forward bending.

Pathophysiology
In the late 1890s, several cadaver studies demonstrated the characteristic pars defect of isthmic spondylolisthesis, leading to many different theories concerning the etiology of the defect. The first theory proposed a failure of ossification during embryonic development, leading to a pars defect at birth, which then progressed to an isthmic slip after the infant began ambulating. Following the development of the Roentgenogram in 1895, population X-ray studies showed that isthmic spondylolisthesis is, in fact, quite common.

Spondylolysis also runs in families and is more prevalent in some populations, suggesting a hereditary component, such as a tendency toward thin vertebral bone. For example, the frequency of spondylolisthesis among the Inuit has been found to be 30–50 percent, as compared with an incidence in the general population of 4–6 percent. It is theorized that the nomadic Inuit have a higher incidence of spondylolysis due to trauma acquired as infants by being carried in an amauti. While in an amauti, the baby is put into compressive extension with each step taken by the mother.

Pain. The cause of pain in patients with isthmic spondylolisthesis remains unclear. The first theory of pain production was segmental instability with excessive forward translation during flexion. however, this has not been demonstrated radiographically. A more contemporary theory of pain generation is excessive tension on the annulus of the inferior disc and foraminal stenosis at the level of the slip. However, this theory has not explained the variance in symptoms experienced by patients. Foraminal stenosis is also thought to play a role, but long-term studies on surgical outcome have shown that many patients have poor results following decompression alone. Though, most likely pain in patients with Spondylolisthesis is simply caused by the actual slippage of the disc in the spinal column.

Surgical
Degenerative spondylolisthesis with spinal stenosis is one of the most common indications for spine surgery among older adults, and evidence suggests that patients have much better success rates and more clinical benefit with decompression and fusion than with decompression alone.

Low-grade isthmic spondylolisthesis
Surgical treatment is only considered after at least 6 weeks and often only after 6–12 months of non-operative therapy has failed to relieve symptoms. Modalities of surgical treatment include:

Posterolateral fusion.

Posterolateral fusion in adult lumbar isthmic spondylolisthesis results in a significant improvement in 2-year outcomes, but the difference between surgical and nonsurgical treatment narrows with time. There has been one randomized controlled trial for low-grade isthmic spondylolisthesis that compared non-operative therapy to surgery. The study evaluated the severity of pain and limitations of daily function in patients with 'lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severely restricted functional ability in individuals 18 to 55 years of age'. At two years follow-up, patients who underwent surgery had significantly better scores for both pain and daily function. The benefits were reduced after nine years. Nevertheless, posterolateral fusion for isthmic spondylolisthesis has been one of the least controversial surgeries for spinal pathology and has consistently demonstrated good outcomes.

The success of stand-alone posterolateral fusion for treating adolescent isthmic spondylolisthesis led several authors, including Dr Leon Wiltse and Dr Eugene Carriagee, to speculate about the effectiveness of posterolateral fusion without a decompression for adult patients with both back and leg pain. In 1989, Drs. Peek and Wiltse, et al. reported on eight cases of adults with high-grade spondylolisthesis who presented with back pain and severe radicular pain. These patients were all treated with an in situ uninstrumented posterolateral fusion and followed for an average of 5.5 years. At final follow-up, all eight patients reported complete relief of their back pain and leg pain, no patients were taking analgesics for back pain, and all patients were unrestricted with respect to work and recreational activities. The mean time to complete resolution of symptoms was 2.8 months and all patients achieved a solid fusion. No patients underwent subsequent surgery for either back pain or leg pain throughout the follow-up period. This was the first report of excellent relief of leg pain in cases of isthmic spondylolisthesis from posterolateral fusion without decompression.


 * Fusion with decompression

The addition of decompression does not appear to improve clinical outcome in addition to fusion for the treatment of low-grade isthmic spondylolisthesis in patients without serious neurological deficit. A randomized controlled trial compared fusion with a decompression to fusion without a decompression in adult cases of isthmic spondylolisthesis. The study enrolled 42 patients and showed no benefit to performing a decompression for isthmic spondylolisthesis; in fact, patients undergoing decompression had worse clinical outcomes and a higher rate of pseudoarthrosis.

High-grade isthmic spondylolisthesis
There are several forms of surgery that have been advocated for the treatment of high-grade isthmic spondylolisthesis, including posterior interlaminar fusion, in situ posterolateral fusion, in situ anterior fusion (ALIF), in situ circumferential fusion, instrumented posterolateral fusion, and surgical reduction with instrumented posterior lumbar interbody fusion (iPLIF). Advocates of these different techniques all cite specific advantages of each approach, but they all have established risks and some are much more complication-prone than others.

The role of surgical reduction in the treatment of high-grade isthmic is a controversial topic. Advocates of surgical reduction state that fusion in situ leaves too much residual deformity and impairs the natural mechanics of the lumbar spine. Patients with high-grade isthmic tend to have hyper-lordosis of the lumbar spine that compensates for the lumbosacral kyphosis associated with the severe slip and many feel that this hyper-lordosis will lead to early arthritis and low back pain. Seitsalo, et al. reported on the largest, long-term cohort of adolescents operated on for high-grade isthmic spondylolisthesis with 87 patients and mean follow-up of 14 years. Of the patients, 54 had posterior interlaminar fusions, 30 had posterolateral fusion, and 3 had an anterior interbody fusion (ALIF). The authors found a significant progression of lumbosacral kyphosis in many of their patients. They also noted that patients undergoing single-level fusions had much worse outcomes (p<0.0001) and they recommend fusing patients to L4 in virtually all cases. The authors also concluded that the clinical outcome, while much better than prior to surgery, still left several patients with significant symptoms and progression of deformity. The authors felt that reduction may offer patients a better chance of excellent long-term outcomes.

Reduction became feasible with the development of pedicle screws, allowing the reduction to be maintained. Several authors have published the results of reduction with pedicle screws and posterior interbody fusion with posterolateral fusion. While the improvement in percent slipped and lumbosacral kyphosis is significant, many have noted a 10–20 percent rate of nerve root injury and a few cases reports of complete cauda equina, especially with complete reduction of the deformity. While many of these injuries improve, several patients are left with permanent deficits. The clinical outcomes after reduction and instrumentation do not appear to be significantly superior to fusion in situ using modern techniques, despite the higher complication rate. It should also be noted that recurrence of deformity is common after reduction and many patients will either bend their hardware or bend at the sacrum, which is often fully segmented during adolescence. These facts have tarnished the notion of reduction and instrumentation for high-grade slips, but the technique is still utilized with theoretical benefits and some authors, particularly Dr Harry Shufflebarger, has reported both low complication rates and good clinical outcomes. Dr. Shufflebarger currently performs reductions for all high-grade slips that are referred to him and is a leading advocate of the technique. It should also be noted that the use of pedicle screw fixation is much more extensive in the US than other countries and that these surgeons are somewhat more inclined to reduce patients, at least partially, while instrumenting. The routine use of pedicle screws for one or two level pediatric fusions (not long fusions for correcting scoliosis) is without proven benefit in clinical outcome or fusion rate, but is associated with more blood loss, increased rate of nerve root injury, and more cases of reoperation.

Until very recently, there was no data comparing the long-term outcome of reduction with instrumented fusion to an uninstrumented in situ fusion. Poussa, et al. recently published the first long-term follow-up report comparing reduction with instrumented posterolateral fusion to uninstrumented circumferential fusion in situ with a mean follow-up of 14.8 years, and concluded that reduction and instrumented fusion resulted in poorer long-term outcome than fusion in situ and that the deformity tended to recur following reduction. The increased risks and more extensive surgery associated with reduction did not translate into better outcomes or permanent correction of deformity.

In addition to the ongoing debate of reduction versus fusion in situ, there is also new evidence emerging as to what form of fusion is most effect for eliminating symptoms and controlling deformity. This discussion of surgical technique has been much enhanced recently by the publication of a long-term follow-up study comparing three different techniques of fusion in situ for treating high-grade spondylolisthesis. The study by Helenius, et al. compared the outcomes for posterolateral fusion, anterior interbody fusion (ALIF), and circumferential fusion that is a combination of posterolateral and anterior fusion. Anterior fusion is a relatively new technique to spine surgery, emerging during the last two decades. It involves either a retroperitoneal or transperitoneal (through the abdomen) approach to the lumbosacral junction with mobilization of the iliac arteries and veins. The surgeon then performs a total discectomy and places a bone graft into the intervertebral space; the graft is usually either a tricortical iliac crest or a femoral ring allograft. For circumferential fusion, after completing the anterior fusion, the patient is turned and a one or two level posterolateral fusion without instrumentation is performed. Circumferential fusion can either be performed under one run of general anesthesia with patient repositioning or the procedure can be staged. Helenius, et al. followed 70 patients for a mean period of 17 years who had been treated by one of the above procedures and concluded that circumferential fusion provided the best long-term outcomes among the three techniques with excellent long-term outcomes and a low complication rate.

Prognosis
The majority of low-grade slips are asymptomatic and do not progress past a patient’s initial presentation. Prospective studies on children with low-grade slips have demonstrated that once a slip occurs, it rarely worsens, even after 40+ years of follow-up. However, high-grade slips do continue to progress in many cases and are much more likely to cause pain.

Some cases do eventually progress to complete spondyloptosis and prevention of progression is the primary focus of surgery for high-grade slips. Why low-grade slips tend not to progress and why certain slips ultimately become severe is not known. There have been few long-term follow-up studies on patients with high-grade spondylolisthesis who did not undergo surgery.

Revision and removal of 2008 unsourced text
I've gone through and updated and adapted as possible. There were only a few sections that had to be deleted: that treatment for spondylolisthesis was "controversial", and while not necessarily untrue, I've yet to find a good article on this matter. I've therefore removed this statement and the article now has everything sourced as is. Now an expansion of the treatment section is beyond needed. Soon.--Cpt ricard (talk) 02:08, 15 July 2016 (UTC)