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Degenerative Spondylolisthesis

Degenerative spondylolisthesis is the forward or backward slip of one vertebra over another due to facet and disc degeneration, most commonly affecting the L4–L5 level in elderly women. It presents with mechanical back pain, neurogenic claudication, or radiculopathy secondary to spinal stenosis. Standing lateral radiographs confirm diagnosis and grading, while MRI assesses canal and neural compression. Conservative treatment—including physiotherapy, anti-inflammatories, and injections—is first-line for low-grade, stable cases. Surgical decompression with or without fusion is reserved for patients with persistent pain, neurological deficits, or instability, providing superior outcomes compared with nonoperative care.


Overview


Degenerative spondylolisthesis is defined as anterior or posterior translation of one vertebral body over another with an intact pars interarticularis, caused by progressive degenerative changes of the intervertebral disc and facet joints. It is one of the most common causes of low back pain and lumbar spinal stenosis.
Prevalence increases with age (peak 70–75 years), affecting 19–43% of individuals, with a strong female predominance (F/M ratio ≈ 6:1). The most frequently involved level is L4–L5, whereas isthmic spondylolisthesis typically occurs at L5–S1.
Degenerative changes—disc height loss, osteophyte formation, facet arthropathy, and ligamentum flavum thickening—contribute to segmental instability and neural compression.


Clinical Presentation


Symptoms arise from both mechanical instability and neural compression:

  • Mechanical back pain: Due to segmental degeneration and abnormal motion.

  • Neurogenic claudication: Caused by canal narrowing and dynamic stenosis.

  • Radicular pain: From foraminal narrowing or nerve root compression.


Imaging


Radiographs: Standing lateral radiographs confirm vertebral translation and allow grading (Meyerding Classification). Bilateral oblique views help differentiate degenerative from isthmic listhesis (“Scotty dog collar sign”).
Typical findings include disc space narrowing, endplate sclerosis, facet hypertrophy, and osteophyte formation.

CT Scan: Defines cortical integrity, facet hypertrophy, canal compromise, and bony overgrowth in detail.
MRI: Demonstrates canal stenosis, neural compression, pseudobulging, and ligamentous hypertrophy; essential for preoperative planning.


Treatment


Conservative management is the first-line approach for low-grade, neurologically intact patients:

  • Activity modification and physiotherapy

  • Analgesics and anti-inflammatory medication

  • Epidural steroid injections or bracing as adjuncts


Surgical Indications


Surgery is indicated for patients with:

  • Persistent symptoms (>3–6 months) despite conservative therapy

  • Radiculopathy or neurogenic claudication

  • Progressive neurologic deficit or cauda equina syndrome (urgent decompression required)

Procedures:

  • Decompression alone (laminotomy/laminectomy) may suffice in elderly or stable cases with minimal instability.

  • Decompression with fusion provides superior long-term stability, lower reoperation rates, and improved outcomes compared with decompression alone.

  • The SPORT trial demonstrated better functional recovery in surgical groups, particularly in patients <65 years and those >80 years compared to conservative care.


Differential Diagnosis


Hip pathology

Vascular claudication

Sacroiliac joint dysfunction

Peripheral nerve entrapments can mimic symptoms.



References

  1. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis: Four-Year Results from the SPORT Trial. J Bone Joint Surg Am. 2009;91(6):1295–1304.

  2. Bydon M, Alvi MA, Goyal A, et al. Degenerative Lumbar Spondylolisthesis: Definition, Natural History, Conservative Management, and Surgical Treatment. Neurosurg Clin N Am. 2019;30(3):299–304.

  3. Inose H, Kato T, Yuasa M, et al. Comparison of Decompression, Decompression plus Fusion, and Decompression plus Stabilization for Degenerative Spondylolisthesis: A Prospective, Randomized Study. Clin Spine Surg. 2018;31(7):E347–E352.

  4. Martin CR, Gruszczynski AT, Braunsfurth HA, et al. The Surgical Management of Degenerative Lumbar Spondylolisthesis: A Systematic Review. Spine (Phila Pa 1976). 2007;32(16):1791–1798.

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