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Steven S. Agabegi

63 David M. Montgomery
Harry N. Herkowitz

Adult Degenerative Spondylolisthesis

Without Lysis


Spondylolisthesis is the anterior sagittal slippage of a vertebra Spinal stenosis commonly coexists with degenerative spon-
on its adjacent caudal segment and can result from a number dylolisthesis. The degenerative changes that lead to hypertro-
of different disease processes. Wiltse et al developed a classifica- phy of the facet joints and ligamentum flavum create narrowing
tion system, which included congenital, isthmic, degenerative, of the spinal canal at the unstable segment. Patients usually
pathologic, iatrogenic, and traumatic causes of spondylolisthe- present with low back pain and neurogenic claudication, con-
sis.29 Marchetti and Bartolozzi divided the causes of spondylolis- sisting of unilateral or bilateral leg and buttock pain that is
thesis into developmental (or dysplastic) in which there is a worse with activity and is improved with rest or lumbar spine
morphologic abnormality in anatomy, and acquired spon- flexion. If stenosis is severe, bowel or bladder dysfunction may
dylolisthesis, in which the anatomy is normal and the slip is due occur, although this is very rare.
to degenerative, traumatic, or pathologic causes.18 The former
is much more prone to progression than the latter due to the
underlying abnormality in the anatomy. IMAGING STUDIES
The most common cause of spondylolisthesis in adults is
degenerative. Unlike isthmic spondylolisthesis, the posterior An anteroposterior (AP), standing lateral, and lateral flexion/
neural arch remains intact. Degenerative slips are much more extension views of the lumbar spine should be obtained. The flex-
common in women, presumably because of increased ligamen- ion and extension views should be scrutinized for motion at the
tous laxity, and in patients of African descent, presumably olisthesed segment. A magnetic resonance imaging (MRI) scan
because of decreased lumbar lordosis and increased sacraliza- should be done if neurologic symptoms and/or signs are present.
tion of L5, which can create increased force across the L4-5 If MRI is contraindicated (e.g., pacemaker, cochlear implant), a
segment. It most commonly occurs at L4-5, which has more computed tomography (CT) myelogram can be obtained to eval-
sagittally oriented facet joints. The L5-S1 facet joints have a uate for stenosis and neural element compression. In many cases,
more coronal orientation, and it is rare to have a degenerative the spondylolisthesis reduces in the supine position and minimal
spondylolisthesis at L5-S1 without a defect in the pars interar- or no slip may be seen on the sagittal MR images or on supine
ticularis. The restraining effect of the iliolumbar ligaments on radiographs. Therefore, standing flexion/extension radiographs
L5 also prevents slips at L5-S1 while predisposing L4 to slip should always be obtained (see Case 63.7).
The spinal functional unit consists of three joints: the
intervertebral disc and two facet joints. Whether disc degenera- NATURAL HISTORY
tion or facet degeneration initiates the degenerative cascade is
unclear and there is evidence for both. But historically, the Matsunaga et al followed 40 patients with degenerative spon-
focus has been mostly on disc degeneration as the initiating dylolisthesis treated nonoperatively for at least 5 years. Thirty
event in the degenerative cascade. Chronic disc degeneration percent of patients had progression of the slip, which rarely
leads to altered stress loading of the facet joints with resultant exceeded 30%.21 No progression of slippage was noted in
laxity in facet joint capsules and the supporting ligamentous patients who showed narrowing of the disc, spur formation,
structures. These changes lead to segmental instability, which subcartilaginous sclerosis, or ossification of intervertebral liga-
represents abnormal motion between two or more vertebrae, ments. Physiologic secondary stabilization of the unstable seg-
and encompasses rotatory subluxation, degenerative scoliosis ment does occur and may lead to resolution or improvement in
and degenerative spondylolisthesis. symptoms. In a follow-up of this study, Matsunaga et al reported


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618 Section VI Spondylolisthesis

on 145 patients with degenerative spondylolisthesis who were (with or without instrumentation), and interbody fusion per-
treated nonoperatively for a minimum of 10 years.20 Thirty-four formed through an anterior (anterior lumbar interbody fusion
percent of patients had progressive spondylolisthesis, which or ALIF) or posterior (posterior or transforaminal lumbar
was not correlated with clinical symptoms. Seventy-six percent interbody fusionPLIF or TLIF) approach. The goals of sur-
of patients with no neurologic deficits at initial examination gery depend on the patients symptoms and findings on imag-
remained neurologically intact at follow-up. Eighty-three per- ing studies. If neurogenic claudication or radicular symptoms
cent of patients with neurogenic claudication experienced neu- predominate, decompression of the neural elements is the pri-
rological deterioration. mary goal. Preoperative imaging studies should be carefully
In general, the natural history of degenerative spondylolis- assessed to determine the stenotic areas that require decom-
thesis is favorable, as only 10% to 15% of patients seeking treat- pression (e.g., central, lateral recess, and/or foraminal steno-
ment will eventually have surgery.25 Furthermore, the amount sis). Fusion is very controversial for the treatment of low back
of slippage in degenerative spondylolisthesis is limited by the pain due to degenerative disc disease without instability. How-
intact neural arch and rarely exceeds 30% of vertebral width.20 ever, a fusion is generally recommended when decompressing
nerve roots in the presence of structural instability, whether
due to spondylolisthesis or scoliosis (with lateral listhesis).
Despite a general consensus to fuse unstable segments, there is
some support in the literature for decompression without
A prolonged course of nonoperative treatment is appropriate (at
fusion for degenerative spondylolisthesis (Table 63.1). Decom-
least 12 weeks) before surgery is considered. The decision to
pression alone may be an acceptable option in select elderly
perform surgery is based on the severity of symptoms and the
patients who do not have motion on flexion/extension views to
degree of disability experienced by the patient. If symptoms are
avoid the higher morbidity and mortality associated with a
debilitating and affect activities that the patient enjoys, surgery
fusion. If this approach is used, patients should be counseled
can be considered. The only absolute indications for surgery are
about the possibility of requiring a second operation to perform
progressive neurologic deficit and cauda equina syndrome, both
a fusion if symptoms persist or if gross instability develops.
of which are very rare in this condition. As mentioned previously,
Patients commonly require extension of the decompression
natural history studies show that most patients with degenerative
to stable levels above or below a spondylolisthesis. For example,
spondylolisthesis do not worsen with time. Therefore, nonopera-
a patient with degenerative spondylolisthesis at L4-5 may also
tive treatment consisting of anti-inflammatory medications, phys-
have stenosis at adjacent segments without spondylolisthesis.
ical therapy, and aerobic conditioning is the initial mainstay of
Decompression of all stenotic segments that may be causing
treatment. Aerobic exercise in the form of stationary bicycling,
the patients radicular symptoms is recommended, but fusion
swimming, walking, and elliptical machines are good forms of
should only be performed at the unstable segment, unless the
cardiovascular exercise. Patients with neurogenic claudication
decompression produces instability of adjacent segments
and radicular symptoms may benefit from epidural steroid injec-
(Cases 63.1, 63.4, and 63.6). Alternatively, interlaminar
tions, although the relief may be temporary.
decompression, in which the spinous process, interspinous lig-
In general, patients who have significant disability due to
aments, and facet joints are preserved, may allow effective
neurogenic claudication or radicular pain, resulting in a sig-
decompression without causing iatrogenic instability that may
nificant reduction of quality of life, despite nonoperative treat-
result from a full laminectomy. Radiographs should be care-
ment of at least 3 months, are the best candidates for surgery.
fully scrutinized for any evidence of instability at the other
Patients complaining primarily of low back pain despite conser-
stenotic segments. If preoperative instability exists, such as ret-
vative treatment of at least 6 months can be considered for sur-
rolisthesis or lateral listhesis, then the fusion should incorpo-
gery. The outcome for relief of back pain is not as predictable
rate these segments. In addition, segments destabilized by
as relief of radicular symptoms in the extremities.
removing a significant portion of the facet joint or pars interar-
Recently, the Spine Patient Outcomes Research Trial (SPORT)
ticularis should be fused. The relationship between radio-
compared the effectiveness of surgical and nonsurgical treat-
graphic evidence of degenerative disease in the lumbar spine
ment in patients with degenerative spondylolisthesis.28 Three
and clinical symptoms is inconsistent and fusion should only be
hundred four patients were enrolled in the randomized cohort
performed for structural instability.
and 303 in the observational cohort. Patients treated surgically
The type of fusion that is performed (posterolateral with or
showed substantially greater improvement in pain and function
without instrumentation and/or interbody fusion) for degen-
during a period of 2 years than do patients treated nonsurgically.
erative spondylolisthesis is controversial. Several well-designed
Extensive crossovers occurred between the surgical and nonsur-
studies are available to guide treatment decisions regarding the
gical groups in the randomized arm of the study, and the above
use of instrumentation. However, there is a lack of solid evi-
result was based on an as-treated comparison. Despite this, con-
dence supporting the addition of interbody fusion for this indi-
founding variables were carefully matched between the surgical
cation. These issues will be explored in more depth below.
and nonsurgical groups. This landmark study provides the high-
est level of evidence to date on the efficacy of surgical versus
nonsurgical treatment in patients with degenerative spondylolis- POSTEROLATERAL FUSION
thesis who have failed a course of nonoperative treatment.
The need for posterolateral fusion with and without instrumen-
tation has been addressed in several studies (Table 63.2), three
SURGICAL TREATMENT OPTIONS of which are prospective randomized trials. In general, combin-
ing fusion with decompression provides better clinical results for
Surgical options for degenerative spondylolisthesis include degenerative spondylolisthesis than decompression alone.2,7,30
decompression alone, decompression with posterolateral fusion Although the addition of instrumentation to a posterolateral

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Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 619

TABLE 63.1 Evidence for Decompression Without Fusion

Study Study Design Group Mean f/u Outcomes/Comments
Epstein and Epstein3 Retrospective None 10 y 69% excellent; 13% good; 12% fair; 6% poor results
Case series (290 Only patients with 4 mm of translation and 1012 of
patients) angulation on dynamic lateral X-rays included; only 8/290
patients required revision surgery for instability or restenosis.
Kristof et al14 Retrospective None 3.73 y 73.5% excellent or good results; 10% underwent revision with
Case series (49 instrumented fusion; patients had no evidence of
patients) hypermobility on dynamic lateral X-rays.
Mardjetko et al19 Meta-analysis (216 69% satisfactory; 31% unsatisfactory; 31% progressive slip; based
patients) on 11 papers, 2 were randomized.
Kleeman et al12 Prospective (54 None 4y 87% had no progression of slip (13/15); 88% good/excellent
patients, only 15 results.
had degenerative
Herron and Trippi8 Retrospective case None 34 mo 20 good, 3 fair, 1 poor result. Mean slip increased by 1 mm from
series (24 pre to postop; no patient had an increase in slip of greater
patients) than 4 mm.

fusion improves the fusion rate, its effect on clinical outcome is of the lumbar spine was included, the randomization process is
somewhat controversial. The evidence seems to suggest that not described, it is not clear how patients were allocated to dif-
long-term clinical outcome is improved with instrumentation ferent treatment groups, analysis was not performed on an
because of the higher fusion rate, but short-term outcome is intent-to-treat basis, and it cannot be determined whether any
not significantly impacted.4,13 Despite the widespread use of spi- measures were taken to conceal the allocation process.
nal instrumentation, an uninstrumented posterolateral fusion The disadvantages of including an interbody device include
is still a viable option in elderly patients with degenerative spon- the added cost, increased operative time, the risk of neurologic
dylolisthesis who have no segmental motion on flexion/exten- injury due to nerve root or dural sac retraction, and the long-
sion radiographs. term, potentially deleterious effects of complete immobiliza-
In 1994, Mardjetko et al performed a meta-analysis of 25 tion of a motion segment on the adjacent lumbar levels. In the
articles published between 1970 and 1993, reporting on 889 absence of a well-designed, prospective randomized study com-
patients with degenerative spondylolisthesis who had under- paring the clinical outcome of posterolateral fusion with or
gone decompression alone, or decompression with posterolat- without concomitant interbody fusion for degenerative spon-
eral fusion with and without instrumentation.19 The fusion and dylolisthesis, definitive statements about treatment efficacy can-
instrumentation group had a 93% fusion rate and a satisfaction not be made. Although one would expect fusion rates to be
rate of 86%, whereas the noninstrumented fusion group had higher with the addition of an interbody fusion, it is not clear
an 86% fusion rate and a 90% satisfaction rate. The group that whether clinical outcomes would be improved.
underwent decompression alone without fusion had only a There are no established guidelines in the literature on
69% satisfactory outcome, and 31% had progression of the slip- whether a PLIF or TLIF is preferred over a posterolateral
page. This analysis showed that fusion improves clinical out- fusion. Therefore, any recommendation on which procedure
comes but the benefit of instrumentation is not clear. should be performed in any particular patient, other than to
perhaps improve the fusion rate, is anecdotal and not based on
good evidence. Proponents of interbody fusion argue that disc
height and lumbar lordosis are restored, thereby improving
In recent years, interbody fusion has become increasingly com- overall sagittal balance and increasing foraminal height for an
mon using ALIF, PLIF, or TLIF in the treatment of degenera- indirect decompression. However, a recent study found that
tive disorders of the lumbar spine (Case 63.2). In general, high while an ALIF restored foraminal height by 18.5% and lumbar
fusion rates and good to excellent clinical outcomes have been lordosis by 6.2, TLIF decreased foraminal height by 0.4% and
reported.17 However, treatment efficacy has not been estab- lumbar lordosis by 2.1.9 At the time of this writing, this is the
lished because the studies are primarily retrospective case only study directly comparing these two approaches for inter-
series, those that are prospective lack a comparison group, and body fusion.
objective and validated functional outcome scales are not con- The above study9 highlights an often-neglected technical
sistently used. To our knowledge, there is only one prospective detail that limits the ability of the TLIF to adequately restore
randomized study comparing posterolateral fusion, PLIF, and foraminal height or lordosis. It is very difficult, to remove a
PLIF combined with posterolateral fusion for degenerative substantial portion of the disc space through a unilateral
conditions of the lumbar spine.10 There were no significant dif- TLIF approach. To adequately restore disc space height and
ferences in the clinical results and fusion rates between the foraminal height, it is necessary to release the annulus fibro-
three fusion methods. However, this study has several limita- sus circumferentially, which can best be performed through
tions: a mixed group of patients with degenerative conditions an anterior approach. It is doubtful that a TLIF procedure

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620 Section VI Spondylolisthesis

TABLE 63.2 Evidence for Fusion With/Without Instrumentation

Study Study Design Comparison Groups Mean f/u Outcomes/Conclusions

Herkowitz Prospective, DLL (25 patients). 3y 96% of fused group had satisfactory outcome, compared
et al7 randomized DLL PLF (25 with 44% of unfused group; pseudarthrosis (36% rate)
patients) did not preclude a successful outcome. Slip
progression occurred in almost all of the unfused
Zdeblick30 Prospective, 3 groups: PLF (51 16 mo Fusion rate with rigid instrumentation (86%) higher
randomized patients) vs. PLFI than without instrumentation (65%); outcome data
(rigid) (35 not separated by diagnosis to compare results
patients) vs. PLFI specifically in patients with degenerative
(semirigid) (37 spondylolisthesis; clinical outcomes determined by
patients) evaluation of work status, pain medication usage, and
level of discomfort.
Bridwell et al2 Prospective cohort 3 groups: DLL (9 At least 2 y Improved fusion rates with instrumented fusion;
Nonrandomized patients) vs. DLL functional improvement in 83% of instrumentation
PLF (10 group, 30% of uninstrumented group and 33% of
patients) vs. DLL decompression group.
PLFI Functional assessment determined only by patients
(24 patients) ability to walk longer (improved) or shorter (worse)
distances after surgery than before surgery; slip
progression significantly less in patients who had
pedicle screw instrumentation.
Fischgrund JS Prospective, DLL PLF (33 2 y minimum Fusion rate higher in instrumented group (82% vs. 45%).
et al4 randomized patients) vs. DLL No difference in clinical outcome. Concluded that
PLFI (35 instrumentation improves fusion rate but not clinical
patients) outcome at 2 y.
Kornblum Prospective, Solid fusion (22 514 y Group with solid fusion had better clinical outcomes
et al13 randomized patients) vs. than the group with pseudarthrosis; concluded that
pseudarthrosis instrumented fusion gives better outcome long-term.
(25 patients)
Kimura et al11 Retrospective case- DLL PLF (29 2y No difference between the two groups with regard to rate
control patients) vs. DLL of fusion or rate of satisfactory outcome.
PLFI (28
Nork et al22 Retrospective case No comparison 2 y minimum 93% of patients satisfied with outcome; SF-36 was used
series group: DLL but only postoperatively and results were compared
PLFI (30 with population norms.
Ghogawala Prospective cohort DLL (20 patients) 1 y minimum Both groups improved but fusion group had substantially
et al5 Nonrandomized vs. DLL PLFI improved outcomes in regards to Oswestry and SF-36.
(14 patients)

DLL, decompressive lumbar laminectomy; PLF, posterolateral fusion (no instrumentation); PLFI, posterolateral fusion with instrumentation.

substantially increases foraminal height to the degree neces- between the L4 pedicle and the L4-5 disc (see Fig. 63.2 and
sary to relieve nerve root compression. Direct foraminal Case 63.3). If there is significant foraminal stenosis, the expo-
decompression is therefore recommended in any patient with sure for a transforaminal interbody fusion will allow complete
significant radicular symptoms and one should not rely on decompression of the nerve root. Because the pars, facet
indirect decompression techniques as the sole means of joint, and the foraminal disc are removed during a TLIF pro-
treating radicular symptoms. Furthermore, loss of lumbar lor- cedure, decompression of the L4 nerve root in the foramen is
dosis or sagittal imbalance is rarely present in degenerative facilitated. The addition of an interbody fusion to this well-
spondylolisthesis. Arguments to support a TLIF for any of performed decompression may increase the likelihood of a
these indications are subject to critique and lack supportive solid fusion.
clinical evidence. It appears that the most compelling reason to perform a
The addition of spondylolisthesis to a stenotic segment TLIF is to improve fusion rates. There is little doubt that a cir-
changes the pattern of nerve root compression. For example, cumferential fusion leads to higher fusion rates and more rigid
most patients with spinal stenosis at L4-5 manifest symptoms immobilization of a motion segment. What is not known is
due to L5 root compression in the lateral recess (Fig. 63.1). whether circumferential fusion, which presumably eliminates
The addition of a slip at the L4-5 level profoundly affects the almost all motion at that level, leads to improved clinical out-
L4 nerve root in the foramen. Sagittal MR images through comes compared with posterolateral fusion alone. How much
the foramen often show that the L4 root is compressed rigidity at one or more levels is required for a clinically success-

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Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 621

lem of adjacent segment degeneration will be further discussed

later in this chapter.

The extent of decompression that is necessary depends on
the location and degree of stenosis. Most patients with degen-
erative spondylolisthesis have central and bilateral lateral
recess stenosis, even if they have unilateral radicular symp-
toms. In addition, foraminal stenosis is more common in
degenerative spondylolisthesis than in spinal stenosis without
spondylolisthesis. As mentioned above, in a typical L4-5 spon-
dylolisthesis, the L4 nerve root is likely to be compressed in
the neural foramen (Fig. 63.1 and Case 63.3), whereas in a
typical case of spinal stenosis (without spondylolisthesis) at
the same level, the traversing L5 nerve root is more commonly
compressed in the lateral recess. Therefore, careful decom-
pression of the neural foramen is very important in these
Traditionally, a midline laminectomy with decompression of
Figure 63.1. Figure showing lateral recess stenosis and foraminal bilateral lateral recesses and neural foramina has been per-
stenosis. The latter is more common in degenerative spondylolisthesis
formed. The patient is positioned with the hips extended to
as the exiting nerve root (L4) is compressed between the L4 pedicle
and the L4-L5 disc in the foramen. In spinal stenosis (without a slip),
simulate the upright posture. This position is preferred when-
the L5 nerve root is more likely to be compressed in the lateral recess. ever a fusion is planned (which is usually the case in spon-
dylolisthesis) and also places more compression on the neural
elements, allowing the surgeon to more accurately assess the
ful outcome? It is a biomechanical principle that more rigid necessary degree of decompression. Fusing the spine in a flexed
stabilization of one level leads to increased motion and stress at position can lead to a flatback deformity.
adjacent levels. In light of the lack of clinical evidence of the After standard exposure of the posterior spine with radio-
superiority of a circumferential fusion, the potentially deleteri- graphic confirmation of the proper level, a Leksell rongeur is
ous effects of more rigid immobilization of a motion segment used to remove the spinous processes and the interspinous liga-
on the adjacent levels must be carefully considered. The prob- ment. When the lamina is adequately thinned with a Leksell
rongeur, a small curet can be used to gain entry to the spinal
canal between the ligamentum flavum and the lamina. A
Kerrison rongeur is used to remove the laminae in a caudad to
cephalad direction. Once the central canal is decompressed,
Dural attention is then directed to decompression of the lateral
recesses and the neural foramina. From the opposite side of
the table, the medial border of the superior articular process is
L4 undercut with a Kerrison out to the medial border of the pedi-
pedicle cle. The traversing nerve root lies just medial to the medial bor-
der of the pedicle and can be followed out into the foramen
just inferior to the pedicle. The lateral recess is decompressed,
L4 nerve if the nerve root is free of compression up to the point of the
medial edge of the pedicle.
The pars interarticularis is then undercut to decompress the
L4-5 neural foramen. If a fusion is planned, the entire pars interar-
ticularis may be removed to thoroughly decompress the neural
foramen. Leaving some of the pars does provide additional sta-
bility even with a fusion and in most cases, undercutting the
pars allows adequate decompression of the nerve root. There
are no clear guidelines on how much of the pars to leave intact.
More of the pars should be preserved in patients with osteopo-
rosis because a thin pars may fracture postoperatively. If a
fusion is planned and significant foraminal stenosis is present,
Figure 63.2. Intraoperative photograph showing the concept dis-
cussed in Figure 63.1. After the nerve root has been deroofed posteri-
it is preferable to remove more of the pars to ensure complete
orly (pars resected), it is still being compressed between the L4 decompression of the nerve root.
pedicle and the L4-5 disc. The compressive disc material must be The key landmark in successful decompression of the lateral
removed to adequately decompress the root. recess and the neural foramen is the pedicle. The nerve root

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622 Section VI Spondylolisthesis

hugs the medial border of the pedicle in the lateral recess and decompressed by removing the pars interarticularis. The disc
subsequently hugs the inferior border of the pedicle out into space is identified just cephalad to the pedicle. The working space
the neural foramen. The Kerrison rongeur should correspond- is between the thecal sac medially, the pedicle inferiorly, and the
ingly follow the pedicle in these regions, decompressing the exiting nerve root superolaterally. Rarely, one may encounter
nerve root as the compressing bone spurs and ligamentum abnormal lumbar nerve root anatomy such a low takeoff of the
flavum dorsal to the nerve root are removed. It is important to exiting nerve root from the thecal sac, or a conjoined nerve root
be in the correct plane just above the nerve root with the foot within the foramen. These anomalies can place the nerve root at
plate of the Kerrison to remove all compressive structures. A risk for iatrogenic injury as the disc space is approached.
hockey stick or Woodson can be used to assess the adequacy of Once the disc space is identified, an annulotomy is made
decompression. Decompression is complete when a hockey and discectomy is performed. The next step is to restore disc
stick can be easily passed out of the neural foramen, both dor- space height using sequentially larger disc space dilators. The
sal and ventral to the nerve root. disc and the cartilaginous end plate are removed, leaving the
bony end plates intact. Removal of the bony end plates predis-
poses to subsidence of the interbody device.
Trial implants for the cage to be used are then used to assess
There are several key elements of the exposure that should be optimal size. The cage is packed with autogenous local cancel-
observed when performing a posterolateral fusion. Exposure of lous bone or bone morphogenetic protein (BMP), and it is
the dorsal surface of the transverse processes is sufficient. Violat- impacted into the disc space. Prior to inserting the cage, autog-
ing the intertransverse ligaments risks excessive bleeding and enous cancellous bone (usually local bone) can be packed into
injury to the exiting nerve roots, which lie in the neural foramen the anterior disc space. Insertion of the cage is the portion of the
located anterior to these ligaments. Also, it is critical that the procedure that is associated with the greatest risk of neurologic
facet joint capsules of the level above the intended level of fusion injury. The exiting nerve root should be well visualized and care-
be preserved. A Cobb elevator is used to strip the soft tissue off fully protected during this step. It is important to have a lateral-
the capsule without disrupting the capsule itself. The junction of to-medial trajectory when inserting the cage so that it crosses the
the transverse process and the superior articular process is iden- midline. The interbody device should be slightly countersunk
tified and cleaned of soft tissue to expose the entry point of the relative to the posterior vertebral body.
pedicle screw. If L5-S1 fusion is planned, it is important to expose After the interbody device is inserted, the rods are placed.
the sacral ala, which lies just lateral to the L5-S1 facet joint. Mild compression can be applied across the pedicle screws to
For a posterolateral fusion (intertransverse process fusion), the lock the cage in position, but we do not feel that this step is
fusion bed consists of the dorsal aspect of the transverse process, absolutely necessary. The remainder of the procedure is similar
the facet joint, and the pars interarticularis. Therefore, decortica- to that described above for a posterolateral fusion.
tion of these anatomic regions with a power burr is performed.
Prior to decortication, all soft tissues that overlie the transverse
process and the lateral aspect of the facet joint are removed. POSTOPERATIVE MANAGEMENT
To properly decorticate the transverse processes (and the
sacral ala), it is helpful to decorticate these areas before pedicle Most patients are mobilized to a chair on the evening of sur-
screws are placed because the screw heads will make exposure gery and are encouraged to ambulate with the aid of a physical
of these regions very difficult. After the pedicle finder is used to therapist on the first postoperative day. Compression stockings
prepare the screw tract and tapping is performed, the trans- are used for deep venous thrombosis prophylaxis. The subfas-
verse process and the lateral aspect of the facet joint can be cial drain is usually removed on postoperative day 1 or 2. Aspi-
decorticated before placing the pedicle screw at each level. For rin and anticoagulants are avoided for 1 week. Patients are
lumbosacral fusions, the sacral ala is decorticated to the depth typically discharged in 2 to 4 days. Elderly patients sometimes
of the L5 transverse process. require transfer to a rehabilitation facility. Patients are seen 2
After pedicle screws have been placed and decompression is weeks after surgery for radiographs and staple removal. There-
performed, rods are inserted into pedicle screws and set screws after, they are evaluated every 3 months with repeat radiographs
are placed. Bone graft is then placed over the decorticated at every visit until the 1 year postoperative visit.
areas in the lateral gutters. Local bone graft harvested during
the decompression can be placed into a bone mill device that
grinds bone into a corticocancellous mush. COMPLICATIONS OF SURGICAL
Complications encountered in the surgical treatment of degen-
A standard PLIF requires bilateral exposure with insertion of erative spondylolisthesis include intraoperative complications
cages on both sides. With a TLIF, only one side is exposed and the that may occur during any spine operation, such as dural tears
interbody work is done from that side. Pedicle screws can be and nerve root injury, to delayed complications such as pseu-
placed before or after the decompression. During the TLIF pro- darthrosis and adjacent segment disease. Wound infections and
cedure, the extent of decompression depends on the patients complications related to pedicle screw instrumentation will be
symptoms and location of stenosis on preoperative imaging stud- discussed in Chapter 66. Delayed complications will be dis-
ies. Bilateral decompression can be performed if necessary, but a cussed in more depth here.
standard TLIF allows decompression of the neural foramen and Dural tears that are repaired primarily typically do not cause
the lateral recess on the symptomatic side. The entire facet joint any adverse sequelae. The management of dural tears will be
on one side is removed. The exiting nerve root is identified and discussed in more detail in later Chapter. Even with the best sur-

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Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 623

gical technique, nerve roots may be temporarily irritated due to and erythrocyte sedimentation rate) should be obtained.
intraoperative retraction and manipulation. Permanent damage Patients with persistent low back pain should also be evaluated
to the nerve root, while rare, may occur. Good surgical for adjacent segment disease, which may be present even in the
technique minimizes these complications. In general, dural presence of pseudarthrosis and may need to be addressed.
retraction should be kept to a minimum. If prolonged retrac- Patients with lumbar pseudarthrosis may be managed con-
tion is needed, periods of relaxation should be allowed by let- servatively in the absence of neurologic compromise or defor-
ting go of the retractors. If a TLIF is being performed, the exit- mity progression. However, after 1 year, it is not likely that the
ing nerve root should be visualized and protected during pseudarthrosis will fuse. In the absence of infection, surgical
insertion of the cage, which is the most hazardous portion of options for an established pseudarthrosis include ALIF, circum-
the operation in terms of risk of neurologic injury. ferential fusion via either combined anterior and posterior
approaches or a posterior only approach (TLIF), or revision
posterolateral fusion. All of these options have a role depending
on the clinical circumstances. Factors that guide the approach
The incidence of pseudarthrosis in the lumbar spine is highly include the approach used in the index procedure, as well as
variable in the literature, reflecting the varying radiographic the need for nerve root decompression, deformity correction,
criteria used to make this diagnosis. Patients who ultimately and removal of migrated implants or broken hardware.
develop pseudarthrosis are generally asymptomatic or mini- An ALIF is an excellent option for a failed posterolateral
mally symptomatic in the early postoperative period. If decom- fusion. It allows correction of kyphotic deformity and provides
pression and instrumentation were performed, relief of leg increased bony surface area for fusion compared with a postero-
pain and the stability afforded by instrumentation often leads lateral fusion. This approach is also ideal for removing a migrated
to an improvement in symptoms. However, as pseudarthrosis interbody device that had previously been placed through a pos-
develops, residual instability leads to progressive pain with time. terior approach. It has been our experience that removal of
In general, one should wait at least 12 months before defini- these devices from a posterior approach is challenging with a
tively diagnosing a pseudarthrosis. high risk of dural tear and nerve root injury due to the presence
In the absence of progressive deformity, hardware failure or of scarring around the roots from the prior surgery (usually a
interbody device migration, the diagnosis of a pseudarthrosis TLIF). The anterior approach allows for removal of the device in
can be challenging. In most cases, a pseudarthrosis presents a controlled fashion without risking injury to the nerve roots. If
with persistent low back pain with or without lower extremity the patient has radicular symptoms as well, removal of the
radiculopathy. Bone scans and single-photon emission com- migrated interbody device, which may be impinging on neural
puted tomography (SPECT) scans generally lack sensitivity structures, may relieve these symptoms. If radicular symptoms
and specificity and are rarely helpful. Standard radiographic persist after removal of the cage, then a posterior revision decom-
views (including flexion and extension lateral radiographs) pression can be performed at a later setting.
and a CT scan are the recommended imaging studies. If there In a patient with a failed anterior interbody fusion, a repeat
is bridging bone between the transverse processes and no anterior exposure may be technically difficult due to the pres-
motion on flexion/extension films, a solid fusion is believed to ence of scarring, especially at L4-5. A posterior approach may
have occurred. The persistence of a radiographic cleft or the be preferred in these cases, with iliac crest autograft and care-
presence of motion on flexionextension lateral radiographs ful decortication of the transverse processes and facet joints.
implies that a pseudarthrosis may be present. However, the Iliac crest autograft should be strongly considered in patients
amount of motion that signifies a pseudarthrosis is not known. undergoing pseudarthrosis repair.
Furthermore, instrumentation can obscure the visualization of Recombinant BMP-7 is currently approved by the U.S.
bridging bone and may also prevent dynamic motion on flex- Food and Drug Administration under a Humanitarian Device
ionextension views, even if a pseudarthrosis is present. Exemption (HDE) as an alternative to autograft in compromised
CT scan with coronal and sagittal reconstruction views is patients (smokers, diabetics, osteoporosis) who need revision pos-
more reliable than plain radiographs but must be interpreted terolateral fusions. Off-label use of bone morphogenic proteins
with caution. The presence of bone resorption and halo forma- should be discouraged until more data are available. In addition,
tion around screws suggests pseudarthrosis, but the lack of risk factors for pseudarthrosis (including tobacco use and use of
these findings does not necessarily indicate the presence of a NSAIDs) should be eliminated if possible.
solid fusion. A stable fibrous union in a patient with persistent
postoperative back pain may be interpreted as a pseudarthrosis
on a CT scan and may lead to unnecessary interventions.
Lucency around pedicle screws may indicate loosening of Various abnormal processes have been characterized as adjacent
the screw. This motion may have predisposed to a pseudarthro- segment disease after spinal fusion, including disc degeneration,
sis. Broken hardware does not necessarily mean that a pseudar- segmental instability (retro- or anterolisthesis), herniated nucleus
throsis is present but should raise the suspicion of a pseudart- pulposus, spinal stenosis, vertebral compression fracture, and
hrosis and prompt further investigation. In the absence of osteophyte formation.23 Risk factors for adjacent segment degen-
infection, it is generally not necessary to remove broken hard- eration include the use of instrumentation, longer fusion con-
ware unless vital structures (vessels, neural elements) are at risk structs, PLIF, sagittal malalignment, facet injury, advanced age,
of injury due to migration of the hardware or interbody device. and preexisting degenerative changes.23
The hardware may have failed during the fusion process as it The incidence of symptomatic adjacent segment disease
was exposed to repeated stresses causing fatigue failure. ranges from 5.2% to 18.5%,23 although the incidence of radio-
Infection should be ruled out in any patient who is diag- graphic adjacent segment changes is much higher. Lehmann
nosed with pseudarthrosis. Laboratory studies (C-reactive protein et al reported the incidence of adjacent segment degeneration

LWBK836_Ch63_p617-632.indd 623 8/17/11 10:59:53 AM

624 Section VI Spondylolisthesis

(defined by segmental instability above the fused level) to be techniques are appropriate in the patient with degenerative
45%, but these radiographic changes did not correlate with spondylolisthesis who often has bilateral stenosis. Although
clinical symptoms and only 5% of all patients underwent a sec- performing an interbody fusion through a minimally invasive
ond lumbar surgery.16 approach is relatively straightforward in experienced hands,
There is extensive in vitro and in vivo biomechanical evi- the decompression can be challenging if there is significant
dence using both animal and human cadaveric spine models bilateral stenosis. There are two approaches to this problem:
that fusion at one level is associated with increased motion and one may perform a unilateral decompression on the symptom-
stress at adjacent levels. In general, the more rigid the fusion, atic side, despite the presence of bilateral lateral recess and/or
the more stress is transferred to the adjacent segments. The nerve root compression on imaging studies. Caution should be
clinical relevance of this fundamental biomechanical concept is used in deciding to perform a unilateral decompression in the
in regards to the addition of interbody fusion, which creates a presence of bilateral stenosis because symptoms may develop on
more rigid fusion construct compared with posterolateral fusion the contralateral side postoperatively. There are no studies doc-
alone. Biomechanical studies have been conducted to assess the umenting the efficacy of this approach in long-term follow-up.
changes in adjacent segments after posterior, anterior, and cir- The other approach is to perform a bilateral decompression
cumferential fusion. In general, these studies demonstrate that through a minimally invasive unilateral approach. Favorable
compared with a posterolateral fusion alone, the addition of an short-term results have been reported with this technique.6
interbody fusion increases loads at the adjacent segments.15,26, 27 Patients with severe bilateral stenosis are not good candidates
The etiology of adjacent segment degeneration is not fully for this approach.
understood, although several theories exist. Adjacent segment Although the results of the minimally invasive TLIF tech-
degeneration may be a manifestation of the progression of nique have been largely favorable, at the time of this writing,
existing degenerative changes in the spine of predisposed indi- there has only been one comparison study of minimally inva-
viduals, but the large amount of biomechanical evidence cer- sive versus traditional PLIF.24 In this nonrandomized study,
tainly suggests that the increased motion and stress that occur there was no significant difference between the two groups in
at adjacent segments to a fusion plays a significant role. Whether the clinical and radiographic results at a minimum of 1 year
posterolateral fusion alone reduces this risk compared with a follow-up. The minimally invasive group had less blood loss,
circumferential fusion has not been clinically proven, although postoperative back pain, and shorter recovery time before
biomechanical studies support this assertion. ambulation, but surgical times were significantly longer and
In some cases, adjacent segment problems are due to errors there were two cases that required revision surgery due to tech-
in surgical technique. Violation of the adjacent superior seg- nical complications.
ment facet joint can accelerate degenerative changes in these The indications for minimally invasive approaches are
joints over time. During the exposure, the facet joint capsule of expanding, and these techniques are being used in patients
the cephalad segment should be preserved by using a Cobb to with multilevel disease. At this time, there is no evidence that
sweep the soft tissue off the facet capsule laterally. A relatively long-term outcomes are improved compared with traditional
more lateral starting point for these pedicle screws (at the open approaches, and technical complications are likely to be
transverse processfacet junction) and angling the trajectory in more common in the hands of a surgeon without extensive
a more medial direction can minimize screw impingement on experience with these techniques. Although these techniques
the facet joint. Attention should also be paid to a rod that is appear to be promising, spine surgeons attempting these pro-
excessively long at the cephalad end of the construct, which cedures should honestly assess their experience and skills and
may impinge on the joint. Following these principles may help undergo proper training to avoid technical complications. As
decrease the incidence of adjacent segment problems. the trend toward less invasive approaches continues, well-de-
Most patients with adjacent segment degeneration are asymp- signed randomized comparison studies are needed to deter-
tomatic. In the symptomatic patient, the dilemma is in determin- mine the efficacy of these approaches.
ing whether the changes in the adjacent segment are causing the
symptoms. After an appropriate course of nonoperative treat-
ment, surgery may be considered after a careful assessment of
clinical findings and imaging studies. The specific pathology dic- Dynamic stabilization consists of semirigid posterior stabilization
tates the surgical plan. If the patient has adjacent segment steno- devices that are designed to reduce motion at the instrumented
sis without any evidence of instability, a decompressive laminec- level to unload the disc and facet joints. The most commonly
tomy is indicated (Case 63.5). If there is any evidence of used dynamic stabilization system is Dynesys (Zimmer, Inc.,
instability, the fusion should be extended as needed. The use of Warsaw, IN).
dynamic stabilization has been described, but there is no good The use of dynamic stabilization in degenerative spondylolis-
evidence at this time supporting its use in this setting. thesis has been reported to have favorable outcomes, but these
reports are retrospective case series or prospective studies with-
out a comparison group. Given the high level of evidence pro-
vided by the SPORT study supporting decompression and
fusion for this condition,28 the use of semirigid stabilization or
To minimize the adverse effects of exposure-related muscle other motion-preserving techniques cannot be justified in the
injury, minimally invasive techniques of decompression and presence of segmental instability. In the absence of a fusion,
interbody fusion are being performed with increasing fre- failure of implants or screws remains a concern on long-term
quency. The reported advantages include less soft tissue trauma, follow-up. Many of these devices are currently under review by
less postoperative pain, and reduced blood loss. The increasing the U.S. Food and Drug Administration, and long-term out-
popularity of minimally invasive surgery in degenerative condi- comes on their efficacy is lacking for degenerative conditions
tions of the lumbar spine raises the question of whether these of the lumbar spine.

LWBK836_Ch63_p617-632.indd 624 8/17/11 10:59:53 AM

Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 625

The use of interspinous process devices has also been evalu- patients with neurogenic claudication and degenerative spon-
ated in patients with neurogenic claudication and degenerative dylolisthesis.1 At 2-year follow-up, overall clinical success
spondylolisthesis. The X STOP implant is a titanium alloy occurred in 63.4% of X STOP devicetreated patients and only
device that is placed between the spinous processes to reduce 12.9% of nonoperatively treated patients. This randomized
the canal and foraminal narrowing that occurs in extension. study showed that the X STOP device is more effective than
Anderson et al performed a randomized study comparing the nonoperative treatment for this condition and may be a viable
use of the X STOP device (St. Francis Medical Technologies, option in elderly patients with significant comorbidities who
Alameda, CA) with nonoperative treatment (33 patients) in are not candidates for a fusion procedure.

CASE 63.1

Figure 63.3 A to E: A 56-year-old woman with bilateral leg spondylolisthesis at L4-5. She underwent decompressive
pain and low back pain. Leg pain/back pain 70/30. She laminectomy at both levels and a posterolateral fusion at
has spinal stenosis at L3-4 and L4-5 and degenerative L4-5. She had an excellent clinical result.



Figure 63.3. (A) Lateral radiograph showing L4-5 spondylolisthesis. (B) Sagittal magnetic resonance
imaging (MRI) showing degenerative spondylolisthesis. (C) Axial MRI showing stenosis at L4-5. (D) Axial
MRI showing stenosis at L3-4. (E) Lateral radiograph after posterolateral fusion and instrumentation L4-5.

LWBK836_Ch63_p617-632.indd 625 8/17/11 10:59:53 AM

626 Section VI Spondylolisthesis

CASE 63.2

Figure 63.4 A to E: A 75-year old-man with left leg pain a TLIF (bilateral decompression) and had complete resolu-
worse than low back pain. He has a degenerative spon- tion of leg pain and back pain postoperatively.
dylolisthesis at L4-5 and spinal stenosis. He underwent



Figure 63.4. (A) Lateral radiograph showing degenerative spondylolisthesis at L4-5. (B) Anteroposterior
radiograph lumbar spine. (C) Sagittal magnetic resonance imaging (MRI) showing stenosis at L4-5. (D) Axial
MRI showing stenosis at L4-5. (E) Lateral radiograph after fusion and instrumentation.

LWBK836_Ch63_p617-632.indd 626 8/17/11 10:59:56 AM

Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 627

CASE 63.3

Figure 63.5 A to D: A 62-year-old woman with a 1-year foramen. It is important to decompress the exiting nerve
history of low back pain and left leg radiculopathy. She root in degenerative spondylolisthesis, which is compressed
underwent a TLIF at L4-5. Note the disc bulge compressing between the L4 pedicle and the L4-5 disc (see Fig. 63.2).
the L4 nerve root in the sagittal MR image through the



Figure 63.5. (A) Lateral radiograph showing spondylolisthesis at L4-5. (B) Sagittal magnetic resonance
imaging (MRI) showing disc bulge compressing the L4 nerve root in the foramen. (C) Axial MRI at L4-5
level. (D) Lateral radiograph after TLIF at L4-5.

LWBK836_Ch63_p617-632.indd 627 8/17/11 10:59:57 AM

628 Section VI Spondylolisthesis

CASE 63.4

Figure 63.6 A to F: A 58-year-old woman with LBP and decompressive laminectomy from L3 to S1 and posterolat-
left worse than right leg pain. She has a degenerative eral fusion and instrumentation from L4-S1. L4-5 and L5-S1
spondylolisthesis at L4-5 and a subtle slip at L5-S1. She levels were fused because of structural instability at both
has spinal stenosis from L3 to L5. She underwent levels.



Figure 63.6. (A) Lateral radiograph in extension. (B) Lateral radiograph in flexion. (C) Sagittal magnetic
resonance imaging (MRI). (D) Axial MRI at L3-4 level showing mild stenosis. (E) Axial MRI at L4-5 level
showing stenosis. (F) Axial MRI at L5-S1.

LWBK836_Ch63_p617-632.indd 628 8/17/11 10:59:59 AM

Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 629

CASE 63.5

Figure 63.7 A to E: A 55-year-old man who underwent developed adjacent segment stenosis. He was treated with a
TLIF for degenerative spondylolisthesis. He had an excel- decompressive laminectomy at L3-4 and had resolution of
lent clinical result with complete resolution of leg and his leg pain. We considered extending the fusion, but we
back pain. Four years later, he developed left leg pain were able to perform a good decompression without creat-
again, mostly in the buttock and thigh region. He has ing instability.


Figure 63.7. (A) Lateral radiograph

showing fusion and instrumentation
L4-5. (B) Anteroposterior radiograph
lumbar spine. (C) Axial magnetic reso-
nance imaging (MRI) at L3-4 level
showing stenosis. (D) Midsagittal MRI.
(continued) C D

LWBK836_Ch63_p617-632.indd 629 8/17/11 11:00:02 AM

630 Section VI Spondylolisthesis

CASE 63.6

Figure 63.8 A to E: A 78-year-old man with significant low

back pain and bilateral lower extremity claudication. We
performed decompressive laminectomy at L3-S1 and pos-
terolateral fusion with instrumentation at L4-5. He had
relief of leg pain and improvement in his low back pain.

Figure 63.7. (Continued) (E) Sagittal MRI through foramen.



Figure 63.8. (A) Lateral radiograph showing degenerative spondylolisthesis L4-5. (B) Midsagittal mag-
netic resonance imaging (MRI). (C) Axial MRI at L4-5 showing lateral recess stenosis. (D) Axial MRI at L3-4
showing lateral recess stenosis. (E) Axial MRI at L5-S1 showing lateral recess stenosis.

LWBK836_Ch63_p617-632.indd 630 8/17/11 11:00:04 AM

Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 631

CASE 63.7

Figure 63.9 A to F: A 74-year-old woman with longstand- sequestered disc herniation at L3-4. Although L5-S1 is
ing low back pain and 1-year history of bilateral leg pain, degenerated, it is probably stable and does not require
left worse than right. She has a degenerative spondylolis- fusion. Reasons to fuse this level include the need for a
thesis at L4-5, which is subtle on supine X-ray and MRI wide decompression that would render the segment unsta-
but is more unstable in the upright flexion/extension ble. This patient did not have stenosis at L5-S1. This patient
radiographs. This illustrates the importance of upright underwent a posterolateral instrumented fusion and
flexion/extension films and the danger of relying on laminectomy from L3-L5 with a discectomy performed at
MRI, which can underestimate the degree of instability L3-4. L3-4 was fused because it was felt to be at risk of fur-
due to patients supine position. She also has a caudally ther degeneration after discectomy.



Figure 63.9. (A) Supine lateral radiograph showing subtle slip at L4-5. (B) Flexion and (C) extension lat-
eral radiographs showing more pronounced instability in upright position. (D) Sagittal magnetic resonance
imaging (MRI) showing subtle slip at L4-5. (E) Axial MRI at L3-4 showing disc herniation. (F) Axial MRI at
L4-5 showing stenosis.

LWBK836_Ch63_p617-632.indd 631 8/17/11 11:00:07 AM

632 Section VI Spondylolisthesis

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