CHAPTER
58
Wiltse and Marchetti/Bartolozzi
Classifications of Spondylolisthesis
Guidelines for Treatment
Classification systems can be developed to serve different pur-
poses. They are used to organize information into groups for
the purpose of taxonomy, comparison, counting, communica-
tion, etiology, prognosis, and especially in medicinetreatment
recommendations.
Frequently, several different classification systems develop
around apparently similar data sets. Controversy may arise over
which one is more usable or more reliable. Grouping findings
into a given system often varies with subject interpretation and
observer viewpoint. Bias may be educational (we are taught to
see something in one way instead of another) or may result
from raising the importance of one subject group over another
(i.e., treating only pediatric patients, only adult patients, vs.
treating patients of all ages). Furthermore, even disparate clas-
sification systems can make valuable contributions even as the
different systems address different components of the condi-
tion being studied. While merging multiple classification sys-
tems may be inclusive and useful to cover the variables being
studied (etiology, description, prognosis, and treatment), the
resulting system may become too cumbersome to be useful.
The lack of a universal system for classification of spon-
dylolisthesis exemplifies this situation.
Spondylolisthesis is a condition in which one vertebra trans-
lates or slips anteriorly with respect to its adjacent caudal
neighbor. Numerous reports describing various characteristics
of such slippage are available. To accommodate the variability
of presentation of spondylolisthesis, classification systems were
clearly necessary. Two classification systems currently are used
in most reports: (1) Wiltse, Newman, and McNabs classifica-
tion of types of spondylolisthesis conditions has allowed for
consistent communication based on the types described. (2) In
1994, Marchetti and Bartolozzi provided a new classification
system that provided further insights into behavior of a prob-
lematic subset of spondylolisthesis. A distinguishing character-
istic of the Marchetti and Bartolozzi classification was that it
provided a method to prognosticate behavior of the develop-
mental type that is made up of the dysplastic and isthmic groups
from the Wiltse classification. By differentiating the degrees of
dysplasia, they were able to predict the behavior of the slip, rec-
ommend the type of treatment, determine when surgery was
necessary, and recommend the type of surgery.
556
LWBK836_Ch58_p556-562.indd 556
Rakerry K. Rahman
Joseph Perra
Mark Weidenbaum
More recently, focus on the role of the sagittal profile and pel-
vic anatomic parameters are occurring in an attempt to better
understand etiologic risk factors and treatment recommenda-
tions5,8 (see Chap. 63).
CLASSIFICATIONS
The Wiltse classification divides spondylolisthesis into five cat-
egories: dysplastic, isthmic, degenerative, traumatic, and patho-
logic18 (Table 58.1).
TYPE 1 (DYSPLASTIC)
Dysplastic or congenital spondylolisthesis is seen when there is a
deficiency in either the bony hook or the catch. The bony hook
is the facet of the vertebrae below the motion segment of inter-
est, which prevents forward translation of the vertebrae above the
level of interest. The facet serves as a buttress to the neural arch
of the vertebrae of the level above. The neural archsuperior
facet configuration is present throughout the spine. Dysplasia or
malformation of the archfacet configuration at any level will
allow for instability and potential anterior translation. However,
dysplasia is most often seen at the L5-S1 level. The most common
abnormality is aplasia of the upper sacrum with deficient devel-
opment of the superior facet of S1 and inferior facet of L5. In
addition, congenital defects such as spina bifida can be the etiol-
ogy of neural arch defects. These defects can allow for significant
instability and major slippage. Often, this is evident by a poorly
developed pars and abnormally shaped L5 or S1 vertebrae.
TYPE 2 (ISTHMIC)
Isthmic spondylolisthesis is identified by a defect in the pars
interarticularis (literally the place between the joints). There
may be changes in the shape of the L5 vertebrae or sacral dome,
which are thought to be remodeling- or stress-related changes.
These are grade II lesions. Wiltse divides the isthmic form into
three subtypes. Subtype A lesions are spondylolytic stress frac-
tures of the pars region. This occurs most often in people
younger than 50 years. Unfortunately, these fractures often do
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 Chapter 58 Wiltse and Marchetti/Bartolozzi Classifications of SpondylolisthesisGuidelines for Treatment 557

Wiltse Classification of Classification of Marchetti

TABLE 58.1 TABLE 58.2
Spondylolisthesis Bartolozzi
I. Congenital (dysplastic) 1982 1994
II. Isthmicdefect in the pars interarticularis
IIA. Spondylolyticstress fracture of the pars region DEVELOPMENTAL
IIB. Pars elongation Due to lysis High dysplastic
IIC. Acute pars traumatic fracture Due to elongation With lysis
III. Degenerativedue to a long standing intersegmental Traumatic With elongation
instability Acute fracture Low dysplastic
IV. Post-traumaticacute fractures in the posterior elements Stress fracture With lysis
beside the pars region With elongation
V. Pathologicdestruction of the posterior elements from ACQUIRED
generalized or localized bone pathology Iatrogenic Traumatic
Pathologic Acute fracture
Degenerative Stress fracture
not heal. Subtype B exhibits pars elongation with potential for Post-surgery
forward slippage. This subtype is thought to be the result of Direct surgery
Indirect surgery
repeated microfractures. In contrast to subtype A, these microf-
Pathologic
ractures heal, which leads to pars elongation as opposed to pars
Local pathology
nonunion. Subtype C is the result of an acute, severe fracture of Systemic path
the pars. Because of the absence of the posterior tether, the disc Degenerative
is stressed and allows for translation of the vertebra. Primary
Secondary
TYPE 3 (DEGENERATIVE)
Degenerative spondylolisthesis is seen later in adulthood and is
group confusing as it has such variable behavior. They realized
probably the most common form of spondylolisthesis. It is a
the common characteristics of those slips that behaved more
result of intersegmental instability secondary to degeneration
aggressively and described the characteristics of the two groups.
of the facet joints and intervertebral disc. A few epidemiologic
In essence, they combined the dysplastic and isthmic groups
variations are notable concerning this category compared with
and divided them on the basis of their behavior9 (Table 58.2).
other types of spondylolisthesis. First, women are more affected
In the developmental subgroup, some degree of congenital
than are men. Second, L4-5 as opposed to L5-S1 is the most
abnormality (dysplasia) exists of the posterior elements.
commonly affected level. Third, slippage more than 1 cm or
Marchetti and Bartolozzi further subdivided this category into
30% is rarely seen as the bony hookcatch complex remains
high and low dysplasia. The high and low dysplasia distinction
intact as does the pars interarticularis. It is commonly associ-
refers to the degree of dysplasia, not location, and frequently
ated with spinal stenosis, and when dynamic, it can be mislead-
can be identified by the degree of kyphosis or the slip angle of
ing to the degree of stenosis when supine imaging is performed,
the lumbosacral segments.
such as magnetic resonance imaging or computed tomography.
Developmental high dysplastic spondylolisthesis is character-
Its nature is better appreciated in upright imaging or imaging
ized by major deficiencies of the neural arches, intervertebral
of the spine when it is axially loaded.
discs, upper end plate of S1, and body of L5. In addition, the
pars is often elongated or interrupted, the anteriorsuperior
TYPE 4 (TRAUMATIC) sacrum is rounded, and the L5 vertebral body is trapezoidal.
Traumatic spondylolisthesis is rare. This category is different Some of these changes are primary lesions and others such as
than the isthmic subtype A in that the fracture involves any part end plate changes are secondary features that develop in
of the bony hook or posterior elements other than the pars response to the slippage. In adolescents, the L5-S1 level is the
interarticularis, usually the pedicle or the facet. This is often a most commonly affected. High-grade slips may already occur by
high-energy injury and relatively rare. adolescence. The degree of deformity makes it highly unlikely
that these patients will make it to adulthood without becoming
symptomatic or having a progressive deformity (Fig. 58.1).
TYPE 5 (PATHOLOGIC)
Developmental low dysplastic spondylolisthesis differs from
Pathologic spondylolisthesis results from generalized bone dis- the high dysplastic in that the L4 and L5 bodies remain rectan-
ease or a lesion that affects the neural arch or associated facet gular and the sacral/L5 upper end plate is preserved. There is
joints. Some examples include infection, Paget disease, tuber- no compensatory hyperlordosis or sacral verticalization. As a
culosis, and benign or metastatic tumors. result, the rate and risk of progression is much less. Furthermore,
any progression usually involves a small degree of translation as
opposed to the tilting or increased slip angle seen with high
MARCHETTIBARTOLOZZI dysplasia (Fig. 58.2).
CLASSIFICATION
PROGRESSION OF DEFORMITY
The MarchettiBartolozzi classification system initially divides
spondylolisthesis by presumed etiology, either developmental The high versus low dysplasia categories are useful for predict-
or acquired. These authors initially described their system in ing progression. The risk of progression is directly related to
1982 and later refined it in 1994. They found Wiltses isthmic the severity of dysplasia. Therefore, patients who fall into the

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 558 Section VI Spondylolisthesis
Figure 58.1. High dysplastic spondylolisthesisnote rounding of
sacrum and high slip angle (kyphosis), age 16 years.
MarchettiBartolozzi developmental high dysplastic category
have one large abnormality or multiple smaller abnormalities
of the bony hookcatch configuration, which lead to significant
instability and a high slippage rate. In contrast, the patients in
the MarchettiBartolozzi developmental low dysplastic category
Figure 58.2. Low dysplastic spondylolisthesisnote maintained
shape of sacrum despite degenerative changes of the disc, age 24 years.
LWBK836_Ch58_p556-562.indd 558
have a low slippage rate. In addition, the level affects the risk of
progression. Deformities at the L5-S1 junction or L4-sacralized
L5 junction have a high risk of progressing. In contrast, L4-L5
slips rarely progress, and when they do, the severity is limited.
The risk of progression in adolescents is dependent on many
factors. Studies have shown that marked insufficiency of the
sacral upper end plate, increased lumbar lordosis, vertical dis-
placement of the sacrum, low lumbar index, a high degree of
slippage, and other congenital abnormalities are associated with
a higher risk of progression.4,13,16,18 The condition of the pars is
very important to predict progression risk. If the pars is lysed as
opposed to elongated, the disc and ligaments anteriorly are the
only remaining stabilizers for the affected level. Once the ante-
rior structures break down, slippage will progress freely. In con-
trast, in the case of pars elongation, slippage is less common
because some degree of posterior stabilization still exists.
ACQUIRED
Acquired spondylolisthesis includes all other etiologies not
encompassed by the developmental category. For historical
purposes, the original MarchettiBartolozzi classification
divided this category into three etiologies: iatrogenic, patho-
logic, and degenerative. The last revision in 1994 divided the
category into four etiologies: traumatic, postsurgery, patho-
logic, and degenerative.
Acquired spondylolisthesis most often affects the pars. Stress
fractures are by far the most common cause of the pars lesions.
This occurs because the pars is the weakest part of the bony
hook. It is also the most likely area to experience repeated
stress (Fig. 58.3).
Any acquired disruption of the bony hook is accounted for
in this category. As such, traumatic lesions to the bony hook
Figure 58.3. Acquired spondylolisthesis with stress fracture of pars
interarticularis in gymnast at L3.
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 Chapter 58 Wiltse and Marchetti/Bartolozzi Classifications of SpondylolisthesisGuidelines for Treatment 559

can result in slippage. Traumatic spondylolisthesis occurs fol- MEYERDING GRADING SCALE
lowing significant acute stress and is rare. However, if present, a
The Meyerding grading scale is germane to the discussion of
thorough evaluation for concomitant spine or spinal column
spondylolisthesis because it provides a common way to quantify
injuries should be performed. Invariably, associated fractures
the degree of tangential slip. This grading system divides the
of the transverse processes are seen. In addition, there are often
inferior vertebral body into one fourth widths to allow for five
injuries to the abdominal organs.
possible grades: grades I to V. The slip is graded on the basis of
Postsurgical spondylolisthesis is another rare form of acquired
the percentage of the inferior body superior end plate, which
spondylolisthesis. This subcategory is further divided into direct
is uncovered as a result of the slip. Therefore, two fourths
and indirect postsurgical forms. Direct forms occur at the level of
uncovered end plate equals a 50% slip or grade II. In a grade
previous surgery and represent a classic example of spondylolis-
V slip, the L5 vertebral body falls completely off the sacrum and
thesis caused by segmental instability. The surgical damage mainly
falls caudally.
relates to the posterior articular components or fracture of the
The Meyerding grading scale stressed its capability to
isthmus following laminectomy. Complete facetectomy, unilateral
describe the degree of tangential slip. However, as noted earlier
or bilateral, may lead to iatrogenic spondylolisthesis. Removal of
in the discussion of developmental high dysplasia, significant
the posterior tension band by surgery results in additional stress
sacral vertebral body alterations can be seen with increasing
being placed on the anterior discs and ligaments. Indirect forms
magnitude of dysplasia. When the sacrum begins to assume a
occur at the level above prior surgery and are considered indica-
dome shape, the L5 vertebrae can drift into significant degrees
tive of adjacent level degeneration. Although Marchetti and
of kyphosis, thereby increasing the slip angle. In this situation,
Bartolozzi felt this was most often seen after midline fusions, it is
there is tangential translation and kyphosis. When this occurs,
seen following any type of fusion where the focused stress acceler-
the Meyerding grading scale does not completely describe the
ates breakdown of the adjacent disc or facets.
degree of deformity. The grading scale that is most useful with
Pathologic spondylolisthesis occur as a result of systemic or
a high slip angle is the modified Newman spondylolisthesis
localized bone pathology. Some examples of processes that can
grading system. This system takes into account both the degree
cause the bony hook disruption include Paget disease, osteo-
of tangential and sagittal slip. The scoring system divides the
genesis imperfecta, metastatic or primary tumors, and localized
dome and the anterior surface of the sacrum into 10 equal
infections.
parts. The divisions along the anterior surface begin at the
Last, degenerative spondylolisthesis results from degenera-
sacral promontory. The divisions along the sacral dome start at
tion of the anterior disc and posterior facet joints allowing a
the posteriorsuperior corner. The score is reported as two
slip without disruption of the bony hook. This, by definition,
numbers and determined by the position of the posteriorinfe-
occurs in a spine not previously subjected to surgical or trau-
rior corner of the L5 vertebrae. Therefore, when a score is 7 +
matic insult (Fig. 58.4).
4, 7 indicates the amount of sagittal slip and 4 indicates the
degree of forward roll (Fig. 58.5).

TREATMENT
A few things should be considered when deciding on a treat-
ment strategy for patients with spondylolisthesis. The first con-
sideration is whether conservative management can be effective.
If not, operative management should be considered. Second, if
the reason to consider surgery is pain, consideration must be
made to determine what the pain generator is. Potential sources
of pain include a lytic defect, degenerative (discogenic, facet)

Figure 58.5. Modified Newman spondylolisthesis grading system.

Figure 58.4. Acquired spondylolisthesis associated with degenera- The degree of slip is measured using two numbersone along the
tive disc and facet disease (degenerative spondylolisthesis L4-5) with sacral end plate and the second along the anterior portion of the
stenosis. sacrum: A 3 0; B 8 6; and C 10 10.

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 560 Section VI Spondylolisthesis
pain, radiculopathy, and stenosis. The nature of surgery should
take into consideration why the surgery is being done: whether
it is for deformity, instability, or pain of various origins. In addi-
tion, given the slip, the surgeon must weigh the risks and ben-
efits of performing a reduction.
As mentioned earlier, one of the benefits of the Marchetti
Bartolozzi classification is the consistent treatment for most
patients that fit into one given category. It is reasonable to
attempt conservative management for the following patients:
asymptomatic high dysplastic adults, asymptomatic low dysplas-
tic adult and adolescents, asymptomatic primary degenerative,
secondary degenerative, and indirect postsurgical. Surgical
management is usually required for the following patients: high
dysplastic adolescents, symptomatic low dysplastics, traumatic
spondylolisthesis, direct postsurgical and symptomatic primary
degenerative. Of those requiring surgical management, a
reduction should be considered for high dysplastic adolescents
with Meyerding grade II and above. Reductions are rarely
required in adults because instability is uncommon. The goal
with reduction is to improve the sagittal alignment and not to
correct the slip completely. The risk of neurologic injury is pro-
portional to the amount of reduction sought. Reductions can
be performed preoperatively or intraoperatively. Intraoperative
complete reductions appear to have increased neurologic risk
for slips greater than 30%.
The classification allows surgeons to predict which patients
are most likely to need surgery. Surgery is indicated in patients
with neurologic symptoms, asymptomatic growing children
with slippage greater than 50%, asymptomatic mature adoles-
cents with slippage greater than 75%, patients with symptoms
recalcitrant to conservative management, and postural or gait
changes secondary to high-grade slips (Table 58.3).
The surgical treatment of choice for symptomatic low-grade
spondylolisthesis in children or adults is in situ posterolateral
arthrodesis. Many authors have used the technique of L5-S1
bilateral posterolateral fusion by using autograft bone and
reported excellent results.7 Fusion rates greater than 90% are
common and patients report 75% to 100% good and excellent
outcomes. Seitsalo et al15 compared in situ posterior or postero-
lateral arthrodesis with conservative treatment at 13 years in
149 children. The surgically treated group had better clinical
results and less pain.15
The addition of instrumentation has not been shown to
improve the rates of fusion in this patient population. However,
Treatment Recommendations
Based on Marchetti
TABLE 58.3
Bartolozzi Classification
Nonoperative
Asymptomatic high dysplastic in adults
Asymptomatic low dysplastic in adults or adolescents
Asymptomatic primary degenerative
Asymptomatic secondary degenerative
Asymptomatic indirect postsurgical
Operative
High dysplastic slips in adolescent
Traumatic spondylolisthesis
Direct postsurgical
Symptomatic low dysplastic
Symptomatic primary degenerative
LWBK836_Ch58_p556-562.indd 560
instrumentation can help patients avoid the use cumbersome
postoperative casting. Decompression is rarely indicated in this
patient group.
High-grade dysplastic spondylolisthesis requires surgical
management when discovered in the symptomatic adolescents
or those in high-risk situations. High-grade spondylolisthesis
rarely is asymptomatic in the adult. When progression occurs,
adults will usually present with radicular symptoms and can be
managed initially nonoperatively. In situ fusion with or without
reduction is one option for adolescents requiring surgery. Some
authors have concerns about the risk of progression after in
situ fusion. There are reported rates of progression as much as
25% despite solid fusions. In addition, the rates of pseudoar-
throsis have been reported as high as 60%. Seitsalo and
Osterman reported long-term results of 87 children treated
with in situ fusion after severe slips. Lumbosacral kyphosis
increased by more than 10 in 45% of the patients, and more
than 10% slip progression was seen in 17% of the patients.15
Harris and Weinstein19 reported a long-term retrospective fol-
low-up of 21 patients treated with posterior interlaminar fusion
and 11 nonoperative patients. Fifteen of the 32 patients were
asymptomatic. Only one patient in each group had significant
symptoms. Eleven operative patients had one or more neuro-
logic findings. Pseudoarthrosis was seen in two patients. The
authors concluded that in situ fusion was an acceptable method
to treat high-grade spondylolisthesis.
The high rates of pseudoarthrosis and slip progression led
some to recommend reduction of high-grade slips.1,2,10,14
However, this remains controversial due to satisfactory out-
comes observed in patients fused without a reduction.15 The
main argument against reduction is the significant risk of neu-
rologic injury. However, proponents of reduction cite the
adverse neurologic outcomes that have occurred with in situ
fusion alone. In addition, foregoing reduction of high-grade
spondylolisthesis can leave patients with abnormal spine
mechanics, crouched posture, shortened trunk, high risk of
sagittal plane progression, pseudoarthrosis, and poor cosmesis.
Therefore, spondylolisthesis reduction is recommended by
some in younger patients to counter the aforementioned nega-
tive outcomes1,2,8,14 (Table 58.4).
Anterior interbody fusion alone for high-grade spondylolis-
thesis is effective and durable.8 Because of the kyphotic nature
of high-grade slips, anterior distraction and fusion with struc-
tural grafting is logical. The graft will be loaded in compression
and can be placed closer to the center of the vertebral body
sagittal rotation. Anterior fusion with reduction has been per-
formed. A study of 14 pediatric patients showed 93% fusion by
using this technique. Anterior fusion has been compared with
circumferential fusion plus reduction. The group undergoing
Treatment of Choice Based
TABLE 58.4 on MarchettiBartolozzi
Classification
Posterolateral in situ fusion
Low dysplastic and low grade (Meyerding grade II or less)
Degenerative, postsurgical
Reduction and interbody grafting
High dysplastic and/or high grade (Meyerding III or higher)
Traumatic spondylolisthesis
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 Chapter 58 Wiltse and Marchetti/Bartolozzi Classifications of SpondylolisthesisGuidelines for Treatment
only anterior fusion demonstrated higher rates of pseudoar-
throsis compared with the group undergoing circumferential
fusion plus reduction (24 % vs. 7%, respectively). While the
reduction group had greater improvements in slip angle, slip
grade, and sacral inclination, patients of the group undergoing
only anterior fusion with solid fusion did not have significant
change in slip angle, sacral inclination, or slip grade. Anterior
fusion may be useful for revision cases with failed posterior
fusion.10
The posterior dowel graft is a technique popularized by
Bohlman for single-stage posterior decompression and inter-
body fusion in patients with high-grade spondylolisthesis.17 The
operation allows for posterior decompression, posterolateral
arthrodesis with iliac crest graft, and anterior arthrodesis with
fibular graft. The fibular graft is inserted from S1 into the dis-
placed L5 vertebral body without any deformity correction. All
of these steps are performed via a posterior approach. By using
this technique, complete neurologic recovery and a solid fusion
was seen in all 11 patients in the series.17 Roca et al12 studied 14
pediatric patients retrospectively and found that all patients
with preoperative motor deficits recovered and had an 88%
solid fusion rate. Others using this technique found it effica-
cious for revision surgery in patients with established posterior
pseudoarthrosis.
The posterior lumbar interbody fusion (PLIF) can be used
for the treatment of high-grade spondylolisthesis. It allows for
decompression and three-column arthrodesis. There are mixed
results in the literature for this procedure. Cloward22 reported
on 100 patients using uninstrumented PLIF without posterolat-
eral fusion. He found a 93% fusion rate and 90% clinical satis-
faction. Fabris et al3 reported on 12 patients with 100% fusion
rate. In contrast, Verlooy21 reported on 20 patients with similar
treatment and had a 55% fair or poor result.
Partial reduction and arthrodesis has been performed. It
appears to be safer than anatomic reduction in terms of neuro-
logic compromise. Studies show that the greatest risk to the
most commonly injured L5 nerve root occurs during the sec-
ond half of the reduction.1 In Laurens series of 13 patients, no
patients had a neurologic complication, the kyphotic deformity
was reduced, the slip angle was corrected a mean 14, and the
slip percentage correction was a mean of only 6%. Twelve of
the 13 patients were better functionally. Boachie-Adjei et al1
reported on six patients undergoing partial lumbosacral kypho-
sis correction. All had solid fusions at 6 months and significant
improvement in slip angle but not slip percentage.1 These stud-
ies led authors to conclude that partial lumbosacral kyphosis
reduction with instrumented circumferential fusion and instru-
mentation is effective for achieving high rates of fusion, restor-
ing sagittal balance and avoiding neurologic complications.
L5 vertebrectomy, so-called Gaines procedure, removes the
entire L5 vertebral segment and fuses the L4 vertebrae to the
sacrum. The neurologic risks of reduction are not completely
avoided. Additional long-term studies are needed to determine
the effectiveness of this procedure.
There are a number of treatments for high-grade spon-
dylolisthesis. Poussa et al11 compared 22 pediatric patients who
were treated with in situ fusion or reduction with pedicle screw
posterior fixation and circumferential fusion. The reduction
group had better radiographic parameters in terms of slip angle
and grade improvement, but no differences were seen in terms
of function or pain.11 Boxall20 reported on 39 pediatric patients
treated with either in situ fusion, decompression and fusion, or
LWBK836_Ch58_p556-562.indd 561
561
reduction and posterior fusion. Twenty-six percent of patients
with solid fusion had a slip angle of greater than 50 preopera-
tively. The author concluded that a high slip angle is a predic-
tive factor of slip progression and recommended reduction and
fusion for such patients. Molinari et al10 reviewed 32 patients
treated with in situ L4 to sacrum fusion, posterior decompres-
sion and instrumented reduction and fusion, or reduction and
circumferential fusion. No patients with circumferential fusion
had pseudarthroses, whereas the in situ fusion and instru-
mented fusion groups had 45% and 29% pseudoarthrosis rates,
respectively.10 Outcomes were excellent in those patients who
achieved fusion regardless of the procedure.
Traumatic spondylolisthesis surgical treatment requires
appreciation of the severity of the injury mechanism. The static
radiograph often does not show the degree of vertebral sublux-
ation at the time of injury. These vertebral injuries are very
unstable and require surgical stabilization as soon as possible.
The ease of surgical reduction is inversely proportional to the
chronicity. Anterior interbody arthrodesis may be necessary to
aid in stability because posterior instrumentation may prove
difficult, given the damage to the structures necessary for pos-
terior or transpedicular fixation.
Primary degenerative spondylolisthesis unresponsive to con-
servative therapy may require surgical management. Most cases
present with a translational listhesis and have symptoms that
resemble classic spinal stenosis. When performing decompres-
sion for the associated stenosis present with primary degenera-
tive spondylolisthesis posterolateral arthrodesis with posterior
instrumentation using pedicle fixation has been associated with
increased long-term success.
Pathologic spondylolisthesis surgical treatment depends on
the etiology of the lesions. The overall therapeutic strategy
should be aimed at the causative disease. The surgeon should
note that the underlying etiology is the priority and seek oppor-
tunities to address the spondylolisthesis at the time of treat-
ment of the primary problem. This happens rarely but has been
accomplished in cases such as tuberculosis.
Information is lacking on the outcomes of surgical options
in the direct postsurgical group, but it seems reasonable that an
interbody arthrodesis would be beneficial for increased fusion
area and to improve sagittal alignment as these may occur at
higher levels of the lumbar spine. Anterior or posterior
approach for the interbody structural graft may prove useful
for help with reduction of the slip kyphosis and provide local
stabilization lost by the absence of a facet or postsurgical boney
loss.
Historically, Wiltses and MarchettiBartolozzis classifica-
tions of spondylolisthesis have been used clinically. However,
much remains to be understood about this complex condition,
and surgical treatment techniques continue to evolve. As a
result, we anticipate that a more comprehensive universal clas-
sification system for guiding patient care with spondylolisthesis
will be developed.
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