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Degenerative spondylolisthesis

93 citationsUpdated Sep 2026

Overview

Degenerative spondylolisthesis is a condition where spondylolysis and spondylolisthesis occur more frequently in symptomatic patients than in asymptomatic individuals [1]. While most symptomatic cases of adult isthmic spondylolisthesis are successfully managed nonsurgically [30], surgical treatment provides significant long-term value compared with watchful waiting [6]. In the Medicare population, surgical treatment for stenosis with or without spondylolisthesis was associated with significantly lower mortality and total medical payments at 2 years compared with nonsurgical treatment [152]. Operative treatment of lumbar stenosis and degenerative spondylolisthesis offers a significant benefit over nonoperative treatment in patients at least eighty years of age [2], and with proper patient selection, posterior decompression with instrumented fusion can be safe and effective for patients 80 years of age and older [153]. Surgeons should anticipate favorable improvements in pain and functional ability in appropriately selected younger patients with symptomatic degenerative spondylolisthesis and stenosis [48].

Surgical intervention is indicated for patients with intractable pain or neurologic symptoms, where decompression and stabilization has shown >80% success in appropriately selected patients [30]. Spinal stabilization and fusion constitute the most important parts of the procedure in spondylolisthesis [15], and arthrodesis is indicated as an adjunct to decompression for patients with spinal stenosis associated with degenerative or iatrogenic spondylolisthesis [10]. However, lumbar fusion has a poor success rate when used to treat back pain associated with multilevel disk degeneration [10]. Current surgical guidelines are based on radiographic assessment of the lumbosacral junction, but recent studies demonstrate the importance of a global assessment of sagittal spinopelvic balance [26]. Reduction and maintenance of reduction in selected cases of severe spondylolisthesis is both desirable and obtainable [35].

Regarding surgical approaches, decompression surgery alone was noninferior to decompression surgery with instrumented fusion for reducing impairment at 2 years in patients with spinal stenosis with degenerative spondylolisthesis [24]. Decompression alone is supported as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively [25]. At two years there was no significant difference in patient satisfaction between decompression alone and decompression with fusion for any of the outcome measures, regardless of the presence of a preoperative spondylolisthesis [5]. Both interspinous process fixation and posterior lumbar interbody fusion following decompression yielded comparable long-term clinical outcomes in patients with degenerative lumbar spinal stenosis and Grade I spondylolisthesis [3]. ALIF for degenerative spondylolisthesis was associated with fewer perioperative complications and lower odds of nonroutine discharge than PLF, though at substantially higher inpatient costs [38]. Both PLF and TLIF were effective and resulted in improved clinical and radiological outcomes for patients treated for low-grade spondylolisthesis [45]. Surgical treatment for spondylolisthesis in young patients was associated with low 90-day complication rates and a 13.1% reoperation rate within 5 years [7]. There was no relationship between epidural steroid injections and improved clinical outcomes over a 4-year study period for patients who chose or were assigned to receive surgery for degenerative spondylolisthesis [16].

Anatomy & Pathophysiology

Bony Anatomy

The spinal column comprises 33 vertebrae distributed across five distinct regions: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 or 5 fused coccygeal vertebrae [65, 70]. Each vertebra consists of an anterior vertebral body and a posterior arch that encloses the vertebral canal [65, 70, 73]. The vertebral body is a cylindrical mass of bone composed of an inner region of cancellous bone surrounded by a thin shell of cortical bone [65, 70]. It functions primarily to bear weight and transfer forces to the pelvis and hips [65]. The posterior arch, or neural arch, is formed by two pedicles laterally and two laminae posteriorly that unite to form the spinous process [65, 70, 73]. This structure provides protection to neural structures and functions as a tension band [65]. The articular processes articulate with adjacent vertebrae to form synovial joints, with their relative orientation determining the degree of flexion, extension, or rotation possible in each segment [73]. The spinous and transverse processes serve as levers for attached muscles [73]. The vertebral canal extends throughout the column, protecting the spinal cord, conus medullaris, and cauda equina [73].

The thoracic spine exhibits the most variable anatomy, representing two transitional zones between the mobile cervical and lumbar regions [67]. Its rigidity, combined with the ribs and sternum, forms a stable bony “cube” [67]. Thoracic vertebral bodies are larger than cervical but smaller than lumbar vertebrae [67]. The pedicles arise more superiorly from the posterior vertebral body and project obliquely from superodorsal to inferoventral [67]. The posterior arch encloses the spinal canal, which is narrowest in this region [67]. Superior articular facets project cranially from the junction of the laminae and pedicles and are oriented coronally, while inferior articular facets are contiguous with the ventral aspect of the lamina, permitting only a small arc of motion [67]. Rib heads articulate with the lateral vertebral bodies via demifacets at the disk space level [67]. The transverse processes of T11 and T12 are shorter and project more laterally, marking the transition to the lumbar spine [67].

Ligaments and Soft Tissue

Successive vertebrae are connected anteriorly by intervertebral disks and posteriorly by facet joints [70]. Passive support is provided by the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, facet joint capsule, interspinous ligament, and supraspinous ligaments [70]. The spinal column is stabilized by paraspinal muscles, including the erector spinae, psoas, and multifidus [70]. The erector spinae runs longitudinally on the dorsal surface to extend the spine [70]. The psoas runs longitudinally on the ventrolateral surface to flex the hip or laterally bend the trunk [70]. The multifidus connects intersegmentally to stabilize the spine by acting like a bowstring to maintain lordosis [70].

Intervertebral Disc Anatomy

The intervertebral disk provides a unique combination of compressive stiffness and flexibility to support normal spine biomechanics [70]. It consists of an inner nucleus pulposus and an outer anulus fibrosus [70]. The nucleus pulposus acts as an osmotic pump, attracting water to generate hydraulic pressure under load [70]. The anulus fibrosus encapsulates the nucleus pulposus, providing mechanical support to contain pressure and constrain intervertebral rotations [70]. The outer anulus fibrosus integrates with the vertebral rim via a fibrocartilage enthesis containing a thin layer of calcified cartilage, or “tidemark” [70]. The end plate is a bilayer of cartilage and bone separating the disk from adjacent vertebrae [70]. The cartilage end plate integrates with the inner anulus fibrosus to fully encapsulate the nucleus pulposus [70]. The end plate must be strong and thick to resist loads yet permeable to favor chemical transport and disk cellular vitality [70].

Biomechanics and Alignment

Normal sagittal alignment includes approximately 15° of cervical lordosis, 20° to 40° of thoracic kyphosis, and 40° to 50° of lumbar lordosis [69]. These curvatures keep the head balanced over the pelvis and transmit axial forces to the pelvis [69]. Kyphotic segments (thoracic, sacral) are “primary” curvatures present in utero and at birth, while cervical and lumbar lordotic curvatures develop secondarily later in life [69]. The center of gravity runs from the odontoid process proximally through the sacral promontory caudally [69]. Changes in sagittal balance that shift the center of gravity too far ventrally can result in significant pain and disability [69].

The basic motion segment, or “functional spinal unit,” consists of two vertebrae, the intervening disk, and the facet joints with their capsules [69]. This unit limits motion within the confines of protecting neural structures [69]. Vertebral bodies are loaded in series, with caudal levels supporting more weight than cranial segments [69]. The vertebral bodies bear 70% to 90% of the static axial load of the spine [69]. The facet joints support 10% to 20% of axial load in standing, neutral alignment [69]. In extension, facet joints may bear up to 30% of the axial load, whereas in flexion, they may be burdened with up to 50% of the anterior shear load [69]. The intervertebral disk absorbs axial loads by deforming the nucleus pulposus to redistribute forces radially, which is resisted by the tensile properties of the anulus fibrosus [69].

Vascular Anatomy

The thoracic and lumbar levels are supplied by paired segmental arteries originating directly from the aorta along its posterior surface and running posteriorly along the midportion of the vertebral body [74]. Branches of these arteries supply the vertebral body, paraspinal musculature, and spinal cord [74]. The cervical spine derives its circulation primarily from the vertebral arteries, which arise from the subclavian arteries and typically enter the transverse foramen at the C6 level [74]. The vascular supply of the spinal cord is primarily from medullary branches of the segmental spinal arteries, which merge to feed the anterior spinal artery [74]. The anterior spinal artery supplies approximately 80% of the vascular supply to the spinal cord [74]. The arteria medullaris magna (AMM), also known as the arteria radicularis magna or artery of Adamkiewicz, is the largest anterior segmental artery and typically arises on the left side between the T8 and L1 level [74].

Neural Anatomy

A typical mixed spinal nerve contains motor, sensory, and sympathetic components [75]. Motor fibers arise from anterior horn cells and innervate skeletal muscles [75]. Sensory fibers arise from pain, thermal, tactile, and stretch receptors, with cell bodies located within the dorsal root ganglia [75]. The sympathetic component of all 31 mixed spinal nerves leaves the spinal cord along only 14 motor roots [75]. The cells of origin for the sympathetic component are in the intermediolateral cell column extending throughout the thoracic and upper lumbar cord segments [75]. After leaving the intervertebral foramina, mixed spinal nerves receive their sympathetic component and branch into anterior and posterior primary rami [75]. The posterior primary rami supply the paraspinal musculature and skin along the posterior aspect of the trunk, neck, and head [75]. The anterior primary rami of all cervical, the first thoracic, and all lumbosacral nerves join to form plexuses [75]. The area of skin supplied by the fibers of a single spinal root is called a dermatome [75].

Pathophysiology and Degeneration

A unique neural arch shape may clarify the pathophysiology of degenerative spondylolisthesis and explain its greater prevalence in females [13]. A decreased number of vertebrae was associated with degenerative spondylolisthesis, suggesting numerical variants may potentially be a clinical problem [17]. Repetitive mechanical loading of the pars interarticularis may represent a key underlying mechanism for the development of isthmic spondylolisthesis [18]. At the L4–5 and L5-S1 levels, facet tropism is associated with degenerative spondylolisthesis and lumbar disc herniation [33]. Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis [123]. The preserved biomechanical behavior in the upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits [87]. Abnormal mechanical stress may contribute to intervertebral disc degeneration in old thoracolumbar fractures with kyphosis [104].

Degeneration of the disc occurs with disc narrowing and subsequent ligamentous redundancy, which compromises the spinal canal area and may ensue instability [79]. Relative hypermobility precipitates the formation of facet overgrowth and ligamentous hypertrophy [79]. The ligamentum flavum may be markedly thickened into the lateral recess where it attaches to the facet capsule, causing nerve root compression [79]. Central spinal stenosis denotes involvement of the area between the facet joints, occupied by the dura and its contents [79]. Stenosis in the central region is usually caused by protrusion of a disc, bulging anulus, osteophyte formation, or buckled or thickened ligamentum flavum [79]. The lateral recess begins at the medial border of the superior articular process and extends to the medial border of the pedicle [79]. Facet arthritis most frequently causes stenosis in the lateral recess zone, along with vertebral body spurring and disc or anulus pathology [79].

The foraminal region lies ventral to the pars, bounded medially by the lateral recess, ventrally by the posterior vertebral body and disc, dorsally by the pars and intertransverse ligament, and laterally by the lateral border of the pedicle [79]. The dorsal root ganglion and ventral motor root occupy 30% of the foraminal space [79]. Causes of stenosis in the foraminal area include pars fracture with proliferative fibrocartilage or a lateral disc herniation [79]. Thickening of the ligamentum flavum can extend into the foramen and be associated with a spur from the undersurface of the pars, especially if foraminal height is less than 15 mm and posterior intervertebral disc height is less than 4 mm [79]. The exit zone is identified as the area lateral to the facet joint, where the nerve root can be compressed by a “far lateral” disc, spondylolisthesis and associated subluxation, or facet arthritis [79].

The most common type of spinal stenosis is caused by degenerative arthritis of the spine, characterized by hyperostosis and spinal rigidity in elderly patients [79]. Acquired forms of spinal stenosis are usually degenerative and most commonly localized to the facet joints and ligamentum flavum [79]. The L4-5 level is the most commonly involved in acquired spinal stenosis, followed by L5-S1 and L3-4 [79]. Disc herniation and spondylolisthesis may exacerbate the narrowing of the spinal canal further [79]. Spondylolisthesis and spondylosis rarely cause spinal stenosis in young patients [79]. Isthmic spondylolisthesis induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the iliocava junction [101]. In patients with L4 isthmic spondylolisthesis, displacement occurs between the anterior and posterior elements of L4, primarily in the form of separation during flexion [32].

Classification

Spondylolisthesis is defined as the forward slippage of one vertebra on its adjacent caudal segment [28]. Historically, cases have been divided into congenital and acquired types [28].

Wiltse Classification: This system is based on radiographic findings and age at onset, describing five types [28]. The Marchetti and Barozzi classification amplified the Wiltse classification [28].

Meyerding Classification: This system grades spondylolisthesis from I to V based on the severity of the slip determined by plain radiographs [140]. Grades are determined by measuring the degree of slip using standing, neutral lateral radiographs of the lumbar spine [140]. The specific grade definitions are as follows: * Grade I: 0% to 25% slip [140]. * Grade II: 25% to 50% slip [140]. * Grade III: 50% to 75% slip [140]. * Grade IV: 75% to 100% slip [140]. * Grade V: greater than 100% slip [140].

Spinal Deformity Study Group Classification: The Spinal Deformity Study Group Classification of Lumbosacral Spondylolisthesis exists as a classification system [168].

Other Considerations: Spondyloptosis is the term for complete dislocation of L5 in front of the sacrum [28]. No clinically applicable and validated classification of spinal stenosis has been published [133].

Clinical Presentation

Epidemiology and Risk Factors

The prevalence of spondylolisthesis increases with age, participation in organized sports, and low back pain [18]. Reported prevalence rates of isthmic spondylolisthesis vary depending on the diagnostic method used [18]. A significant number of acquired cases of isthmic spondylolisthesis occur during adolescence [18]. In degenerative spondylolisthesis, a decreased number of vertebrae was associated with the condition [17]. A unique neural arch shape may explain the greater prevalence of degenerative spondylolisthesis in females [13]. Double-level lumbar spondylolysis and spondylolisthesis occurred more often in women, with the most common site being L3–L5 [11].

History and Physical Examination

Clinical history and physical examination aid in the diagnosis of degenerative lumbar spinal stenosis [42]. Patients with intractable pain or neurologic symptoms from adult isthmic spondylolisthesis may benefit from surgical decompression and stabilization [30]. Surgical treatment of intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis provides significant value to the patient over the long term [6]. No catastrophic progressions to neurologic deficit occurred as a result of watchful waiting for these conditions [6].

Imaging and Diagnostic Assessment

Imaging studies are used to confirm the diagnosis of degenerative lumbar spinal stenosis and identify the levels involved as well as any associated pathology [42]. Plain standing AP and lateral radiographs may demonstrate spondylolisthesis, disk space narrowing, end plate sclerosis, osteophytes, and facet hypertrophy [42]. Lateral and flexion and extension stress radiographs may be helpful in determining whether spondylolisthesis is mobile [42]. These stress views may demonstrate a slip that is not visible on the plain standing lateral view [42].

No consensus exists regarding the definition of spinal stenosis in terms of the diameter of the spinal canal or area measurements [42]. The degree of soft-tissue compression caused by ligament infolding is often underestimated when using diameter or area measurements to assess spinal stenosis on CT [42]. Measurements of midsagittal and anterior-posterior canal diameter may appear normal in patients with trefoil-shaped spinal canals who have clinically relevant lateral recess stenosis with compression of traversing nerve roots [42]. The degree of spinal stenosis is best evaluated on MRI because it can demonstrate disk degeneration or herniation, hypertrophy of the ligamentum flavum and facet capsule, and narrowing of the central canal and lateral recess [42]. Parasagittal T1-weighted magnetic resonance images may demonstrate loss of epidural fat at the exiting nerve root or frank nerve root deformation, which suggests entrapment of the root in the foramina [42].

Instability and Special Findings

Radiographic findings that indicate likely instability include the presence of gapped facets on axial CT scan and fluid-filled facets visible on axial T2 weighted magnetic resonance images [42]. Lumbar lateral instability, defined as increased mobility in the coronal plane on lateral bending radiographs, correlates with more pronounced patient-related symptoms in degenerative L4–5 spondylolisthesis [36]. The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone may result in a greater likelihood of failure [29]. This study revealed the occurrence of displacement between the anterior and posterior elements of L4, primarily in the form of separation during flexion, in patients with L4 isthmic spondylolisthesis under weight-bearing conditions [32]. Disc degeneration and instability are not concurrent in adolescent spondylolisthesis, as early disc degeneration observed on MRI is not always associated with abnormal mobility of the corresponding motion segment [34].

Clinical Outcomes and Prognosis

Surgical decompression and stabilization for appropriately selected patients with adult isthmic spondylolisthesis has shown >80% success [30]. Surgical treatment for spondylolisthesis in young patients was associated with low 90-day complication rates [7]. Surgical treatment for spondylolisthesis in young patients was associated with a 13.1% reoperation rate within 5 years [7]. Young patients with lumbar degenerative spondylolisthesis commonly, but do not always, experience clinically meaningful gains in pain relief, function, and quality of life after transforaminal lumbar interbody fusion [31].

Clinical outcome was not related to the obtained radiographic reduction of the slipped vertebra in patients with a lumbar fusion for low grade spondylolisthesis [8]. A correlation between correction of sagittal rotation and clinical outcome was demonstrated in patients undergoing lumbar spinal fusion of low-grade degenerative spondylolisthesis [27]. Patients improving pelvic tilt after fusion achieved good clinical outcomes in degenerative spondylolisthesis [12]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion for spondylolisthesis [37].

Surgical Considerations

Surgical treatment of degenerative spondylolisthesis usually consists in posterior release associated to instrumented fusion [20]. Standalone oblique lateral interbody fusion had better clinical outcomes at 1 week and 3 months than oblique lateral interbody fusion combined with percutaneous pedicle screw fixation in patients with spondylolisthesis [52]. Both interspinous process fixation and posterior lumbar interbody fusion following decompression yielded comparable long-term clinical outcomes for single-level grade I degenerative spondylolisthesis [3]. Microendoscopy-assisted extraforaminal lumbar interbody fusion produces good clinical results with fewer complications and can be applied in most single-level spondylodesis cases [47].

Investigations

MRI: Magnetic resonance imaging is the standard for advanced spinal imaging, offering superior soft-tissue contrast and resolution compared to CT [86]. It directly visualizes intervertebral discs, nerve roots, the posterior longitudinal ligament, and the intervertebral foramen [85]. However, MRI consistently underestimates the lumbar spinal canal cross-sectional area relative to CT, a discrepancy that may impact surgical planning and outcomes [185]. Prevalence data indicate that MRI evidence of lumbar disc degeneration is present in 35% of patients aged 20 to 39 years and in 100% of patients older than 50 years [86]. Consequently, imaging findings must be carefully correlated with the clinical impression, as demonstrated abnormalities may be asymptomatic [86]. MRI findings are not predictive of the development or duration of low-back pain in asymptomatic subjects [187]. The most effective approach to interpreting MRI is to pose specific questions derived from history and physical examination regarding neural compression, instability, and deformity [86].

CT: CT myelography is reserved for patients with contraindications to MRI or equivocal MRI examinations, as it is invasive and more costly [85].

Specific Pathological Findings: Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels [182]. A positive MRI T2-weighted image of the lumbar disc with a high-intensity zone (HIZ) indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain [191]. Lumbar segmental instability was recognized at all levels even in individuals who appeared to be normal or to have mild disc degeneration on MRI and plain radiographs [193]. In adolescent spondylolisthesis, early disc degeneration observed on MRI is not always associated with abnormal mobility of the corresponding motion segment [34]. MRI features of facet joint degeneration and spinal stenosis did not show any relevant correlation with reported pain relief after facet joint infiltration [190]. Longitudinal change of MRI parameters showed no differences between low back pain patients treated with or without fusion surgery, other than more endplate changes in the surgery group [184].

Assessment of Instability and Alignment: The combination of natural sitting and supine sagittal MRI was suitable to the traditional flexion-extension modality for assessing translational instability in patients with degenerative lumbar spondylolisthesis [165]. The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone may result in a greater likelihood of failure, and the addition of stabilization procedures should be considered [29]. Double-level lumbar spondylolysis and spondylolisthesis occurred more often in women, with the most common site being L3–L5 [11].

Advanced Imaging Techniques: MRI combined with paraspinal mapping or diffusion tensor imaging showed clear benefits in determining decompression levels of lumbar spinal stenosis compared to MRI combined with neurological examination [188]. Three-dimensional reconstruction measurements were used to determine safe distances among critical bone markers, the intervertebral space, and nerve roots in patients with 1-degree degenerative lumbar spondylolisthesis [189].

Other Considerations: An imaging study alone is insufficient to confirm a diagnosis; imaging studies must be concordant with clinical symptoms and signs to be of diagnostic value [83]. Spondylolysis and spondylolisthesis occurred more frequently in symptomatic than in asymptomatic patients on comparative roentgenographic study [1].

Treatment

Non-Operative

Non-operative management is a prerequisite for surgical consideration, requiring at least one year of conservative treatment before operative intervention is evaluated [175]. This period allows for the assessment of alignment and injury mechanism via standing radiographs and MRI [175]. In athletes with spondylolysis, nonoperative treatment achieves successful pain relief in approximately 80% of cases [157]. For spondylolysis associated with osteopetrosis, symptoms may be protracted but generally respond to non-operative measures such as a lumbosacral corset or thoracolumbosacral orthosis [54]. Non-surgical spinal decompression has been associated with reduced pain and increased disc height [171]. While watchful waiting does not result in catastrophic neurologic deficits, surgical treatment of degenerative spondylolisthesis provides significant long-term value to the patient [6].

Operative

Indications: Surgical intervention is indicated when non-operative measures fail, particularly for patients with spinal stenosis associated with degenerative or iatrogenic spondylolisthesis, where arthrodesis serves as an adjunct to decompression [10]. Fusion is also indicated for progressive degenerative lumbar scoliosis [10]. However, the role of lumbar fusion remains controversial; it has a poor success rate when used to treat back pain associated with multilevel disk degeneration [10]. Direct surgical repair is considered for recalcitrant cases of spondylolysis in athletes [157]. Anterior fusion may be indicated in rare conditions, such as traumatic spondylolisthesis combined with back skin damage, where a posterior approach is hazardous [119].

Surgical Approach / Technique: Surgical treatment of degenerative spondylolisthesis usually consists of posterior release associated with instrumented fusion, though some cases may be more complex [20]. The procedure is designed to stabilize the involved vertebra, relieve nerve-root irritation, and permit prompt mobilization with support, yielding a high percentage of good results [50]. Spinal stabilization and fusion constitute the most important parts of the procedure in spondylolisthesis [15]. For low-grade lytic spondylolisthesis, uninstrumented fusion demonstrates established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches [160].

Decompression vs. Fusion: Decompression alone is not inferior to decompression and fusion in patients with single-level lumbar spinal stenosis with spondylolisthesis [60]. At two years, there was no significant difference in patient satisfaction between the two treatment groups for any outcome measures, regardless of preoperative spondylolisthesis [5]. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively [25]. Among patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis, lumbar facet arthroplasty was associated with a higher rate of composite clinical success than fusion at 24 months postoperatively [46]. Both procedures yielded comparable long-term clinical outcomes, supporting individualized surgical decision-making in patients with degenerative LSS and Grade I spondylolisthesis [3].

Implant Selection: Both posterolateral fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) are effective and result in improved clinical and radiological outcomes for patients treated for low-grade spondylolisthesis [45]. Both OLIF and TLIF are effective surgical modalities in the treatment of degenerative lumbar spondylolisthesis [132]. Standalone OLIF had better clinical outcomes at 1 week and 3 months than OLIF combined with posterior pedicle screw fixation (PPSF) in patients with spondylolisthesis [52]. The general clinical efficacy of isobar hybrid dynamic stabilization with posterolateral fusion is equivalent to titanium rod fusion surgery, presenting an alternative treatment for individuals with mild and moderate lumbar degenerative disease [115]. CICPS is safe and effective in the treatment of spondylolysis-type lumbar spondylolisthesis complicated by osteoporosis [128].

Alignment / Balancing Strategy: TLIF can effectively relieve the symptoms of patients with continuous double-level lumbar spondylolisthesis, restore lumbar lordosis and sagittal spinal sequence, and improve the quality of life of patients [114].

Adjuncts: Non-contact orthopedic robot navigation for the treatment of lumbar spondylolisthesis was demonstrated to be a minimally invasive, precise, and stable surgical method [151].

Other Considerations: Both surgical methods can achieve satisfactory clinical efficacy in treating degenerative lumbar 4/5 spinal stenosis [134]. Specific radiographic and technical considerations should be evaluated by surgeons before realizing a lumbar fusion [148].

Complications

Surgical Approach and Disposition: Anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis is associated with fewer perioperative complications and lower odds of nonroutine discharge compared with posterolateral fusion (PLF) [38]. However, ALIF is associated with substantially higher inpatient costs than PLF [38].

Instrumentation and Revision: No differences were found in 90-day aggregated postoperative adverse events or 5-year lumbar revision surgery rates between instrumented and noninstrumented posterolateral approaches for lumbar degenerative spondylolisthesis [155].

Durability and Recurrence: Lumbar diskectomy is a relatively durable procedure with 84% durability at 4-year follow-up [57]. Early revision surgery for complications occurred in 3.3% of patients following lumbar diskectomy [57], while late revision for recurrent pathology occurred in 11.6% of patients [57].

Other Considerations: Some patients undergoing microdecompression for lumbar synovial cysts develop late-onset low back pain and radicular pain [55]. These patients may need additional surgery [55]. The rate of fusion was 93 per cent in patients with spondylolisthesis treated with spinal arthrodesis with pedicle screw-plate fixation [61]. In contrast, the rate of fusion was 65 per cent in patients with preoperative pseudarthrosis treated with spinal arthrodesis with pedicle screw-plate fixation [61].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range-of-motion and strength recovery.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physiotherapy phasing, immobilisation durations, weight-bearing or range-of-motion progressions, or brace removal timing.

Functional milestones: At two years postoperatively, patient satisfaction showed no significant difference between treatment groups for any outcome measures, regardless of preoperative spondylolisthesis [5]. Patients with long-term preoperative leg numbness experience poorer outcomes at this two-year mark [163]. At mid-term follow-up, posterior lumbar interbody fusion and oblique lumbar interbody fusion provided sustained improvement in pain and function for lumbar spinal stenosis [149].

Other Considerations: Surgical treatment of degenerative spondylolisthesis provides significant value to the patient over the long term [6]. No catastrophic progressions to neurologic deficit occurred as a result of watchful waiting for degenerative spondylolisthesis [6]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion [37]. Beneficial effects of surgical intervention for lumbar synovial cysts persist long term, with an average follow-up of nearly ten years [55]. However, some patients undergoing surgical intervention for lumbar synovial cysts develop late-onset low back pain, radicular pain, and may need additional surgery [55]. The long-level fusion group maintained acceptable clinical and radiological outcomes compared to the short-level fusion group at a minimum of 10 years of follow-up [58]. Early revision surgery for complications occurred in 3.3% of patients undergoing lumbar diskectomy [57]. Late revision for recurrent pathology occurred in 11.6% of patients undergoing lumbar diskectomy [57]. Seven percent of lumbar disc patients had a residive lumbar disc operation within five years of their first operation [195]. Factors significantly associated with a successful outcome after reoperation on the lumbar spine included younger age, working outside the home, an initial period of improvement after the previous operation, fewer spinal levels operated on previously, and a revision procedure incorporating anterior interbody arthrodesis [196]. The timing between cauda equina syndrome diagnosis and decompression surgery did not significantly affect the long-term risk of conversion to fusion [197].

Key Evidence

• [L3] Spondylolysis and spondylolisthesis occurred more frequently in symptomatic than in asymptomatic patients. [1] (10.2106/00004623-197658060-00017)
• [L2] Operative treatment of lumbar stenosis and degenerative spondylolisthesis offered a significant benefit over nonoperative treatment in patients at least eighty years of age. [2] (10.2106/jbjs.n.00313)
• [L3] Both procedures yielded comparable long-term clinical outcomes, supporting individualized surgical decision-making in patients with degenerative LSS and Grade I spondylolisthesis. [3] (10.1186/s13018-026-06683-w)
• [L3] At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a preoperative spondylolisthesis. [5] (10.1302/0301-620x.95b7.30776)
• [L4] Surgical treatment of intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis provides significant value to the patient over the long term, with no catastrophic progressions to neurologic deficit occurring as a result of watchful waiting. [6] (10.5435/jaaos-20-03-160)
• [L3] Surgical treatment for spondylolisthesis in young patients was associated with low 90-day complication rates and a 13.1% reoperation rate within 5 years. [7] (10.2106/jbjs.23.01242)
• [L2] Clinical outcome was not related to the obtained radiographic reduction of the slipped vertebra in patients with a lumbar fusion for low grade spondylolisthesis. [8] (10.1186/1471-2474-14-245)
• [L4] The role of lumbar fusion for treatment of degenerative disorders of the lumbar spine is controversial; arthrodesis is indicated as an adjunct to decompression for patients with spinal stenosis associated with degenerative or iatrogenic spondylolisthesis and in the treatment of progressive degenerative lumbar scoliosis, but has a poor success rate when used to treat back pain associated with multilevel disk degeneration. [10] (10.5435/00124635-199505000-00002)
• [L4] Double-level lumbar spondylolysis and spondylolisthesis occurred more often in women, with the most common site being L3–L5. [11] (10.1186/s13018-018-0723-3)
• [L4] Patients improving pelvic tilt after fusion achieved good clinical outcomes in degenerative spondylolisthesis. [12] (10.1186/1471-2474-12-69)
• [L3] This unique neural arch shape may clarify the pathophysiology of degenerative spondylolisthesis and explain its greater prevalence in females. [13] (10.1186/s12891-021-04901-6)
• [L3] The authors conclude that spinal stabilization and fusion constitute the most important parts of the procedure in spondylolisthesis. [15] (10.1007/s004020050422)
• [L3] There was no relationship between ESI and improved clinical outcomes over a 4-year study period for patients who chose or were assigned to receive surgery for degenerative spondylolisthesis. [16] (10.2106/jbjs.19.00596)
• [L3] A decreased number of vertebrae was associated with degenerative spondylolisthesis, suggesting numerical variants may potentially be a clinical problem. [17] (10.1302/0301-620x.103b7.bjj-2020-1760.r1)
• [L4] [18] (10.1177/23259671261466477)
• [L5] Surgical treatment of degenerative spondylolisthesis usually consists in posterior release associated to instrumented fusion, though some cases can be more complex. [20] (10.1016/j.otsr.2016.06.022)
• [L1] In patients with spinal stenosis with degenerative spondylolisthesis, decompression surgery alone was noninferior to decompression surgery with instrumented fusion for reducing impairment at 2 years. [24] (10.2106/jbjs.22.00307)
• [L1] This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively. [25] (10.1302/0301-620x.104b12.bjj-2022-0340.r1)
• [L5] Current surgical guidelines for spondylolisthesis are based on radiographic assessment of the lumbosacral junction, but recent studies demonstrate the importance of a global assessment of sagittal spinopelvic balance. [26] (10.5435/jaaos-20-04-194)
• [L3] However, a correlation between correction of sagittal rotation and clinical outcome was demonstrated. [27] (10.1007/s00402-019-03282-9)
• [L3] The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone may result in a greater likelihood of failure, and the addition of stabilization procedures should be considered. [29] (10.5435/jaaos-d-24-00763)
• [L5] Most symptomatic cases of adult isthmic spondylolisthesis are successfully managed nonsurgically, but patients with intractable pain or neurologic symptoms may benefit from surgical decompression and stabilization, which has shown >80% success in appropriately selected patients. [30] (10.5435/00124635-200910000-00003)
• [L3] Young patients with lumbar degenerative spondylolisthesis commonly, but do not always, experience clinically meaningful gains in pain relief, function, and quality of life after transforaminal lumbar interbody fusion. [31] (10.1097/corr.0000000000001252)
• [L3] This study revealed the occurrence of displacement between the anterior and posterior elements of L4, primarily in the form of separation during flexion. [32] (10.1186/s13018-024-05033-y)
• [L3] At the L4–5 and L5-S1 levels, facet tropism is associated with degenerative spondylolisthesis and lumbar disc herniation. [33] (10.1186/s12891-017-1849-x)
• [L4] The study demonstrates that disc degeneration and instability are not concurrent in adolescent spondylolisthesis, as early disc degeneration observed on MRI is not always associated with abnormal mobility of the corresponding motion segment. [34] (10.1007/bf00390186)
• [L4] Reduction and maintenance of reduction in selected cases of severe spondylolisthesis is both desirable and obtainable. [35] (10.2106/00004623-196648050-00006)
• [L3] Lumbar lateral instability, defined as increased mobility in the coronal plane on lateral bending radiographs, correlates with more pronounced patient-related symptoms in degenerative L4–5 spondylolisthesis. [36] (10.1186/s12891-022-05017-1)
• [L3] Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion. [37] (10.1186/s13018-015-0186-8)
• [L3] ALIF for degenerative spondylolisthesis was associated with fewer perioperative complications and lower odds of nonroutine discharge than PLF, though at substantially higher inpatient costs. [38] (10.5435/jaaos-d-25-01337)
• [L5] [42] (10.5435/jaaos-20-08-527)
• [L3] Both surgical procedures PLF and TLIF were effective and resulted in improved clinical and radiological outcomes for patients treated for low-grade spondylolisthesis. [45] (10.1055/s-0040-1718781)
• [L1] Among patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis, lumbar facet arthroplasty was associated with a higher rate of composite clinical success than fusion was at 24 months postoperatively. [46] (10.2106/jbjs.23.00719)
• [L4] It produces good clinical results with fewer complications and can be applied in most single-level spondylodesis cases. [47] (10.1186/s13018-021-02313-9)
• [L5] Surgeons should anticipate favorable improvements in pain and functional ability in appropriately selected younger patients with symptomatic degenerative spondylolisthesis and stenosis. [48] (10.1097/corr.0000000000001309)
• [L3] Standalone OLIF had better clinical outcomes at 1 week and 3 months than OLIF+PPSF in patients with spondylolisthesis. [52] (10.1186/s12891-020-3051-9)
• [L4] Spondylolysis associated with osteopetrosis may be painful, and symptoms may be protracted but will generally respond to non-operative measures such as use of a lumbosacral corset or a thoracolumbosacral orthosis. [54] (10.2106/00004623-199711000-00010)
• [L3] This study provides outcome data at an average of nearly ten years post-operative, demonstrating that beneficial effects of surgical intervention persist long term, though some patients will develop late-onset low back pain, radicular pain, and may need additional surgery. [55] (10.1186/1749-799x-2-5)
• [L3] Lumbar diskectomy is a relatively durable procedure (84% durability) at 4-year follow-up, with early revision surgery for complications occurring in 3.3% of patients and late revision for recurrent pathology occurring in 11.6%. [57] (10.5435/jaaos-d-25-00292)
• [L3] The long-level fusion group maintained acceptable clinical and radiological outcomes compared to the short-level fusion group at a minimum of 10 years of follow-up. [58] (10.1186/s12891-015-0836-3)
• [L1] Therefore, decompression alone is not inferior to decompression and fusion in patients with single-level lumbar spinal stenosis with spondylolisthesis. [60] (10.1186/s12891-024-07641-5)
• [L4] The rate of fusion was 90 per cent in patients with painful degenerative disease, 93 per cent in those with spondylolisthesis, and 65 per cent in those with preoperative pseudarthrosis. [61] (10.2106/00004623-199173080-00006)
• [L3] The preserved biomechanical behavior in the upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits. [87] (10.1186/s12891-025-09238-y)
• [L4] ISPL induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the ICJ. [101] (10.1016/j.otsr.2020.02.013)
• [L3] Abnormal mechanical stress may contribute to this degeneration, highlighting the importance of managing stress in kyphotic deformities. [104] (10.1186/s12891-024-08157-8)
• [L4] TLIF can effectively relieve the symptoms of patients with continuous double-level lumbar spondylolisthesis, restore lumbar lordosis and sagittal spinal sequence, and improve the quality of life of patients. [114] (10.1186/s12891-022-06018-w)
• [L3] The general clinical efficacy is equivalent to titanium rod fusion surgery, presenting an alternative treatment for individuals with mild and moderate lumbar degenerative disease. [115] (10.1186/s12891-023-06329-6)
• [L5] Anterior fusion may be indicated in rare conditions such as traumatic spondylolisthesis combined with damage to the skin of the back, where a posterior approach would be hazardous. [119] (10.1016/0020-1383(83)90260-7)
• [L3] Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis. [123] (10.1155/2020/2453503)
• [L4] CICPS is safe and effective in the treatment of spondylolysis-type lumbar spondylolisthesis complicated by osteoporosis. [128] (10.1186/s12891-022-05904-7)
• [L1] Both OLIF and TLIF are effective surgical modalities in the treatment of degenerative lumbar spondylolisthesis. [132] (10.1530/eor-22-0042)
• [L5] No clinically applicable and validated classification of spinal stenosis has been published, which has substantially limited the development of an evidence-based algorithm for treatment. [133] (10.5435/jaaos-d-15-00034)
• [L3] Both surgical methods can achieve satisfactory clinical efficacy in treating degenerative lumbar 4/5 spinal stenosis. [134] (10.1186/s12891-025-08623-x)
• [L3] [140] (10.1186/s13018-024-04647-6)
• [L3] It should be considered by surgeons before realizing a lumbar fusion. [148] (10.1016/j.otsr.2013.09.003)
• [L3] At mid-term follow-up, PLIF and OLIF provided sustained improvement in pain and function. [149] (10.1186/s13018-026-06818-z)
• [L3] The non-contact orthopedic robot navigation for the treatment of lumbar spondylolisthesis was demonstrated to be minimally invasive, precise, and stable surgical method. [151] (10.1186/s12891-024-08019-3)
• [L3] Surgical treatment for stenosis with or without spondylolisthesis within the Medicare population was associated with significantly lower mortality and total medical payments at 2 years compared with nonsurgical treatment, although residual confounding could have contributed to these findings. [152] (10.2106/jbjs.22.00181)
• [L4] With proper patient selection, posterior decompression with instrumented fusion can be safe and effective for patients 80 years of age and older with degenerative lumbar conditions. [153] (10.1186/s12891-016-1239-9)
• [L4] No differences were found in 90-day aggregated postoperative adverse events and 5-year lumbar revision surgery rates, suggesting that instrumentation can be safely performed and that both approaches had similarly durable results. [155] (10.5435/jaaosglobal-d-25-00192)
• [L5] Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, and direct surgical repair can yield high rates of pain relief in recalcitrant cases. [157] (10.2106/00004623-200402000-00027)
• [L5] Non-operative treatment for stable thoracolumbar burst fractures and uninstrumented fusion for low-grade lytic spondylolisthesis demonstrate established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches. [160] (10.1302/0301-620x.98b1.37508)
• [L3] Patients with lumbar spinal stenosis with long-term preoperative leg numbness have poorer outcomes at 2 years postoperatively. [163] (10.1186/s13018-022-03452-3)
• [L3] The combination of natural sitting and supine sagittal MRI was suitable to the traditional flexion-extension modality for assessing translational instability in patients with degenerative lumbar spondylolisthesis. [165] (10.1097/corr.0000000000001542)
• [L3] [168] (10.1186/s12891-022-05794-9)
• [L3] In terms of outcomes with an average follow-up time of 2 years, the deeper the screw depth is within the safe range, the better the spino-pelvic sagittal balance may be restored and the better the quality of life may be. [169] (10.1186/s12891-021-04736-1)
• [L3] Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. [171] (10.1186/1471-2474-11-155)
• [L2] Non-operative treatment must be provided for at least 1 year before considering surgery, and standing radiographs and MRI are required to assess alignment and injury mechanism. [175] (10.1016/j.otsr.2018.11.021)
• [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. [182] (10.1186/s12891-025-09182-x)
• [L3] Other than more endplate changes in the surgery group, no differences in longitudinal change of MRI parameters were established between LBP patients treated with or without fusion surgery. [184] (10.1186/s12891-023-06242-y)
• [L4] MRI consistently underestimated the lumbar spinal canal cross-sectional area compared to CT, which could impact surgical planning and outcomes. [185] (10.1186/s13018-025-05653-y)
• [L2] The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. [187] (10.2106/00004623-200109000-00002)
• [L2] MRI + (PM or DTI) showed clear benefits in determining decompression levels of lumbar spinal stenosis than MRI + NE. [188] (10.1186/s13018-016-0382-1)
• [L4] This study measured safe distances among critical bone markers, the intervertebral space, and nerve roots in patients with 1-degree degenerative lumbar spondylolisthesis and non-DLS via three-dimensional reconstruction. [189] (10.1186/s13018-025-05474-z)
• [L4] MRI features of facet joint degeneration and spinal stenosis did not show any relevant correlation with reported pain relief after facet joint infiltration. [190] (10.1186/s13018-017-0685-x)
• [L1] A positive MRI T2-weighted image of the lumbar disc with HIZ indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain. [191] (10.1186/s13018-023-04187-5)
• [L3] Lumbar segmental instability was recognized at all levels even in individuals who appeared to be normal or to have mild disc degeneration. [193] (10.1007/bf00426175)
• [L3] Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. [195] (10.1186/1471-2474-8-2)
• [L3] Factors significantly associated with a successful outcome included younger age, working outside the home, an initial period of improvement after the previous operation, fewer spinal levels operated on previously, and a revision procedure incorporating anterior interbody arthrodesis. [196] (10.2106/00004623-199605000-00010)
• [L3] The timing between CES diagnosis and decompression surgery did not significantly affect the long-term risk of conversion to fusion. [197] (10.5435/jaaosglobal-d-22-00153)

See Also

• Lumbar fusion
• Lumbar spinal stenosis
• Lumbar disc herniation
• Low back pain
• Cauda equina syndrome

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