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SPINE Volume 28, Number 10, pp 10271035

2003, Lippincott Williams & Wilkins, Inc.

The Natural History of Spondylolysis


and Spondylolisthesis
45-Year Follow-up Evaluation

William J. Beutler, MD,* Bruce E. Fredrickson, MD,* Albert Murtland, MD,


Colleen A. Sweeney, MA,* William D. Grant, EdD,* and Daniel Baker, MD

has not been a prospective study to delineate the course


Study Design. A prospective study of spondylolysis of individuals with a spondylolytic defect, whether
and spondylolisthesis was initiated in 1955 with a radio- symptomatic or not, through their lives. The purpose of
graphic and clinical study of 500 first-grade children.
this investigation was to delineate the natural history of
Objective. To determine the natural history of spon-
dylolysis and spondylolisthesis. spondylolysis and spondylolisthesis in a study popula-
Summary of Background Data. Most studies on the tion of 30 individuals.
natural history of spondylolysis and spondylolisthesis are In the early 1950s, Dr. Daniel Baker initiated a pro-
based on patient populations presenting with pain. Criti- spective study to determine the incidence and natural
cal to any natural history investigation is the study of a
history of spondylolysis and spondylolisthesis.2 From
population of affected individuals, whether symptomatic
or not, from onset of the condition through their lives. 1955 to 1957, radiographs were taken of all first-grade
Methods. By study of a population from the age of 6 children in a northern Pennsylvania town, a study pop-
years to adulthood, 30 individuals were identified to have ulation of 500 children. A total of 22 subjects 6 years of
pars lesions. Data collection at a 45-year follow-up as- age were determined to have a lytic defect of the pars
sessment included magnetic resonance imaging, a back
interarticularis, giving a rate of 4.4%. By adulthood,
pain questionnaire, and the SF-36 Survey.
Results. No subject with a pars defect was lost to lumbar lytic lesions had developed in an additional eight
follow-up evaluation once a lesion was identified. Sub- subjects, bringing the total to 30 subjects and establish-
jects with unilateral defects never experienced slippage ing an incidence of 6%. Four decades of follow-up eval-
over the course of the study. Progression of spondylolis- uation in this prospective study have now been
thesis slowed with each decade. There was no associa-
concluded.
tion of slip progression and low back pain. There was no
statistically significant difference between the study pop- The study population currently is older than 50 years.
ulation SF-36 scores and those of the general population The 30 subjects were located, and detailed clinical and
the same age. radiographic follow-up data were obtained. Initial find-
Conclusions. This report is the only prospective study ings were reported in 1984, with the study population in
to document the natural history of spondylolysis and
their third decade of life. In 1988, follow-up assessment
spondylolisthesis from onset through more than 45 years
of life in a population unselected for pain. Subjects with included lumbar radiographs and a back pain question-
pars defects follow a clinical course similar to that of the naire. In 1999, similar studies were conducted with the
general population. There appears to be a marked slow- addition of MRI and the SF-36 questionnaire. Specifi-
ing of slip progression with each decade, and no subject cally, the authors continue to examine the rate of slip
has reached a 40% slip. [Key words: natural history, spon-
progression, any symptoms presenting over a subjects
dylolisthesis, spondylolysis] Spine 2003;28:10271035
lifetime, and any clinical or radiographic findings corre-
lating with spondylolisthesis progression.
The natural history of spondylolysis and spondylolisthe-
sis has been studied and debated for years.15 The fetal Materials and Methods
incidence has been shown conclusively to be zero.2,3,6 9
The 6% incidence at adulthood has been verified in ad- The only inclusion criterion for the study population required
that the child had attended one of the local elementary schools
ditional studies, with some ethnic variation.3,10 There
in the years 1954 to 1957. Parental permission was obtained
for each child in the study. The small size of the first-grade
From the *State University of New York Upstate Medical University,
Syracuse, New York, and Guthrie Clinic, Sayre, Pennsylvania.
classes made it necessary to conduct the study over three con-
Funded by a research grant from the North American Spine Society. secutive years. Children with a lumbar spine lesion initially
Acknowledgment date: April 18, 2002. First revision date: October 2, were followed yearly. Lesions were identified by consensus
2002. with a radiologist. Questionable lesions were studied with sup-
Acceptance date: October 7, 2002. plemental oblique radiographs and tomography. The fol-
Device status/drug statement: The submitted manuscript does not con-
tain information about medical devices or drugs. low-up evaluation to the age of 29 years is detailed in the
Conflict of interest: Professional organizational funds were received in authors 1984 report.2
support of this work. No benefits in any form have been or will be During the adult phase of the study, consent was obtained
received from a commercial party related directly or indirectly to the for each contact. Institutional review board approval was
subject of this article.
Address correspondence and reprint requests to Bruce E. Fredrickson,
maintained throughout the adult phase of the study. In the
MD, SUNY Upstate Medical University, Orthopedic Surgery, 550 Har- early phase of the study, permission was obtained through the
rison Center, Suite 130, Syracuse, NY; E-mail: fredricb@upstate.edu existing hospital committees of the era. In 1988 and in 1999,

1027
1028 Spine Volume 28 Number 10 2003

Figure 2. The method of measuring lumbar index.

to allow simplified grading of disc and foraminal changes from


MRI images from various centers around the United States.
The sagittal image in Figure 4 exemplifies each grade of disc
Figure 1. The method of measuring percentage of slip (%slip degeneration. The axial image of Figure 5 demonstrates mod-
A/B 100%). erate foraminal stenosis on the right and severe stenosis on the
left. Figure 6 provides an example of mild foraminal stenosis at
the slipped level.
anteroposterior, oblique, and lateral radiographs were ob- An independent reviewer provided statistical analysis. Sta-
tained. In 1988, both supine and erect radiographs were com- tistical analysis included the application of 2, analysis of vari-
pleted for comparison of the two study techniques. Magnetic ance for repeated measures, and logistic regression. All data
resonance imaging was included in the 1999 studies.
Clinical follow-up assessment in 1988 involved completion
of a back pain questionnaire. Questions presented to the sub-
jects sought information on severity, frequency, and duration
of any back and leg symptoms. Time off work, medication use,
and disability information also were obtained. In 1999, a sim-
ilar questionnaire was used, but was supplemented with the
SF-36 questionnaire.
Isthmic spondylolisthesis was measured by a modification
of Taillards method. Lumbar index and slip angle were mea-
sured on lateral radiographs (Figures 13). Disc height was
determined at both the defect level and the level above, and
reported as an average height of anterior, posterior, and middle
disc measurements.
Magnetic resonance imaging availability in the 1999 fol-
low-up assessment allowed evaluation of disc degeneration,
disc herniation, and foraminal narrowing. Disc degeneration
for each of the lumbar discs was graded on a scale from no
degeneration to mild, moderate, or severe degeneration. Disc
herniation at any lumbar level was recorded. Foraminal steno-
sis at the level of listhesis was graded from no stenosis to mild,
moderate, or severe foraminal stenosis. The grading system
used for disc degeneration and foraminal stenosis was devised Figure 3. The method of measuring slip angle.
Natural History of Spondylolysis and Spondylolisthesis Beutler et al 1029

Figure 4. No disc degenerative changes are demonstrated at


L1L2 and L3L4, and mild change is shown at L4 L5. Moderate
changes are seen at L2L3, and severe disc degeneration is
evident at L5S1.

analysis was completed using SAS-SPC for Windows, Version


8.01.

Results
Of the 500 children in the study population, 22 subjects
(4.4%) were found to have unilateral or bilateral pars
interarticularis defects of the lumbar spine at the age of 6
years. Defects developed in an additional eight subjects
between the ages of 12 and 25 years. This group of 30
subjects with identified pars lesions consisted of 10 fe-
males and 20 males. Of the 30 subjects, 22 had bilateral
L5 pars defects and 8 subjects had unilateral defects (1 at
L1, 1 at L2, 1 at L4, and 5 at L5). No subject with a pars
interarticularis defect was lost to follow-up evaluation
once the lesion was identified.
Healing of a pars defect was seen in three subjects, and Figure 5. A, Severe foraminal stenosis is noted on the left. B, The
only with unilateral defects. Oblique lumbar radiograph right foramen is graded as moderate stenosis.
was used to confirm the healing. Tomography was used
to clarify questionable cases. Healing at the age of 31
years was noted in one male subject with a unilateral L5 graphs. Four subjects consented to clinical but not radio-
defect found at the age of 16 years. Another male with a graphic follow-up assessment. Magnetic resonance im-
unilateral L5 defect found at the age of 14 years was aging was obtained for 21 subjects. Lumbar radiographs
healed at the age of 31 years. The third subject to expe- were obtained for 22 subjects. All of the three deceased
rience healing of a pars lesion was a female with a uni- subjects had completed the 1988 clinical and radio-
lateral L5 defect found at the age of 8 years. Healing was graphic follow-up assessment. One deceased male with a
noted at the age of 28 years. bilateral L5 pars defect found at the age of 25 years had
In 1988, 24 subjects consented to follow-up evalua- an 18% slip in the 1988 studies. He died of congestive
tion. In 1999, all 30 subjects were located. Three subjects heart failure at the age of 46 years. A second male died of
had died after the 1988 follow-up. In 1999, of the re- a myocardial infarction at the age of 44 years. He had a
maining 27 subjects, all but one completed the SF-36 and bilateral L5 pars defect found at the age of 6 years with
back pain questionnaire. This one subject refused to no initial slip. He had progressed to a 24% slip at the
complete any follow-up evaluation, including radio- 1988 follow-up assessment. The third deceased subject
1030 Spine Volume 28 Number 10 2003

Bilateral Defects
There were 22 subjects with bilateral pars defects. All
bilateral pars defects were at L5. Initial examination at
the age of 6 years found 15 bilateral L5 pars defects. One
bilateral defect was found a year later. These subjects
were termed the early defect group. Six subjects were
grouped into a late defect group with bilateral L5 le-
sions developing between the ages of 12 and 25 years.
Both groups had a male:female ratio of 2:1.
Over the course of the study, spondylolisthesis never
developed in 4 of the 22 subjects with bilateral L5 le-
sions. There also was no documented healing of the pars
interarticularis defects.
Initial slip at the lumbosacral level was noted in 10 of
the 16 bilateral L5 defects discovered in subjects at the
age of 6 years. Of the five female subjects with early
defects, all but one presented with a slip in addition to
the defect. The average slip was 11% for all subjects with
initial spondylolisthesis. Slip progression was slow. The
average slip in the 1999 studies for this group was 18%.
Figure 6. Mild foraminal stenosis is demonstrated at the slipped Of the six subjects with early bilateral L5 pars defects,
level. but without spondylolisthesis at the initial 1956 study,
three never experienced slippage, and the other three
progressed to an average slip of 24%. One subject in this
died of prostate carcinoma at the age of 45 years. He had
group had the largest slip of the study population (39%).
a unilateral L2 defect found at the age of 6 years.
Six subjects were in the late bilateral defect group.
Unilateral Defects Bilateral L5 lesions developed in these subjects between
The eight subjects with unilateral defects never experi- the ages of 12 and 25 years. The ratio of men to women
enced slippage over the course of the study. This group was again 2:1 for this group. Again, there was diversity
consisted of five men and three women. Three subjects in this group with respect to slip progression. At the final
had healing of the unilateral defect (one by the age of 12 follow-up assessment, one had never slipped, one had
years, and the others by the age of 31 years). The slip slipped up to 10%, two had slipped up to 20%, and two
angle for subjects with unilateral defects went from 28 had slipped up to 30%.
in 1960 to 18 in 1988. The lumbar index was 74 in In 1988, both supine and erect lateral lumbar radio-
1955 and 85 in 1988. The disc height at L5S1 was graphs were obtained. The purpose for both views was to
maintained at 92% of the L4 L5 disc height over the evaluate in the study population any difference in the
course of the study. The back pain questionnaire in 1988 percentage of slip and the other evaluated indexes with
noted that no subject with unilateral pars defect ever had each radiographic view. In the studies of the 1950s and
more than mild low back pain, and four of the subjects 1960s, only the supine lateral view had been obtained. In
reported only rare back pain lasting less than 1 day. 1988, 18 of the subjects had consented to both sets of
The SF-36 data in 1999 noted that two of the subjects radiographs. The average slip for those with spondylolis-
scored lower than 80 on the bodily pain scale (moderate thesis in 1988 was 9% on the supine radiographs and
pain). One of these subjects was a female with an L4 pars 10% on the erect views. There was no statistically signif-
defect who had a sedentary job. The second subject with icant difference in the percentage of slip between the two
moderate reported pain was a male with a unilateral L5 radiographic techniques, similar to findings in other
defect and a history of discectomy at L4 L5. He worked studies of adult spondylolisthesis.3
a heavy duty lifting position as a machinist. He was Lumbar index was evaluated in 1956, 1970, and
the only subject with a unilateral defect ever to use nar- 1988. The average lumbar index for all subjects was 78
cotic analgesic medication. in 1956 and 80 in 1988. There was no statistical associ-
The MRI data on the unilateral defect group noted ation between lumbar index, spondylolysis level, early
that only two of the eight subjects had any disc degener- versus late slip, percentage of slip, or progression of slip
ation. One subject had degeneration at the L5S1 disc for most years of follow-up evaluation. An associated
space only (with a L1 pars defect). The other subject had lower lumbar index with a greater percentage of slip was
a unilateral L5 defect, with disc degeneration noted at all noted in the 1988 data (P 0.0089). The lumbar index
lumbar levels except L1L2. In the 1999 follow-up, there in childhood offered no predictive value for later slip.
were no disc herniations in the unilateral group. Fora- Slip angle was evaluated in the 1960 follow-up eval-
mens were maintained with no significant narrowing at uation and in 1988. The slip angle ranged from 29 to
any level. 12 for all subjects in 1988. There was an association
Natural History of Spondylolysis and Spondylolisthesis Beutler et al 1031

between percentage of slip and more positive slip angle in herniations were noted in the 1999 studies, and none
1988 (P 0.0079). There was no predictive value in the were at L5S1. There was a relation between percentage
slip angle and ultimate slip on late follow-up assessment. of slip and the severity of foraminal stenosis at L5S1.
Disc height was measured on the initial 1950s radio-
graphs and on the 1988 and 1999 studies. There was an Clinical Follow-up Evaluation
inverse relation with decreasing L5S1 disc height, as a Three study subjects underwent lumbar spine surgery as
ratio to the L4 L5 disc height, with greater percentage of adults. The first subject, who had a unilateral L5 defect,
slip, but it was not statistically significant. Concomitant had a L4 L5 discectomy for acute disc rupture. The sec-
degeneration of the L4 L5 disc, although mild as com- ond subject underwent a discectomy at L3L4 for acute
pared with that of L5S1, may weaken the statistical disc rupture. This subject had bilateral L5 defects and a
relation. There was a statistically significant inverse re- slip of 18% at L5S1 at the time of his surgery. The third
lation between the absolute height of the lumbosacral subject, with a history of lumbar surgery, had bilateral
disc and the percentage of slip (P 0.0062). There was L5 defects and a slip of 9% at L5S1 at the time of his
no association between the percentage of slip at L5S1 fusion without instrumentation. Follow-up evaluation of
and degeneration of the L4 L5 disc. this subject in 1999 radiographs noted appearance of slip
There were 10 subjects (6 males and 4 females) with progression to 18% with pseudarthrosis. The subject re-
early segmental laxity. These subjects presented at the ported that a work-related injury had precipitated the
age of 6 years with bilateral pars defects and initial spon- onset of his pain before his surgery. He denied pain on
dylolisthesis. Initial slip in this subgroup ranged from the 1999 SF-36 questionnaire.
7% to 17%. There was a wide variability in progression There was no association of low back pain with preg-
of slip. Five subjects (3 males and 2 females) had no nancy in the six female subjects that carried a pregnancy
progression of slip over the next 45 years. Five subjects (3 to term. Each of these had between two and four chil-
males and 2 females) had progression of the slip, with dren. All but one denied any pain with pregnancy. The
increases of 7% to 20% from the initial slip. one who had experienced pain reported that it was dur-
Three subjects, all males, had late segmental laxity. ing a twin pregnancy with complications unrelated to her
These subjects presented with bilateral pars defects at the lumbar spine while she was on bed rest for the last tri-
age of 6 years, but no documented spondylolisthesis. mester. She had experienced no pain with a later single
Spondylolisthesis developed in each over the following birth. Of the remaining four female subjects, one had
decade. Again, there was wide variability in any progres- miscarriages, one refused the survey, and two were never
sion of slip noted in early adulthood. The first subject pregnant. After the childbearing years, no female patient
had no progression of his 11% slip. The slip of a second had a documented increase in percentage of slip.
subject went from 14% to 24%, and the slip of the third Three subjects, all males, died between the 1988 and
subject had gone from 22% to 36% at the last follow-up 1999 follow-up assessments. All had completed both the
assessment. clinical and radiographic 1988 follow-up evaluation.
Slip progression was greatest early in life, regardless of The 10% death rate (3/30) of the current subject group is
early or late defects, or whether the subject demonstrated similar to the 6.2% rate reported in 1990 for subjects
early segmental laxity or late segmental laxity. In the first born in 1950 in the United States.11
decade of follow-up evaluation, the average slip progres- During childhood and adolescence, only one pain ep-
sion was 7% for those that did progress. Progression in isode was noted in any of the study subjects. A female
the second and third decades was an average of 4%. In subject, in whom a bilateral L5 defect had developed at
the fourth decade of follow-up evaluation, average pro- 12 years of age, had experienced low back pain at the age
gression was 2%. of 16 years. It resolved with conservative therapy. She
MRI Data had experienced no further pain until the age of 28 years,
Magnetic resonance imaging data at the 1999 follow-up when she again had an episode of back pain. In 1988, 12
demonstrated that most subjects had some disc degener- subjects denied any pain, 11 subjects reported mild in-
ation at some level. Only two subjects, both with unilat- termittent low back pain, and 1 subject, who had initial
eral pars defects, had no degenerative changes at any spondylolisthesis and a slip of 10% in 1988, reported
level. Only two subjects with bilateral L5 defects had no moderate low back pain. No subject reported any severe
degeneration of the lumbosacral disc. Both of these sub- low back pain episodes.
jects had no spondylolisthesis. A slip exceeding 15% al- In 1999, all but one of the living subjects indepen-
ways was associated with moderate or severe degenera- dently completed the SF-36 questionnaire. For each of
tion of the lumbosacral disc. the function and pain indexes, there was no significant
There was an association between a greater degree of difference between the subject population and the SF-36
disc degeneration at L5S1 and percentage of slip (P Health Manual Survey for subjects 45 to 55 years of age
0.0006). There was no association between disc degen- (Figure 7).12,13 There was no statistically significant dif-
eration at L4 L5 and percentage of slip. Only two disc ference in the pain or physical functioning scores be-
1032 Spine Volume 28 Number 10 2003

Figure 7. The SF-36 data for the


study group (n 26), ages 45 to
54 years, and the SF-36 mean
values from the SF-36 Health Sur-
vey Manual. GH, general health;
PF, physical functioning; RP, role
limitation from physical health; RE,
role limitation from emotional
problems; SF, social functioning;
MH, mental health; BP, bodily pain;
VT, energy/fatigue.

tween the subject group as a whole or those with a slip days was reported by 20.2% of men ages 25 to 34 years,
and the SF-36 norms. with an increase to 28.5% in 65-to 74-year-olds. The
No subject ever filed a disability claim related to low proportion of women the same age reporting low back
back pain. In 1999, 14 subjects reported episodes of back pain went from 31.1% to 38.8%. Population studies
pain lasting longer than 5 days over their lifetime (9 also have noted a greater incidence of disc degeneration
subjects with a slip and 5 subjects without a slip). Eight with age.20
subjects reported a day of lost work over their lifetime Pain was not prominent in the current study popula-
because of low back pain (5 with a slip and 3 without a tion. A number of studies have reported the prominence
slip). Only three subjects had any narcotic analgesic use of pain with spondylolisthesis, but the populations stud-
for low back pain over their lifetime. ied had presented initially with symptoms. The current
findings show no difference in pain or function indexes
with the degree or progression of slip. There was no
Discussion
significant difference in the SF-36 scores for unilateral or
Clinicians understanding of the natural history of spon- bilateral pars defects and the norms for the general pop-
dylolysis and spondylolisthesis remains incomplete. ulation. The onset of slip, whether in childhood or ado-
Most current studies involve review of a symptomatic lescence, did not occur with pain in those years, nor was
patient group seen at a spine center and maintained un- it associated with pain in adulthood.
der observation.1,3,5,14,15 The current study provides the In 1990, the authors reported a relation between slip
natural history of these disorders in a group of asymp- progression and disc degeneration.21 Other authors have
tomatic subjects from the time of onset until the age of 50 reported similar findings since that time.4,5,15 This rela-
years. tion of both the height of the L5S1 disc and the severity
The authors report in 1984 noted a 4.4% incidence of disc degeneration with the overall percentage of slip
of spondylolysis in 6-year-old children.2 This increased continued at the 45-year follow-up assessment.
to an incidence of 6% in adulthood. These findings are The etiology of the initial slip in the authors 6- and
similar to those in other studies. The male:female ratio of 7-year-old subjects is more problematic. Ten of their
2:1 in the current study also is similar to that reported in subjects presented at this age with bilateral pars defects
population studies.9,16 18 and initial spondylolisthesis. They categorized this group
The prognosis for a 6-year-old child with a pars inter- as having early segmental laxity. A degree of initial slip is
articularis defect in terms of disability and pain appears determined by individual disc laxity idiopathic to each
to follow that of the general population. Pain with these person. This laxity occurs within the disc complex.
lesions is rare in childhood and adolescence. It is inter- Farfan et al22 postulated that the prevalence of isthmic
esting that this time of life also is associated with the spondylolisthesis in childhood is explained by a slip of
greatest slip progression for the subjects that do experi- the epiphyseal plate. These authors noted that in the
ence slip. young spine, the bond between the disc and the epiphy-
Pain did increase as the study population aged. In the seal plate is strong and the epiphyseal line does not close
study group, only one subject had a brief episode of pain until the late teenage years. Whether the laxity was
in the first two decades. By the fifth decade, the authors within the disc or the growth plate in the current subjects
noted seven subjects with a score of lower than 50 (mod- with early segmental laxity could not be determined by
erate pain) on the SF-36 pain assessment. However, in this study.
the general population, the incidence of low back pain There does not yet appear to be an increased risk of
increases with age. Santos-Eggimann et al19 reported in a slip progression in the adult decades of the current study.
recent study that low back pain lasting longer than 7 This finding has been confirmed in other studies investi-
Natural History of Spondylolysis and Spondylolisthesis Beutler et al 1033

gating the natural history of spondylolisthesis.5,14,23 the current subjects is consistent with studies investigat-
Some spondylolisthesis studies have reported adult slip ing the asymptomatic general population of the same
progression, but in a pain-selected study population. Flo- age. Boden et al25 noted a 51% incidence of lumbar disc
man15 reported on 18 patients presenting to a spine cen- degeneration in 40- to 59-year-olds, and Jarvik et al20
ter with incapacitating low back pain. These patients noted a 49% incidence of lumbar disc degeneration in
were retrospectively found to have a 9% to 30% slip asymptomatic 45- to 55-year-olds.
progression after the third decade of life. A review of The current MRI data show a greater degree of disc
radiographs noted the concurrent observation of disc de- degeneration and foraminal stenosis with greater overall
generation at the slipped level. Floman15 concluded that percentage of slip. There was no association of spon-
disc degeneration explained how an asymptomatic lesion dylolisthesis with disc herniation. Any disc herniation
would become symptomatic and lead to increased slip in was noted at levels other than the slip, and usually at
adulthood. The author estimated that his study patients L4 L5 level. Classic teaching has maintained that herni-
represented 20% of his clinic population, and reported ation occurs at the level above the listhesis. The current
this as an incidence of adult slip progression in patients data show an increased percentage of subjects with de-
with spondylolisthesis. This incidence of adult slip pro- generation at L4 L5 and L5-S1, as compared with the
gression compares the 23% incidence of slip progression higher lumbar levels. There was no association between
reported by Seitsalo et al.24 the degree or incidence of degenerative change at L4 L5
The current authors agree that disc degeneration can and the percentage of slip at L5S1.
lead to increased slip and possible low back pain.5 Their Much effort has been expended to determine indica-
unselected study population had only a small increase in tors for future slip.1,5,14,24 This determination is of par-
slip as adults, and no relation of progression to painful ticular interest to parents who have a child or adolescent
symptoms or disability was noted. Their data support with the finding of a pars defect or spondylolisthesis. In a
the findings of the pain-selected studies if only the symp- study population of symptomatic patients, Seitsalo et
tomatic subjects are observed. When the five subjects al24 did find a predictive value in the percentage of slip
with at least moderate pain in the 1999 follow-up assess- observed on presentation. Saraste5 noted a lower lumbar
ment were examined, the authors noted only one subject index in young patients with spondylolysis, and a lower
with slip progression in the forth and fifth decades. This lumbar index in patients with spondylolisthesis, as com-
would result in a 20% incidence (1 in 5 subjects) of adult pared with a control group. She did not find a predictive
progression of 10% or more slip associated with low value of the lumbar index for slip progression. In a nat-
back pain. Only with selection of symptomatic subjects ural history study with a 7-year follow-up period, Fen-
does the current incidence of progression compare with nered et al1 retrospectively studied 47 symptomatic pa-
that of the pain-selected patient population studies. tients with spondylolysis or spondylolisthesis. No
However, the incidence of symptomatic slip progression prognostic factor for progression of slip or need for fu-
in adulthood among the current unselected study popu- ture operative treatment was found. In the current study,
lation presenting with bilateral L5 lesions in childhood only the presence of a bilateral pars defect versus a uni-
or adolescence would be 5% (1/22). This 5% incidence lateral defect was associated with a greater probability of
of progression in adulthood appears to be an appropriate slip later in adult life. There was no predictive value in
estimate to use for counseling of a child or adolescent the percentage of slip, age of the subject at the time of the
presenting with bilateral L5 pars lesions. slip, lumbar index, or slip angle at the time of presenta-
Some spondylolisthesis studies have noted a 1:1 ratio tion for the final slip.
of men to women.14,24 These studies use a symptomatic The degree of initial slip in a child or adolescent pre-
patient population. The current asymptomatic study senting with bilateral pars interarticularis defects is de-
population ratio was 2:1 (20 men and 10 women). This pendent on an individuals disc laxity. The authors found
ratio becomes 1:1 (3 men and 2 women) if only the symp- subjects with early segmental laxity and subjects with
tomatic spondylolisthesis subjects in the 1999 follow-up late segmental laxity (slip in adolescence or later, but
assessment are included. A higher female percentage is bilateral defects at the age of 6 years). They also found
reported in symptomatic study populations and may cor- that 18% (4/22) of their subjects with bilateral L5 pars
relate with female reporting of more intense pain or defects never experienced slippage over the 45 years of
other factors not identified.1 follow-up evaluation.
The inclusion of MRI data in the current study is Early or late development of pars defects was not as-
unique to a study reporting on the natural history of sociated with early or late segmental laxity. Later slip
spondylolysis and spondylolisthesis. Osterman et al4 re- progression could not be predicted by the age of the
ported looking at 15 patients with mild olisthesis and subject at time of the initial slip. The current study and
finding disc degeneration in all of them, but offered no others have found disc height reduction at the level of
correlation with percentage of slip or progression. Stud- slip. Specifically, the current authors found disc height
ies so far have relied on radiographs to document col- reduction associated with the degree of slip in adulthood
lapse of the disc, indirectly assessing evidence of degen- follow-up evaluation. However, in childhood and ado-
eration. The finding of some disc degeneration in most of lescence, the presence of spondylolisthesis was not asso-
1034 Spine Volume 28 Number 10 2003

ciated with the disc height, and disc height offered no disc degeneration will accelerate the current minimal slip
predictive value for later slip. progression.
There was an association between disc degenera-
tion on MRI and degree of slip in the 1999 follow-up
assessment. The degree of slip was associated with the Key Points
loss of disc height noted on plain radiographs, and Unilateral pars defects were not associated with
with the degree of degenerative findings on MRI. It spondylolisthesis or disability.
may be that future study of MRI findings in a child- Bilateral pars defects followed a clinical course
hood spondylolysis population will lead to a clinical similar to that of the general population.
indicator of individual segmental laxity and a predic- The natural history of spondylolysis and spon-
tor of future slip. dylolisthesis shows a slowing of slip progression
The current death rate was similar to national sta- with each decade to the age of 50 years.
tistics for the age group.11 The lumbar surgical history Bilateral pars defects will develop symptomatic
of the current subjects appeared to have no relation to progression in only a small percentage of subjects
presence of spondylolisthesis at the lumbosacral level. in long-term follow-up studies.
Only one subject had surgery directed at the slipped
level, but this subject went on to further asymptomatic Acknowledgments
slip. A study over 50 years cannot be completed without the
Which comes first, significant disc degeneration or input of many people. The authors thank the North
slip? The degree of degenerative change at the lumbosa- American Spine Society for their support of this work
cral level in the adult MRI studies did not correlate with through a research grant. This report is given in memory
pain, but was associated in the subjects with greater of Drs. Dan Baker and Albert Murtland, who had the
overall slip. However, the degenerative changes on MRI foresight to initiate this study and tirelessly continue it
did not correlate with any progression of slip in the pre- over its many decades.
ceding decade. It is possible that the current subjects will
increase their current slow progression of slip over the
next decade as the lumbar degenerative process becomes
more prominent. References
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first 50 years of life. Only a small percentage of subjects dylolysis and spondylolisthesis. J Bone Joint Surg [Am] 1984;66:699 707.
3. Hensinger RN. Spondyloysis, spondylolisthesis in children, adolescents.
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Point of View

Stuart L. Weinstein, MD
University of Iowa
Iowa City, Iowa

The literature on spondylolysis and spondylolisthesis has investigation begun in the 1950s. Although the study
many shortcomings. Minimal natural history is available. numbers are small, this report adds valuable information
Most of the reported studies are retrospect reviews, with on the natural history of this condition. Although the
children and adolescents combined. Type 1 (dysplastic) and varying methodologies used in the sequential studies
Type 2 (isthmic) spondylolisthesis often are combined as could be criticized, the report provides very valuable
well, as are patients with lysis and listhesis. Radiographic long-term information about spondylolysis. It confirms
parameters vary from study to study. Radiographic posi- the generally benign nature of the condition. It demon-
tioning often is not standardized, and different outcome strates that unilateral pars defects are not associated with
measures are used. As with most retrospective reviews, in- further slip, and that those with bilateral defects follow a
ter- and intrarater reliability issues surface. clinical course similar to that of the general population.
This article by Beutler and colleagues reports a long- Although further slippage may occur in adulthood, most
term follow-up evaluation of the only population study patients live active, pain-free, fully functional lives. The
on spondylolysis available in the literature. The study study highlights the generally benign nature of the spon-
represents the conclusion of a four-decade prospective dylolysis affecting the majority of patients.