Overview
Spondylolisthesis is a condition in which one vertebral body translates anteriorly (anterolisthesis) or posteriorly (retrolisthesis) relative to the adjacent vertebra below. This displacement can range from subtle to severe and may be stable or dynamic — with movement occurring between flexion and extension. When slippage is significant or associated with neural element compression, it produces a characteristic clinical syndrome of back pain, radiculopathy, and neurogenic claudication.
Classification
The Wiltse classification remains widely used to categorize spondylolisthesis by etiology:
- Isthmic (Type II): Results from a defect or stress fracture in the pars interarticularis (spondylolysis). Most common in active adolescents and young adults; L5–S1 is the predominant level
- Degenerative (Type III): Develops from facet joint arthrosis and disc degeneration in older adults; most common at L4–L5. Often associated with spinal stenosis
- Dysplastic (Type I): Congenital deficiency of the posterior elements; highest risk of high-grade slippage
- Traumatic (Type IV) and Pathologic (Type V): Less common; result from fracture or systemic bone disease
Severity is graded by the Meyerding system from Grade I (<25% translation) through Grade IV (>75%) and Grade V (spondyloptosis, complete dislocation).
Symptoms
- Low back pain — often worse with lumbar extension and prolonged standing
- Buttock pain and hamstring tightness (particularly in isthmic spondylolisthesis)
- Radiculopathy from neural foraminal compression at the slipped level
- Neurogenic claudication in degenerative spondylolisthesis with associated stenosis
- Step-off deformity palpable at the spinous processes in high-grade slips
- Neurological deficits (rare in low-grade, more common in high-grade)
Diagnosis
Standing lateral radiographs are the primary diagnostic tool, with flexion-extension views identifying dynamic instability. MRI characterizes the disc, neural elements, and associated stenosis. CT provides detailed bony morphology, essential for preoperative planning in high-grade or complex cases.
Non-Surgical Treatment
Low-grade stable spondylolisthesis without progressive neurological symptoms is often managed conservatively. Physical therapy focused on lumbar stabilization, core strengthening, and hamstring flexibility forms the foundation of non-operative care. Epidural steroid injections address radicular components, and activity modification reduces mechanical provocation.
Surgical Treatment
Surgical indications include progressive neurological deficits, failure of conservative management, high-grade slippage, or documented radiographic progression. The surgical approach is individualized:
- Decompression alone: Reserved for rigid, low-grade degenerative listhesis in carefully selected elderly patients without instability
- Decompression and fusion: The standard treatment for most symptomatic spondylolisthesis, restoring stability and decompressing neural elements simultaneously
- Reduction and fusion: High-grade slips may benefit from partial or complete reduction before fusion to restore sagittal alignment
- Approach selection (TLIF, PLIF, ALIF, LLIF): Determined by patient anatomy, level of pathology, and surgeon experience
Dr. Kwan employs robotic navigation for pedicle screw placement, enhancing accuracy and reducing radiation exposure in these complex procedures.
Consult Dr. Kevin Kwan
Spondylolisthesis management requires precise diagnosis, characterization of instability, and individualized surgical planning. Dr. Kwan has extensive experience with both minimally invasive and open correction of spondylolisthesis across all grades and etiologies.